- Ancient proverb
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“About 95 percent of our plans are similar. We both set up a government plan that would allow people who otherwise don't have health insurance because of a preexisting condition, like my mother had, or at least what the insurance said was a preexisting condition, let them get health insurance. We both want to emphasize prevention, because we've got to do something about ever escalating costs and we don't want children, who I meet all the time, going to emergency rooms for treatable illnesses like asthma.”
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"We're going to make sure that we reduce costs by emphasizing prevention."
- Sen Barack Obama, Democratic Debates, 21 Feb 2008
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What does this line really mean in the health care debate: “We both want to emphasize prevention, because we’ve got to do something about ever escalating costs…” Would “prevention” have prevented Sen Obama’s mother’s pre-existing condition? Of course not. So why do we hear this?
Simple: because it sounds reassuring. It'll all be handled. Really it will.
But do "prevention" programs really reduce costs to our health care system? Can people with cancer or heart disease or pneumonia or multiple sclerosis “prevent” their disease? Can people “prevent” getting older? Can all accidents be “prevented?” How about arthritis or diabetes? Can we prevent their onset? Can government force people to eat less or stop smoking? Would we want this? Or in the case of the much ballyhooed genetic testing – can people really “prevent” a genetic disease from developing? As a doctor, I’d love to prevent all disease that afflicts man, but I know this is impossible. I rarely see patients until they have a problem - people just don’t want to think they could become sick.
But new “prevention” initiatives are underway by healthcare insurers who “reward” (bribe?) their policy members with financial incentives to participate in weight reduction classes and to stop smoking. We are told this will keep costs down. But the overall benefit to reducing costs to our healthcare system has not been clearly demonstrated. On the contrary, a recent study in the obese evaluated the lifetime costs of this disorder and concluded that although annual health-care costs are highest for obese people earlier in life (until age 56 years), and are highest for smokers at older ages, the ultimate lifetime costs are highest for the healthy (nonsmoking, nonobese) people. Hence the authors argue that medical costs will not be saved by preventing obesity. Could it be that cost savings are actually for the insurers who identify those “at risk” as defined by their industry’s own actuarial tables rather than real data?
Even with heart disease, we are now questioning the low LDL hypothesis and the use of statins as a means of improving myocardial infarction outcomes through lowering LDL levels in the blood. Certainly, most clinical cardiologists and primary care physicians do perceive that there is a reduction in the number of large Q wave myocardial infarctions recently. But why? Is it the statins? Or is it the implementation of anti-smoking legislation? Perhaps it’s because people are thinner. Or are they? It certainly couldn’t be because people are fatter – or could it?
Huge monies are involved in promoting therapies and testing for prevention. Companies need to “get the word out” to sell their wonder drugs and scanners. Nowhere is this better illustrated than the marketing of Gardasil by Merck to “prevent” cervical cancer. While the drug is good for specific forms of preventing cancerous precursors caused by the human papilloma virus, it is not perfect, since it immunizes for only four strains of human papilloma virus (6, 11, 16, and 18). But in an attempt to achieve perfection, boys are being considered as potential recipients of the vaccine – all at significant cost to our healthcare system. How many other viruses should we be similarly immunizing against? What would the cost be to our society?
What is clear is that programs and tests to perform “prevention” are consuming huge health care dollars – from advertising, marketing, frequent doctor visits, early CT scans, carotid ultrasounds, lipid monitoring, mammography, colonoscopy, genetic testing – all of these are expensive (and becoming more so). Just diagnosing something earlier – does that save healthcare costs or increase them overall? Early diagnosis might prevent later complications of disease, to be sure. But it might also increase the contact with the healthcare system and extend expensive treatments. Early diagnosis also provides a convenient means for insurers to deny a patient coverage if they change jobs. This might save the insurers costs, but the patient? Will this activity ultimately save overall healthcare costs or increase them? Also, additional earlier diagnosis might prolong the time until a definitive surgical cure takes place – adding additional follow-up costs. Finally, in the case of the dying, isn’t death remarkably economical to our healthcare system?
So before claiming that “prevention” programs will be our way of controlling healthcare costs, we should stop and ask if these programs save money or waste it. To do otherwise will doom our healthcare system to continued escalating costs in the name of "prevention."
Remember, when it comes or promising "prevention" programs as a means to save healthcare costs: Primum non nocere. (First, do no harm).
Reference: Cohen JT, Neumann PJ, and Weinstein MC. Does Preventive Care Save Money? Health Economics and the Presidential Candidates. New Engl J Med 14 Feb 2007; 358 (7): 661-663.