More Attacks on Prevention and Its Role in Health Reform That Make No Sense
Co-written with Lydia Ogden
Two recent newspaper pieces on prevention by Carla Johnson (Associated Press) and David Harsanyi (Denver Post) repeat some long-standing misperceptions about prevention. Because prevention is central to health reform, it's time to set the record straight.
Both the articles suffer from baby-with-bathwater syndrome, brought on by lumping all kinds of prevention into one big pot. Imprecise language is dangerous, particularly in the realm of policy-making. It leads to fuzzy thinking and that produces bad policy.
Research shows that scientifically sound prevention programs for both individuals and populations improve health and save money. Research also shows that effective prevention programs are targeted. They work because they reach the right people at the right time in the right places with the right interventions. Ironically, both these journalists miss the point that good prevention, like good reporting, addresses the five Ws and an H, just like they were taught in first-year journalism class. Who, What, When, Where, Why, and How are just as fundamental to sound prevention as they are to sound reporting.
Prevention can be divided into three parts: Things we do to avert disease (primary prevention), like vaccinations for children or the YMCA diabetes program mentioned in the article. Things we do to find and treat disease in its earliest stages (secondary prevention), like mammograms and colon cancer screenings. And things we do to avoid complications when people are already ill (tertiary prevention), like programs to help older people with multiple chronic conditions manage their care at home, like the PACE (Program of All-Inclusive Care for the Elderly) and similar initiatives. Dumping various interventions for various groups together and concluding prevention doesn't save money is just plain wrong.
Not all prevention programs work, many because they aren't grounded in science. Not all of them save money. All medical interventions -- including secondary and tertiary prevention -- cost money. Screening for common and costly diseases, like diabetes, high blood pressure, and high cholesterol, may actually raise spending in the short-term, because people who need treatment will get it. But over the long-term, that treatment is likely to avert even more costly complications, and thereby avoid higher spending.
Many studies show well-designed prevention programs are cost-saving. For example, a significant reduction in total health care spending is linked to community-based lifestyle interventions (primary prevention). Research shows that savings range from a short-term return on investment of $1 for every $1 invested, rising to more than $6 over the longer term. An investment of $10 per person per year in community-based programs tackling physical inactivity, poor nutrition, and smoking could yield more than $16 billion in medical cost savings annually within 5 years. This is a remarkable return of $5.60 for every dollar spent, without considering the additional gains in worker productivity, reduced absenteeism at work and school, and enhanced quality of life.
The Breast and Cervical Cancer Early Detection Program funded by the Centers for Disease Control and Prevention (CDC) is a great example of secondary prevention. It targets uninsured and underinsured women (18 years and older) at or below 250% of federal poverty level. Services include clinical breast examinations, mammograms, Pap tests, diagnostic testing for women whose screening outcome is abnormal, surgical consultation, and referrals to treatment. Last year, 301,209 women had mammographies who wouldn't otherwise have had care. Nearly 3,800 breast cancers were found. And 321,296 women got Pap tests. More 5,201 cervical cancers and high-grade precancerous lesions were found.
Worksite health promotion programs, too, are effective at both primary and secondary prevention. A systematic review of more than 50 studies meeting rigorous guidelines for review by the U.S. Task Force on Community Preventive Services found strong evidence of WHP program effectiveness in specific areas: reducing tobacco use, dietary fat consumption, high blood pressure, total serum cholesterol levels, and days absent from work due to illness or disability, as well as improvements in other general measures of worker productivity. At Citibank, for example, a comprehensive health management program showed a return on investment of $4.70 for every $1.00 in cost. A similar comprehensive program at Johnson & Johnson reduced health risks, including high cholesterol levels, cigarette smoking, and high blood pressure, and saved the company up to $8.8 million annually.
As far as tertiary prevention goes, there's evidence of effectiveness for that, too. Here's one of the best: For nearly 25 years, senior researchers at the University of Pennsylvania have implemented a series of large, randomized controlled trials with high-risk elders. Their studies have demonstrated that comprehensive tertiary prevention focused particularly on transitional care produces better health outcomes and significant cost savings. Their most recent research showed a 56% reduction in readmissions and 65% fewer hospital days for patients in transitional care. At the 12-month mark, average costs were $4,845 lower for these patients. If this model were scaled nationally with an investment of $25 billion over 10 years, savings could reach $100 billion over the same period.
