An Obituary

Please pause for a moment of silence….[Jesu, Joy of Man's Desiring (with choral)]….Thank you. The idea that preventive medicine saves money is dead. Mammograms don't pay for themselves. Nor do Pap smears. Nor prostate cancer tests. Nor general checkups for healthy people. Etc., etc., etc. Yes, there are some exceptions — childhood immunizations and prenatal care for at-risk mothers, for example. But the exceptions are few and far between. Louise Russell, who knows more about the economics of preventive care than anyone, put some additional nails in the coffin in a recent article [gated, but with abstract] in Health Affairs:

Over the past four decades, hundreds of studies have shown that prevention usually adds to medical spending. [Examination of] 279 cost-effectiveness ratios for preventive interventions (and 1,221 ratios for treatments) from 599 studies published between 2000 and 2005 [show that] less than 20 percent of the preventive options (and a similar percentage for treatment) fall in the cost-saving category — 80 percent add more to medical costs than they save.

Does preventive care save lives? Of course. Does it save money for some patients? Definitely. But the cost of screening healthy patients outweighs the savings on patients whose diseases are caught in their early stages. Preventive medicine is desirable. But there's no free lunch.

 

For this real downer moment,
who is better than Johnny Cash?

Here's the bottom line. Preventive care is not like an investment good that pays a positive rate of return. Instead, it's like a consumption good. Preventive care leads to better health. But the enjoyment of that result must be traded against the enjoyment of other goods and services we also consume. I know this discovery will not bother most loyal readers. However, it will be crushing news to others.

When did the patient die? More than two decades ago. Almost ten years after the death of Elvis, if memory serves. Yet many people haven't gotten the word. Think how many trees have been felled, supplying thousands of pages, supporting millions of words, by legions of misguided souls — all in the belief that the idea is alive and well. Think how many political candidates — Republican and Democrat, conservative and liberal — repeated the error in the last election.

So feel free to pass this obit along to the uninformed. You'll be helping the environment, saving trees and eradicating public policy illiteracy — all in one fell swoop. Oh, and tell them Elvis is dead as well.

Comments (23)

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  1. Steve C. says:

    Great post, John.

  2. Nancy says:

    It is a nice post. But it’s hard to make the transition from Bach to Johnny Cash.

  3. Tom H. says:

    The belief that preventive medicine saves money attracts almost religious devotion. I have no idea why.

    Can anybody explain this huge departure from evidence-based medicine?

  4. Linda says:

    A great deal of generally accepted health care policy is a departure from evidence-based principles.

    So the preventive care religion isn’t a huge departure. Plus, lots of groups can get money for doing stuff that is easy, has little value, but sells really, really well to the politicians who fund it. How can you oppose more spending for preventive care for children and pregnant women without being labeled a monster, for example?

  5. [...] click here to see why John Goodman says “The idea that preventive medicine saves money is [...]

  6. Robert Blandford says:

    This is another instance of the classic, irreconcilable conflict between a procedure which is good for the individual, but is not cost-effective. These criteria are not the same.

    An expensive procedure can very often create more QALYs if spent differently, even if it is very effective for an individual. So it is often hard to justify spending tax dollars for such a procedure.

    We must never end up in a system where an individual is forbidden to spend their own money on such a procedure for themselves, for a relative, for a great but poor artist, for a friend, etc.

  7. James C. says:

    John:

    One item I wonder about is whether we focus a lot on some of the most expensive prevention, while not putting enough into the cheap stuff. For example, we put a small fortune into trying to get adults over 50 to have colonoscopies to detect colon cancer. This is a laudable goal. Yet, I have seen research indicating that there are some fairly simple colon cancer prevention tips out there. I have seen studies indicating that aspirin use reduces colon cancer risk. Here is an example:

    http://content.nejm.org/cgi/content/short/356/21/2131

    The same dirt-cheap aspirin that one may take for preventing heart disease and blood clots also appears to benefit the colon.

    I have seen similar evidence for other simple interventions that fall under the broader category of preventive medicine. However, while doctors will hound people about colonoscopies, you will almost never here one offer advice on other evidence-based prevention strategies. In many cases, cheap prevention is overlooked in a focus on more expensive detection.

    I must also really question how the abstract can lump “diet and exercise to prevent diabetes” as an intervention that costs more than it saves. How does not eating sugary junk food and taking a walk create undue costs? I am a diabetic and eating a healthier diet and getting some exercise didn’t create any costs. It saves me money because the healthier foods tend to cost less than the alternatives. One doesn’t have to join a health club to get exercise. I walk to work every day, which cost nothing.

    The article also seems to be mixing up “prevention” and “detection” as interchangeable. They are not so. A number of the screening tools mentioned detect the disease earlier, such as cancer, once you already have it. The goal is treatment at an earlier stage with higher survival odds. Some of these detection tools, like colonoscopies, may have a prevention role by trimming pre-cancerous polyps, but the primary role is detection – not prevention.

