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?
LR: In recent years, medical prevention has been at least eight to nine percent of total medical spending. And, of course, we spend lots outside the medical sector, on everthing from highway safety to safe water.
TL: Is that enough? Is there an ideal number that policy makers should aim for?
LR: There is no number we should aim for. Instead, we should evaluate each intervention—whether it’s prevention or treatment—and focus our efforts on making sure that the ones that bring the most health for the money are provided to everyone who can benefit from them before we spend money on less effective care.
TL: What should we be doing to really control the costs of medical care?
LR: We have to decide how much we are going to spend as a country and then stop when we reach that point. We need to set a cap on total spending in some way. We already spend so much more than other countries that any cap would in the end be quite generous.
TL: Who would oppose such caps?
LR: Just about everybody. Patients who think that a cap means they won’t get the care they need. Hospitals, clinics, and doctors who know that it means they will not be able to grow as they have in the past or, in some cases, continue to be paid as well. Insurers who benefit from the large flows of revenue that come through their companies. Drug and device manufacturers that have seen their markets grow rapidly.
TL: If we don’t set such caps, ultimately what will happen?
LR: Medical spending will continue to rise as a share of national income. We currently spend sixteen to seventeen cents of every dollar on medical care. If we don’t change things, that number will keep growing.