The AP article's Mrs. Jones is 55 years old, obese, and at risk for diabetes. Studies show that in 10 years, when she turns 65 and enters Medicare, the government will spend $20,000-$40,000 more on Mrs. Jones' health care than Mrs. Smith's, who's the same age but a normal weight. Over 30% of the recent rise in Medicare spending in the last decade is associated with the persistent rise in obesity in the Medicare population. The increase in obesity-related chronic diseases among all Medicare beneficiaries and particularly among the most expensive 5% is a key factor driving growth in traditional fee-for-service (FFS) Medicare. Six medical conditions, all related to obesity -- diabetes, hypertension, hyperlipidemia, asthma, back problems, and co-morbid depression -- account for most of the recent rise in spending in the Medicare population. Preventing Ms. Jones' obesity by helping her to eat healthy, exercise, and avoid smoking, is good for her and good for the American taxpayer. Healthy people are underwriting unhealthy people, in our private health insurance premiums and in public health care programs paid for with our tax dollars.
Chronic disease resulted in more than $987 billion dollars in private spending -- most of it covered by private health insurance, which means higher premiums for everybody. Nearly all of every Medicare dollar -- 96 cents of each and every one, or more than $447 billion last year -- and 85 cents out of every dollar in Medicaid -- nearly $300 billion -- go to care for chronic disease, most of which is preventable. In one year, total, this amounts to approximately $1.7 trillion spent treating patients with one or more chronic diseases -- roughly 75 percent of all U.S. health care spending. This is essentially a hidden tax on every taxpayer in America. Anyone who cares about long-term health spending, particularly government health care spending, should support prevention. It's common sense.
Mr. Harsanyi's argument that we should avoid prevention because "the longer people hang around, the longer they utilize the health-care system" and drive up costs is hardly worth addressing. It's a bizarre concept that a civilized society would let people die of preventable causes. And it's economically inaccurate. Obese and chronically ill Americans tend to live shorter lives, but chronic diseases and obesity are linked to two-thirds of the growth in U.S. health spending since the mid-1980s. We're not cutting any corners in health care costs by allowing these people to meet the Grim Reaper earlier.
The other major point both Mr. Harsanyi and Ms. Johnson miss is the "how" of prevention. How are policymakers proposing to increase effective prevention inside and outside the health care system? Contrary to how their articles describe it, the idea isn't to insert one-off prevention efforts into the existing system. Instead, Congress and the President are proposing fundamental changes to the way we deliver prevention, care, and treatment. That means improving community-based primary and secondary prevention, strengthening primary care (primary and secondary prevention) and incentivizing providers and patients to better prevent and manage diseases (secondary and tertiary prevention). In sum: A comprehensive prevention plan rather than scattershot, unconnected -- and ineffective -- efforts.
By preventing costly diseases or better managing them, we can help contain our out-of-control health spending. We can boost productivity. In our troubled economy, we need to do both. Even if it didn't save money, preventing suffering when we can is the right thing to do. Research, common sense, and ethics all tell us the same thing: An ounce of (science-based) prevention is worth a pound of cure.
Kenneth Thorpe, Ph.D., is the Robert W. Woodruff Professor and Chair of the Department of Health Policy & Management, in the Rollins School of Public Health of Emory University. He serves as the Executive Director of the Partnership to Fight Chronic Disease.
Lydia L. Ogden, M.A., M.P.P. is the Chief of Staff for the Institute for Advanced Policy Solutions of the Center for Entitlement Reform at Emory University.
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Can someone explain these preventative care actions to me and tell me whether they are preventative actions or not and why? Thank you.
No alcohol during pregnancy? Avoid fetal alcohol syndrome?
Avoid nicotine during pregnancy? Avoid unnecessary complications?
Containing infectious disease by not going to work or school and spreading it to others?
The flu shot?
Taking vitamins to prevent Osteoporosis?
