Does preventive medicine save money or cost more in the long run?

It depends if you see the glass half empty or full.

I’ve written on several occasions that there is little evidence that preventive medicine saves money, despite what some politicians say or believe. A recent study from Health Affairs provides more clarity, as it related to the long-term implications of diabetes.

There are two decidedly different takes on the article. First, according to The New York Times’ Prescriptions, it only confirms the belief that preventive medicine actually costs more money: “The report projected that people with Type 2 diabetes who participated in a disease management program to prevent serious complications would cost the federal government slightly more money over 25 years than they would have without any intervention.”

But wait, says the ACP’s Bob Doherty, that’s actually better news than what we’d been hearing.

He argues that most of the cost savings estimates from the Congressional Budget Office only spans out 10 years. So, this new data means that, “over 25 years, aggressive interventions to control diabetes almost pay for themselves.”

The bottom line, however, remains the same. Whether you’re looking out 10 years or 25, there isn’t much evidence that preventive care saves money. I agree that we still should do what we can to prevent disease according to evidence-based practices, but advocating prevention to cut costs is misguided.

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  • Doc99

    Defining quality health care in terms of cost isn’t NICE.

  • http://askanmd.blogspot.com/ Doctor D

    I think the issue is what you get for the you spend. Of course, care costs money. No medical care at all is very cheap but the human costs can be severe.

    If we are interested in buying “health” preventive care is one of the best purchases we can make.

  • http://www.milanmooremd.com Milan Moore, MD, MPH

    Kevin,

    There are two misconceptions that confuse commentary about preventive medicine:

    Misconception #1: Preventive medicine is about treating disease after it has already occurred. Real preventive medicine is about lowering the risk factors for disease prior to the disease occurring. In the case of the article you site, the disease – diabetes – is playing out its natural course… the cat is already out of the bag.

    Misconception #2: Preventive medicine is about early detection. Again, the disease state is already present…. early testing simply starts treatment earlier.

    Real preventive medicine addresses the underlying causes of disease: the obesity (or diabesity) epidemic, the overfed and undernourished state of our nation (eg. eating food from a box; Vit D deficiency with the return of rickets in this country), the lack of exercise, chronic inflammation and oxidative stress, and the poor behavioral choices our patients make. In this realm, you will find that the cliche about an ounce of prevention vs a pound of cure does apply. The tragedy occurs when we ignore the evidence that my childrens’ generation is the first in the history of the US which faces a lower life expectancy than the previous generation. We ignore prevention at our own peril.

    Milan S. Moore, MD, MPH

  • http://adenacb.blogspot.com Adena

    I agree with Dr. Moore. Prevention isn’t just about finding disease that’s already there; it’s about preventing it in the first place. That WILL save money! It was the very first thing I learned about in grad school: primary prevention, secondary prevention, tertiary prevention. Testing is secondary prevention. Real primary prevention is preventing cancer, diabetes, heart disease, etc. before they even begin!

  • http://laurieboris.pnn.com Laurie Boris

    Dr. Moore is right on the money. If healthcare reform has to be about the bottom line, isn’t it far cheaper to offer programs that encourage and support people to improve their health habits and PREVENT life-threatening (and far more expensive) conditions like diabetes, stroke and heart disease than to only consider programs that try to do damage control? It seems like a pretty simple prescription to me.

  • ninguem

    It probably costs more in the long run. Cheapest is to have a sudden cardiac death at age 50.

    That doesn’t mean you don’t do preventive care, just don’t expect it will save the entire system money in the long run.

  • Brian

    I’m not entirely sure how I feel about this. I wonder whether the study considers additional costs not readily apparent by just considering the cost of health care alone. For instance, better preventive care might well lead to better health overall, greater level of function and quality of life, and reduced time away from work. If a person is better able to work, is he or she not saving money that would otherwise go to pay for disability, &c.?
    Furthermore, I have to imagine that preventive care resulting in greater longevity, greater quality of life, and greater productivity could conceivably lead to a reduction in the incidence of depression among those affected, thereby further reducing medical costs and social burden.

    These are just off the top of my head, and I must admit a certain degree of ignorance with regard to the intricacies of medical economics.

