Why Preventive Medicine Can Be Harmful To Our Health

Posted on February 2, 2009
Filed Under General Rationing Issues |

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Not all the strenuous efforts being put forth by our political leaders, to convince us that they know how to avoid healthcare rationing, rely on eliminating waste and inefficiency. Some of their efforts, instead, rely on instituting robust preventive medicine services.

It is inarguable, they argue, that preventive medicine will reduce costs. To even a simpleton it should be beyond question that preventing a disease must be far cheaper than letting the disease happen, and then having to pay for its treatment.

Here is how our leaders propose to accomplish preventive healthcare. First, they will re-invigorate primary care medicine, by some unspecified means, and under this renewed system the practitioners (who ideally will be some flavor of professionals inherently more malleable and compliant than the doctors who have now been, successfully, all but driven from the field) will cheerfully follow the evidence-based prevention tools du jour. Those new tools, which presumably will be thought up by one or more of the endless health policy think tanks, and blessed by Mr. Daschle’s Fed Health Board, (DrRich: Don’t you read the papers? - ed.) may employ disease management, pay for performance, medical homes, guidelines and flow charts, and other, more modern marvels of efficiency. Whichever tools are finally enlisted to implement appropriately-selected preventive measures in primary care practices, they will lead, as the night follows the day, to a healthier, happier, and above all, cheaper populace.

It is permitted that we may disagree on how to accomplish preventive healthcare (Mr. McCain’s plan for doing so was different from Mr. Obama’s, for instance), but it is not permitted for us to question, in political or policy circles, whether prevention actually will save money. Republicans, Democrats, conservatives and liberals are all on the same page here. The dogma is universal.

Now to be sure, there have been several papers in the peer-reviewed medical literature which have called this dogma into question, and similar articles in some of the health policy literature.  But these dissenting voices carry no more weight than the voices of numerous healthcare economists and medical ethicists who have declared that healthcare rationing is unavoidable, or of those environmental scientists (or those people who have looked out their windows over the past month) who say that global warming is exaggerated. Such fringe points of view, whether on rationing, global warming, or preventive medicine, are simply ignored by those who control the political and media agendas, and are not open for consideration.

So: Instituting preventive medical services will help save our healthcare system’s runaway cost structure. Anyone who says otherwise is undeserving of our attention.

What we can see from this synthesis is that, under our new paradigm of universal healthcare (which, as readers will know, DrRich accepts as a given), the fundamental purpose of preventive medicine has been changed. Preventive medicine was originally invented to prevent medical problems. Its purpose now is to save money.

But in truth, we should not need brave dissenting voices, nor expensive randomized clinical trials, to convince us that preventive medicine sometimes will not save us money, and that, indeed, sometimes preventive medicine will be quite expensive.

Fundamentally, it costs money to prevent anything you may want to prevent.  Indeed, it is trivial to note that whether you save money in the long run depends on four variables:

1) how much it costs to administer the preventive measure,

2) how effective the preventive measure is in actually preventing the target condition,

3) the cost of the target condition, should it occur, and

4) whether preventing the target condition results in the patient having more time to consume healthcare resources for their other medical conditions.

Variable #4, in particular, is rarely discussed in polite circles, but it is important. Take, for instance, sudden death. Preventing sudden cardiac death, even if it were cheap to do so (which, given the cost of implantable defibrillators, it decidedly is not), would be very expensive for society. People who experience sudden cardiac death almost always have significant, chronic, underlying heart disease, and if we prevent their sudden death they would likely live for several extra years, during which they would continue consuming costly healthcare resources (not to mention Social Security).  They would finally die only after the healthcare system purchases for them a typical full-court press in an expensive ICU. When you compare this more standard variety of cardiac death to simply dropping dead at the bus stop, then sudden death can readily be appreciated as a clean and inexpensive modus exodus, and preventing it as bad public policy.

