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.
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