Or…it’s complicated.
The New York Times today published a story titled, “No, Giving More People Health Insurance Doesn’t Save Money.” A piece of the argument is, as the author Margo Sanger-Katz puts it, “Almost all preventive health care costs more than it saves.”
What do you think? What’s the evidence? Leave aside, for the moment, the “big duh” fact that at least in the long term saving people’s lives in any way will cost more, because we are all going to die of something, and will use a lot of healthcare on the way. Leave aside as well the other “big duh” argument: It may cost money, but that money is worth it to save lives and relieve suffering. Leave that argument aside as well. The question here is: Does getting people more preventive care actually lower healthcare costs for whoever is paying them?
My thoughts? #1: No consultant worth his or her salt trying to help people who are actually running healthcare systems would take such a blanket, simple answer as a steering guide. Many people running healthcare systems across the country are seriously trying to drop real costs, and how you do that through preventive care is a live, complex and difficult conversation all across healthcare.
#2 thought: It depends. It needs analysis. It depends on which preventive tests, screens, and prescriptions you’re talking about, and how it is decided whom to help with them. Sanger-Katz’ article only shows that we cannot assume that every preventive screening or test saves money and/or is worth the money spent. Mammograms, for instance, show no benefit (no extra tumors caught, no lives saved) over breast exams alone (Canadian Breast Cancer Study, n=89,000 over 25 years).
This is true of many preventive items, including the annual checkup — it’s hard to show a true benefit from them. So yes, if you assume that every preventive test, screen, or prescription is worth it, and then you give more people access to those, you’ll end up spending more money. Equally important, the assumption is that you screen everyone, and you do it the most expensive way, like giving older people regular colonoscopies as a test for colon cancer. There are far less expensive ways to pre-screen people for that. This one assumption alone costs an estimated $10 billion per year in the U.S..
The problem is that these assumptions mean giving a lot of medical care, much of it not even effective, to people who are well. There are reasonable ways to narrow the focus of expensive, personal, procedural preventive care and maintenance to the 5% or so who really need it. Find that 5%, give them extra care, and you will save money.
Joe Flower is a healthcare futurist and author. He is a contributing editor with THCB.
Categories: Uncategorized
I thought that was a really good and informative comment.
I don’t see much there that fits the description of preventive care and screening tests as commonly discussed except, perhaps, for dental checkups. Ironically, most people don’t have dental insurance and most of those who do, if not all, are subject to balance billing.
If you wanted to prevent the most costs per citizen per lifetime, it might be good to push smoking so that lifetimes are short.
If you wanted to prevent the most costs per lifetime but you wanted to also maximize lifespan, it might be best to prevent dental caries.
If you wanted to prevent the most costs per one year of life per 15-30 yr citizen, it might be best to work on seatbelts and alcohol and drugs.
If you wanted to maximize longevity in the world on average it might be best to work on malaria.
If you wanted to maximize longevity in the US it might be best to work on neonatal and perinatal diseases and nutrition.
If you wanted to maximize longevity for adults aged 30-85 in the US it might be best to focus on sepsis protocols and infectious disease prevention.
If you wanted to make sure health insurers made the most profit, you might try the maximum cost sharing in co’s and deductibles.
…just being whimsical with boundary conditions.
Company-sponsored wellness/prevention programs do not save money.
Tom
In his new book “The United States of Excess,” Robert Paarlberge makes note of the distinction between “mitigation” and “adaptation.”
http://regionalextensioncenter.blogspot.com/2015/08/the-health-implications-of-us-gluttony.html
“Mitigation” goes mainly to “prevention” activities per his proffer, whereas “adaptation” infers post-dx treatment.
The boundaries are not so cleanly demarcated, though, are they? I am about to undergo 9 weeks of daily Calypso IMRT for prostate cancer. It’s a tx (“adaptive”?), but is “mitigative” (a “reversal”) in the sense that it will likely nuke and prevent my lesion from metastasizing, whereupon I’d need even more expensive tx (and it’s by no means clear what one can do “lifestyle-wise” to reliably avoid getting an adenocarcinoma). But, then, that will keep me alive long enough to perhaps encounter another dire clinical malady of even greater expense someday.
