“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.