two pounds of prevention

One argument in favor of universal healthcare is that by guaranteeing basic health services, more costly emergent care can be averted.  This theory holds, for example, that it would be cheaper to give everyone colonoscopies, removing their precancerous polyps, than it would be to provide costly surgery or end-of-life care for everyone whose polyps went on to become a cancer.

The problem with this argument is that it overestimates your odds of getting colon cancer.  Yes, it is cheaper to get a screening than to treat cancer, but the odds were already in your favor against getting any specific cancer -- the screening is just a way to be sure.

Giving everyone a colonoscopy is more expensive than just treating the few who would actually get the disease.  After all, you don't get colonoscopies because they're cheaper than cancer -- you get colonoscopies because it's a price well worth paying to catch cancer early.  Big difference.

In fact, there's evidence that screening actually opens up the floodgates to a bunch of costly treatment for conditions that would never have manifested with actual symptoms.

Today's first link is from The New York Times.  This essay by Dr. H. Gilbert Welch ran during the presidential campaign, and it observes how both candidates were buying into the new myth about "preventive" care:

The myth is that like magic, preventive medicine will simultaneously reduce costs and improve health.

...

It may sound like common sense. But it is still a myth.

The term “preventive medicine” no longer means what it used to: keeping people well by promoting healthy habits, like exercising, eating a balanced diet and not smoking. To their credit, both candidates ardently support that approach.

But the medical model for prevention has become less about health promotion and more about early diagnosis. Both candidates appear to have bought into it: Mr. Obama encourages annual checkups and screening, Mr. McCain early testing and screening.

It boils down to encouraging the well to have themselves tested to make sure they are not sick. And that approach doesn’t save money; it costs money.

...

Early screening is like the “check engine” light in your car. It can alert you to problems that need to be fixed, but too often it picks up trivial abnormalities that don’t affect performance, like one sensor’s recognizing that another sensor isn’t sensing.

And if we look hard enough, we’ll probably find out that one of your check-engine lights is on.

Overdiagnosis occurs even among what were once considered uniformly deadly diseases.

When it comes to cancer, for example, there is a very broad spectrum of diseases. Some kill rapidly, some progress slowly, and some do not progress at all.

...the United States Preventive Services Task Force recently recommended against prostate cancer screening in men over 75. Similar phenomena have been documented in early-stage breast cancer, lung cancer and melanoma.

Most diseases exist along a similar spectrum. Even without treatment, most cases of aortic aneurysm never result in a fatal rupture, most patients with osteoporosis won’t fracture their hip, and most people with diabetes won’t lose a limb.

Likewise, this piece ran last week at foxnews.com:

"When you talk about prevention that involves visiting a doctor and stumbling upon a high cholesterol that you didn't know about or a high blood pressure, that kind of medical prevention almost inevitably leads to more medical things being done, more medications being prescribed," Dr. Abraham Verghese of the Stanford University School of Medicine told FOX News.

After more tests, a patient with high cholesterol could be prescribed a statin, which might reduce his chance of a heart attack. But because only one or two men among several thousand with high cholesterol might suffer a heart attack, that ounce of prevention could be too costly.

"If you're looking at a population of men, for every life you save, it costs $150,000 to extend life by one year, in terms of statin use," Verghese said.

An ounce of prevention, they say, is worth a pound of cure.  The reality is that even two pounds of prevention is better than a pound of cure, and if you have the money it may indeed be worth it.  But we shouldn't pretend that it's cheaper.

That's the John Galt Line.

Comments

[Ben in Boston]

The focus should be on getting the cost of the test down to the point where people individually can make a cost/benefit analysis based on the chances that it will find something important versus the cost. If you put the information and the choice in the hands of the individual consumer, then each person has control of their own destiny. In the current scenario, nobody does. We're all paying into a big pot to pay for everybody. Look how well that's working out for us.

[Hank Rearden]

Excellent post. However, I must point out something; and it actually harkens back to one of your earlier posts referring to "good" versus "great" medicine. Ample preventative care could conceivably reduce costs over the long haul, provided that actual physicians weren't burdened with that additional mandate. Legislation that specifically targets the ease of getting preventative care (thereby making it cheaper to get most preventative screening) could reduce healthcare costs. BUT, and this is a big but, said preventative care would need to operate independently of other medical care. Hypothetically, approved medical tests would be carried out by individuals other than physicians. Also, the legislation would need to establish some kind of “cutoff” point for testing; the goal of which would be to prevent overuse. In short, it would make “good” health screening a legal, out-of-pocket expense, which would be a step in the right direction.

[Hal Horvath]

Reasonable post I think, but for completeness, readers might want to see the brief summary article much of the national discussion on this is based on:

http://content.nejm.org/cgi/reprint/358/7/661.pdf

Of note: considering *only* medical costs along over time -- ignoring various non-medical costs and savings -- about 20% of "preventive" care is (medical) cost-saving. Further large portion of preventive care statistically buys life-years at very low cost (e.g.-- for example for less than $10,000/life-year).