One could even extend this observation to smoking. Smoking cuts off 3 - 4 years of life, on average, during which the individual would otherwise be consuming lots of Medicare and Social Security dollars.  Furthermore, smokers have an increased risk of sudden death (which, we have already established, is a positive thing for our healthcare budget) and lung cancer (which is often refractory to treatment, and as chronic diseases go is a relatively short-lived one), so on the whole the smoker’s demise may be somewhat cheaper than average. Earlier and cheaper. That’s a good thing. Add to this the exorbitant tobacco taxes smokers pay into society’s coffers their whole lives, and then tell DrRich that expensive smoking cessation programs will be cost effective.  It is perhaps only because such programs usually fail that the healthcare system can continue tolerating them.

Admittedly, DrRich offers the cost-ineffectiveness of preventing sudden death and of smoking cessation at least partly to point out the amusing irony of it all. But there’s a more serious point to be made here.

We appear headed toward a healthcare system in which our leaders will insist that: a) all useful healthcare is to be covered; and b) all preventive measures that reduce disease will also reduce the cost of healthcare.  From these foundational principles, it becomes clear that if the system declines to cover a preventive service, the only allowable interpretation will be that the forbidden preventive service is ineffective (and not that it increases the cost of healthcare). Furthermore, since the forbidden service is indeed healthcare, but since for a very good reason (i.e., lack of sufficient efficacy) it is not covered by the universal system, then it ought to be illegal to purchase that service outside the healthcare system. (While it is not yet settled that purchasing healthcare outside the system is to be made illegal, DrRich has posited that this outcome is likely.)

In other words, a universal healthcare system that restricts the individual’s prerogatives, combined with the dogmatic view that all preventive services will save money, will necessarily render at least some very effective, but cost-ineffective, preventive services relatively if not entirely unavailable. The implantable defibrillator is one obvious example. A new miracle drug that reduces, say, the risk of heart attack, or breast or prostate cancer, but only at a very high cost, would be another example.

What may be less obvious is that some preventive services that are prohibitively expensive for society would be quite affordable for the individual.  Highly effective preventive measures are common in everyday life. We buy them routinely and without complaint. But many of these preventive measures, if they were subject to the kinds of calculations we use to assess cost effectiveness in healthcare, would immediately be seen as far too expensive.

The cost per life-year saved with airbags is estimated to be $1.6 million.  The reasons airbags are OK despite such an inefficient use of preventive dollars is that we pay for them ourselves, as individuals. To you, it may seem a good bargain to buy a car with airbags all around, since the potential of saving the lives of your family is easily worth a few hundred extra dollars. But when we insist on paying collectively for preventive measures, the calculus completely changes.  For society, buying you airbags amounts to spending $1.6 million for each of your family members whose lives are saved. It would be completely and unarguably irresponsible for society to do so.

So if some government program were responsible for buying the everyday preventive measures we cheerfully accept (and pay for) as a matter of course - smoke detectors, carbon monoxide detectors, shin guards and airbags -  such measures would immediately become far too expensive. Now, if that government payment plan also operated under the same dogma that currently binds the healthcare system (the dogma that effective prevention always reduces costs), they would have to tell us something other than that they don’t wish to pay for this obviously effective preventive tool. Likely, they would tell us that airbags really don’t work so well after all (stressing, for instance, as the media did so vociferously a few years ago, the potential hazards of airbags), and further, for this reason they have to make airbags illegal.

Some preventive healthcare will take on the same characteristics as airbags - they will be highly effective at preventing some negative outcome, economically affordable for much of the population on an individual basis (especially considering the cost to the individual if they were needed but not present), but extraordinarily expensive on a population basis. The cost-benefit calculation, in other words, makes perfect sense to the individual, but not to society.

Such preventive measures will have to be disallowed by our universal healthcare system, as they will greatly increase overall costs for relatively little overall return. That would be fine if the individual could still purchase the preventive service themselves, after making their own, individual cost-benefit assessment. But the dogma we now embrace (that we cover everything that works, and everything that works reduces cost) will conspire to make such measures unavailable altogether to the individuals who would benefit from them, both within the system and without.

