The myth that preventive medicine saves money

in Uncategorized | 15 responses

Great stuff by Dartmouth’s Gilbert Welch. Both Presidential nominees actively flaunt the cost-efficiency of preventive medicine.

In fact, the opposite is true. Prevention costs money:

It boils down to encouraging the well to have themselves tested to make sure they are not sick. And that approach doesn’t save money; it costs money.

Dr. Welch likens screening the a car’s check engine light:

Early screening is like the “check engine” light in your car. It can alert you to problems that need to be fixed, but too often it picks up trivial abnormalities that don’t affect performance, like one sensor’s recognizing that another sensor isn’t sensing.
And if we look hard enough, we’ll probably find out that one of your check-engine lights is on . . .
. . . It’s hard to ignore a “check-engine” light. Some mechanics reset them and see if they come on again, but often they lead you to a repair. And you may have had the unfortunate experience that a repair makes matters worse.

I really have nothing to add to this piece. More medicine isn’t necessarily better. But it’s certainly more expensive.

topics: preventive medicine, cost control

Comments

Deron Schriver
I’m not ready to write off the value of preventive medicine just yet. Dr. Welch’s point about candidates touting things that they know little about is well taken. However, I would be curious to see how he defined preventive medicine when he did his analysis (not to mention where the numbers are to back up his claim). I have a sense that his version of preventive care involves a lot of testing, and to be fair I think that’s the same version that many share. However, we need to get back to the old school definition that he highlighted, in which providers have engaging discussion with patients about their health. That face to face time will be a cornerstone of effective reform.
Anonymous
If you look at other countries that have preventive medicine, they’re healthcare costs are not only better but less expensive. Many of the diseases that wind up becoming very expensive are the so-called silent disease such as hypertension, heart disease and diabetes. Simple inexpensive tests can detect these conditions early when intervention is possible, before the disease becomes chronic. I think even you must believe that cigarette smoking is the scourge of the last century. With preventive medicine, patients can be counseled and prescribed medications to help them stop. Preventive/interventive medicine is the only way to go to get the right care.
Dr. K
some simple inexpensive tests can detect a disease before it becomes chronic and expensive. For example, hypertension, heart disease, and diabetes. Data have shown that the USA has the most expensive healthcare system, but ranks near the bottom as far as quality of healthcare. One thing stands out between our system and others. We base our healthcare system on procedures while the better ones base theirs on preventive medicine. Adding blood pressure screening, cholesterol testing and glycosylated hemoglobin testing will add little to our healthcare costs, but will save down the road, tens of billions on chronic diseases.
Anonymous
Anon at 10:39, but Europe does a lot less testing than the US – e.g. they start mammorgrams at 50 and do it once every two years; they don’t recommend PSA, etc. So your point about other countries is backwards – they have it cheaper because they do less testing than the US. They also ration care more, especially for expensive conditions like cancer.
The topic is not about which way to get the right care, but the cost. Your points about heart disease and diabetes don’t consider NNT. Prescribed drugs like statins are actually quite expensive if you consider how many people need to be treated for how many years to prevent one heart attack. Same about early detection – when you add up numbers needed to screen, false positives, overdiagnosis – your costs become higher than savings.
I think the Welch’s point about people not knowing what they are talking about applies to you. Please go and learn some epidemiology, would you?
Anonymous
Why do you suppose the candidates are talking about preventative medicine? Because it resonates with voters. Patients are increasingly drawn to alternative medicine practitioners because they sell the idea that mainstream medicine “only treats symptoms” and doesn’t treat “the whole person”. I don’t think patients necessarily view preventative medicine as “more tests more often”. I think they want their doctors to spend more time talking with them about how to stay healthy, and I think most patients would agree that physicians should be compensated for time spent discussing healthy lifestyle choices.
Anonymous
This is old news. Serious policy makers have never believed prevention is cost-saving. Worthwhile prevention can be cost-effective, and this isn't a bad thing.
Prevention makes you live longer (on average). Prevention costs more than non-prevention because (1) you rack up greater incidental health costs as you live, and (2) when you finally get that incurable terminal condition–and you will–your care will still be expensive (barring sudden death of course).
What really matters is whether prevention extends your productive working life (good for the economy and potentially cost-saving) or your less-productive retirement years (bad for the economy and definitely not cost-saving). It's like smoking cessation…the ultimate preventive health service. If patients quit smoking, it's great for employers because there will be fewer sick days among employees <65 years old. But it's bad for the U.S. economy since you now have retirees with longer lifespans _after_ age 65. From a strict economic growth point of view, you want workers who drop dead the day they retire. They pay into national savings and investment and then never make a withdrawal. Smoking comes close to accomplishing this.
Not happy with smoking? Then you probably agree that cost-savings isn't the point. A better goal is probably buying life years when the price is good (i.e,. consuming cost-effective care).
Anonymous
Anon at 3:07: whether or not cost-savings are important depends on the subject being discussed. If it is – which procedures to recommend and to cover by insurance, then you are right. However, the moment cost-savings claims come into play, you get policy-makers and employers trying to mandate certain preventive procedures (like annual checkups) mandatory in the mistaken belief that this will save them money. Edwards, for example, wanted to mandate annual checkups. There are some employers who tried to do the same or to even penalize employees for having LDL over 130 regardless of their weight. German government wanted to penalize people who didn’t want to be screened for cancer believing it would save them money if everyone is screened. Never mind the evidence that it would not.
Hence, it is important to talk about cost savings as these misguided claims can lead to policies that interfere into the decisions that should be between a doctor and a patient.
Dr. K
