LR: Probably not. And I think it’s important to remember that some things that might reduce medical spending do so by increasing costs outside the medical sector, so they are a kind of cost shifting. This is often true of self-management, which can require considerable time, effort, and cost on the part of the patient, and the patient’s family and friends.
TL: Are people being misled about preventive care ?
LR: It’s so easy for people to misunderstand the issue. I hesitate to think that people who say preventive care saves money are deliberately misleading. I think most of them don’t understand it.
TL: What is cost effectiveness analysis?
LR: It projects the costs and health outcomes from different medical choices. It’s a way of comparing costs and health outcomes for different ways of dealing with a disease, such as preventing it before it happens or waiting until it happens and treating it.
TL: Is the term “cost effective” misused ?
LR: The term once meant cost savings, because it was used in situations where you were getting exactly the same result either way and just wanted the cheapest way to get that result. It still carries that connotation, but now we are looking for the most effective way to spend money. If it costs $5000 to save one year of life with smoking cessation programs, and $200,000 to save one year of life with statins, then we say smoking cessation is more cost effective than statins. But neither one saves money.
TL: What is the conflict between making such choices and marketing new products?
LR: If you make a new product, you want to sell it, but it may not be the most effective thing for peoples’ health, or the most important thing to spend money on. The conflict is between the seller and the health policy maker who wants to make sure that people’s health is well served.
TL: Are we spending our prevention dollars inappropriately?
LR: There is some evidence that we are. We should be making sure that the elderly get flu shots, for example. A survey of five countries, including the U.S., indicated that the U.S. may already do more prevention than other countries, but we are living proof that more prevention does not reduce medical spending. New Zealand, Australia, the UK, and Canada all spend less of their GDP on medical care and have longer life expectancies. To me, flu shots illustrate the problem. Those countries emphasize more cost effective interventions like flu shots, instead of annual Pap smears, which are far less cost effective.
TL: Is cost effectiveness about depriving people of care? In other words, does it bring about the “r” word—rationing?
LR: No, it’s about making sure that people get the most valuable and effective stuff first. We spend a lot of money on interventions that don’t bring us much benefit, like statins for people with moderately elevated cholesterol and few or no other risk factors for heart disease. The idea is to make sure we are doing the most effective stuff first.
TL: How do other countries engage in cost effectiveness activities?
LR: Other countries often require drug makers to provide cost effectiveness analyses of drugs that the manufacturers want covered by health insurance. Government panels that review the analyses can decide that the drug is not cost effective enough to warrant coverage, although the manufacturer can still sell it. Managed care plans and pharmaceutical benefit managers in the U.S. may use cost effectiveness analysis in deciding which drugs to include on their formulary lists.
TL: The conventional wisdom is that if only people made lifestyle changes, medical care would be a lot cheaper. Is there any truth to this “blame the victim” cost control strategy?
LR: We really don’t know. Nobody has analyzed the full costs. It would involve some of that cost shifting I mentioned earlier. People would be spending time and effort outside the medical sector to make these changes. There’s no question, for example, that exercise is good for health, but it’s not riskless or costless. Lifestyle changes are tough in a society that makes it easy to get the wrong foods and hard to get the right exercise.
TL: What stories should the press be writing?
LR: They should not be writing that prevention saves money. It rarely does, and it certainly is not the solution to anything in terms of medical costs. They should realize that some prevention is worth doing and some isn’t. Each intervention needs to be evaluated on its own merits.
TL: Can you give some examples of interventions that are worth doing and some that are not?
LR: Smoking cessation and flu shots are worth doing. So are statins for high-risk patients. But statins for low-risk people—those with no risk factors for heart disease other than elevated cholesterol—may not be worth doing, at least not until we have made sure that the more cost-effective interventions are done, like giving diuretics for elevated blood pressure.
TL: Can you give reporters a few bullet points to guide them in writing about preventive care?
LR: They should ask:
• How effective is the intervention, and for whom?
• How is it done and how often. This drives the cost of the prevention.
• How much does it cost to get results after figuring in the full costs of prevention, the savings, and the magnitude of the effects on people’s health?
TL: I’ve heard that the country spends just three to five percent of total medical spending on preventive care? Doesn’t that prove that we spend too little?
