How Much Would Prevention Really Save?

There have been many champions of “prevention” who insist it should be the major focus for health reform. Estimates have varied as to how much of current sickness care expenditures could be eliminated if prevention were universally applied and adopted – somewhere between60% and 80% used to be common, though one recent author claims: “Today, preventable illness accounts for close to 90% of all health care costs. [E. Kasen “Preventive Care Strategies: The Carrot and the Stick” Employee Benefit News Mar 1, 2010 (http://benefitnews.com/news)]

Unfortunately, all such champions are focusing on the wrong question. While it seems to be the case that only 5% of our national health expenditures are devoted to prevention, the real question is how much difference “prevention” would make, in practice, to sickness care costs. The classic argument against any universal adoption of prevention (whatever that means) is that it typically has to be applied to a lot of people in order to make a difference to as many as one person.

Answering the question of how much would prevention save requires estimating:
1. how many people would have to be “treated” with a given preventive intervention
2. how much that would cost, and
3. what precise difference to sickness care costs, plus perhaps losses of productivity and performance attributable thereto, would be made

Cost-effectiveness analyses of a wide range of preventive interventions have yielded a wide range of results, in terms of both expenditure savings and quality-adjusted life years (QALYs) gained through preventive interventions. Flu shots tend to show up on the positive side, with low cost per shot and high levels of sickness care and lost productivity savings.

But a host of other preventive interventions cost a good deal more than they save, sometimes orders of magnitude more, and end up costing as much as millions of dollars per QALY added for the people affected. In effect, preventions is subjecting itself to the same myopic approach that medical treatment usually applies in judging whether and which treatment should be used in sick patients.

The typical approach is to look solely at effectiveness, the degree of positive impact a given treatment has, compared aeffective, in this sense, it is part of quality care; if, by chance, there have been comparative effective studies made, the most effective treatment should be used.

Back in the “old days”, i.e. before individual differences (usually genetic) were recognized as affecting which treatments work best, and even which work at all, practitioners could justify their efforts entirely based on whether or not they were proven to be effective. Arguments have been common about which are most effective, and practitioners have insisted on their rights as professionals to make decisions on an individual patient basis, even when science indicates otherwise.

With the move toward the personalization of sickness care, the need to recognize personal differences has become greater. It even applies to preventive efforts. A recent study indicates that when weight management diets are selected based on genetic data, they are significantly more effective than when such personal differences are not recognized. [“DNA Test Could Predict the Most Effective Diet” BBC News Mar 5, 2010 (www.healthandwellnessassociation.com/news)]

This complicates the determination of effectiveness and cost-effectiveness of preventive treatments of all kinds, since it means that separate calculations must be made for as many different segments of the population are affected by individual differences. But the item most frequently omitted from calculations of the relative cost-effectiveness of prevention is the cost of getting providers and patients to adopt preventive methods, particularly those that require repetition or must be sustained, perhaps repeated over long periods.

It is one thing to lose weight for example, but what is the cost – to both sponsors of weight loss efforts and those who participate therein – of doing so? With weight loss, how much more expensive will the right diet be, and how much will the exercise cost? How much time, effort, and expense will be incurred by practitioners of various kinds in coaching, nagging, or whatever roles will be required?

And particularly with weight loss, how long will the effects of interventions be sustained? A recent study of 757 hospital workers who participated in a voluntary 12-week wellness program focused on diet and exercise found that obese patients averaged a 3.0% weight loss after the program was completed, but only a 0.9% loss after one year. Overweight patients lost an average of 2.7% of their body weight at the end of the program, but only 0.4% after one year. [R. Preidt “Workplace Wellness Programs Work” Health & Wellness Association Mar 3, 2010 (www.healthandwellnessassociation.com/news)]

Rarely, for example, do “before and after” pictures of weight loss participants reflect the experience of the average participant, and even more rarely do they show the average participant after one or two years post completion of the program. Typically, something like 95% of participants gain weight back, often ending up weighing more than when they started. This yields virtually a permanent market for weight loss products and services, but little value for prevention investors.

While it is simpler, and far more persuasive to over-simplify the prevention issue, it is also a great disservice. Preventive efforts should be analyzed in terms of their full costs, including costs of achieving widespread adoption and any necessary repetition/continuation thereof. And they should be analyzed in terms of the true effects, recognizing their relapse rates, and other lifetime factors that may diminish their value over time.