Posted by: notdeaddinosaur | August 10, 2010

One More Time: Preventive Care Doesn’t Save Money!

I like reading Maggie Mahar’s Health Beat. She usually gets it, from the function of insurance to the complexities of assorted payment systems, I get the sense that she is generally rational when it comes to paying for health care. This doesn’t mean there aren’t times when she gets it wrong. Her embrace of primary care provided by nurse practitioners shows a truly spectacular lack of understanding of what primary care really entails. Still and all, most of the time I find her remarks pretty much on target.

That was the case for the bulk of this post, in which she discusses the “individual mandate” part of the health care reform bill, and explains succinctly and clearly the concept of “insurance”:

The very idea of health insurance is predicated on the notion that none of us knows who will be laid low by accident or disease and when. The great advantage of insurance is that it spreads the risk over a large group of people exposed to the contingencies of fate. It is worth remembering that most disease and injuries can be traced to the accidents of one’s gene pool (accounting for 30% of premature deaths), social circumstances (15%),  “environmental factors”  (such as air quality where you happened to grow up) (5%) , or being in the wrong place at the wrong time, whether on the highway, playing a sport, riding a horse, or crossing a street.

Unfortunately, she goes astray in the very next paragraph:

By paying premiums, we also “pre-pay” for the routine care that we all need. This, too, serves a larger social good. If we ensure that everyone has access to preventive care, with no co-pays (something the new law guarantees), it is less likely that someone will need long-term acute care at some point in the future—treatment that the rest of us would wind up funding through taxes, higher insurance premiums or higher hospital fees.

No, no, no! The idea that preventive care finds medical problems early, treats them more cheaply and effectively than if they weren’t addressed until symptoms appear, and saves money in the long run is attractive, intuitive, and WRONG!!

Not only that, but which medical services should fall under the label of “preventive care” (the recommendations of the USPTF seem to be routinely ignored) remains the subject of bitter debate. The need for annual physicals, mammograms, and PSA testing have all been debunked.

The American mentality of “more is better” drives much of the demand for the so-called “Executive Physical”. Annual EKGs, cardiac stress tests, and extensive panels of “screening” blood work is wasteful and expensive. We’re going to go bankrupt in a hurry if this is what people are led to expect from health care reform’s “routine care” (without co-pays or deductibles to boot!)

Don’t get me wrong: I think preventive care is important and valuable in terms of adding productive years of life. But unless you widen your perspective to include the wages earned and taxes paid by those who have benefited from those extra years, you won’t see actual monetary savings. It’s similar to why insurance companies can get away with paying for all the maternity care you want, but not birth control. The reason is that the overall cost of a baby is far more than just the maternity care, as well as dwarfing the cost of the birth control. The financial benefits of preventive care don’t show up on the medical ledger.

I agree with Maggie that the individual mandate is a necessary step towards the provision of reasonable health care for everyone. But I wish she and all the other health care wonks would recognize the fallacy of preventive care as a cost saving measure. Preventive care increases health, happiness, and productivity. But it doesn’t save money.

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Responses

  1. Hi-

    Thanks for your kind words about HealthBeat.

    On preventive care: first, by preventive care I mean the care recommended by the USPTF. (Under the reform legislation this is generally the standard.)
    I’ve written a number of posts about the risks associated with mammograms and PSA testing and the research suggesting that annual physcial provides no clear benefits.
    On the question of whether preventive care saves lives, it is true that people who receive good preventive care likely to live longer– long enough to develop Alzheimer’s, or a form of cancer that does not kill quickly, and which they wind up battling for many years.
    This is wipes out the savings from preventive care.
    On the other hand, if you include chronic disease management in preventive care, if a diabetic’s disease is managed and he avoids blindness and amputations, and ultimatelyl dies of a stroke while sleeping at age 75, the management of his disease probably saved money.
    (Assuming he didn’t require acute care for another disease in his sixties or early 70s.)
    Finally, short-term, preventive care can save money. And, as we enter a period of health care it woudl be very helpful if preventive care and chronic disease menagment keeps people out of hospitals.
    It’s not just the cost of hospital care, but the risks (errors, complications, infectoins) that really add to our healthcare bill.

  2. Hi-
    I didin’t mean to make the comment above anonymous–just forgot to fill in my name . .

  3. Maggie:

    “..it is true that people who receive good preventive care likely to live longer.”

    No! That is exactly the kind of “self-evident” truism that hasn’t actually been proved anywhere.

    When actually studied, it turns out the best ways to live longer are to avoid smoking and dangerous activities, maintain an active lifestyle and an ideal body weight, and, ideally, come from long-lived parents. Whether or not those count as “medical care” depends on definitions (counseling, etc), but can certainly be accomplished without ever darkening a physician’s door.

    “Finally, short-term, preventive care can save money.”

    Again, this is an evidence-free statement. In point of fact, it would cost far less to treat every case of advanced colon cancer than it would to do a colonoscopy every 10 years on everyone over 50. I’m not saying this would be a good idea. Preventive care increases health, happiness, and productivity. But it doesn’t save money.

  4. Preventive care can save money.

    The NEJM article you link to rather addresses the need for more research on cost-effectiveness ratios and for example more specific targeting. In fact, it warns against broad generalizations on cost-effectiveness of prevention, yet you almost seem to do so 😉

  5. It would be more accurate to say that very few preventive care measures actually save money, because the NEJM article you linked to indicates that a few do. Pediatric immunization may be the major outlier here, reported as saving over $16 for every $1 spent (Zhou et al. Arch Pediatr Adolesc Med. 2005 Dec;159(12):1136-44.)

    Many of these arguments about saving money annoy me because I don’t think the point of health care is to save money. Withholding health care from everyone would save us a fortune, were that our most important goal.

  6. Sometimes preventive care saves money; sometimes it doesn’t. “Preventive” and “screening” also tend to be incorrectly conflated; they are not, in fact, the same thing.


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