My old mentor Brent James, MD, M.Stat, of IHC, once noted to us that “don’t think we’re gonna QI our way out of the larger societal resource problem. Every optimal, effective treatment you provide today just insures that someone will face an older, sicker, more expensive patient down the line.”
Right on, Allan. A free market can decide–through millions of votes ( purchases)–not only what to prevent but what those costs should be. Otherwise, government and policy people are talking about fog…because each item needs a separate discussion on the agenda. One discussion: Eg. everyone as we get older acquires seborrheic keratoses. They are benign unimportant skin lesions. To prevent these would cost billions by having a dermatologist whack every new one with liquid nitrogen. It is cheaper to whack the ones that grow large and forget the small ones. Second discussion: It is easy to diagnose sickle cell disease and trait. If people who have this know they have it, they can choose to live outside of airplanes and avoid thousands of dollars in misery with thrombi and micro emboli all over the place.
Without a free market, we have to have our superiors in government discussing thousand of these individual preventive strategies, assesing risks and costs. We get it done free by the votes in a free market…as long as people are knowledgeable. Everyone can understand these simple risks if we approach them with respect and teach. The market works if we respect its participants.
Early diagnosis to date hasn’t proven that it saves money.
Prevention such as the flu vaccine might save money if targeted correctly. I am not aware of any other preventative methods that save money.
Proper infrastructure can save money and lives. Think of appropriate sewage control.
What does all markets are constrained mean when discussing healthcare? Does it mean there is no free lunch? Of course, but that doesn’t mean the free market isn’t the best way to go nor does it mean that a free market can’t take certain things into account. That is why I pointed out that the free market doesn’t prevent insurance, subsidies or other things that do not significantly alter the free marketplace.
A free market involves a willing buyer and a willing seller or at least that is how Adam Smith described a free marketplace.
“otherwise we will go for the fanciest thing that our insurance or personal finances will pay for, taking the cost as a marker for quality.”
That is because you are talking about markets and I am talking about free markets. The Soviet Union, present day Russia and Cuba all have marketplaces. The problem is they are not free marketplaces.
The consumer as a buyer and the insurer as a seller create what is known as traditional insurance. Too much coverage prices go up. Too little coverage and the consumer isn’t getting what he needs. The balance will be found in the free market place. But it is not government that decides profit margins and things of that nature rather the marketplace for if those profit margins are very high others will enter the marketplace with lower prices.
“In a fee-for-service system”
This is your problem. You are trying to decide what is best delivery system for me and others instead of letting the free marketplace make that decision. You are using the old Soviet style marketplace where government decides how things will be divided up and who should pay what to whom.
Get rid of that idea. Let capitation, FFS etc. all compete in the free marketplace. Let people be free and make their own choices. They know better what they need than you know.
> The answer is easy. Free market competition.
Not so easy. All markets are constrained in one way or another. That’s what makes them markets, if only to provide a place to sell your goods, a trusted medium of exchange, some kind of information exchange to convey the value. (“The market for sheep will be on the third Thursday of each month, in the sheep meadow south of town. All coinage may be brought to the bailiff for inspection to avoid cheating. Sellers must have all sheep present for inspection by buyers. All sellers will pay two pence to the bailiff to pay for the guards to keep out the sheep thieves.”)
In the market for preventive tests, though the need is great and clearly perceivable (“Don’t want to die of cancer!”), we as consumers rely on medical authorities to tell us what is necessary and sufficient — otherwise we will go for the fanciest thing that our insurance or personal finances will pay for, taking the cost as a marker for quality.
So what drives the competition is the question: What are we competing for? How do healthcare providers “win” in this market? In a fee-for-service system, they win by convincing the consumers to get the greatest number of the most expensive tests that the provider can get reimbursed for. Change the payment system to something that in any way pays for the outcome instead of the procedure — the maximum prevention for the least money — and the competition is upended. Then you get healthcare organizations (as Kaiser does) educating the consumer that, yes, you really need to test for colon cancer, but a mail-in stool test really is adequate for first-level screening — no need for a colonoscopy with its hefty co-pay unless we find something of concern in the stool test.