LR: Those numbers are wrong. Some researchers have traced them back to a 1988 number included in a brief report in CDC’s Morbidity and Mortality Weekly Report. From that brief report, it looks like the study didn’t include any preventive care that takes place in doctors’ offices and clinics, but focused just on public health stuff, like the programs of state health departments.





But "medical spending" is a vague term.
How do you get a number for the cost of our private insurance system? It's been reported that the U.S. spends far more on administration of healthcare than do Canada and other indistrialized nations.
Don't we need to isolate "cost of administering and operating private insurance" and pull that out of "medical spending"? When a 1- or 2-physician office has to hire 2-3 staff people just to handle insurance claims, including repeat submissions and appeals (not to mention the insurers own staffing, administration, advertising, etc.), each with multiple plans and levels -- I suspect this cost might be a big part of medical spending. How can we isolate the cost of our for-profit medical insurance system?
Posted by SB on Tue 16 Jun 2009 at 05:19 PM
Interesting interview but both parties are speaking from a strictly one sided viewpoint. Numbers. Neither works in the medical field and this should be made very clear.
Prevention, like solar panels, will save money, save lives and possibly save the planet, it just wont do it, on an epidemilogical scale in the near future, certainly not in the short attention spans of those studies quoted.
Any cardiologist will tell you that they rush in to the ER or cath lab so much less often for the mid night heart attack today than when they were in training a short 10 years ago, ditto for diabetic coma, status asmaticus, full blown eclampsia, ARDS and many other preventible emergencies. Thes are generic examples and in each case the admission and weeks of hospital in intensive care would have cost hundreds of thousands of dollars. Cost savings up front!! These are only a few examples of daily events prevented around the world that dont enter those studies. Where I agree with the professor is that the extant system of prevention is subject to much misuse, over use and mostly inappropriate use. Any criticism of preventive care should include a recognition of why prevention gets so expensive, the greed and malfeasance of the Health In dustry, Big Phrma with DTCA, careless media (in a great hurry to make copy with the latest miracle drug) and unscrupulous doctors. Anything less is indeed throwing out swimming pool when all you need is to remove a few floating leaves and a good vacuuum.
Posted by Dr Wilbur larch on Tue 16 Jun 2009 at 10:28 PM
To SB: "Medical spending" means the goods and services valued in the National Health Expenditure Accounts, which are produced by the US Department of Health and Human Services. Their estimates have been the definitive information on how much the US spends on medical care for more than 50 years and can be found at http://www.cms.hhs.gov/nationalhealthexpenddata/. The administrative costs of our system are a fair point, but not an issue on which I have any special expertise .
Dr. Larch may be thinking of 'business case' analyses when he refers to the "short attention spans" of studies. He will be glad to know that cost-effectiveness analyses (CEAs), on which I base my conclusions, estimate costs and savings over the lifetimes of a cohort of patients, from the beginning of a preventive intervention until all the patients have died, often a span of 60-80 years or more.
CEAs do count those hundreds of thousands of dollars of savings, but they also count the drip-drip-drip of the millions of doctors' visits, millions of prescriptions, millions of monitoring tests, and whatever else is necessary to prevent disease. Added up, those individually-small costs are greater than than the more impressive savings for some patients.
And the savings don't come up front. They can't. Prevention has to start years before the person would develop heart disease. It would be nice if it could start the day before that expensive admission and prevent it then, but we're not there yet.
Posted by Louise Russell on Wed 17 Jun 2009 at 12:50 PM
It's "preventive," not "prevenative."
You can take the copy editor out of the newsroom, but he stays a copy editor forever.
Posted by Stephen G. Esrati on Wed 17 Jun 2009 at 01:48 PM
Societal health care costs are typically calculated as a percentage - 100 x health care costs/GDP. Some preventable illnesses not only incur medical expenses but also contribute to a loss of productivity, and thus presumably reduce GDP to some discernible extent. To what extent would many elements of preventive care that increase costs in absolute terms reduce them in relative terms by amplifying the denominator of the fraction more than the numerator?
