HEALTH CARE: Just What Do We Mean By Prevention?
At a meeting we attended about health reform the other day, one side of the room was saying of course prevention saves money and the other side was saying with equal certitude that of course prevention doesn't save money. (Forget the irony that we were having this discussion over a pizza lunch. With no salad.) A lot of other people are having this debate, and we attended a helpful panel discussion recently sponsored the Alliance for Health Reform.
We'll grant that if you look, you can find good solid economic arguments that prevention (depending on how it's defined, but more on that in a minute) doesn't save money. At least it doesn't save money in the five- or 10-year budget windows that Washington is used to talking about (and which legislation must be measured against). Economist Louise Russell has been writing about this for years, and her widely cited article earlier this year in Health Affairs (and a shorter version on the Hastings Center blog) makes that argument. Note she is not saying prevention isn't a good thing; she's saying it isn't a "money-saver," strictly defined.
But you can find good solid arguments, too, that prevention and wellness does save money, and can save it quickly. A number of major corporations—Intel, Pitney Bowes, IBM, to name a few—report a high return on investment within a few years (sometimes sooner). They have taken a variety of steps—incentives for diet and exercise, tobacco-counseling, health screenings, no-copay screenings—that are producing a healthier workforce at lower cost.
As they say on Facebook... It's complicated. Let's break it down.
- How are we defining prevention?
Does prevention mean medical screenings for everybody that lead to uncertain or ambiguous findings that lead to more tests for things that (for most patients) will turn out to be nothing? Mammograms starting at age 40? Or at 50? Until when? Colonoscopies from 50 through old age, or one colonoscopy between the age of 60 and 64? Diabetes screenings for everyone at 65, or only for people with certain risk factors?
Genetics and other advances in personalized medicine may eventually help us target screenings better. In the meantime, it is true that some of these interventions across an entire population will cost money because we are screening everybody, not just the relatively small number who will eventually get sick. But it will also save lives.
Or is prevention something other than screenings? Is it immunizations? Schools that get rid of soda machines and serve fruit with lunch? Anti-smoking campaigns? These steps can save money.
Is it medical homes and a robust primary care system that can take time with patients so they can stay well, or detect diseases at earlier manageable and sometimes reversible stages? That can save money.
Is it making sure we have healthy schools and healthy neighborhoods, so kids get time to run around during recess, and communities have sidewalks and bike paths, and grocery stores open in poor neighborhoods that currently have little access to healthy fresh fruits and vegetables. The Robert Wood Johnson Foundation's Commission to Build a Healthier America (which we've written about several times over the past year) has made recommendations for a healthier society that reaches well beyond health insurance. Screening can be important, but it's not the only way we keep well.
- Are we confusing prevention and disease management?
Keeping an 80-year-old with five chronic conditions out of the hospital is not "wellness." It's "less sickness." We need to learn how to do this better—it's where most of our health dollars go. But let's not confuse managing disease toward the end of life with preventing disease at the beginning (or middle...)
- How are we defining savings?
Is it a number that shows up within a five- or 10-year budget window that CBO can score? What about savings that will show up 20 or 30 or 40 years from now? If you stop a child from getting fat, or a teenager from smoking, it may not save money next year or the year after that, but it can make a huge difference down the road. Bill Frist, of all people, has made this message a current mission of his.
- What if the savings aren't found only in the health care system?
How about if they reduce absenteeism and increase productivity in the private sector work force, as some businesses have found? Or if an intervention, like having a nurse educator work with high-risk families during the first years of a child's life ends up saving the juvenile justice system money 15 years down the road? It isn't saving Medicare or Medicaid money, but it's certainly saving money. (And improving lives.)
- Will the obesity crisis change the math?
The jury is still out, but we are getting so fat, so fast, so young, that the costs (of diabetes and cardiovascular diseases) are rising so fast that it might change the prevention cost calculus sooner than we'd like. Dr. Steven Woolf of Virginia Commonwealth University, at a recent conference on prevention and cost sponsored by the Center for Health System Change, cited estimates that the obesity epidemic, linked to diabetes and cardiovascular disease, could raise health spending by some 30 percent.
- Why do we ask prevention to prove its worth, but we don't ask whether certain brand name drugs, or high-cost tests and surgeries save money?
In fact, if we even talk about studying or comparing cost benefits, we get a screed about government bureaucrats and socialized medicine. (We aren't bothering to link, you've heard it...But if you have somehow not noticed, you can start with the Wall Street Journal editorial pages or those Republicans, mostly but not only in the House, who recite Frank Luntz's talking points.)
- The last point we want to make here—When we discuss prevention, should we be talking less about savings and more about value?
The public strongly favors prevention (maybe telling a pollster they want to spend money on wellness assuages the guilt of a couch potato nation). Health reform isn't only about financing. It's about better health. And that is something that we all can value.