How Much is An Ounce of Prevention Really Worth?

“An ounce of prevention is worth a pound of cure”. Right? It often feels like that to the patient– sometimes prevention can even save lives. But what’s it worth in budgetary terms? What if we’re talking about government budgets? Household budgets?

For decades, policymakers have been told that investments in preventive healthcare pay off– not just in better health for patients– but in budgetary savings. It’s an intuitive argument. Namely, that preventing illness is more efficient, effective, and frugal than trying to cure a disease that’s already taken hold. That’s why we make routine dental appointments, take multivitamins, wash our hands, get mammograms, and avoid allergens. We know that preventive activities can help keep us healthy.

But does it ultimately save money?

That depends on several factors.

Warning: This analysis will seem crass to some. I will plow ahead with the following caveat: At no point am I claiming that preventing disease is not inherently valuable to a patient and a patient’s family. Nor do I claim that the costs of preventive services as a whole outweigh the human benefit of avoiding disease. I merely hope to provide context to counter the argument that disease prevention techniques and technologies will always, or almost always, pay off in budgetary terms.

Not all “ounces” of prevention are created equal. As a starting point, it seems that the following questions should be considered:

Effectiveness/Efficiency: How much does the “ounce” of prevention in question cost? How likely is it that this “ounce” is, indeed, going to find early stages of disease? If the “ounce” can definitively find early disease, how common is the disease in question? How many people, on average, will receive the “ounce” before early disease is found in one person? How often must one take advantage of the “ounce” in order to appropriately protect against advanced disease?

Incentives for Use: Who’s paying for the “ounce”? The patient? An insurer? The government? If it’s the government, are private payers or patients already typically paying for this service? Would a new government benefit merely shift the costs back onto the taxpayer? Do the medical providers who provide the “ounce” have an incentive to provide “ounces” to people who may not be at risk of the disease? How inconvenient is the “ounce”? Is it uncomfortable? Lengthy? Quick and painless?  How many more people will take advantage of the “ounce” if its use is encouraged by payment incentives or government programs? Will enough patients avoid costly disease to justify the cost of expanded utilization?

Long term cost: Without the “ounce”, what would happen? How expensive is treatment for the disease, or worse, the cost of succumbing to disease? Does that patient stop being a productive, self-supporting citizen due to disease or premature death? What are the costs of premature death to family members and society? Alternatively, if a patient avoids the disease that was prevented or alleviated by the “ounce”, will he or she simply succumb to another? Are the ultimate costs of the alternative disease comparable to the costs of the potential “cure” for the first?  What happens to a patient who uses lots of “ounces” and avoids disease for many years? Does he spend more time being an end user of other resources due to an extended lifetime? Or does he contribute in a way that far outweighs these costs? Does he spend many years in expensive nursing home care, or require other services that outweigh the probable costs of his earlier disease? Does he rely on family caregivers who must quit jobs, cut back productive hours, or make other life decisions that cost them?

Many of these are uncomfortable and even offensive questions. But assuming that we’re talking about budgets, and not what’s best for a patient or his family, they provide a picture of the kinds of concepts we don’t necessarily consider when we assume that efforts to promote prevention are inherently budget-friendly over the long-term.

For years, policymakers in Congress have been meeting with patient advocacy groups and industries that support the government requirement for coverage of, or taxpayer subsidies for, various preventive services and treatments. In so doing, they’ve claimed that the potential for cost savings to the government is a foregone conclusion. Typically, policymakers lament that they wish the expected savings could be “scored” (lawmaker parlance for an estimate of the budgetary cost or savings from implementing a bill), but that the Congressional Budget Office doesn’t allow for acceptable dynamic scoring models to be used. Therefore, they either endorse these policies with the presumption that they save money, or they avoid them until the presumed savings can be demonstrated in black and white. While it’s true that the CBO doesn’t typically employ dynamic accounting to estimate expected bill scores, it’s not as cut and dried as that. A 2009 letter from the CBO Director explains this in more depth.

In short, preventive health programs may be beneficial in the long run, but just because they’re beneficial for patients doesn’t necessarily mean that those benefits will be borne out on the balance sheet. Of course, these sorts of determinations must be made on a case-by-case basis, since all preventive services aren’t created equal. To make a long story shorter, all proposals deserve a hard look before they’re passed off as being natural Medicare or Medicaid budget-savers– or savers for other programs.

Creating a Market for Bone Marrow?

In December of last year, the 9th Circuit Court of Appeals ruled that it is no longer considered illegal to compensate a bone marrow donor, if the method by which this donor gives marrow is considered similar to donating blood plasma. This is a major change, since compensating donors for organs or tissue has been illegal since the 1980s.

Technology seems to be the main reason for this change. Through peripheral blood stem cell (PBSC) donations, bone marrow extraction can be simpler and less painful than the traditional extraction process. Traditional extraction, however, is still used because some recipients are better able to accept bone marrow that is extracted traditionally, rather than through the blood stream.

Other forms of blood and reproductive assets are commonly legally compensated of course, such as blood plasma and egg donations.

The court’s ruling, which was opposed by the Obama Administration and may be appealed to the Supreme Court, raises some interesting questions about personal freedoms, the common good, medical markets, and the degree to which donations based on altruism are typically in the best interest of patients.

For example, if a patient desperately needs a bone marrow donor, but has trouble finding a match, shouldn’t he or his family have the right to offer payment in order to track down an asset that is in high demand? In this case, bone marrow from a willing donor?

Does the introduction of compensation for marrow donations make it more likely that donors won’t be properly informed of the risks associated with extraction procedures? Does it put non-profit national donor programs at risk by creating a situation where donors come to expect payment for their donations?

