Proposals for reforming our countryâs dysfunctional healthcare system often emphasize that prevention can save us money, but the Washington Postâs David Brown cautions that it doesnât always work out that way. He notes that some interventions, like uniform childhood immunization and colonoscopies for men ages 60-64, are clear financial winners, either because they donât cost a whole lot or because they prevent diseases that are expensive to treat. But when it comes to reducing smoking and obesity, two of the big risk factors for the U.S. population, the answers arenât as clear-cut.
Smoking may be âthe most unhealthful thing a person can do,â but Brown points out that many smokers still make it to 70, and a 50-year-old male smoker with high cholesterol with untreated moderate hypertension has only a 25% chance of having a heart attack over the next decade. In other words, a lot of people in high-risk categories will survive without interventions, so the number of lives saved through prevention efforts is smaller than a lot of people expect.
The type of intervention and the target population matter, too. Brown gives two examples of interventions with very different cost-effectiveness figures:
Prevention can be expensive even when it doesn't involve taking drugs or undergoing procedures. Even giving information can be uneconomical. That's because giving information takes time, and the yield in terms of behavior change that leads to less disease is very low -- as anyone who has been told to eat less and exercise more knows.
For example, Australian researchers tried out a program in which general practitioners watched a video and read a booklet about how to help their patients lower their heart attack risk. The patients were then given a series of videos and a self-help booklet on the same topic.
How cost-effective is this instruction? When it is provided for women at low risk of heart disease, $9.8 million has to be spent for every year of life saved in the prevention of premature heart attack deaths.
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In just one example of dozens of cost-effectiveness studies examining strategies to reduce smoking deaths, a team of British researchers in 2002 calculated that providing brief counseling, nicotine replacement and the anti-craving drug buproprion to smokers would save one year of life for every $1,300 spent -- an incredible bargain.
I wonder how the Australian numbers would change if the intervention were offered only to women at high risk of heart disease â the expense per years of life saved would probably be a lot lower. And if the British researchers had only offered counseling, their expense would probably have been higher.
Then, of course, Brown points out that preventing obesity and smoking might contribute to our populationâs overall health, but it might not save money in the long run. He cites the PLoS One study published in February about lifetime healthcare expenditures. When researchers studies three groups â obese people, smokers, and âhealthy-living personsâ (non-obese nonsmokers) â they found that, due to differences in longevity, the healthy-living cohort actually had the highest lifetime health expenditure, and smokers the lowest. Smokers may require expensive treatments for emphysema and lung cancer, but many of them donât live long enough to get the other expensive diseases that often develop in old age.
Brown concludes, âPrevention can be a great investment, but itâs still an investment.â This is an important point for healthcare reformers to keep in mind. When we argue for more investment in healthcare, we have to be clear about what the costs and benefits will be. The costs will still be substantial, and in many cases, the benefits come in terms of quality of life rather than years of life. Making our population healthier is still a worthwhile goal, and a good use of money.
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"due to differences in longevity, the healthy-living cohort actually had the highest lifetime health expenditure"
I have to admit that when I read this in Brown's article, I had a bit of a "well, duh" response. And this overly simplistic view seems to skew the picture a bit.
What about average cost per year? More importantly, how do the lifetime costs of the health expenditure compare with the lifetime benefits of added years in the workforce and added productivity?
Granted, he ended the article by stating that the importance of human health needs to be weighed very heavily against the cost of health expenditures... but even if you look at it from a purely economic standpoint, it still seems like a very (overly) simplistic analysis.
The "obesity" bugaboo is also one of those infinitely elastic terms used to create whatever data someone desires. When they want to make it a big problem, they say that anyone more than a pound above a number is overweight, no matter how healthy the person is otherwise. The actuarial tables don't support the "stop eating and you'll live forever" theme; they do support the "stop smoking and you'll live longer" idea even though there are always genetic freak exceptions.
In the US, they push a number called the "body mass index" that sets weight totaslly arbitrarily. I am overweight, even though I have some muscle and work out 6 days a week, because my BMI (at 180 lbs) is 25.3, with a ceiling of 25. Based on that I get these "counseling" lectures via e-mail all the time from my health insurance provider. I finally told them that if they came to me again I was going to switch from salads and broccoli to Cheetos and Twinkies as my primary diet (even though I'm "too heavy", my cholestrol is 135)
I agree the that BMI often does not reflect reality. This hurts people like me, a female with a "high" BMI who is otherwise active, healthy, excellent diet, low cholesterol, low BP, etc. The index fails to observe that I wear a men's large hatsize, cannot fit womens' watches on my fat-free wrists, and wear a size 11 shoe--bone will always be more dense than other tissue.
Also, the philosophy of using prevention to save money should be recognized as having the intent to save money for the INSURER, only; the patient is irrelevant. Case in point: insurers will not cover the cost of shingles vaccine to patients under 60, even though fully half of shingles cases are to people under 60. But, shingles doesn't cost insurers much--a few office visits, some meds--and it's the patients who suffer the agony, the lost work time, the inability to care for themselves. So using healthcare policy as a way to save money sentences MANY to suffer the consequences.
Anyway you look at it, our system of healthcare in U.S. is completely dysfunctional, and has as its singular goal the maximization of profit-making. To pretend that it's about health "care" is slickly disingenuous.