Of course best of all is to have a very competent doctor that can gauge your individual risk factors well and competently decide how much screening tests you need.

That's where a market-based system, such as the one I advocate is...superior.

http://findingourdream.blogspot.com/2009/06/new-way-to-hold-down-health-care-costs.html

[John Galt]

"Further large portion of preventive care statistically buys life-years at very low cost"

Ah, but at whose cost?

[Hal Horvath]

Indeed.

Pragmatically, and I think in terms of *both* pragmatic and ideal outcomes -- we currently already pay for free Emergency Room care for those that cannot afford to pay for their own health insurance and costs, therefore those particular preventive health care measures that actually do save net costs, including such costs such as governmental (taxpayer supported) disability payments to very sick people who could have been healthier with preventive care....are of course a relative bargain. So "at whose cost" becomes for these *particular*, limited measures: "at whose savings".

Now, there is further complexity, and there is no way for the *public* (government, panels, etc.) to *choose* the trade off on a personal level....thus....outcome-based incentives (reimbursement according to outcomes-over-time) are better. See?

I suggest specifically we set up good market structure (payments related to value, exactly like in other markets for other goods and services), and let the actual choices then be made privately.

Sound familiar? This is typically called a "free market" -- when individuals choose trade-offs of value vs. cost on their own.

[John Galt]

You can sometimes be unclear. Is it possible to summarize that? (And a link to a longer document is not "summary.")

[ConservativeLibertine]

Excellent Post. Many of my friends are under the illusion that preventative care for all is the magic bullet.

I saw an excellent piece in the Wall Street Journal that makes the same case you do. Preventative care means more procedures and more costs. The dramatic increase in demand for tests and procedures quickly out strips the cost of just treating those who become diagnosed with the illness. But now I can't find it. Still looking though.

Besides, how do you do preventative care for cancer? By telling me what to eat? not drink? how much? how little?

Anyway. You are right. The numbers don't add up. Here is some more evidence.

http://online.wsj.com/article/SB10001424052970204619004574322401816501182.html

you can't get away from the law of supply and demand. Just like you cannot spend your way out of debt.

[Hal Horvath]

Anyone can read the links I offered, and both links can be read easily in under 20 minutes, and both will offer considerable insight. Also, Conservlib -- your generalization about preventive care isn't quite on target: some preventive care creates cost-savings in medical costs alone, some creates cost-savings when additional non-medical costs are included, some increases net medical costs if done indiscriminately, etc., etc. In other words, complexity, like in real life. And my previous comments offer the links.

[John Galt]

I was hoping to avoid this.
Consider this quote, Hal, from one of your comments:

"Pragmatically, and I think in terms of *both* pragmatic and ideal outcomes -- we currently already pay for free Emergency Room care for those that cannot afford to pay for their own health insurance and costs, therefore those particular preventive health care measures that actually do save net costs, including such costs such as governmental (taxpayer supported) disability payments to very sick people who could have been healthier with preventive care....are of course a relative bargain."

Now, best I can tell, that's all a single sentence. So it shouldn't be surprising that I can barely understand it.

I don't want to read twenty more minutes' worth of that. Can you summarize your point?

As it is, I honestly cannot tell if you think subsidizing "preventive" screening for everyone saves more money than it costs, or who you believe should be paying for it.

Do I really need to read for 20 minutes to understand your position?

[Hal Horvath]

yeah, that was an out-of-control sentence. But I have a sharp-eyed friend who helps edit my blog posts, and I think they are *much* easier to read than this example.

The trouble on the other hand with trying to summarize my proposal on how to pay for outcomes over time is that it really should be judged on its practical effects. But its practical effects depend entirely on its detailed structure.

I may eventually get to changing it into a bullet-form, but that is more than a 20 minute task.

In the meanwhile, if you read it, it is indeed possible to skim portions (without leaving out a portion) and see its overall structure.

It includes for instance how to set up the entire complex medical process into markets and market-like mechanisms, where there is little or no work for bureaucrats, past maintaining web sites.

[Hal Horvath]

See, the difficulty in health care as a market is information-assymetry. How can the buyer choose? *That's* one thing a good reform can address, in a market-building way.

[John Galt]

Are you unable to provide a simple clarification of your comments on this post?

[Hal Horvath]

Don't you think other than the one sentence my comments were clear?

[John Galt]

If your comments were clear, I'd understand whether you think subsidizing "preventive" screening for everyone saves more money than it costs, or who you believe should be paying for it. As it stands, I have no idea.

Do you think you've explained that clearly here?

[MaryAlice Nelson]

And how about the groups that are not fans of the big med/big pharm methods ? Christian Science, Jehovah Witness to name two groups plus many individuals that rely on vitamins, herbs, homeopathic and other systems that give us good results without the huge costs of the orthodox medical programs. We will be stuck with the whole tab for insurance that we will not use. It will be like having to buy auto insurance when you take the bus.