More Attacks on Prevention and Its Role in Health Reform That Make No Sense

By preventing costly diseases, we can help contain our out-of-control health spending. Research, common sense, and ethics all tell us the same thing: An ounce of prevention is worth a pound of cure.
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Co-written with Lydia Ogden

Two recent newspaper pieces on prevention by Carla Johnson (Associated Press) and David Harsanyi (Denver Post) repeat some long-standing misperceptions about prevention. Because prevention is central to health reform, it's time to set the record straight.

Both the articles suffer from baby-with-bathwater syndrome, brought on by lumping all kinds of prevention into one big pot. Imprecise language is dangerous, particularly in the realm of policy-making. It leads to fuzzy thinking and that produces bad policy.

Research shows that scientifically sound prevention programs for both individuals and populations improve health and save money. Research also shows that effective prevention programs are targeted. They work because they reach the right people at the right time in the right places with the right interventions. Ironically, both these journalists miss the point that good prevention, like good reporting, addresses the five Ws and an H, just like they were taught in first-year journalism class. Who, What, When, Where, Why, and How are just as fundamental to sound prevention as they are to sound reporting.

Prevention can be divided into three parts: Things we do to avert disease (primary prevention), like vaccinations for children or the YMCA diabetes program mentioned in the article. Things we do to find and treat disease in its earliest stages (secondary prevention), like mammograms and colon cancer screenings. And things we do to avoid complications when people are already ill (tertiary prevention), like programs to help older people with multiple chronic conditions manage their care at home, like the PACE (Program of All-Inclusive Care for the Elderly) and similar initiatives. Dumping various interventions for various groups together and concluding prevention doesn't save money is just plain wrong.

Not all prevention programs work, many because they aren't grounded in science. Not all of them save money. All medical interventions -- including secondary and tertiary prevention -- cost money. Screening for common and costly diseases, like diabetes, high blood pressure, and high cholesterol, may actually raise spending in the short-term, because people who need treatment will get it. But over the long-term, that treatment is likely to avert even more costly complications, and thereby avoid higher spending.

Many studies show well-designed prevention programs are cost-saving. For example, a significant reduction in total health care spending is linked to community-based lifestyle interventions (primary prevention). Research shows that savings range from a short-term return on investment of $1 for every $1 invested, rising to more than $6 over the longer term. An investment of $10 per person per year in community-based programs tackling physical inactivity, poor nutrition, and smoking could yield more than $16 billion in medical cost savings annually within 5 years. This is a remarkable return of $5.60 for every dollar spent, without considering the additional gains in worker productivity, reduced absenteeism at work and school, and enhanced quality of life.

The Breast and Cervical Cancer Early Detection Program funded by the Centers for Disease Control and Prevention (CDC) is a great example of secondary prevention. It targets uninsured and underinsured women (18 years and older) at or below 250% of federal poverty level. Services include clinical breast examinations, mammograms, Pap tests, diagnostic testing for women whose screening outcome is abnormal, surgical consultation, and referrals to treatment. Last year, 301,209 women had mammographies who wouldn't otherwise have had care. Nearly 3,800 breast cancers were found. And 321,296 women got Pap tests. More 5,201 cervical cancers and high-grade precancerous lesions were found.

Worksite health promotion programs, too, are effective at both primary and secondary prevention. A systematic review of more than 50 studies meeting rigorous guidelines for review by the U.S. Task Force on Community Preventive Services found strong evidence of WHP program effectiveness in specific areas: reducing tobacco use, dietary fat consumption, high blood pressure, total serum cholesterol levels, and days absent from work due to illness or disability, as well as improvements in other general measures of worker productivity. At Citibank, for example, a comprehensive health management program showed a return on investment of $4.70 for every $1.00 in cost. A similar comprehensive program at Johnson & Johnson reduced health risks, including high cholesterol levels, cigarette smoking, and high blood pressure, and saved the company up to $8.8 million annually.