Is stuff like this not preventative care or am I misunderstanding what "preventative" care means?
Smoking cessation/BP treatment/
Weight management = prevent diabetes
Diabetes control = prevent blindness/kidney failure
Treating to prevent these catastrophic problems is better for the affected patient and ultimately cheaper for the healthcare system.
Thank you very much for answering my questions. I had always thought that "preventative" care was in the best interests of patients and fiscally responsible.
I am confused by the comments against preventative care. I think informing the public and having health education is a positive action against dis-ease. Why are others against it?
I don't want to assume it is because they are part of the anti-reform against health care, so I wonder what else could it be.
Yes, Julia those are examples of primary prevention.
thank you. I suspected they were, but after reading some of the comments here, I got confused by the negative response.
3 main goals
a. coverage for all Americans who have jobs
b. emphasis on preventative care
c. lower costs for physicians, hospitals, rx, health insurance, medical equipment
to accomplish this use our current healthcare system to allow:
1. All American with jobs should have healthcare insurance
a. For Americans without jobs Medicaid is necessary but it cannot cover everything and it has to encourage preventative care.
b. COBRA has to be extended to say 18 months and made more affordable.
2. primary care and preventative care to be encouraged
a. remove copays and deductibles for primary care (maybe cap # of visits per year to 6)
b. no copays and deductibles for certain screening tests associated with diabetes, colon cancer, and heart disease
c. have credit system for good BMI and healthy status
d. reimburse physician for group classes to discuss smoking cessation, diabetes, nutrition, exercise, cholesterol, etc.
e. higher copays and deductibles for specialist and specialty testing.
3. emergency care should be last resort
a. have primary care clinics near to hospitals that are available 24/7 365 days.
b. Have high copays and deductibles for emergency service
4. rx negotiations and use of generics
5. not-for-profit co-ops encouraged
a. independent co-ops should be encouraged to form that will compete with for-profit healthcare insurance companies.
I've noticed something about Obama, the media and this columnist when they speak of prevention and our healthcare savings.
They always speak of smokers and the obese.
Why do they never mention AIDS and homosexuals. AIDS is an entirely preventable disease that is spread through lifestyle choices. Yes, heterosexuals have it as well but it seems odd that one of the smallest demographics in America has the largest AIDS rate.
I guess it wouldn't be politicaly correct to point fingers at solid Democratic voters and donors.
"I guess it wouldn't be politicaly correct to point fingers at solid Democratic voters and donors."
For what exactly?
One of the faster growing demographics for the development of AIDS is Seniors. I don't think they are Obama's demographic.
MedMickey,
Could you please enlighten us with some numbers and cost impact on your claim of the dev of AIDS in seniors demographic or did you just make it up?
Link please.
I think you made this up.
Iwill,
The vast majority of chronic conditions, the ones that are most expensive, are linked to obesity and smoking. Thank you for your "generous heart" to include HIV victims. We didn't know that you cared.
For-Profit Health Care is against prevention for one simple reason,...
They can't make a profit if we are healthy. They only make a profit from treating disease symptoms (or percieved symptoms) if they can be maintained in a chronic, if managable state.
If we are generally healthy - Then we don't need them. If we don't need them - we don't buy their expensive treatments. If we don't buy their expensive treatments - they have to make less money and can't pay their CEOs and marketing people big salaries.
Prevention is a personal choice, not made any easier by the corporates who control the food chain (literally).
That being said, "the unluck of the draw" is an equal opportunity wild card in everyone's life.
What we as a nation must confront is the essential commitment we are prepared to make to our citizenry.
It is, in my opinion, akin to civil rights, human rights, and the dignity of all men, women, and children.
At present there is only one driver for the equation that pertains to every individual's health: money, and the need for profits, championed by all insurance companies and the likes of the AMA.
Because the of extraordinary cost of a medical education in this country (a cost which other nations in their enlightened self-interest provide for free), most doctors today are also motivated more by making money than caring for people.
This means that the PEOPLE, sick and well alike, have become profit centers for all the "stake-holders" in the game.
Until we disentangle this (as other civilized nations have managed to do), our entire social fabric is at risk.
