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.

 

Comments

[NoOneSpecial]

Has it ever occur to anyone that the Republicans oppose virtually everything "Mom" ever taught you about how to live a better life?

[historymatters]

Excellent article. Nice to see someone arguing for the use of science versus ideology and opinion.

I would add a a couple of things. First, there's a huge assortment of entrenched special interests who like the system just the way it is and they're making a fortune off it. It ranges from big pharma to big ag to Madison Avenue advertisers.

Second, I think there's a huge underlying class issue that's really holding up meaningful health care reform. When some people here the phrase "preventive care," they think of community health programs and public health clinics. In other words, they think of poor people, or maybe non-whites, or maybe immigrants. Just people they don't much like, in other words. And what they really wish in their heart of hearts is that all those undesirables would just go away and die quietly. If they would, then all the "right" folks would be able to live any way they want, consume as many resources as they want, and not have to worry about caring about anyone but themselves.

Between the profits and the prejudice, I really wonder if there's any room left for meaningful reform.

[GrannyCanuck]

Dr. Thorpe, the article accessed by the following link ought to reinforce your argument:

http://www.thestar.com/unassigned/article/655070

[AmyTuteurMD]

"... 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."

Of course it's worth addressing; it's the crux of the matter.

No one says we should let people die to save money. The issue is whether preventive care in the aggregate saves enough money to pay for people who are currently not covered. The existing evidence indicates that preventive care does not save money.

Moreover, no one says that no form of preventive care saves money. Vaccination and Pap smears almost certainly save money because they are low cost and they dramatically improve health.

Other preventive care, like preventing AIDS, does not save money. HIV testing is inexpensive. Treatment to prevent progression to AIDS, though, is extraordinarily expensive and does not cure the disease. It can cost over $10,000 a month for anti-retrovirals. And the medication merely turns a disease that is fatal in the short term to a chronic disease that may last years and is fatal in the long term. The benefits to the patient are, of course, incalculable, but the costs are massive.

That does not mean that we should stop HIV testing or other extremely expensive forms of preventive care. We are ethically mandated to provide testing and treatment, even though it costs a considerable amount. It does mean, though, that we must shed our delusions that the "cost savings" of preventive medicine can finance healthcare reform.

[historymatters]

"Other preventive care, like preventing AIDS, does not save money. HIV testing is inexpensiv­e...'

Never heard of condoms, eh? The rest of your argument is equally shortsighted.

[AmyTuteurMD]

Ever heard of IV drug abuse? How about hemophilia?

You've just illustrated two of the naive assumptions of those wish preventive care saved money.

First mistaken assumption: all cases of a disease can be prevented. That is never true, except for vaccine preventable diseases. Condoms can prevent some cases of HIV, but many cases of HIV are caused by IV drug abuse and transfusion of blood products. Moreover, most people who should use condoms don't .

Therefore, people will continue to get HIV, plus many people who have it who don't yet know that they do. The costs of diagnosing and treating them are absolutely massive, and that will continue for the forseeable future.

Your second false assumption is that if a particular disease can be prevented, people will remain healthy forever. Everyone dies, and very few drop dead of sudden cardiac death. Therefore, almost everyone will get sick or be in a life threatening accident before death. 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.

The bottom line is that preventive care does not save

[DrP]

During the health plan town hall meeting, at one point, the network flashed up a screen that said that 50% of medical costs go to treat 3 conditions: obesity, diabetes, and heart disease. I went off into a reverie - I had a dream: that everyone with those 3 conditions would have the same epiphany I did 10 years ago and would read the science of insulin-resistance - then adopt a very low-carbohydrate, high fat/protein diet. The i realized how devastating that would be to our economy. It would destroy Big Pharma (I take no prescriptions; there goes the market statins, beta blockers, metformin, injectable insulin) Big Agri and the food industry (I eat no processed food, sugar, grains, or starches) - what would happen to Coke, Pepsi, Con-Agra, Sara Lee, Frito-Lay); and of course the health industry itself (I haven't been to a doctor in 3 years). The only industries that might benefit would be meat (unprocessed), dairy, and fresh vegetables farmers, (that's all I eat), health clubs, bike manufacturers, and athletic wear manufacturers. Ah well, it was only a dream.