As far as tertiary prevention goes, there's evidence of effectiveness for that, too. Here's one of the best: For nearly 25 years, senior researchers at the University of Pennsylvania have implemented a series of large, randomized controlled trials with high-risk elders. Their studies have demonstrated that comprehensive tertiary prevention focused particularly on transitional care produces better health outcomes and significant cost savings. Their most recent research showed a 56% reduction in readmissions and 65% fewer hospital days for patients in transitional care. At the 12-month mark, average costs were $4,845 lower for these patients. If this model were scaled nationally with an investment of $25 billion over 10 years, savings could reach $100 billion over the same period.

The AP article's Mrs. Jones is 55 years old, obese, and at risk for diabetes. Studies show that in 10 years, when she turns 65 and enters Medicare, the government will spend $20,000-$40,000 more on Mrs. Jones' health care than Mrs. Smith's, who's the same age but a normal weight. Over 30% of the recent rise in Medicare spending in the last decade is associated with the persistent rise in obesity in the Medicare population. The increase in obesity-related chronic diseases among all Medicare beneficiaries and particularly among the most expensive 5% is a key factor driving growth in traditional fee-for-service (FFS) Medicare. Six medical conditions, all related to obesity -- diabetes, hypertension, hyperlipidemia, asthma, back problems, and co-morbid depression -- account for most of the recent rise in spending in the Medicare population. Preventing Ms. Jones' obesity by helping her to eat healthy, exercise, and avoid smoking, is good for her and good for the American taxpayer. Healthy people are underwriting unhealthy people, in our private health insurance premiums and in public health care programs paid for with our tax dollars.

Chronic disease resulted in more than $987 billion dollars in private spending -- most of it covered by private health insurance, which means higher premiums for everybody. Nearly all of every Medicare dollar -- 96 cents of each and every one, or more than $447 billion last year -- and 85 cents out of every dollar in Medicaid -- nearly $300 billion -- go to care for chronic disease, most of which is preventable. In one year, total, this amounts to approximately $1.7 trillion spent treating patients with one or more chronic diseases -- roughly 75 percent of all U.S. health care spending. This is essentially a hidden tax on every taxpayer in America. Anyone who cares about long-term health spending, particularly government health care spending, should support prevention. It's common sense.

Mr. Harsanyi's argument that we should avoid prevention because "the longer people hang around, the longer they utilize the health-care system" and drive up costs is hardly worth addressing. It's a bizarre concept that a civilized society would let people die of preventable causes. And it's economically inaccurate. Obese and chronically ill Americans tend to live shorter lives, but chronic diseases and obesity are linked to two-thirds of the growth in U.S. health spending since the mid-1980s. We're not cutting any corners in health care costs by allowing these people to meet the Grim Reaper earlier.

The other major point both Mr. Harsanyi and Ms. Johnson miss is the "how" of prevention. How are policymakers proposing to increase effective prevention inside and outside the health care system? Contrary to how their articles describe it, the idea isn't to insert one-off prevention efforts into the existing system. Instead, Congress and the President are proposing fundamental changes to the way we deliver prevention, care, and treatment. That means improving community-based primary and secondary prevention, strengthening primary care (primary and secondary prevention) and incentivizing providers and patients to better prevent and manage diseases (secondary and tertiary prevention). In sum: A comprehensive prevention plan rather than scattershot, unconnected -- and ineffective -- efforts.

By preventing costly diseases or better managing them, we can help contain our out-of-control health spending. We can boost productivity. In our troubled economy, we need to do both. Even if it didn't save money, preventing suffering when we can is the right thing to do. Research, common sense, and ethics all tell us the same thing: An ounce of (science-based) prevention is worth a pound of cure.

Kenneth Thorpe, Ph.D., is the Robert W. Woodruff Professor and Chair of the Department of Health Policy & Management, in the Rollins School of Public Health of Emory University. He serves as the Executive Director of the Partnership to Fight Chronic Disease.

Lydia L. Ogden, M.A., M.P.P. is the Chief of Staff for the Institute for Advanced Policy Solutions of the Center for Entitlement Reform at Emory University.

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