We need a new standard for health and health care, and the PEOPLE have to demand it.
Single Payer is the only fair and ultimately sustainable, way to go.
If we cannot count on our government to create the framework for democracy in action, that is, a level playing field for all, then the great American experiment is over.
Thank you Pax for your excellent commentary.
What worries me about the "screw preventative care" spiel is that a lot of Americans might be predisposed to buy into it. Deep, deep down in the roots of this nation's Puritan background is the conviction that suffering is good--that it's something God expects of us. That suffering is part of living a "righteous" life. While people might not verbalize this, and might well even scoff at it when someone else does, it's very real. I've lived in the American South for most of my life and I've seen people accept chronic illness as an essential part of their existence.
I agree. It is not just the American South. I grew up in Wisconsin, and it was the same conviction. It was almost as if you didn't suffer, you did not gain the merits for 'heaven'. Or one was doomed to suffer in silence, and not communicate what was 'stewing inside', so as to have a dialog. "We just don't talk about that!" So the wanabee sufferers keep brethren alive on life support, and almost seem to take a holier than thou attitude that they are doing god's work. I have seen this at work in my own family, and can only be grateful to the powers that be that I did not subscribe to it myself. Quality of life supersedes the fear of the transition to the unknown, and when that quality has me at the mercy of tubes and artificial means, I'll trust the next journey, thank you.
The most effective primary prevention is actually outside of the health care system. Prevention is less expensive, and therefore more cost-effective, when it can be incorporated into personal lifestyles rather than added on as a clinical intervention.
Any health reform needs to include incentives for changes in individual, community and corporate behaviors. Its one thing to say we need to walk or bike more, its another to be sure that safe routes are available. We should exercise more, but have all but eliminated PE from schools, allowed parks to be taken over by gangs and have 10 - 12 hour work days, 6-7 days a week, leaving no time nor energy to exercise. We've designed cities, towns, communities, shopping areas and work around the driver rather than the pedestrian. We should eat better but it is cheaper and easier to grab fast food or highly processed foods. Many of us eat one or more meals a week while in the car. We have many companies whose products are not just unhealthy but outright dangerous to health.
The appropriate question is not whether prevention can make money for the payers for health care, but, whether it promotes health at a reasonable price.
An excellant respone. Preventive actions will allow us to live longer and more productive lives, BUT not everyne buys into, less tobacco, less alcohol, more excercise and healthlier diets. WHY, It is my right to do for me, whatever I please, as long as others are not adversely affectied. Oh Yeah, one of my rights per Pres. Jefferson.
Since, me personally is both a cancer survivor and cardiac patient in the last decade, the progressives we'll get people to behave correctly is NAIVE. Remeber Prohibiitons
Conspiracy theories are fun, but tell us nothing about whether preventive care saves money.
Proponents of preventive care make two naive assumptions:
1. Prevention prevents all cases of a disease.
Except for vaccinations, nothing can prevent all cases of a particular disease. Consider HIV. Condoms prevent sexual transmission of the virus, but many cases are caused by IV drug abuse or transfusions . Moreover, many people are transmitting the disease sexually because they don't know that they have it.
Prevention of AIDS, ALSO means preventing the progression of HIV to AIDS, and will continue to do so for the foreseeable future. Preventing progression to AIDS is extraordinarily expensive. The cost of the medication is tens of thousands of dollars per month, and most people die eventually any way.
2. Preventing a particular disease means that person lives forever and never gets sick.
Everyone dies eventually, and except for those few who have sudden cardiac death, they usually require extensive medical care before hand. Consider:
Suppose that instead of dying at 65 because of diabetes, Mrs. Jones lives to be 80, but in the interim develops cataracts that require surgery, hearing loss that requires hearing aids, falls and breaks her hip requiring surgery, hospitalization and rehab, and then eventually dies of pneumonia after a 2 week stay in the ICU. All that costs $100,000, so not only has no money been saved by diagnosing Mrs. Jones' diabetes, but a lot of extra money has been spent.