> If prevention works, it saves money.
Not necessarily, either in the aggregate, over long periods of time, or in individual cases.
Certain types of prevention will save money.
Others will cost more money, but be worth it in terms of lives saved and suffering avoided.
Some types of prevention will cost money, but could be supplanted by screening techniques that cost much less or even nothing. (examples, as I said, are the use of mammograms — especially computerized mammograms — and colonoscopies as initial mass screening for cancers.) These types are ones we would do well to focus cost-reduction efforts on. That does not happen under a fee-for-service system because we get paid to do the more expensive methods.
I don’t think the question should be whether or not a preventative care or early diagnostic technique costs or saves money. We mostly know the answer for today’s science. Targeting preventive care as Joe says is an important consideration, but the real question should be how do we get the price down. For the answer to that question all we have to do is look at the world around us and ask what has brought prices down. The answer is easy. Free market competition.
(Please take note that free market competition permits insurance and government subsidies.)
There was a good article in the NY Times on this subject yesterday. The bottom line is that preventive care probably does cost money for a couple of reasons. First, the number needed to treat to prevent one heart attack or colon cancer case is sufficiently high to ensure that the overall cost of prevention probably exceeds treating the one case that could have been prevented with screening but wasn’t in those two instances. Second, to the extent that prevention helps people to lead longer healthier lives, that’s a good thing for them personally but it’s more expensive for the healthcare system because they are more likely to live long enough to get an expensive disease or condition like Parkinson’s, Alzheimer’s, MS, cancer, etc.
The question I have that maybe one of the physicians can respond to is how many diseases are out there which are very expensive to treat if not diagnosed until symptoms appear but could have been caught much earlier when they could have been treated or cured relatively cheaply if discovered by a preventive screening test? Colon cancer comes to mind as one but colonoscopies are expensive, especially if done in a hospital outpatient setting or even a stand-alone facility if it’s owned by a hospital system. By contrast, blood tests that measure cholesterol are very cheap but lots of people taking a statin drug indefinitely can add up, even for some of the generics.
I always have trouble here too, Joe. I guess the long term goal of health care has to be “Prevent everything…and go home. Make death optional for a couple of hundred years.”
But short of whimsy and in our real world, I guess we have to look at C/Bs of every preventive intervention. And then we have to find a number like $50,000/qaly that we all agree on….like NICE did.
I wish we could prevent our nuclei acumbens from seizing on opioids, nicotine, alcohol and amphetamines. I wish we could prevent so many suicides and keep happy levels of dopamine and serotonin about in our synapses. I wish we could detect and prevent the phenotype of borderline personality, psychopathic personality disorder and schizophrenia.
And I wish we could finally decide that putting bad content into our brains might cause some ugly nasty behavior…by the inverse realization that putting good content, love, happiness into our noggins makes us nicer to each other and feel better.
But “prevention” unfortunately doesn’t mean all this stuff.
“Not sure money is the variable we should be looking at.”
Really? That is one of preventions great claims, that it reduces costs in the long run. The economics matter plenty. There are people who can get a free colonoscopy for screening, but cant get a diagnostic colonoscopy because of high deductibles. We have got to examine the economics. Health Care spending is way out of control, already getting to 20% GDP or so. Where should it stop?
This is a good post. Prevention is the new growth sector being taken advantage of by the medical field. Fortunately it is receiving some well deserved scrutiny.
And then prevention is another of those fuzzy new age terms ..
How do we define it? A this point the term is so broad as to be almost meaningless.
Ask a wellness consultant and a guy from Vermont and you’ll get two very different answers ..
Agree with Joe. Hard to generalize to massive populations.
If prevention works, it saves money. If it doesn’t, it doesn’t.
Does that make prevention a bad idea?
Not sure money is the variable we should be looking at.
The other thing to consider is that even if preventive care were extremely effective, it might still wind up costing more. In that scenario, though, while healthcare costs may go up, their share of the overall output of the economy should go down because it should result in a much more productive work force. Which in the end should be the goal of the healthcare system: to help people live happier, healthier, more productive lives.
Good post, Joe.