Does prevention save money? That is, does increasing access
to preventive health care, doing more screening tests on a larger number of
people, end up saving more money in the long term by reducing the cost of
caring for the diseases that are prevented? This is the question asked in “Conventional
wisdom clashes with data on health care savings”, by Margot Sanger-Katz in
the New York Times on August 7, 2015.
Ultimately, she answers “no”; indeed, in the online version dated August 5 that
the link above takes you to, the article is titled “No, Giving More People Health Insurance Doesn’t
Save Money”. Although it of course depends upon which preventive test we
are talking about; “Counseling on contraception is one [of the preventive interventions that
actually do save money] because the costs
of prenatal care, delivery and pediatric care associated with an unplanned
pregnancy are so substantial. But a lot of the preventive health measures that
we tend to value a lot — mammography, screening for diabetes — tend to cost
more than they save.”
The motivation
for this article at this time is clearly the Affordable Care Act (ACA), which
not only resulted in more people receiving coverage but mandated that
preventive services be covered with no co-pay. President Obama made the case
for it in part by talking about cost savings; Sanger-Katz quotes his 2009
address to Congress: “There’s no reason
we shouldn’t be catching diseases like breast cancer and colon cancer before
they get worse. That makes sense, it saves money, and it saves lives.” But, in fact, the discussion on the cost vs
cost-saving from preventive services is not new; it has been frequently
addressed in the literature. I have written about it several times, including
two sequential posts on February 2 and February 9, 2009: Prevention
and Cost and Economics
and Disease Prevention, that cited two important articles on the topic, by
Russell in Health Affairs[1]
and by Woolf in JAMA.[2]
Sanger-Katz also cites two studies to support the argument,
one old and one more recent. The famous RAND health insurance
experiment from the 1970s and 80s that examined the impact of providing
free (to the patient) access to health care, and the more recent Oregon health insurance experiment,
begun in 2008, where poor people who were not already on Medicaid were
lotteried into receiving health coverage or not. As she notes, in both studies,
people who got free or low-cost coverage used more care, and thus cost more
money. This, she notes, is consistent with basic economic theory, and ”…follows the pattern for nearly every other
good in the economy, including food, clothing and electronics. The cheaper they
are for people, the more they are likely to buy.”
But, while true, this misses the most important point. I
have written about both studies before, I discussed the RAND study in Insurance
company profits up and patient care down, May 11, 2011, and also refer to
it in my discussion of Oregon, The
Oregon Lottery: Far from enough, but at least they are doing something,
July 19, 2012. In the latter, I quote from a June 22, 2012 New York Times article by Annie Lowrey, “Oregon Study Shows
Benefits, and Price, for Newly Insured” that the study “has found that gaining insurance makes people feel healthier, happier
and more financially stable,” and that “The
insured were 25 percent less likely to have an unpaid medical bill sent to a
collection agency and 40 percent less likely to borrow money or skip paying
other bills in order to cover their medical costs.” This is the truly
important point; people are getting medical care that they need, and are not
having to cut back on their other basic needs (remember, these are poor people who don’t have lots of
discretionary income) to do so. It echoes the findings of RAND, which were
basically: yes, people who got free health care used more care, and indeed used
more care that experts considered “inappropriate” (the classic “going to the ER
for a cold” trope). But it also found that, and this is the real take-home
message, they used more appropriate care;
the corollary trope is going to the ER for chest pain, instead of staying home
and hoping it would go away because you’re afraid to incur the cost. Free
health care not only saved lives, it improved health.[3]
Ultimately, as Sanger-Katz points out, everyone dies. While
provision of preventive services may save lives from one disease “…every
time you prevent people from dying from one disease, they are likely to live
longer and incur future medical expenses. The patient who benefits from the
cholesterol screening may go on to develop cancer, arthritis, Alzheimer’s or
some other costly illness.” This may seem obvious, but only if you think about it. In the 1980s, I was
the only physician student in a class on Health Administration; the other
students were planning on being health administrators but did not have a
medical background. In one class, a student reported that we were likely to
save money in the future because people were adopting healthier lifestyles –
eating better, exercising more, not smoking as much. I pointed out that the
opposite was true; this would mean people lived longer, and were more likely to
develop long-term chronic diseases leading them to, for example, long
hospitalizations and nursing home stays. If you truly wanted to save money,
you’d encourage a high-cholesterol diet, no exercise, and 2 packs of cigarettes
a day, so everyone would drop dead from a heart attack in their late 40s and be
done with the cost.
This may sound macabre, but the point it makes is that cost
is not the only issue. Examining the cost of providing free health care, as in
RAND 40 years ago, or free preventive care, as in ACA, is a legitimate
activity, but it is not the only, or even most important outcome. Access to
health care, prevention of premature death, and improvement in quality of life
are also critical considerations. Cost is important, but cost control cannot be
measured in such crude ways as “does prevention save money”? First, as
Sanger-Katz noted, different preventive services have stronger evidence behind
them, and have a smaller “number needed to treat” (NNT) to have an impact on
either cost or lives saved or quality of life (thus a high priority should be
expanding access to contraception and contraceptive counseling). Second, there
is the expansion of indications (reasons for doing a test), either through
providing preventive services to a larger group of people than those shown to
have the most benefit in studies, or by ratcheting down the “goal” for things
like cholesterol, blood pressure, or blood sugar. These both have the same
effect; they decreases the average long-term benefit while increasing the cost
(and, not coincidentally, the profits for the manufacturers of the drugs and
purveyors of the tests).
Third, and by far the most important in terms of both cost
and justice, is the application of different standards to different
populations, based on insurance status, wealth, and race. Performing preventive
services for people who are unlikely to benefit is a problem, but performing
much more expensive interventions for people who almost certainly won’t benefit
just because they want them, and they (or their insurer) can pay for them, and
because the providers doing them make money, is a far greater issue for cost.
In addition, there is the question of “what is a fair price?” for any service,
preventive or therapeutic, indicated or not (well, if not indicated, the fair
price is zero!). In The
high cost of US health care: it's not the colonoscopies, it's the profit,
Jul 28 2013, I cited the work of Elisabeth Rosenthal of the New York Times, on this topic; she
presents the wide variation in costs for this and other procedures. Thinking of
the myriad types of preventive interventions as if they were all the same and
of the same value is like thinking of “cancer” as one disease, rather than
hundreds; it is simple and it is incorrect.
Ultimately, the cost issue is addressed by equity. Everyone
should have access to all interventions that are likely to help them, and no
one to those that will not.
[1] Russell,
LB, “Preventing chronic disease: an important investment but don’t count on
cost savings”, Health Affairs, Jan/Feb 2009;28(1):42-45
[2] Woolf
SH, “A closer look at the economic argument for disease prevention”, JAMA
4Feb2009; 301(5):536-8. (9th)
[3] Brook
RH, et al., “Does Free Care Improve Adults' Health? — Results from a Randomized
Controlled Trial”, N Engl J Med 1983; 309:1426-1434
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