Does Preventive Care Save Money?

Yes and no. Yes, because prevention is often worth a pound of cure, and no, because often preventive care can identify problems that are expensive to fix (as opposed to not spotting them, after which the patient’s death is less expensive. Look, I’m not a dick – that’s just the way the costs work).

That’s the short version of this quite well-argued piece in the latest New England Journal of Medicine, Does Preventive Care Save Money? Health Economics and the Presidential Candidates.

With health care once again a leading issue in a presidential race, candidates have offered plans for controlling spiraling costs while enhancing the quality of care. A popular component of such plans involves greater promotion of preventive health measures. The first element in Hillary Clinton’s plan is to “focus on prevention: wellness not sickness.” John Edwards has stated that “study after study shows that primary and preventive care greatly reduces future health care costs, as well as increasing patients’ health.” Mike Huckabee has said that a focus on prevention “would save countless lives, pain and suffering by the victims of chronic conditions, and billions of dollars.” Barack Obama has argued that “too little is spent on prevention and public health.”

Indeed, some evidence does suggest that there are opportunities to save money and improve health through prevention. Preventable causes of death, such as tobacco smoking, poor diet and physical inactivity, and misuse of alcohol have been estimated to be responsible for 900,000 deaths annually — nearly 40% of total yearly mortality in the United States. Moreover, some of the measures identified by the U.S. Preventive Services Task Force, such as counseling adults to quit smoking, screening for colorectal cancer, and providing influenza vaccination, reduce mortality either at low cost or at a cost savings.

Sweeping statements about the cost-saving potential of prevention, however, are overreaching. Studies have concluded that preventing illness can in some cases save money but in other cases can add to health care costs.[PDF] For example, screening costs will exceed the savings from avoided treatment in cases in which only a very small fraction of the population would have become ill in the absence of preventive measures. Preventive measures that do not save money may or may not represent cost-effective care (i.e., good value for the resources expended). Whether any preventive measure saves money or is a reasonable investment despite adding to costs depends entirely on the particular intervention and the specific population in question. For example, drugs used to treat high cholesterol yield much greater value for the money if the targeted population is at high risk for coronary heart disease, and the efficiency of cancer screening can depend heavily on both the frequency of the screening and the level of cancer risk in the screened population.

The focus on prevention as a key source of cost savings in health care also sidesteps the question of whether such measures are generally more promising and efficient than the treatment of existing conditions. Researchers have found that although high-technology treatments for existing conditions can be expensive, such measures may, in certain circumstances, also represent an efficient use of resources. It is important to analyze the costs and benefits of specific interventions.

I agree. I think the authors are a mite too involved with efficiency-based arguments (as opposed to equity-based arguments) and, as a result, run right past the fact that unversal health care (for example) is an intervention – possibly the intervention.

Their solution? A meta-analysis! Possibly useful, possibly not. Meta-analyses are often of little worth. The result:

Our findings suggest that the broad generalizations made by many presidential candidates can be misleading. These statements convey the message that substantial resources can be saved through prevention. Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not. Careful analysis of the costs and benefits of specific interventions, rather than broad generalizations, is critical. Such analysis could identify not only cost-saving preventive measures but also preventive measures that deliver substantial health benefits relative to their net costs; this analysis could also identify treatments that are cost-saving or highly efficient (i.e., cost-effective).

The chart is interesting. I’m not so sure this is way to go: we are interested in the cost-effectiveness of preventive care, relative to palliative (or curative). This has dis-aggregated the studies along identified cost-effectiveness thresholds, but that is not what is of policy interest, surely. Moreover I see, in this, a big risk of Simpson’s paradox. Looking at the table they provide of “selected” studies, I also see a mis-match in the conditions to which preventive vs. palliative/curative care are being sorted. Can we compare colonoscopy screening with anti-retroviral treatment for HIV? ‘Cause I have a suspicion that is what might have occurred.

This is standard for systematic reviews: one is pulling together mis-matched data for retrospective analysis for which the data was never designed. This generates value-of-information problems across the board, and we ought to remember this as we ponder the results. Ultimately, too (and more importantly), I think this piece really mis-reads the point of so-called “socialised medicine”.

That said, the authors are up-front about their motive not being to solve the problem: they are commenting upon less-informed debate by Presidential candidates. Now, one (say, me) could easily reply that this is pointless: Presidential candidates are selling us themselves, not a policy – there is a big agency problem and we really shouldn’t take them too seriously. If a candidate trotted out his/her future cabinet and invited the country to openly and knowingly elect the lot of them, then I’d pay attention.

Retail surprise?

UPDATE: the Big Picture already beat me to this post. The bastard. Go there for his take on the affair also.

Surprising to whom, I wonder.

Retail sales in the U.S. unexpectedly rose in January, easing concern that the world’s largest economy has already slipped into a recession.

The 0.3 percent increase was led by spending on autos, clothes and gasoline, the Commerce Department said today in Washington. The figure followed a 0.4 percent decrease the previous month. Purchases excluding automobiles and gasoline were unchanged.