Arguably, the fact that bone marrow donors and recipients must be carefully matched can be both an argument for and against the monetization of marrow donations. The fact that many, particularly those of mixed ethnic backgrounds, struggle to find a match argues for their right to use monetary incentives to seek out acceptable donors. However, this is a “market” unlike typical blood drives, where a patient or a group of patients seeking marrow has a much more specific set of criteria. Does a donor who is swabbed and determined to be a match hide facts about his or her own medical history or risky personal behaviors– thereby tainting the supply and possibly harming recipients– because he or she needs the money?

Interestingly, the National Marrow Donor Program has 9.5 million members of its bone marrow match registry. The program doesn’t compensate these donors, and they donate based solely on a desire to help others.

U.S. Government Releases Draft Recommendations for Cervical Cancer Screening

Photo courtesy of Crescent City Women's Center site

For many years, women have been instructed to get annual pap tests in order to screen for cervical cancer and related variants of the disease. In 2009, the American College of Obstetrics and Gynecology changed its guidelines to recommend that women get them once every two years, but many doctors continued to recommend annual screening.  

On October 19th, the U.S. Preventative Services Task Force issued new draft guidelines which suggest that this directive from gynecologists and women’s health advocates is too aggressive.

The draft recommendations from the government panel may be viewed here. The draft recommendations were made available for public comment, and aren’t final recommendations on cervical cancer screening. The draft recommends that women get screened once every THREE years as opposed to once a year or once every two years, and suggests that more frequent screening can sometimes do more harm than good.

Furthermore, the new draft recommends against screening for cervical cancer using HPV testing, alone or in combination with pap test results, in women younger than thirty years of age. 

When it comes to biopsies and treatment of precancerous lesions, the USPSTF asserts that many of these precancerous cervical lesions will regress on their own, and other lesions are so slow-growing that they have little clinical impact. The draft guidelines state that “identification and treatment of these lesions constitutes overdiagnosis, with unnecessary potential for treatment-related harms”.

Since these are draft guidelines, the medical community may weigh in with comments supporting some current screening protocols and practices. It seems the takeaway though, is to pursue all the facts (and perhaps a second opinion) when a doctor tells you to undergo a surgical procedure to screen for or treat cervical cancer, rather than assuming that the recommended procedure is always in your best interest.

FDA Approves First Lupus Treatment in 52 Years

Today, the FDA approved the first treatment targeted to the needs of Lupus patients in over half a century.

Human Genome Sciences, Inc., a small biotech company, will share profits on the drug with GlaxoSmithKline, a major pharmaceutical company that is co-marketing the drug.

Exiciting news for patients dealing with the effects of this often-misunderstood, and potentially disabling disease. Click here for additional coverage.

Breast Cancer Army

Goldie Hawn in Private Benjamin

An initiative called the Army of Women continues to organize volunteers around the U.S. and around the world for the purpose of providing clinical trial participants for studies that could lead to breast cancer breakthroughs. Clinical trials are crucial for data collection, drug approvals, and ultimately, cures. To that end, the “Army” is collecting information from women (and men!) who are interested in participating in breast cancer clinical trials, which are often not as involved and complicated as they sound.

The “Army” emails participants about trials going on in their own geographical areas, that apply to their own medical history, age, family specifics, etc. It basically speeds up the clinical trial screening process, and hopefully provides a larger pool of willing participants for researchers.

For more information, and to sign up for the “Army”, click here.

Drug to Reduce Risk of Premature Birth Approved

In February, the FDA approved a drug, administered to pregnant women, that reduces the risk of premature birth. The injectible drug, called Makena, is intended to be administered to women who have already had a premature birth, and are pregnant with one baby. The drug isn’t approved for use in women who are pregnant with multiples.

Since the causes of pre-term birth are largely unknown, this is a big step forward for women who’ve already endured the uncertainty and hardships of having a preemie, and are pregnant again.

Makena is basically the same as an existing drug that is often compounded in pharmacies. In a clinical trial, 37% of women who were treated with Makena delivered before 37 weeks. In the control group, 55% of the women delivered before 37 weeks. Therefore, the drug doesn’t necessarily prevent pre-term birth, but it does appear to lower the risk of delivering prematurely.

For more information about pre-term birth in the U.S., see the March of Dimes’ Prematurity Campaign site.

 

Test Your Genes- At Home!

 

The fact that a consumer can purchase a genetic testing kit that can indicate whether one has genetic markers for certain diseases is pretty neat. From a purely scientific standpoint, it is just plain fascinating to see the early uses of the sequencing of the human genome rolling out. From a capitalist’s standpoint, it’s interesting to see how the benefits from this major scientific feat are not only changing how clinicians approach disease, but is also being marketed directly to consumers.

It’s a cool idea, but direct-to-consumer genetic testing is starting to get a pretty dubious reputation. Consumer Reports’ Health blog discusses the fact that these tests aren’t all they’re cracked up to be. They may be giving consumers information that is, at best, confusing, and at worst, inaccurate.

The Government Accountability Office recently released a report about these tests, and it wasn’t a glowing recommendation. Not only did the companies surveyed provide misleading information, they were also accused of deceptive marketing tactics. For an example of a company that provides DTC genetic tests online, see the Pathway Genomics site. 23andMe is another company offering these tests. Their site offers three packages ranging in price from $399 to $499.

It remains to be seen how these DTC genetic tests will be regulated. The Genetic Alliance site provides links to some arguments about how best to go about it. This was mostly spurred by the recent revelation that 96 customers who purchased a test from 23andMe received the wrong results. The FDA later issued letters to five companies, demanding that they go through the medical device regulatory process.