By Kip Sullivan
Everywhere you turn these days, you hear someone saying prevention is a sure-fire way to reduce health care costs.
A doctor from the Mayo Clinic tells the Minnesota Health Care Access Commission, "If you decided to fund all preventive care, … five years from now … your health care costs will be lower."
Hillary Clinton announces, "Primary prevention can reduce costs."
This belief that prevention cuts health care costs has had a profound influence on the debate about how to solve the health care crisis. All three current presidential candidates declare they will cut health care costs with more preventive services.
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Here in Minnesota, two commissions released reports in February claiming that Minnesota’s health care costs could be reduced dramatically if only doctors would deliver more preventive services. In the last week of February, DFL leaders introduced legislation based on the assumption that prevention cuts costs.
But the research demonstrates prevention does not reduce costs. Here is how experts characterized the professional literature on preventive medicine in the Feb. 13, 2008, edition of the New England Journal of Medicine: "Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not."
There are several reasons why most preventive services don’t save money. One is that they are given to massive numbers of healthy people, but only a small fraction were going to get the disease anyway. A second is that preventive services are rarely 100 percent effective. The result: We spend lots of money providing preventive services to millions of people, but the savings from warding off disease in a tiny percentage of those people are too small to offset the cost of administering the preventive service.
Flu shots illustrate this rule. According a 2007 study, also published in the New England Journal of Medicine, flu shots reduce the risk of hospitalization for flu in the elderly from seven-tenths of 1 percent to six-tenths of 1 percent.
Hospitalization is expensive (it’s about $8,500 per episode for flu in adults over 50), so reducing hospitalization rates even by one-tenth of 1 percent saves a lot of money. But flu shots are not free (they cost about $25 a shot). Vaccinating all 40 million of the country’s seniors would cost us about $1 billion. We would save about one-third of a billion in reduced hospitalization costs, which means total health care spending would rise by two-thirds of a billion.
The moral of this story is not that prevention is a waste of money, but that we should do prevention to minimize human suffering, not to save money. (If we count savings from improved health generated in the work place, the odds that preventive medicine will generate a positive return on investment goes up. But that’s a different rationale. The rationale I’m addressing here is the argument made that prevention saves money within the health care system.)
The rule of thumb that prevention does not save money applies as well to a close cousin of preventive medicine known as "disease management." Whereas preventive medicine generally refers to services given to people who don’t have a disease, "disease management" refers to educational and monitoring services given to people who already have a disease, typically a chronic disease like asthma, diabetes, or cancer.
Research indicates that a few types of disease management save money (management of congestive heart failure is an example), but most don’t and some raise costs.
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Here is how a review of the scientific literature published last December in the American Journal of Managed Care characterized the current evidence: "(T)he results of our review suggest that, to date, support for … disease management is more an article of faith than a reasoned conclusion grounded on well-researched facts. Evidence for the effect of disease management: Is $1 billion a year a good investment?"
The myth that prevention and disease management cut health care costs persists in part because insurance companies peddle the myth to enhance their sales. They tell their customers that they are experts at delivering prevention and disease management services, and these services save money.
But those claims are false. Insurance companies are not experts at preventive medicine (or any other type of medicine, for that matter), and in any case prevention and disease management don’t save money. We must look elsewhere for a solution to the high cost of health care.
Sullivan is the Health Systems Analyst for the Greater Minnesota Health Care Coalition. He is a 1965 graduate of John Marshall High School. Send comments to letters@postbulletin.com
