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.
TL: So, then, how much does the U.S. spend on preventive care as a country?