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:

NEJM chart

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.

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