    The study also lumps in drugs used to manage a disease state such as hypertension or hyperlipidemia as “prevention”. Again, from a practical standpoint, you already have a disease. The drugs are prescribed to help manage the visible symptoms of it. To the extent these drugs are seen as “prevention” is that they might prevent the underlying high blood pressure, for example, from causing a stroke. But, the drugs don’t “prevent” the disease. They only, it is hoped, keep it from worsening.

    Immunization and pre-natal visits are true prevention strategies. So are diet, exercise, stress management, a reasonably clean environment (with potable water), etc., in that these items may actually prevent someone from developing the disease.

    I think it is not good thinking to lump prevention and detection in the same basket. As noted above, it may lead to overlooking doable true prevention strategies and the substitution of detection or disease-state management strategies as if they were actual prevention. It also will skew any attempt at rational cost-benefit analysis for prevention.

    If the majority of diseases in the nation are lifestyle related, then cheap lifestyle changes are still a logical course to advocate.

    While I agree that prevention is not a magical fix, some of it is extraordinarily cheap and effective. I just think we need to break it out into that which is true prevention, that which is disease-state or symptom management, and that which is actually disease detection.

  8. Malcolm M. says:

    Mr. Goodman,

    I would expect that most of us learned by the time we entered high school (if not much earlier) that there is no free lunch.

    While prevention does have a cost, I would like to know which people would say that they would prefer not to have the services because cost savings are low.

    The question may be more about trade offs and their costs and benefits.

    Interestingly, I have tried many times to explain to one of my friends in the U.K. why the U.S. healthcare system is so costly. I basically think it is because of many cost factors which are rarely balanced by savings. If everyone wants the services and they are accessible, then the costs will definitely be higher. Even insurers cannot control the costs. In this sense you are right, if we want the services, then there are the costs as well.

    What has always concerned me is that while there is no set amount of resouces that has to be used for health services, there seems to be no way to limit the resources or the growth either. Other countries have found ways to manage the costs but we have not.

    But, as Albert Einstein pointed out, describing a problem is not a solution.

  9. Jay H. says:

    John:
    The metaphor to this premise is that Russian roulette’ only kills 1 out of 6 people. I am a great example. Not everyone needs and health exam? Maybe not, but what if EVERYONE didn’t. Had I not gone to the doctor three years ago I would not have known my blood pressure (144/107 at the time) was high or that I even had a problem. My medical insurance plan did not cover wellness exams, so the cost was mine. But what of less health minded people? The fact that less than 10% of a given employee population even participates in wellness (my client data) raises the question of who (as participants) take advantage of wellness and what would be the true cost savings and risk mitigation be if the percentage of participants was closer to 100%. Mandating wellness and providing value based medicine would be far more cost effective than current employer sponsored plans with state and federal benefit mandates. How about tax credits for compliance to wellness plans with additional tax credits for patient compliance? It’s far more effective and still has room for the current health care delivery system. There is a cost to 100% compliance unless BMI parameters are established that waive “costly” participation, and even if you do that some risk factors can be missed, like mine, like the 28 year old woman in this year’s Turkey Trot, etc.

  10. Ralph F. Weber says:

    That’s why they stopped allowing people to have annual physicals in Canada.

  11. Bob Kramer says:

    Any knowledgeable physician knows that this is basically true.

  12. Steve Barchet says:

    Right on topic. Too many folks still adhere tightly to the conventional notion that “Healthcare equals Health and Well-being.” Were that so and the case. I don’t have an exact figure but I suspect that the total of HC services adds probably not much more than 20% or so to the store and stock of health of the U.S. population. The basics contributing to optimal attainable health remains the same but that’s not where the ‘real money’ and all those revenues and ‘rents’ lie.

    Getting the bulk of our fellow citizens to pursue diligently those basics of healthy living remains the far greater task if the real objective of healthcare services is optimal attainable health of the public. Reducing continuously and effectively the burdens of illness, injury, disability, and premature death is IMO the predominant working objective of Health and HC services — but so far I don’t see that in practice.

    Keep up all the wonderful work you and your colleagues do so well.

  13. Ralph says:

    When healthcare spending started its sharp upward trend in Canada, preventative care was one of the first things to go. In Canada, there are actually 10 different provincial plans, so each province has a certain amount of flexibility.

    John mentions that they have to pay to screen all the healthy people, which is where the “wasted costs” are. I was told that the bigger reason is that if they don’t diagnose it they don’t have to treat it. Some will die of other causes, some will become inoperable, and not need treatment, and in only a small percent of people do they actually catch it early enough such that they can recommend a more “cost effective” treatment.

  14. Marcy Zwelling says:

    [reply to Ralph]

    Population based preventive medicine has never been shown to be cost effective. If it were, P4P would be cost effective. Data demonstrates that doing mammograms every year in women from the ages of 40-50 rather than every other year (the old recommendation) cost $250,000 per year of life saved…. BUT… a mammogram costs the individual $75.00 (cash) … I just had mine.