Preventive care does not save
So Mrs. Jones doesn't die at 65 from DM, has an additional 14 years of good health before she falls and breaks her hip at 79. In that interim, lets say that she plays a significant role in her granddaughter's life and turns her away from being a runaway and using drugs towards a better life. Or, Mrs. Jones, being the CEO of a small company, is able to secure that company's future. Its not just a simple issue of dollars in and dollars out.
You are correct that prevention cannot prevent all cases of a disease nor guarantee good health forever. You are also correct that by saving lives earlier in life that more chronic disease, and the associated costs, can build on the other end. Prevention can reduce the burden of disease, both in morbidity and mortality. In the case above, because of prevention, Mrs. Jones doesn't develop CAD and avoids an angiography, two stent placements, a pacemaker and, later, bypass surgery; she dramatically slows her osteoporosis so that her hip breaks at 79 rather than at 70, she avoids the spinal fractures that would've required years of meds; she avoids disease of the retina so is able to have sight restored with cataract surgery, rather than several retinal surgeries. How much is all that worth?
Prevention is not a panacea. Prevention has its own associated costs, both direct and indirect. But I believe that benefits and total costs of prevention far outweigh any on the down side.
You may believe that, but the actuarial and financial data show otherwise. I offered the example to demonstrate why preventive care does not save money, not to convince anyone. It's a fact whether or not lay people choose to believe it.
Since it is a fact, we must find another way to finance the increased access to healthcare that we should provide.
Anyone who thinks Mrs. Jones @ age 70 will influence her granddaughter, 16, is really dreaming
Amy,
I suggest you and the others here read "The Cost Conundrum" by Dr. Atul Gawande in The New Yorker of June I, 2009 or just Google it. You will learn some truths about what really drives health care costs-----the current approach to reimbursement of health care providers!
I've read Gawande's article and it has nothing to do with what we are discussing. The issue is very simple: does the scientific and actuarial data show that preventive cares saves money in the aggregate and the answer is no.
Expanding access to healthcare is an incredibly important goal and it's not going to happen if we are not honest about the fact that it will cost money. Pretending that preventive care can pay for it is foolish and helps no one.
And you are a doctor. First as a proponent of prevention I find both of your "naive" assumptions ridiculous. Also concerned with moral and ethical questions. And you are a doctor??????
I was puzzled by these comments from a "doctor" as well. I am open to listening to differing opinions and after reading these comments I thought maybe I should re-evaluate the meanings of "preventative" care and its long term effects.
After doing more reading, I still believe that preventative care is the most effective and fiscally responsible thing to do so why do some still not see the benefits?
"Prevention can be divided into three parts"
Actually, a fourth part can be included, the same part that also prompted the two newspaper
pieces on prevention with which you take issue.
The two people writing the articles "believed" that they were correct based on their points
of view (which stems from their respective beliefs--just as yours does).
If you believe in good health and expect good health because it is rightfully yours, you will
have good health. If you believe the self is flawed, burdened with original sin, just a machine
that needs repairs occasionally and out of your control, then you will need not only the entire
medical profession to assuage your beliefs, but the entire religious syndrome also.
Your 'beliefs' are choices, not mandates from others.
The GOP wants a sick, stupid and fearful population because that's easy to control. This is what Bush/Dick tried for 8 years - ridiculous education programs, eliminating healthcare for a huge portion of the population, and inducing constant terror in the people that "this is all for your own good". Meanwhile the uber-rich like HMO's, pharmas, and other friends of the GOP are getting uber-richer. It almost worked.
My idea is to take a substantial portion of the future monies appropriated and build free public access gyms in every community which also would have paid trainers on staff. That sounds like a ounce of prevention to me. More folks would go if they could afford it.
It would REALLY help prevention if the corporations would stop poisoning US with their "food" and drugs.
I mean, all you have to do is watch the Drug commercials on TEEVEE to see how poisonous most of these things are they want you to run to your doctor and ask for.
The powers that be definitely don't want us healthy; they couldn't make as much moolah off us if we were.
I'll say it again-It's About The Money,Control of the masses.Eve
.I'll say it again-It's About The Money,Control of the masses.Eve
Let's keep Bu shco outta this.
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