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Preventive health care - money saver?

19 08 09 - 12:28

The Problem With Prevention
By Michelle Andrews - The New York Times

When politicians talk about prevention and health care, they are prone to sweeping statements about how preventive services not only keep people healthy but also save money. Just last Sunday, President Obama wrote in The Times:

Most importantly, we will require insurance companies to cover routine checkups and preventive care, like mammograms and colonoscopies. There’s no reason we shouldn’t be catching diseases like breast cancer and prostate cancer on the front end. That makes sense, it saves lives, and it can also save money.

In a podcast on his Web site, Senator Tom Harkin, the Senate Health, Education, Labor and Pensions Committee point person on prevention, had this to say (MP3): “The full panoply of wellness and prevention provisions in our bill will result in countless tens of billions of dollars in annual savings.”

If only it were that simple. Nearly 40 percent of all deaths in the United States every year are a result of smoking, poor diet, lack of exercise or alcohol abuse. Preventing those behaviors or reducing their incidence is likely to save money. And one thing that everyone seems to agree on is that putting money toward community-based activities is a good thing, from widening sidewalks so people can get out and walk to getting fresh fruits and vegetables into grocery stores and healthy lunches into school cafeterias.

“You can’t rely on a clinical setting to help people stop smoking, lose weight and make healthier food choices,” said Dr. Steven Woolf, a professor of family medicine at Virginia Commonwealth University who has written extensively about preventive medicine.

But the picture is murkier for other preventive interventions. Very few actually save money. A study published in The American Journal of Preventive Medicine in 2006 examined 25 common preventive services and found that just a handful resulted in savings (PDF). These included childhood immunizations, offering to help smokers kick the habit and discussing daily aspirin use with people at risk for heart disease.

There are many reasons prevention doesn’t always save money, including how often a preventive service is performed and whether it is aimed at the appropriate population. Blood testing to screen for high cholesterol, for example, is a valuable preventive service, but unless it’s restricted to people at risk for heart disease, the costs outstrip the benefits.

Preventive screening for breast cancer or abdominal aortic aneurysms (both of which are covered in the House bills) often identifies potential abnormalities that lead to follow-up testing and treatment. But many of these abnormalities are false positives that might never have caused trouble in the first place, noted Dr. H. Gilbert Welch, professor of medicine at Dartmouth Medical School and author of the book “Should I Be Tested for Cancer? Maybe Not and Here’s Why.”. Treating them can increase risks to patients and raises costs.

“I’m not saying never do this, but it’s not a slam dunk,” Dr. Welch said.

The key is to invest in measures that provide the most bang for the prevention buck — high clinical value at a reasonable cost. “The right question to ask is whether it’s a cost-effective use of health dollars,” said Rob Gould, president of the Partnership for Prevention, a nonprofit that promotes preventive health.

Judged this way, certain preventive services, but not all, may be considered worthwhile, in that while they may not save money, their cost is considered reasonable for the years of sickness and the deaths that they help people avoid. By those criteria, effective prevention includes colorectal cancer screening for adults ages 50 and older, adult flu shots and screening for high blood pressure in appropriate patients.

But even widespread adoption of effective prevention measures carries financial risks, too. As the Congressional Budget Office noted in a health care budget options paper last December, “Discouraging smoking reduces spending … for smoking-related diseases, but the lower mortality rates that result … could increase federal spending for Social Security and Medicare.”

Sometimes you just can’t win for losing.




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