Posted by Fred Moolten on Wed 17 Jun 2009 at 09:06 PM
Although the concept of disease causation ergo prevention is ancient, prevention as an epidemiologic stratergy is not. I am curious as to what proven preventive approach has been studied over a 60 to 80 year period (Prof Russell). To the lay reader all they need to do is to follow the various battles of the last few U.S. Surgeons General nearly all embraced their own favourite prevention of the day. Tobacco, Obesity, HIV, lack of Exercise etc. Keep in mind that prevention is a cornerstone of Public Health and clinical medicine, which, whether cost analysis approves or not, has always worked.
Prevention in medicine as a universal medical concept has to be effective, cheap, widely applicable and acceptable to the public (from an old medical text book), the same with screening (if you talk of secondary prevention). I dont believe that this has been tested and shown to be cost ineffective.
What passes for prevention today and over the last decade or two are myriad add-on, me- too, wanna be, unproven or half proven stratergies which I think have contaminated the data. I will mention some examples, keep in mind the usual suspects (perpetrators) I listed in my previous note.
A colonoscopy showing a large polyp (>1 cm) done in a person over 50 with a family history of colon cancer (first degree family) will prevent colon cancer, hospitalizations, surgery, chemo etc, cost of colonoscopy $200, but in the last 10 years the gastroenterologist found it less of a bother if he got an anesthesiologist to join in and do it under anesthesia, do it on every one once they cross 50, and repeat every few years, cost goes up to a recurring $200 +$600 and a low yield of people with the cancer (this is not medicine, its business).
Other examples are Gov Rick Perry trying to make HPV vaccine mandatory, doing stress tests, Holter monitors, and cardiac MRI's with no indication or the doctor owns the technology, carotid Dopplers in people without a stroke history, testing Vitamin D levels and indiscriminate Bone Scans, CT angiogram of the heart in low risk patients (egged on by a Dr. Gupta specials on CNN).
The same thing for prescribing expensive name brand Statins and blood pressure drugs, this is more drug rep than evidence based. Even if the JNC VII / WHO ISH and NCEP II Guidelines say so, remember the panels are replete with the Industry point men and women.
As the French General said of the Charge of the Light brigade, C'est magnifique, mais ce n'est pas la guerre." ("It is magnificent, but it is not war.") this is the buiness end of medicine, a commodified entrepreneurial abuse, it is not a failure of preventive medicine.
Posted by wilbur larch on Thu 18 Jun 2009 at 12:23 AM
Louise Russell, thank you for the clarification on "medical spending."
Posted by SB on Thu 18 Jun 2009 at 11:17 AM
As a followup to my brief comment yesterday, the link that follows is to an analysis that emphasizes the significant savings potentially available from effective preventive strategies aimed at common chronic illnesses - savings exceeding $1 trillion in the costs of lost productivity annually:
http://www.aafp.org/online/en/home/publications/news/news-now/health-of-the-public/20080604milken-report.html
If the link doesn't work, the article is from AAFP and is entitled "Chronic Diseases Spark Dramatic Increases in Treatment Costs While Lowering Productivity, Study Says".
As I suggested yesterday, the typical means of calculating health care costs is not in absolute dollar terms, but as a percentage of GDP. This makes sense, because what is most important is how we allocate society's total capital among competing demands. Lost productivity increases costs calculated by this method by reducing GDP (the denominator), and if prevention is implemented wisely rather than wastefully, the productivity savings could substantially reduce health care costs in the sense of the term that most affects our economy.
Posted by Fred Moolten on Thu 18 Jun 2009 at 09:48 PM
I've always calculated the cost of our current for-profit system at 22% of current health care costs (the 31% that we use for the insurance bureaucracy LESS the 9% that I think a single payer system would cost). Both numbers include billing staff at hospitals and clinics. We also say that a pure Medicare-for-all system would save $400 billion per year. Could that all be the elimination of the insurance industry?
Posted by Jack Lohman on Thu 23 Jul 2009 at 07:47 PM
In response to Fred Moolten's point, it is important to remember that effective treatment also boosts productivity. The argument that prevention or treatment can make us more productive is true, but does not solve our cost problem. We do lots more of both now than we did 50 years ago, when we spent about 5 percent of GDP on medical care. Today we spend more than 16 percent.
Posted by Louise Russell on Fri 4 Sep 2009 at 12:01 PM