“Today’s report will diminish recession anxieties, but it doesn’t dispel them altogether,” said Richard DeKaser, chief economist at National City Corp. in Cleveland, who accurately forecast the sales gain. Federal Reserve Bank of St. Louis President William Poole said yesterday “the best bet” is the U.S. will avoid a recession.

A) Is this volume, is it revenue, what are retail sales? Previously we’ve seen this, discussing volume, and the volume has been on steeply-discounted goods at discount stores. This could very well (and, most likely, will) be the same – meaning there’s no ‘there’ here.

B) This is more likely than not to be inflation-driven, either (i) because prices are up, or (ii) because people expect prices to go up even further, so tomorrow’s consumers are entering today’s markets, trying to save a bit of money (the article specifically mentions gasoline and its appreciating prices at bowsers across the country)

C) This is according to Commerce department. The department whose job it is to sell us the economy, and a department in an administration known for selling many bad goods under fake bills, across the board. Which gets us back to part A).

Am I a cynic and a pessimist? No – this counts merely has having pulled-wool-proof eyes. When oh when will we learn not to believe the hype? Back at Bloomberg:

Department-store sales dropped 1.1 percent. Stores selling building materials showed a 1.7 percent decrease in sales, after falling 2.5 percent. Sales also fell at electronics, appliance and sporting goods stores.

Excluding autos, gasoline and building materials, the retail group the government uses to calculate gross domestic product figures for consumer spending, sales rose 0.2 percent, after a 0.1 percent decrease the prior month. The government uses data from other sources to calculate the contribution from the three categories excluded.

Today’s Commerce Department report on retail sales also runs counter to industry figures that show January sales fell at stores from Target to Nordstrom Inc. even as some retailers slashed prices by as much as 75 percent. Sales at stores open at least a year rose 0.5 percent from a year earlier, the worst January since 1970, according to the International Council of Shopping Centers.

D) Month-by-month data isn’t all that relevant. So what if January sales did increase .3% on December sales – by what percentage have previous Januaries out-done their Decembers? That’s the yard-stick.

Popping over to the Census Bureau:

Very non-sexy graphics, I’m afraid. What does it mean? Nothing, really. January’s CPI figures are due February 20th. PPI figures too, probably – although December’s were down which, in a soft economy, may also not mean much.

Don’t get me wrong – I’m not poo-pooing potentially good news. We’ve already seen only recently, however, how foolish it is to try to capture the macroeconomy in real-time. I don’t know why we persist.

Off the Wall: A Portrait of Robert Rauschenberg

New book! Having marked my way through 175 Eco 1 mid-terms, Economics doesn’t interest me so much at the moment. So, art:

Calvin Tomkins first discovered the work of Robert Rauschenberg in the late 1950s, when he began to look seriously at contemporary art. While gazing at Rauschenberg’s painting Double Feature, Tomkins felt compelled to make some kind of literal connection to the work, and it is in that sprit that “for the last forty years it’s been [his] ambition to write about contemporary art not as a critic or a judge, but as a participant.” Tomkins has spent many of those years writing about Robert Rauschenberg, whom he rapidly came to see as “one of the most inventive and influential artists of his generation.” So it seemed natural to make Rauschenberg the focus of Off the Wall, which deals with the radical changes that have made advanced visual art such a powerful force in the world.

Off the Wall chronicles the astonishingly creative period of the 1950s and 1960s, a high point in American art. In his in his collaborations with Merce Cunningham and John Cage, and as a pivotal figure linking abstract expressionism and pop art, Rauschenberg was part of a revolution during which artists moved art off the walls of museums and galleries and into the center of the social scene. Rauschenberg’s vitally important and productive career spans this revolution, reaching beyond it to the present day. Featuring the artists and the art world surrounding Rauschenberg–from Jackson Pollock, and Willem de Kooning to Jasper Johns, Frank Stella, and Andy Warhol, together with dealers Betty Parsons, and Leo Castelli, and the patron Peggy Guggenheim–Tomkins’s stylish and witty portrait of one of America’s most original and inspiring artists is fascinating, enlightening, and very entertaining.

Bloody fascinating. I picked it up at Jasper Johns: Gray, an exhibition at the Metropolitan Museum of Art. An exhibition all about the use of one colour by one artist – who’d have thought? If you’re in NY it, too, is entirely worth your time.

The book covers a very large and long period in American art, through the 20th century. I’m a big (big) Jasper Johns fan, so the Rauschenberg/Johns/Castelli nexus of abstract expressionism/etc. is of most interest to me. You can pull up a lot of this book over at Google books. E.g.

Which is somewhat mis-representative. The book is about Rauschenberg, but its location of his life and art within (and, often, without) his community, through collaborative work with Cage and Cunningham, various dealers before Castelli, Johns, etc. makes for a truly fascinating insight into his career.