Prevention Costs

More prevention will not cut health care costs.  Tuesday’s Post:

Most of us naturally assume that preventing a disease is cheaper than waiting for the disease to appear and then treating it. That belief is especially dear to politicians, who often view prevention as an underused weapon in the battle against health-care costs. …

In 1986, a health economist named Louise B. Russell published "Is Prevention Better Than Cure?," in which she concluded that prevention activities tend to cost more than they save. Since the book’s appearance, her observation has been borne out by studies of hundreds of interventions — everything from offering mammograms to all women and prescribing drugs to people with high cholesterol to requiring passenger-side air bags in cars and shortening the response time of ambulances. …

For example, Australian researchers tried out a program in which general practitioners watched a video and read a booklet about how to help their patients lower their heart attack risk. The patients were then given a series of videos and a self-help booklet on the same topic.  How cost-effective is this instruction? When it is provided for women at low risk of heart disease, $9.8 million has to be spent for every year of life saved in the prevention of premature heart attack deaths. …

Some disease-preventing activities … save money, although they are relatively rare. Childhood vaccinations are the classic examples. … Providing a single colonoscopy to men 60 to 64 years old also saves money. …

Similar to the finding that prevention rarely saves money is the calculation that people in good health probably rack up higher lifetime medical costs than their less-healthy brethren.  The reason?  Healthy people tend to live longer.

Added:  I’m mentioned in today’s NYT re prediction markets, alas again as the extremist.

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  • http://maggiesfarm.anotherdotcom.com/archives/8105-A-few-Weds.-Morning-Links.html Maggie’s Farm

    A few Weds. Morning Links

    Obama campaign: Get me more white people. Dick Morris: Obama’s weakness is weaknessMr. Free Market loves TexasLaShawn on chastity.Fun with Richard Dawkins. Video at ThompsonPrevention does not reduce medical costsTraumatizing bl…

  • alex

    Is the quality of life experienced by the subjects the same in both tests? I’d guess those in preventative tests would end up with a higher average quality of life, but that’s just a guess…

  • poke

    None of this seems surprising. If you’d asked me to sort preventative health care measures by cost effectiveness before reading this article, I would have put one time interventions at the top, continuing programs of education far at the bottom, and ongoing screenings somewhere in between (albeit closer to the bottom). The article appears to confirm this intuition. I’d guess anytime you have a demographically-targeted one-time intervention it’s likely to be a benefit (i.e., vaccinations for childhood diseases, a single colonscopy for middle-aged men) and anytime you need an ongoing public education campaign (i.e., healthy eating, exercise, etc) you’re essentially throwing money away.

  • anonymous

    alex, healthcare cost analyses generally use QALY as a metric, so differences in quality of life are already taken into account.

    In case it wasn’t clear, the article mentions that the costliness of prevention is due to the fact that few people even in “very high risk” categories actually develop the targeted disease. IOW, prevention may still be highly cost-effective if combined with improved risk assessment.

  • http://stuartbuck.blogspot.com Stuart Buck

    Here is an ongoing list of medical treatments that appear to be ineffective or even harmful.

  • http://julesandjames.blogspot.com/ James Annan

    There’s some very obvious cherry-picking going on in some of those examples (mammograms for *all* women, *women at low risk* of heart disease). In the UK at least there is a healthy (IMO) debate about the role of preventative treatment. That doesn’t mean they always get it right, but it does seem like they are generally trying to make reasonably rational decisions.

  • http://profile.typekey.com/BenSchiendelman/ BenSchiendelman

    Now, if all those prevention costs were in the healthcare system, I might agree that there’s an issue. But because most of those costs are personal costs which individuals can choose whether to heed or not, that’s in their domain, not the domain of the taxes collected and spent on healthcare.

    This is a psychology discussion more than a cost discussion – we need to understand better how people *actually* behave when provided with prevention information.

  • http://rationalanalysis.blogspot.com Enginerd

    Prevention may be more expensive overall right now, but that just means we need to focus on it more. Improving accuracy and reducing the cost of screening techniques would be enormous.

    Plus, general health education can be made remarkably cheap due to mass production. Printing pamphlets is not expensive, and the research is already done. If you focus on keeping the population healthy in general, your costs will be much smaller. Might help if health class in school weren’t such a joke, but then, it only matters 20 years later.

    What about government subsidized gym memberships, with nutrition info freely available at the gyms?

  • http://www.wholefamilynutrition.com Nicholas Hundley

    Yes it’s true: preventive medicine isn’t cost effective. We shouldn’t conclude, however, that prevention done differently wouldn’t be cost effective.

