Thursday, July 2, 2009

Asking the Right Questions About Prevention

The following is a guest post from Partnership for Prevention President Robert J. Gould, PhD, and Executive Vice President Corinne G. Husten, MD, MPH., that appeared on the blog for the Robert Wood Johnson Foundation's Commission to Build a Healthier America.

When the answer is that living longer is a problem, you know you’re asking the wrong question.

The Congressional Budget Office recently issued a memo identifying areas where Congress could save money in a health reform bill. When it came to disease prevention and health promotion, the logic in its response was troubling.Promoting healthier lifestyles may help reduce the prevalence of costly chronic diseases, the CBO said, but the "overall budgetary effect also depends on the cost to the government... by people who live longer." It said such people could cost the government more in terms of health care costs and Social Security payments generated during their additional years of life.

Too often, the notion of investing more in prevention is being summarily dismissed on the grounds that prevention “doesn’t save money.” Such assertions have been repeated of late by articles in CQ (here for subscribers) and The Wall Street Journal. Those critics are asking the wrong question, and the answer to that question turns logic on its head. The proper question should be: what gives us the most bang for the buck?

Here are the facts: some preventive measures save money, while some don’t. Some medical treatments cost more than others. In each case, some are more effective than others in terms of improving health. But those facts should not result in a blanket dismissal of prevention. Even when preventive measures cost money, they offer tremendous benefits at a relatively low cost.

Partnership for Prevention conducted an extensive review of clinical preventive measures – those that can be performed in a doctor’s office. We found five measures that, if used more broadly, could altogether save an additional 100,000 lives a year. Three of those measures – daily aspirin use, tobacco cessation counseling, and colorectal screening – actually save money as well as lives. The other two – flu immunizations for older adults and breast cancer screening – save lives and are still more cost-effective than most medical treatments. Even so, all of those preventive measures remain under-utilized, due partly to lack of public awareness and partly to deductibles, co-pays and lack of coverage that can discourage clinicians from recommending those services and discourage patients from having them performed.

In a separate study, we reviewed the 25 preventive services recommended by the US Preventive Services Task Force. It found that six of them actually saved money, while 12 were highly cost-effective in that they cost less than $50,000 for each year of life saved. That compares with an LVAD device that helps keep alive heart failure patients who can’t get a transplant – which costs $900,000 per each year of life saved.

As for helping people live longer, prevention pleads guilty as charged. But should we really put proponents of prevention in the Orwellian position of apologizing for helping people live longer, healthier lives? Expensive medical treatments for people who are already sick also help people live longer. But isn’t that the whole purpose of our health care system?

Our current system doesn’t provide value, as evidenced by our low ranking in health status among industrialized countries. But prevention can help change that, because prevention provides great value. The investment to cover and pay for preventive services produces tremendous returns, and providing and increasing utilization of these services will create a much more efficient health care system.

Meanwhile, private-sector companies are reporting phenomenal results from implementing science-based wellness and prevention programs in the workplace. Safeway CEO Stephen Burd said in a recent Wall Street Journal op-ed that the wellness program his company started in 2005 has kept its health care expenses flat while those expenses increased by 38 percent nationally. Dow Chemical Company says that its wellness program saved the company more than 9,000 employee absentee days last year alone and had a return on investment that was equal to seven cents a share of company stock. Pitney Bowes estimates that its health promotion initiatives have saved the company $40 million over nine years.

Perhaps that’s why a recent survey of Americans by the Trust for America’s Health and the Robert Wood Johnson Foundation showed that 77 percent of Americans believe prevention will save money. Even more importantly, it showed that 72 percent of Americans favor increased investment in prevention, even if it didn’t save money.

It’s critical that we conduct widespread cost-effectiveness research to find out what delivers the most health at the least cost are critical. Prevention measures should be a part of that research, so that we can find the way in which our health care system can make the most effective and the most efficient use of both prevention and treatment services. In the meantime, we hope Congress will increase the nation’s investment in high-value preventive services that help people live longer, healthier lives.

Is prevention a “panacea for cost savings?” No, but that’s not the question. The real question is: is prevention a proven, cost-effective way to improve our health and our health system. The answer to that question is “yes.”


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