campaign desk

Excluded Voices

An interview with Rutgers professor Louise Russell
June 16, 2009

This past year’s health discussion has been remarkable for the narrow range of ideas and opinions that have floated down to the man on the street. Journalists have sought out the same organizations and sources for their stories, offering up what has become the conventional wisdom for reform. To bring more voices into the conversation, our series, Excluded Voices, will intermittently feature health care experts who aren’t on the media’s A-list of sources. This is the fifth entry in the series, which is archived here.) We want to offer journalists more options for their stories and encourage a deeper conversation. To that end, we’ve asked the experts featured in each post to respond to questions from Campaign Desk readers.

Ask any pol or business exec how to lower the cost of medical care, and most will reply “preventive care.” Average Americans apparently agree. A new poll by the Robert Wood Johnson Foundation and Trust for America’s Health found that more than three quarters of Americans believe funding for preventive care should increase. The reasoning goes like this: if you catch illness early, it saves treatment costs in the long run. What can be more straightforward? Problem is, there’s oodles of evidence that prevention costs more than it saves.

Few in the media have cast a skeptical eye on preventive care as a magic wand that will make expensive medical care disappear. More should. To help those wanting to give audiences the complete story on preventive care, Campaign Desk talked to Rutgers research professor Louise Russell, whose work is well known in academic circles but less well known in the popular press.

Trudy Lieberman: What exactly do we mean by preventive care?

Louise Russell: Primary prevention, such as vaccines, completely prevents the disease. Secondary prevention either treats a risk factor for disease or detects disease in an early stage, when it can be treated more effectively. Blood pressure medicines and statins to lower cholesterol and pap smears are good examples. Tertiary prevention means someone already has a disease but wants to prevent further consequences. An example is treating diabetes by controlling blood sugar and blood pressure, and conducting eye exams and foot checks to prevent blindness and amputations.

TL: Do people confuse risk factors with disease?

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LR: Sometimes. People often think that if they have high blood pressure or high cholesterol, they have a disease—when, in fact, they are being treated to reduce the risk of diseases associated with those conditions.

TL: Why does prevention seem like such an easy answer to the cost problem?

LR: It just seems so logical, since if you prevent the disease, you avoid the cost of treating it. And people tend to focus on the cost per person, which can look low, not on the aggregate costs of mounting a preventive intervention.

TL: Can you amplify that a bit more?

LR: In order to get the benefit of prevention, you have to treat lots of people, often for a long time, and the cost of that treatment adds up. The cost to treat one person may look small, but the cost for everyone is large. And prevention isn’t perfect. Some people will get the disease in spite of preventive care. Others would not get it even without preventive care. The upshot is many people incur costs for prevention, but only some experience savings.

TL: Can you still go further?

LR: For example, you may have to give prevention, say blood pressure medication, to 100 or 1000 people for years to prevent one death from stroke or heart disease. All of those people incur the costs of prevention, but savings accrue only for the one whose death is prevented. That’s why, most of the time, prevention does not produce savings.

TL: Then it is not a panacea, right?

LR: It’s touted as one, but it is not. In fact, prevention has contributed to our rising medical costs.

TL: Can you give an example?

LR: Statins are widely used for millions of people. They do not save money and are enormously expensive, costing thousands of dollars—in some cases hundreds of thousands of dollars—for every year of life that they save.

TL: Does that mean we shouldn’t use them?

LR: Not necessarily. It is perfectly legitimate to decide that the better health gained from statins is worth the expense. But it does mean that we need to realize that prevention is not going to help reduce the growth of medical spending.

TL: Some people say, “Yes, but if one life is saved, it’s worth it.” Is there another way to think about the individual vs. the population question?

LR: That’s a choice people can make. But they might want to think about it a little differently. If you think about how many years of good health you can buy for a million dollars, studies show that some interventions buy a lot, others very few. For example, flu shots for the elderly buy a lot of years of good health, but annual Pap smears—as opposed to screening less often—buy very few. The comparison suggests that it’s important to make sure that we do the most effective things first, like the flu shots.

TL: But what about the studies that claim there are savings?

LR: Some studies claim savings but they are usually not just looking at medical costs and savings. You will see studies claiming that a preventive intervention saves five dollars for every one dollar spent. What they are doing is valuing every life saved at the future earnings of the person and including those dollars along with medical costs and savings.

TL: Is that valid?

LR: Not if the point at issue is whether prevention will reduce medical spending.

TL: Does self-management of a disease save money? It’s been promoted as a way to cut costs.

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.

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.

Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for CJR's Covering the Health Care Fight. She also blogs for Health News Review and the Center for Health Journalism. Follow her on Twitter @Trudy_Lieberman.