Our leaders’ eagerness to provide for us all preventive healthcare services, therefore,  may ultimately threaten our health.

Comments

7 Responses to “Why Preventive Medicine Can Be Harmful To Our Health”

  1. Marilyn Mann on February 7th, 2009 9:35 am

    Nice post. To take another example: primary prevention with statins, recently discussed in the context of the JUPITER trial. It so happens that the most potent statins, atorvastatin and rosuvastatin, are still on patent. Each first cardiovascular event prevented with atorva or rosuva is quite expensive. There are some costs saved, of course, since treating heart disease can be quite expensive. Yet I suspect that the overall cost of primary prevention with atorva and rosuva is quite high, especially in view of the fact that a significant proportion of first heart attacks are fatal.

    Unfortunately, although there are generic statins available, they are less potent and result in less risk reduction than atorva and rosuva, and a high dose (80 mg.) of simvastatin was shown in a recent clinical trial to have significant safety issues.

    Does this mean that society should not pay for statins for primary prevention? I don’t think so, but it is very difficult to know where to draw the line. Whose risk is high enough to make the expenditure worth it?

    From an individual point of view, especially for people with good insurance coverage, the out-of-pocket cost of taking a statin, even an on-patent statin, may seem worth it.

  2. anon on February 10th, 2009 1:14 pm

    Can you give an example of a measure of prevention that is cheap to the individual (and as a result, accessible to most individuals in society) like a smoke detector, but is expensive for society at large?

    While the cost/QALY might be high, most folks wont quibble over the cost of this kind of device, ie, a couple of bucks. However, an AICD, also with a high cost/QALY is a deal breaking fortune to introduce on a grand scale–too damn expensive.

    A million smoke detectors are cheaper than a 100 defibrillators. I see a huge difference here.

  3. DrRich on February 10th, 2009 3:12 pm

    Anon,

    Crestor and other statins immediately pop into mind. See this article:

    http://covertrationingblog.com/general-rationing-issues/limiting-crestor

    Antihypertensive therapy. Rheumatic fever prophylaxis. Etc. etc. Once we start subjecting preventive therapy to cost-effectiveness analysis we will be surprised by how much it costs to save a life with relatively “cheap” interventions.

    ICDs, by the way, would be much cheaper overnight if people were deciding whether to buy them for themselves. The cost is kept artificially high by the inept funding mechanism we have all adopted. We have price controls today, but these price controls guarantee a minimum price that is astronomical.

  4. anon on February 10th, 2009 6:56 pm

    Know the statin data very well. Dont buy it.

    You can have an intervention that has a cost/Qaly that is extraordinarily high, but the modality be very cheap and accessible, ie, for rare events, one in a million, with a “treatment” costing pennies. A one time investment for a smoke detector is not the same as pricing out years of generic or trade statins.

    IN terms of AICDs–you can jigger numbers or other examples any way you like–was meant to be an illustrative example. WOuld still be prohibitively expensive even if price reduced by 25%. Pick another high tech toy, no difference.

  5. btparts on February 10th, 2009 10:41 pm

    Interesting post, but I took on a different perspective jsut a few weeks ago:

    “If you have been on our website long enough you probably get it by now – American healthcare is in the pits and we are in desperate need of some real solutions. And as has always been the case with healthcare reform, it is the solutions (and often who implements them) that tend to divide us most.
    There is one particular solution however that appears readily available and relatively free of contention – prevention. Or so we thought.

    Recently a New York Times news analysis reflected upon New York Governor Patterson’s public prevention ideas that include a state sugar tax, requiring fast food establishments to post calorie counts and banning junk food in public schools. Much of the program emulates New York Mayor Michael Bloomberg’s much touted public health program.

    But despite some initial enthusiasm for the plan, in the article some critics go on to weigh in:

    “There’s a lot of buzz about prevention,” said Peter J. Neumann, director of research at the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center in Boston. “In general, I am sympathetic to that, but you have to be careful about what you’re claiming and about the science and the evidence.”