    The thing that kills me—and it kills all of us (no pun intended)—is that nutrition is barely considered a part of the medical prevention paradigm. It’s all talk of colonoscopies and mammograms. I don’t really consider these to be prevention per se. They’re actually better defined as early-detection interventions to treat the existing disease before it gets bigger. There’s a difference. And yet, faster crisis response times, mammograms, colonoscopies, a few seconds of “eat more fiber says doctor” once per year are all we get. The truth is, we haven’t truly even tried prevention. We haven’t! True prevention hasn’t been tried. (I’m in the US. I know it’s slightly better in developed countries with socialized medicine. And overall health is better there, too.)

    A Harvard team has concluded (via the Nurse’s Health Study and meta-analyses) that MODERATE changes in lifestyle could drastically reduce our disease burden (and thus health care costs. And yes, if we live longer we incur more costs. But if we live longer and healthier, we contribute more to the GDP. And we’re happier).

    Diabetes (which is our leading health care burden because it leads to both heart disease and dialysis:yikes!) is 92% preventable with moderate diet and activity changes and no smoking.

    Colon cancer, another major burden, is roughly 71% preventable with similar moderate lifestyle changes.

    Coronary heart disease: 82% preventable with similar moderate changes.

    I almost feel like a quack quoting those numbers. It seems almost unbelievable to me. Can you imagine the health savings if we could implement that?

    I bet the pharmaceutical companies would love to boast similar percentages on the curing/treatment side of things.

    I’ll emphasize that almost no money goes into prevention. Oh, roughly one to two percent of our healthcare spending goes into it. It’s like we’re trying to use a tree branch to stop a river and then labeling dams as ineffective. We need orchestrated, smart, and well-invested prevention. Then we can compare. Then prevention will work.

    The example of $9.8 million spent for every year saved was not orchestrated prevention. It was an isolated attempt over a short time. But the intent was good.

    There are plenty of other aspects to the prevention topic. I’m not saying the transition will be easy. But the transition is necessary if we think we can “have our cake” and be healthy too (just a pun; I’m not extreme enough to ban cake).

    Yes, it is a psychological issue. How can we educate and motivate people to change their lifestyle? That WILL cost money. But if you compare it to the billions we in the US spend on medical research, we could do A LOT better in the education arena.

    It’s also political. How can we balance the food supply (if you’d like me to explain what I mean by that I’d be glad to comment later) and make industry more accountable for the quality of their food? How can we curb industry from so effectively pretending unhealthy food is actually healthy? Labeling practices are woefully inadequate, especially here in the US.

    You see, the food companies are the ones providing 90% of the “nutrition education” for consumers. Consumers plain and simple don’t really know what’s healthy. And if they do find out what’s healthy, they find enormous obstacles in their environment to applying it (i.e. how easy is it to find a salad or apple nearby when you’re on the road or at work? It’s not easy for most.)

    We need a major paradigm shift TOWARD real prevention. But the medical system isn’t equipped to do it alone. That’s why we need those politicians to think globally on the topic and apply orchestrated policies.

  • corafan

    Prevention is “everything from offering mammograms to all women and prescribing drugs to people with high cholesterol to requiring passenger-side air bags in cars and shortening the response time of ambulances”? None of that is what I think of when I consider prevention. I think of avoiding twinkies and donuts — which is free.

    When I saw the headline, I expected the argument to be that people without severe health problems consume more health care services than people with severe health problems because they live so much longer. (Compared to someone who lives to be 100, how much health care can you consume if you die at 50 of a heart attack?) Smokers, for example, are cheaper to treat than non-smokers over the course of their lifetimes.

    But if we’re counting living longer as a good thing, I can’t imagine that actual preventative measures like eating a paleolithic diet — as opposed to completely brain-dead measures like giving everyone statins — would be less cost-effective than treatment.

  • Manon de Gaillande

    Nicholas Hundley: I don’t know how things are in the US, but in France (and, as far as I know, all western Europe), there are enormous amounts of pro-balanced-diet propaganda. It doesn’t work. It could be that it has only started recently (less than a generation is too short), or there isn’t enough of it, or we aren’t doing it the right way. But my guess is that it’s actually counterproductive: the only people who heed this advice are those who are already following it, sometimes to extremes (such as anorexia), most people simply ignore it, and overweight people do the opposite, because talking so much about food stimulates appetite, because it separates “healthy food” and “good food” or simply because they’re sick and tired of it (count me in the latter).

    I value health, fitness, and life. But I also value pleasure, and I get pleasure out of eating what I want (be it apples or donuts). I consciously choose to trade a few decades of healthy life for taking pleasure in what I eat. (Now, I have to resist temptation (and often fail to do so) to avoid eating more than the acceptable tradeoff. My point is still valid.)

    Changing our eating habits will certainly make us healthier and is cost-effective. But it’s not necessarily worth it, it’s probably a bad idea to force it on anyone, and we haven’t found out how to do it yet.

  • http://removingcomplexity.wordpress.com/ Matt Blass

    @Manon

    There’s a small niche market for healthy food choices, but it’s like less than 1% of the options. From my perspective, health education as a general topic is high on everyone’s minds, but with little specifics. Basically, everyone in America knows we’re a pretty fat country. Everyone knows we should eat better (either by eating less or eating different foods). Everyone knows that we should exercise more. Everyone knows all of this, and probably come across these thoughts once a day or more. However, that’s not education.