    The yearly physical is NOT not cost effective. Think about it … why would you wait to examine someone, if they had an ongoing problem? Health is an ongoing “event”… we have a system that is financially driven… so we actually call it a physical and charge extra.

    Every year, I do an “update”… 90 minutes to catch up … to make sure that we have adequately addressed ongoing issues and that we are on top of things. It is not just a physical, we spend 70 of the 90 minutes talking and educating. Rarely if ever do I find something new during the exam.

  15. Ralph says:

    [reply to Marcy Z.]

    A major difference between a private and a public system is that in a private system they develop profitable options that are appealing, but not cost effective. Annual physicals are one of those things. It’s something you can see and use right away. Marketers feel that if people aren’t “using” their plan, they won’t see the value in it.

  16. Forrest Huggins says:

    You forgot one thing in your article. Prevention is no fun.

    Cigarettes: Chill you out.

    Beer: You can have a daily six pack without working out.

    Cheeseburgers: Taste better than veggie burgers

    Maybe Obama can just get us a Huey Lewis “New Drug.”

  17. Uwe Reinhardt says:

    I recall that the National Caner Institute in the early 1990s came out with a study reporting that mammograms for women under age 50 (or was it 40?) were not cost-effective in the sense John describes it. Therefore, the Clinton’s excluded mammograms for women under 50 (40?) from the mandated benefit package in the Clinton plan, although that plan (I still have a copy) explicitly stated up front that nothing in the plan would prevent any American from buying any health service they wanted (but not in the benefit package)with their own money.

    Whereupon then Republican Senatorial candidate Bernadine Healy, M.D., just retired as head of the NIH, published an op-ed piece in the Wall Street Journal accusing the Clintons of proposing to ration health care. Because the Wall Street Journal editorial page publishes generally only views with which the editors agree, I presume that they bought into that argument.

    And that explains why it is so hard to make sensible health policy in this country and why we spend as if there’s no tomorrow. Note that AdvaMed and Pharma succeeded in having the language in the stimulus bill this month changed from “comparative effectiveness analysis” (which might include a consideration of costs) to merely “comparative clinical effectiveness analysis,” to preclude cost-effectiveness analysis. To them John Goodman sounds like a Communist.

    More importantly, though, I do not believe that Johnny Cash was actually playing his guitar in the piece John posted. You can’t run your hand up and down the board so casually the way he does and get sensible tones out of a guitar. There must be a law against that kind of deception. Might this be the basis for a class action suit, to get our money back on the CDs we bought?

    Uwe Reinhardt

  18. Stephen C. says:

    Johnny Cash lip syncing his guitar? Say it aint so Johnny.

  19. Michael Antonovich says:

    STILL NEED TESTING. NOT ALWAYS APPARENT THAT ONE HAS AN ILLNESS.

  20. John Baden says:

    “Does preventive care save lives? Of course. Does it save money for some patients? Definitely. But the cost of screening healthy patients outweighs the savings on patients whose diseases are caught in their early stages. Preventive medicine is desirable. But there’s no free lunch.”

    I have no doubt you’re correct. However, consider the Park Service’s “Golden Age Passport”. It gives lifetime admission to the entire Park system for $10! Is the Park Service stupid? Strategic?

    I’d bet the latter. What are the attributes of those who buy the Passports? Not random for sure. Consider correlates with voting patterns. I’d guess the same variables hold for those using preventative care and think it’s likely that this has political implications highly relevant to health care reform.

    While efficiency may be a Schelling point, it’s hard to mobilize people to march under its banner.

    Just a random thought.

  21. To Screen or Not to Screen | Sean Khozin, MD, MPH says:

    [...] the actor, but the “father of health savings accounts”), writes the following on his blog: Does preventive care save lives? Of course. Does it save money for some patients? Definitely. But [...]

  22. Richard Stroup says:

    [Reply to John Baden]

    John B.,

    I think you are right. But if John G. is right too, about medical cost effectiveness as we both think he is, AND if he is effective in getting the word out, then the cost savings to private or publicly provided insurance, from streamlining the care package, will, IF AND AS his message is understood, begin to outweigh in buyers/voters eyes, the current “feel good” effects of all the unnecessary preventive care built into so many plans now. The world will, with education like his, become a better place.

    What you and I have done for so long, and John G. too, is to help make the real world safer for people proposing more efficient, honest and principled solutions. And he’s doing it, even as he fights the bad information we have all operated with for decades. You and I have been there and done that, sometimes alongside John G., as any good policy analyst does daily. Agreed?

    Yet what you said does help explain why we get some of the bad proposals out there–smart or instinctive politicians, but short-sighted and typically lacking the patience and perseverance to lead in the way as John G. is doing.

  23. [...] For the rationale of achieving cost control by this means, it is time to write an obituary, writes John Goodman. [...]