[Star2000dancer]

Body Wise, an health organization produced inulin, it's natural insulin. My friend was born with .brittle diabetes. She took 4 shots a day. She took my product for a month. She woke up & her blood count was normal for the 1st time in her life. She was stunned.
She called her Doctor & told him, got back to me and was terrified. She stopped taking the natural product, & went back to her life long synthetic drugs.
I could tell you stories like bringing a man out of a wheel chair at the club, or getting a woman off 9 years of a cane. Making seized shoulders pain free in minutes, sciatic nerve pain go, etc. , I have all those problems now no one can help me. They just treat the symptoms, I couldn't get an x ray or a cast for 2 fractured wrists. "Nothing is wrong" means I don't know. FDA approved means beware.
Massage Therapy & Chiropractic , natural remedies, swimming, exercise, flexibility, acupuncture, yoga.
America, doctors are killing & permanently disabling people right now. Every good, honest doctor I find, I lose because of the system. Don't reform it, lose it.! Go back to basics, it's too informal as is, now you're talking about web chats?
One doctor made it clear I had 10 min. if it took longer, he charged me for 2 visits. Stop making people sicker to make being sick profitable. It should be an honor to cure, not a scam

[smileatfear]

A high fat diet would be devastating to me with multiple sclerosis. No one diet is good for everyone and any extreme diet, except one developed for a specific disease, can be disasterous.

[amanda5]

The facts support health care reform. More spokespeople need to get in the media and start giving data. No stupid talking points with cute little phrases. Dazzle them with the facts. The hard core numbers. The facts are the enemy of the RNC. I thought our congressmen were supposed to act to in the best interest of the American people not for their own party. Party and Country are quite different and the congressmen sitting on the right side of the aisle would do better by remembering that.

Heath care reform is tied to our country's economy. It's past time to quit talking and start acting. I know this will mean less time in the tanning bed for Congressman Boehner from my home state of Ohio. He is an embarrassment. Instead of contributing to a plan to reform health care; he chooses to put on a performance. He acts like he is performing in a theater. UGH Please do your job congressman and do a little research. Read a little.

[exposure]

I haven’t been able to get anything in print regardless of tone or subject.
The Aristocracy on Capitol Hill as well as many State Governments is pretty much at ease through this transitional period of Obama’s Rhetoric to push through Bush II’s well-anchored strategies and sixty years of bipartisan enactments of policy to bring our country to its’ knees.
My Senator Brown from Ohio swaggers with the same arrogance while retorting “Clarity of vision”. With pleas of a more encompassing perspective, enforcement of controls, elimination of conflicts of interest, incarceration of White-Collar criminals and considerations to the ripple effect, his comments were still far from realistic or ethical. This is a done deal, in the worst interest of working class America.
You have factions using “Grass Root” organizations to solicit and distort data on prime issues of urgency and as the smoke obscures the trillions of dollars given to decadent cronies to buy up Senate approved toxic assets, for pennies on the dollar, to literally own this country.
If you’ve noticed, the rats that evaded prosecution from as far back as the seventies, are all on board again to reap the treasonous seeds they sowed?
The only resolve is to expose the real enemies that control our politicians and bring them up on charges for crimes against humanity, seize their ill-gotten wealth and re-enforce world economy. The taking down of a few thousand undesirables will prevent a few billion deaths via flu & war.

[Californiajew]

It is time to demonstrate IN THE STREETS for public medical coverage!

[rinpochet]

I completely agree! Would like to see some of the large organizations pushing for single payer to get together and organize something. The people will be there. Organize for single payer which is the only thing that will work and we may get a public option.