    Sure, we’re aware of what generally should be done, but that doesn’t get results. Actually, it tends to put people off to be told what they should do over and over again. However, they’ve yet to be equipped with the proper knowledge about what to actually do, and more importantly, they haven’t had the right habits from a young age creating a poor sense of pleasure for adulthood.

    Food habits are bred into us from a young age. It’s no wonder that even having a life threatening event happen in adulthood that the vast majority of people won’t change their lifestyle to prevent that same from happening again. Most people are off on the wrong foot from a very young age, so they’re pretty much screwed when they get older, and they see it just as you’ve put it, “I also value pleasure, and I get pleasure out of eating what I want.”

    The problem starts where your sense of pleasure is all out of whack, and from a young age. Salads and apples and unprocessed food taste bad to people with an American diet in comparison to fast food style preparations. Fast food is the benchmark, and while apples are sweet, they’re still below the ‘fast food’ benchmark making the tendency to make a better choice less common. Eat only well prepared salads (I’m not saying vegetarian, you can have chicken and other stuff on salads) for a month, and then try eating anything else, and you’ll learn how much your body’s become used to the high levels of sugar and fat in most foods American style food because you’ll notice the difference and possibly dislike what you used to. You might actually crave a good salad instead of a burger, which is the kind of pleasures we need to learn at a young age.

    It shouldn’t be a question between craving salads or donuts. You should naturally choose the ‘salad’ option over the ‘donut’ option, and when you choose the donut option, you can’t have very much because it quickly becomes too much for your pleasure limits. If you grow up living like that, then it won’t be such a problem later in life, but we usually don’t start thinking about this until we’ve got decades of habits built into our routines.

    I’m oversimplifying since our bodies like to store sugar and fat for a rainy day, so we tend to crave them differently than other foods, but that doesn’t change the problem of learning bad habits from childhood, and then trying to correct them way after the fact. Prevention isn’t about just about getting people to change, it’s about getting us to start on the right foot, and assuming long life is worth the add cost, this is how prevention should be viewed. Checking to see if your bad habits have caused problems is not prevention, it’s early detection as previously mentioned.

  • http://www.wholefamilynutrition.com Nicholas Hundley

    Manon de Gaillande and Matt Blass:

    I really liked both your comments. Manon, your point is well taken about people being tired of propaganda telling them to eat less. Actually, I get annoyed by it, too. Propaganda, not surprisingly, doesn’t work when people’s psychologies immediately produce various seemingly logical reasons NOT to change their lifestyles. Most people who see propaganda (aside from those already practicing preventive measures) are probably thinking one or more of the following thoughts:

    A) I will enjoy life less if I change my diet (I don’t like healthy food)
    B) I don’t know how to actually apply that
    C) I would like to be healthier, but I don’t have the time
    C) I’m young; I’ll worry about that later
    D) I don’t need to worry because I’m not fat

    Propaganda doesn’t even address those roadblocks in people’s psyches that have virtually doomed it to failure before it even starts.

    As a person who tries to live a very healthy life, I am perhaps biased. I’m sold on the benefits of living healthy and I think it’s well worth the effort, both for the benefits now as well as in the future. I don’t have those psychological biases I mentioned above; but I also know that I had to work extremely hard and learn a lot to get over them. I can’t expect others to work that hard at it when they’ve got other things going on in their lives. I don’t blame them for thinking those things.

    The thing is, I enjoy food just as much now that I eat healthy as I did when I ate whatever I wanted (I actually enjoy food more, but that’s beside the point). I enjoy life more. I’m just as happy. I understand how much more physical and mental energy I now have because of it, even though I’m only 28. I understand that even though I couldn’t get fat if I tried (lucky genes), low BMI doesn’t necessarily make someone healthy. I understand that what I eat now affects my health in the future. And so on.

    But should people have to work as hard as I did to realize that? I’ve dedicated a lot of time to learning those things.

    I think people could digest and understand the reasons for eating healthy (without working as hard as I did) if we can give them something well-presented– more than just a quick shot of propaganda. You know, if we could actually address those psychological concerns in a more detailed sort of way. In retrospect, I do understand that the knowledge is out there. If we can get the knowledge to people, and we don’t ignore their concerns, they’ll be on board. I am often surprised to see how much people really do want to know the details of prevention. Also how much they enjoy healthy food that’s prepared right. They just don’t have the technical knowledge or the time to learn it.

    I think people can overcome their food biases through better education (and improved food supply as mentioned before). The beauty of it is that once we overcome the inertia we’re in now, good health will become almost automatic as the attitude is passed from parent to child. The medical system will then become far less expensive to run.

    But you’re right; it’s not easy. I think it’s worth it, though.

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