Does prevention improve health care outcomes and lower costs?

by Joseph W. Stubbs, MD, FACP

The eighth paragraph of the modern Hippocratic Oath reads: “I will prevent disease whenever I can, for prevention is preferable to cure.”

Support and encouragement of prevention are deeply rooted among physicians. Intuitively, to prevent a deadly or disabling disease from occurring or stop it at an early stage seems like a bread-and-butter concept with obvious health benefits.

But it should also accrue cost savings by avoiding the treatment of the disease and its complications. Indeed, prevention has been the mantra of many pundits and politicians during the past year’s debate on health care reform. Many have held out prevention as the touchstone of health care reform that would bring improved health care outcomes at lower costs.

Health care reform prominently promotes prevention by requiring preventive services to be included in every health plan offered through the health insurance exchange, and by eliminating co-pays for obtaining preventive services. What could be wrong with that?

Enter the U.S. Preventive Services Task Force (USPSTF) recommendations regarding mammogram screening for breast cancer, published on Nov. 17, 2009. The USPSTF’s recommendation against routine screening mammograms in women ages 40 to 49 set off a public and political firestorm. In the public’s eye, the recommendation was a callous government indictment against the need for prevention of breast cancer itself, not, as it truly was, an evidence-based conclusion regarding a particular program for preventing breast cancer. While the recommendations stated screening in this age group should be based on conversations between a woman and her doctor, some politicians politicized them as a tip-off of the “true” aim of health care reform, to ration care and allow people to die of preventable diseases in order to save money.

To label something as “prevention” does not guarantee that it is good for health care, even when lives could possibly be saved. There’s no question that prevention has potential benefit. Tobacco smoking, poor diet, physical inactivity and misuse of alcohol are estimated to be responsible for 900,000 deaths annually, or nearly 40% of the total yearly mortality in the United States. The preventive health benefits of an obese patient voluntarily losing weight are clear. What remains much less clear is the effectiveness of any particular preventive service to encourage weight loss, such as one involving dietary counseling in a medical office.

Too often our patients extract a psychological reassurance from screening tests that is not grounded in reality. “My mammogram was normal” translates into “I don’t have breast cancer.” “My chest X-ray was clear so I can keep smoking.” “My normal PSA means I do not have prostate cancer.” Sadly, the false sense of reassurance that makes cancer screening measures popular even with little or no evidence to back the claim does not translate to other preventive programs such as immunizations, which are indeed highly effective in preventing disease.

Likewise, it is a mistake for people to think that prevention will overall save money. Experts suggest that only about 20% of preventive measures, such as counseling a smoker to quit smoking, vaccinating against influenza, and screening men for colorectal cancer, actually generate true cost savings. The other 80% cost money. But prevention is a social good resulting in better health. As such, the important question is not “Can we save money through prevention?” but “How can we get the most ‘value’ from prevention for the dollars spent?”

The frequency of the screening and level of risk of the targeted group have a significant impact on the effectiveness and value of the test. Rutgers economist Louise B. Russell, PhD, calculated that Pap smears for cervical cancer screening every three years cost $41,000 per healthy year, compared with no screening. Screening every two years adds $1.3 million to the tab, and annual Pap smears cost an additional $3.3 million per healthy year gained.

Clearly, prevention is not the Holy Grail of health care reform. It is a very important and powerful tool, but one that requires careful, evidence-based analysis, not politicization. As with any other form of health spending, assessing the benefit of a particular screening intervention requires answers to three questions:

1) Is the intervention effective in improving health outcomes?

2) What is the value of the benefit per dollar spent?

3) How does it compare to other options?

Hard questions? Yes, but if we are to maintain a quality health care system at a price that is affordable, we must begin this process, even if it sounds more like spinach instead of bread and butter.

Joseph Stubbs is President of the American College of Physicians.

Originally published in ACP Internist.

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  • Kim

    Why do doctors always lump screening tests with prevention? Mammography and PSA don’t prevent cancer. Mammography increases the risk one will get cancer.

  • NeuroDoc

    It makes me absolutely cringe when I hear politicians proclaim how much cost they are going to save by enacting sweeping preventative care measures. Preventative care, though morally right, has never been shown to decrease costs systemwide. Indeed blanket imposition of preventative procedures will undoubtedly increase costs. Are the politicians truly clueless or are they deliberately misinforming the public on this issue?

  • Doc99

    And to whom is the intervention deemed of value? The doctor? The patient? The Bureaucrat? As with Beauty, value is in the eye of the beholder.

  • madoc

    When I read this post I thought of the story of Pellagra and the discovery by the USPHS of Niacin as the crucial dietary factor in prevention. I am sad and mad.

  • docguy

    i wonder if there is data on using statins to lower the ldl below 100, this is prevention as well but I wonder if costwise it’s worthwhile to get LDLs that low.

  • doc

    The “cure all” concept of prevention without sometimes direct evidence of effectiveness of a particular strategy (much less its cost effectiveness) is frequently driven by a multimodal web of vested interests including health care providers, politicians and the media.

  • Margalit Gur-Arie

    How about getting a bit creative with prevention?
    1) Build an annex to every Community Clinic to house a completely free Community Gym.
    2) Make home exercise equipment and gym memberships tax deductible.
    3) Increase Phys Ed time in all schools
    4) Subsidize local fresh vegetable & fruit farmers and drop the wheat/corn/beef subsidies
    5) Finance healthy food stores in poor neighborhoods (social business model)
    6) Build more parks, playgrounds and sidewalks
    7) Outlaw snack & soda machines …. just kidding…. :-)

  • Fred Goldstein

    It all depends upon how you define Prevention. This piece while true is a very narrow view of prevention and focuses mostly on secondary prevention or the early detection of people at risk or who have a condition that they are not aware of. Of course screenings and tests will cost more, and that is why the CBO could not score the savings in the bill; but prevention also includes primary and tertiary prevention.

    Primary prevention are the things you do to keep yourself healthy – eat right, don’t smoke, get exercise, wear your seat belt, maintain an appropriate weight, etc. While tertiary prevention is the appropriate management of persons who already have a chronic disease. The Milken Institute in their study “An Unhealthy America – The Economic Burden of Chronic disease” released in October of 2007 estimated that if a comprehensive prevention program were set up today, the economic impact would be in excess of $1 trillion annually by 2023. These savings would accrue from Medical cost savings but more importantly improved productivity. Studies by Drs Ron Loeppke, Dee Edington and others have shown that the productivity expenses of poor health are about $3 times the medical costs.

    This is why companies are looking at comprehensive prevention and wellness programs and why a broader look at “prevention” shows the great potential of creating a healthier and more productive society .

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