Epidemiology?? I’m talking about science, not science fiction. Perform randomized clinical trials and measure LDL, blood pressure, diabetes, etc. Not the phoney baloney of observational studies relying on questionaires. I don’t need to learn about epidemiology when it is well know that billions could be saved as well as thousands of lives if intervention was imposed.
Anonymous
I read an article in Atlantic Monthly in 1993 on health care that made the point that early prevention and treatment does not reduce costs. It increases cost. One reason is that you extend the lives of people. It costs more to care for the old – who develop serious health problems that costs lots of money to treat. Years ago, we paid much less for health care because pneumonia killed everyone in their 40s.
Anonymous
With our fleet of four cars -parent of teens- we call the engine warning light the pay toyota light .
No reason to think these plans are any different.
Anonymous
Perform randomized clinical trials and measure LDL, blood pressure, diabetes, etc. (…) I don’t need to learn about epidemiology when it is well know that billions could be saved as well as thousands of lives if intervention was imposed.
Last time I checked “it is well known” wasn’t exactly a scientific argument. How many things exactly that were “well known” at one time or another before they were proven to be untrue?
OK, let’s take statins as an example, since you mentioned LDL. Yes, treating one high-risk person with statins is cheaper than treating the heart attack in that person (unless the heart attack is immediately fatal). What about treating 50 people for 10 years to prevent a heart attack in one person? 100 people? Based on randomized trials, how many people do you need to treat with statins and for how many years (for PRIMARY PREVENTION) to prevent one heart attack? What about primary prevention in women? What exactly randomized studies say about that?
Or maybe we should do math on some of the screening tests? Ever heard about NNS? False positives? Overdiagnosis?
Can you multiply? E.g. the cost of preventive tests/treatment multiplied by the number of people by years vs the cost of one heart attack or one advanced vs early cancer? Add to it, treating side effects, if any. Or, in case of tests, evaluating false positives and, because of overdiagnosis, treating more people.
Talking about randomized studies, can you show me a randomized study that says that annual checkups in otherwise healthy symptomless individuals save money?
Now you want to impose interventions? Just because you BELIEVE that it’ll save money even if you have no evidence that it will. NO, randomized studies of any of these interventions didn’t include cost saving computations. As to saving lives, while this is a valid argument for recommending an intervention, since when this is a valid argument for imposing it on adults? What if tomorrow new evidence comes out that the particular intervention did more harm than good? Or do you think this never happen? There are no biases in randomized studies, all potentially lethal side effects are known? They never later shown to be wrong?
You talk about science and randomized studies, yet in the same sentence you say that you don’t need to know epidemiology. Tell me, how can you read and understand the studies results if you feel you don’t need to know epidemiology? Especially since you clearly don’t understand either NNT or NNS? Do you understand the difference between relative risk and absolute risk? How about cost-effectiveness and cost-savings?
Pray, somebody tell me that this guy is an exception, and that doctors today actually do learn some epidemiology….
Deron Schriver
With measures such as the obesity rate increasing so rapidly, I think the game is changing. Preventive care is probably needed more now that when many of the studies were done. Preventive care does not have to equal a lot of tests, and it doesn’t even have to involve physicians. Let NPs provide education and guidance, because that’s what they do best. By the way, nothing will be successful if patients don’t take responsibility for their own health.
The normal retirement age must also be indexed to life expectancy and quality of life. Otherwise the financing won’t be there to support the system.
Anonymous
The normal retirement age must also be indexed to life expectancy and quality of life.
Life expectancy is an interesting measure since it is an average. It is affected by fewer infants dying, it is affected by people who are diagnosed with heart desease or cancer at the age of 50 dying at 60 instead of 55.
Additionally, increased life expectancy doesn’t mean that one experiences mental decline or decline in physical abilities later. Their problem-solving ability, ability to learn, memory is still declining which makes competing with younger people for jobs difficult. Same about physical strength.
But most people still die between 60 and 80. Those who survive into their 80s and 90s are mostly those with “good genes” – those whose parents also lived into 80s and 90s. Most 70-year-olds are still unable to work. Even if they are able to work, most companies don’t want to hire them. Even if they are still smart or strong (depending on type of job they do), most employers still don’t want them. Try getting a job at the age of 60, then talk about how retirement age shall be indexed to life expectancy.
Anonymous
Why does the establishment treat the patient as a helpless, irresponsible, and lazy idiot. WE ARE NOT. We are confused about our personal health risk and what actions we can take that are effective. How are we ever going to know what preventive care actually works if it is not part of our healthcare data. As for cost, I like the old teach a man to fish theory. If you educate me and treat my health as a whole not only will I improve my health I will improve the health of my family. How much does that save?
Anonymous
If you idea of “preventive medicine” is early screening/diagnosis, then maybe you have a point. However, your reasoning is false. It assumes ALL people will eventually get disease X, and that if we catch disease X early we will incur some sort of cost-savings down the road because their symptoms won’t balloon to the point where treatments are horrendously expensive. Prevention isn’t early diagnosis. Prevention implies that the diagnosis doesn’t ever have to come.
What if we could stop disease from ever occurring in the first place? There is no reason to do screenings for diabetes if not as many people get it or display risk factors for it, just as there is very little reason to provide a prophylactic dose of statins to someone with low blood cholesterol. By making significant society-wide pushes to get people active, eating right, and PREVENTING disease from even manifesting itself, we can incur a significant cost-savings down the road.
Now HOW to do this is a different issue – it’s a Herculean task. But the basic premise is still sound. I realize that prevention takes money out of physicians’ pockets, but perhaps it is the physicians who need to take a look at themselves. Does a healthy population undermine the spirit/status of their profession?