3) Preventive Medicine Saves Money

When proponents of healthcare reform are challenged regarding how they expect to pay for all their plans, their response inevitably includes (along with awarding to the "rich" an especially prominent role in this noble endeavor), relying on a vigorous preventive medicine initiative to "bend the cost curve." Indeed, it is primarily preventive medicine, they tell us, which will pull our healthcare system out of its fiscal nose dive.

This is an interesting development. The primary purpose of preventive medicine has always been to prevent disease. But now, the primary purpose of preventive medicine has officially become to save money.

It is therefore unfortunate that quite often - indeed, most of the time - preventive medicine actually increases the cost of healthcare. This has been documented in the peer-review medical literature, of course, but one does not actually need to read the literature to understand that this is the case.

Indeed, it is trivial to note that whether the healthcare system actually saves money on a preventive service depends on at least four variables:

• A) how much it costs to administer the preventive measure,
• B) how effective the preventive measure is in actually preventing the target condition,
• C) the cost of the target condition, should it occur, and,
• D) whether preventing the target condition results in the patient surviving longer, so as to have more time to consume healthcare resources for other medical conditions.

Variable D, 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 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). Their ultimate demise would occur, most likely, 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.

DrRich hopes he has not offended too many people by his use of the implantable defibrillator to demonstrate, unequivocally, how preventive medical services do not always save money. This is admittedly an extreme example. But there are many other, much less extreme examples.

One of those less extreme examples, and a more timely one, might be breast cancer screening. Recent recommendations on breast cancer screening by the United States Preventive Service Task Force (USPSTF) have proven controversial. The agency recommended (among other things) that most women between ages 40 to 49 (and above age 75) no longer receive screening mammograms.

DrRich is well aware of the complexity and the controversy surrounding breast cancer screening, and is by no means an expert in this area. (Here's a take on the new USPSTF recommendations from an actual expert - About.com's Guide to Breast Cancer.) But we can cut through much of the complexity simply by asking ourselves, "By what reasoning did the USPSTF choose to recommend screening mammograms for 50-year-old women, but not 40-year-old women?"

And based on the USPSTF's own words (in which they say, for instance, that ". . .the USPSTF recognizes that the benefit of screening seems equivalent for women aged 40 to 49 years and 50 to 59 years.”), the decision to recommend screening only after age 49 was primarily a fiscal one. The panel specifically invokes a new study, which it apparently found dispositive, suggesting that it costs approximately 40% more in screening tests to save the life of a 40-year-old woman, than a 50-year-old-woman.

We should find nothing surprising about this kind of cost-based screening recommendation by the USPSTF (which, by the way, the denials of Secretary Sebelius to the contrary notwithstanding, are indeed meant to determine federal policy). After all, our political leaders tell us quite forthrightly that they are going to use preventive medicine to reduce the cost of healthcare. That is, the primary purpose of preventive medicine, from now on, is to reduce costs.

Since a given preventive medicine service may either increase or decrease the cost of healthcare, which means that at least some of the time we are going to have to choose between cutting costs and actually preventing disease, we should no longer be surprised when coverage decisions are made in the direction of reducing cost, rather than prevention.

And all those the bright-eyed stories we're seeing about reducing the cost of healthcare through preventive medicine, DrRich submits, are vastly overblown.

More of the Top 10 Overblown Health Stories of the Decade.

_Sources:

_{Cohen JT, Neumann PJ, Weinstein MC. Does Preventive Care Save Money? Health Economics and the Presidential Candidates. New Engl J Med. 2008; Volume 358:661-663.}

_{Russel LB. Preventing Chronic Disease: An Important Investment, But Don’t Count On Cost Savings. Health Affairs, 2009;28:42-45.}

_{US Preventive Services Task Force. Screening for Breast Cancer Recommendation Statement. November, 2009. http://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanrs.htm (Accessed, December 4, 2009).}