[mbaty]

I agree that we must focus on prevention--on creating an atmosphere of wellness that incorporates many "alternative" therapies into our health routines. But of course, there's that old problem of "we don't have enough money." Ultimately, we will have to move to a health system that operates without making a profit. That would lead to quickly realized solutions to many conditions and cures for many diseases simply because it doesn't benefit anyone to keep someone on a costly treatment unless someone is making a profit. The human immune system in it's idealized state is quite effective, but when there is so much money to be made, why cure anybody? We have to look forward to the day when sickness is a thing of the past, when all or most diseases can be cured in one treatment, and when all people are taught how to keep themselves well through diet, exercise, and other alternative therapies.

[Firbolg]

The argument for concerted targeted preventative action made here is compelling. It certainly points the way to improving the lives of countless Americans while, at the same time, saving untold billions.
While the examples based on obesity are telling I think much more can be achieved in a very short term by focusing on a smaller group, say of around 600 or so, addicted to greed, lust and bullying. I’m thinking, of course, of Congress and the Administration.

[historymatters]

gotta include the lobbyists and the special interests they represent in there too, imho.

[pm247]

The thing is, "prevention" amounts to lifestyle changes for Americans. It means all our decadent, wasteful, gluttonous and filthy habits of consumption will be under the microscope. Corporations spend billions to teach us these habits which translate into big profits. And though they make us sick we don't want to hear about it. Just give us some pills and let us be Americans.

[saami]

So by being intelligent and using preventative medicine and life style changes we can get healthier people and lessen our carbon footprint at the same time. So it is a double win. Going green can create lots of jobs as can preventative medicine. What's not to love?

[historymatters]

But all those corporations would lose their profits, silly! Profits have to come first, it's the American way.

[propitiousmoment]

It will also mean that food producers will have to change their ways or go bankrupt. Just about everythign packaged or processed is full of HFCS, fat, and sodium, no to mention all those cancer-causing chemicals. I'd venture that a large amount of lobbying money goes into their efforts to avoid having to face the music in that regard.

[smileatfear]

The first order of business should be to get all our farm animals off of a corn/soy based diet and back onto the foods they were evolved to eat, namely grasses. This would cut the use of antibiotics in meat production way down and give us meat and milk that contains far less saturated fat. Just that alone would probably make a tremendous improvement in the overall health of the nation, not to mention a lot less methane production from our ruminants.

[Mike Tikkanen]

After 12 years served as a volunteer guardian ad-Litem for the county, I can attest to the fact that communities save no money by disregarding the mental health needs of children. MN supreme court chief justice Kathleen Blatz made the statement that 90% of the youth in juvenile justice had passed through child protection services. Nationally, over 60% of youth in juvenile justice suffer from mental health disorders and fully half that number have multiple, chronic conditions.

I've witnessed 4 year old suicides and a judge that sends me the Ritalin, Prozac, and other psychotropic med schedules of young children in her courtroom among other surreal child related mental health experiences.

No other industrialized nation treats it children so poorly. It is why our schools struggle and our streets are unsafe, or as Pliny said 2500 years ago, "what you do to your children, they will do to your society"

http://www.invisiblechildren.org/2008/06/15/what-we-do-to-our-children-they-will-do-to-us/

[pm247]

Kids are at the mercy of their parents. This is okay in a healthy culture, but American culture is in a death spiral. Child abuse is rampant, parents are drug addicts and/or mentally disturbed, and there is no meaningful intervention except in the worst of the worst cases.

High risk households need a social worker on the spot, even before birth of a child, to teach parenting skills, delineate unacceptable practices, help arrange child care and doctor visits, and watch for signs of neglect and abuse. The horror of child abuse, with all its resulting problems, is PREVENTABLE.

There's that sticky word again: prevention.

[propitiousmoment]

And just how closely do you want to monitor every individual household to identify potential risks? There has to be a line drawn somewhere. The previous comment was referring to children who are already in the system. The phenomena you describe may be more prevalent than we could wish, but they are hardly the norm, meaning vast numbers of families are healthy and supportive of their children. It would hardly be productive to subject all of them to the kind of scrutiny your plan would require.