  • jsmith

    Sorry guys, but preventive care and healthy lifestyles have not been shown to save societies money, and there are good reason to think that they won’t. Hot off the presses from the Journal of Public Health: http://jpubhealth.oxfordjournals.org/cgi/content/abstract/fdp079v1that
    Prevention and healthy lifestyles are (sometimes)great to prevent disease and to live healthily, but if we think they’re gonna save our financial bacon, we might be in for some disappointment.

  • jsmith

    Well, this is embarrassing. My link did not work. Google Rappange Journal Public Heath to get the article.

  • Doc Stone

    This is exactly why we should keep control of our own health dollars as much as possible–so that we can spend them according to our values and not an accountants values.

  • newsdoc

    The politicians and the public do not differentiate between primary and secondary prevention. Their primary concern is the cost of the healthcare system. In that sense prevention does increase the dollar costs since people would and do live longer have more illnesses and get more treatment. And more people will use up the social security and Medicare dollars. Frankly I and many others may feel that the longer lives and improved health quality would be worth the extra cost but most just look at the bottom line and possible new taxes. Doctors are not necessarily the best people to do primary prevention. Diet, exercise, drug use and smoking are best addressed in the childhood years. If people are having problems with obesity, smoking, drug and alcohol abuse, a fifteen minute appointment will not help much. A dietician, a counsellor, a smoking cessation class or group can give more personalized advice at a much reduced price over the hourly cost of a physician. Obese women know they are overweight and smokers know they need to quit but they often lack the personal tools and strong motivation to do it.

  • gregg

    it makes sense that preventative health care in a long-lived population would cost more than no preventative health care in an unhealthy, short-lived population.

    even if that’s the case, preventative health care is still worth society paying for it. during the prolonged, healthier, and more productive lifespans of its citizens, society will generate more economic output as a result of higher levels of investment in health.

  • http://www.fitnessrocks.org drmonte

    Dr. Moore’s comments are excellent, and right on the mark.

    The world Health Organization, based on several peer-reviewed studies, has stated that 90% of all cases of type 2 diabetes can be prevented by a healthy lifestyle. Likewise, 80% of all cases of coronary heart disease and about a third of all cancers can be prevented by the same healthy lifestyle habits.

    The healthy lifestyle habits are: 1. not smoking 2. eating five or more fruits and vegetables per day 3. exercising every day 4. maintaining a BMI less than 25.

    How expensive is a healthy lifestyle as described?

    Another important concept is “compression of morbidity.” Researchers at Stanford Medical School have been writing since 1980 about their studies showing that people who adhere to a healthy lifestyle as outlined above not only live longer on average, but they have fewer medical disabilities at every age, and develop disabilities around 7 years later in life compared to people who don’t have healthy lifestyles.

    We doctors have got to get past the idea that getting people to eat right and exercise is something less than real medicine. I’ve interviewed researchers from around the country working on the issue of lifestyle and chronic disease. They all make the same comment: “Nothing in modern medicine is as powerful as the four basic habits of a healthy lifestyle for preventing chronic diseases.”

    So, with such a powerful role to play one would think that lots of people would take the simple steps toward living a healthy lifestyle. However, the numbers on this are appalling: a 2005 article in the Archives of Internal Medicine revealed that only 3% of Americans have a lifestyle that incorporates all four healthy habits. Additional studies by separate research groups have confirmed this dismal number.

    Measuring blood glucose and cholesterol every year or so, performing colonoscopies and mamograms are important screening measures – and cost money. But, these medical tests do nothing to prevent the diseases they may detect. I am constantly confronted with patients and physicians who believe that since their last cholesterol test was “normal” they have nothing to fear and no need to watch their diet or exercise – as if coronary heart disease were something that develops acutely instead of chronically over several years or decades.

    Before we discount the role of prevention as too expensive to pursue, let’s make sure we define what prevention really means. It’s something people do for themselves – not something the medical system does for them.

    Monte Ladner, M.D.

  • http://www.fitnessrocks.org drmonte

    I have looked at the article abstract that jsmith references. I don’t have access to the full article. Here is an email I sent to the lead author of the article in Journal of Public Health:

    Dr. Rappange,

    Are you familiar with the concept of “compression of morbidity?” I don’t have online access to your full article, so I could only read the abstract.

    The point you bring up about aging populations costing more is true when we look at people who are kept alive by medical interventions. But, researchers from Stanford Medical school have repeatedly demonstrated that healthy lifestyles not only prolong life, they also reduce medical disabilities at all ages and delay the onset of medical disabilities by around seven years. Compression of morbidity refutes the argument that healthy lifestyles will result in more old people with lots of medical disabilities to care for.