    Sure, scientific evidence showing the efficacy of such public health initiatives maybe light, but the policy emphasis on preventing disease and maintaining health is just what the doctor (besides Neumann) ordered. And there is data to support this, even aside from the existence of an intensifying obesity epidemic in this country.

    Prevention based policy is a neglected aspect of American healthcare. At current, the United States spends less than 2% of its health budget on population – based prevention, while it is well known that 60% of diabetes cases could be prevented by weight loss, good nutrition and exercise.

    Prevention based public health initiatives are nothing new and their positive effects are evident. Early 20th century American public hygiene campaigns, despite their controversy, asked us all to stop spitting in public and simply wash our hands after the bathroom and before we eat. Who today would say that such a health education campaign was ineffective or moreover, a waste of time and resources?

    One other critic of prevention- based policy mentioned:

    “…what struck her about the governor’s agenda was that it took health care outside of the medical sector, like food and water regulations. “You don’t go to a doctor’s office, you go to a greenmarket,” she said. “You’re not in a hospital when you get those calorie counts.”

    What she fails to account for is that public prevention of course doesn’t intend to take health care out of the medical sector, but rather include health in other areas beyond it (aka one’s lifestyle). Judging from the efficacy and the cost of one engaging the medical sector in this country with a serious ailment, the more people we can prevent from having to interact with it, the better.

    Perhaps data on prevention’s benefits may be harder to come by because when healthcare keeps people healthy, it is harder to turn them into a disease - based statistic. Health food for thought.”

  6. Dr. Val on February 16th, 2009 8:52 am

    I’m not sure I understand the logic in making treatments, that are perceived to be ineffective, illegal. The American culture is unlikely to tolerate forbidding options to individuals who can pay out of pocket for them. What’s your reasoning for that one? Just because it happened in Great Britain?

  7. DrRich on February 16th, 2009 10:07 am

    Val,

    The question of whether Americans are to be permitted to spend their own money on their own healthcare, outside the “official” system of universal healthcare, is indeed the fundamental question. The rationale for limiting this right to the pursuit of happiness is: If we allow the “rich” people to go outside the system, then the inevitable result will be a two-tiered healthcare system, one for the greedy rich and one for the masses. That is, it is the ancient question of whether the purpose of our government should be to try to guarantee equal opportunity, or equal outcomes. The equal outcomes people today clearly have the upper hand.

    I have written about some of the legal actions taking place today to limit the ability of individuals to contract with doctors on their own (e.g., anathemizing retainer practices), but really, one need look no further than the restrictions already placed on Medicare patients and doctors, the moment they both agree to participate in Medicare, or more to the point, the severe restrictions on the prerogatives of individual doctors and patients that were to be part of Mrs. Clinton’s healthcare reforms in the 1990s. Heck, look at the restrictions being discussed for the corporate magnates who have taken money from the government - while I can cheer on their public humiliation along with the best of them (the stupid, greedy bastards), what they are now experiencing is really a reflection of a fundamental truth. Namely, once we agree to accept government handouts (whether it’s to bail out our companies or for our heart surgery), then the government feels entirely within its rights to decide that we can just go ahead and fly our executives around on commercial airplanes - or decide we can just go to the doctor (or non-physician medical professional) they tell us to go to. If we protest that we’re only using our own money on our corporate jets or our concierge doctors, and only because our internal analysis shows that spending our own money in this way is likely to improve our outcomes, the government counters that, if not for their gracious handouts, we would not even have “our own” money - so there’s really no such thing.

    It seems crystal clear to me that restricting the rights of individuals to use their own resources for their own healthcare is a key agenda of many healthcare reformers, not as a policy choice but as a matter of fundamental principles, and the only question is how they can do it without letting on that they’re doing it. It’s what makes HSAs and concierge physicians, in the eyes of many, not merely a suboptimal approach to healthcare policy, but instead morally, viscerally, horrifyingly wrong and even Satanic, and this of course renders proponents of such things subhumans, not deserving of any respect or other considerations normally provided to fellow members of one’s species.

    I hope I am wrong. But I sure don’t think so.

    Rich

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