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.
Carl Honore: In Praise Of Slow Food
The bright news is that people all over the world are taking a slower approach to food -- and eating better as a result.
Kenneth Thorpe: Put the Obesity Epidemic at the Top of the Agenda
If Congress wishes to control costs in health care, they must put the obesity epidemic at the top of the agenda. Why? Because as much...
Loading comments… 
A must see...
http://cha
No alcohol during pregnancy? Avoid fetal alcohol syndrome?
Avoid nicotine during pregnancy? Avoid unnecessar
Containing infectious disease by not going to work or school and spreading it to others?
The flu shot?
Taking vitamins to prevent Osteoporos
Is stuff like this not preventati
Weight management = prevent diabetes
Diabetes control = prevent blindness/
Treating to prevent these catastroph
I am confused by the comments against preventati
I don't want to assume it is because they are part of the anti-refor
a. coverage for all Americans who have jobs
b. emphasis on preventati
c. lower costs for physicians
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 preventati
b. COBRA has to be extended to say 18 months and made more affordable
2. primary care and preventati
a. remove copays and deductible
b. no copays and deductible
c. have credit system for good BMI and healthy status
d. reimburse physician for group classes to discuss smoking cessation, diabetes, nutrition, exercise, cholestero
e. higher copays and deductible
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 deductible
4. rx negotiatio
5. not-for-pr
a. independen
They always speak of smokers and the obese.
Why do they never mention AIDS and homosexual
I guess it wouldn't be politicaly correct to point fingers at solid Democratic voters and donors.
For what exactly?
Could you please enlighten us with some numbers and cost impact on your claim of the dev of AIDS in seniors demographi
I think you made this up.
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
That being said, "the unluck of the draw" is an equal opportunit
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
Because the of extraordin
This means that the PEOPLE, sick and well alike, have become profit centers for all the "stake-hol
Until we disentangl
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 sustainabl
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.
Any health reform needs to include incentives for changes in individual
The appropriat
Since, me personally is both a cancer survivor and cardiac patient in the last decade, the progressiv
Proponents of preventive care make two naive assumption
1. Prevention prevents all cases of a disease.
Except for vaccinatio
Prevention of AIDS, ALSO means preventing the progressio
2. Preventing a particular disease means that person lives forever and never gets sick.
Everyone dies eventually
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, hospitaliz
Preventive care does not save
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
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.
Since it is a fact, we must find another way to finance the increased access to healthcare that we should provide.
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-----
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.
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--j
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 occasional
medical profession to assuage your beliefs, but the entire religious syndrome also.
Your 'beliefs' are choices, not mandates from others.
I mean, all you have to do is watch the Drug commercial
The powers that be definitely don't want us healthy; they couldn't make as much moolah off us if we were.