    The metaphor for the phenomenon of compression of morbidity is a light bulb burning brightly until the very end, and then going out quickly.

    Monte Ladner, M.D.

  • Outrider

    >>Measuring blood glucose and cholesterol every year or so, performing colonoscopies and mamograms are important screening measures – and cost money.>>

    These are only important screening measures when recommended appropriately. When overused, they are a waste of money. But try telling a 40-year-old female with no risk factors that cholesterol screening is nearly useless… never mind explaining that mammograms in her age group with no family history of breast cancer are of questionable screening utility.

    People believe the marketing.

  • jsmith

    Dr. Monte, I’d be interested in the long-term studies that prove that compression of morbidity plus prevention and healthy lifestyles reduce societal health care costs. Would you please share these references?

  • http://www.fitnessrocks.org drmonte

    jsmith,

    I don’t know that there are any studies that show what the health care savings or costs are over the lifespan of people who live healthier lifestyles. A study like that seems overwhelming to me – imagine all the variables.

    My point is that when we start confusing expensive medical screening tests with “prevention” we end up concluding that prevention is too expensive and somehow this quickly gets translated into the umbrella conclusion “there is no cost savings in coaching patients to live healthier lifestyles – why bother.”

    Dr. Mathew Reeves of Michigan state university told me in an interview that there is no more powerful tool for preventing chronic diseases than getting people to adhere to the four simple lifestyle habits of eating a diet based on fruits and vegetables, exercising daily, not smoking, and maintaining a BMI < 25. Dr. Reeves published his study in the Archives of Internal Medicine in 2005 showing that only 3% of our population has such a lifestyle. You can read his article abstract at this link: http://archinte.ama-assn.org/cgi/content/abstract/165/8/854?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=healthy+lifestyle+characteristics&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

    You can also listen to my recorded interview with Dr. Reeves in Fitness Rocks podcast 103 at this link: http://www.fitnessrocks.org/?s=mathew+reeves

    There are two studies on compression of morbidity that are worth looking at. The first is entitled “Aging, Health Risks, and Cumulative Disability” it is in the NEJM and the article abstract is at this link: http://content.nejm.org/cgi/content/abstract/338/15/1035

    The second article on compression of morbidity is in the Archives of Internal Medicine called “Reduced Disability and Mortality Among Aging Runners.” The article abstract is at this link: http://archinte.ama-assn.org/cgi/content/abstract/168/15/1638

    I did an interview with the lead author of the Reduced Disability in Runners article in Fitness Rocks Podcast 108 and you can listen to that interview at this link: http://www.fitnessrocks.org/?s=reduced+disability+in+aging+runners

    I don’t see how we will ever get clear data that healthy lifestyles save money – you would need to follow an enormous group of people for decades and somehow verify that they were really living a healthy lifestyle the whole time.

    But, we have irrefutable data that healthy lifestyles prevent chronic diseases more effectively than anything else we have. Chronic Diseases have been estimated to account for 75% of healthcare spending. Given the low cost of walking around your neighborhood, eating apples instead of donuts, not buying cigarettes at $7.00 or more per pack, and not being obese – I think it’s a good investment.

    By the way, I should mention that Dr. Steven Blair, who I interviewed in Fitness Rocks Podcast 097, states that his decades of research on exercise have shown that remarkably little exercise is needed to get significant benefits with regard to lowering morbidity and mortality from chronic diseases. The link to that interview is http://www.fitnessrocks.org/2008/05/11/fitness-and-risk-of-cancer-an-interview-with-dr-steven-blair/

    I have spent the past three years reviewing the medical research on lifestyle and health. I have interviewed dozens of medical researchers about their work. All of this is available to the public for free at http://www.fitnessrocks.org. Fitness Rocks is my retirement hobby. I have no financial incentive for doing it. The website has links to article abstracts of hundreds of excellent articles on the subject.

    Monte Ladner, M.D.

  • jsmith

    Dr. Ladner, Thanks for the info. I’ll look at the references. I think healthy lifestyles are great and advise them for my pts. I think I am justifiably skeptical, however, when politicians and others state such things will save society money in the long term. Time will have to tell on that issue.