The emphasis in preventive care always seems to focus on medical interventions only. What about expanding our definition of prevention to include mandatory paid sick time, insurance-covered massages, infrastructure to support active transport, etc.?
Of course preventive care alone isn't going to save a lot of money because you are missing the bigger picture of what drives a healthier society.
52
These interventions are unlikely to be cost saving.
Dr. Carroll's article seems to agree that cost savings are not the only criteria by which we should judge interventions.
I think you and he are on the same page.
In the current climate, advocating for insurance-covered massages is not a realistic health policy option.
7
Right of the bat this is wrong. Yes they go to the emergency room more if people get health insurance. But that's because it's new and yes convenient. Over time if they had sustained coverage most would get a regular doctor or group they trust and would go to emergency less. And in doing so they would catch that polyp before it turns to cancer. Or be told they are on their way to too much sugar before they get there. Or stopping that high blood pressure before it turns into an attack. Preventive care and guidance definitely saves money over emergency room. And if everyone knew they would be taken care of without worrying & stressing about financial burden, the whole country's health would infinitely improve.
85
Right. One just has to look at other OECD life expectancy stats. The USA is dead last (no pun unintended) compared to the rest of the advanced countries both because of lack of universal medicare and because of low primary physician coverage.
Of course, doctors running prescription mills for opioids in the USA just add to a dismal life expectancy situation.
20
You are totally correct. Measuring the results of increasing preventive care on a mass scale is something that takes decades, not just a few years. Of course people went to the ER more when covered, they had to suck it up and bear it before because they couldn't afford to be sick. This also doesn't seem to calculate other costs outside of health care when quality of life is improved. How many people have to quit jobs or spend hours and money taking care of people in poor health that got no preventive medicine over the years. That is a societal cost, that is not included here. Improved quality of life that reduces the burden on society of older people is a huge benefit to the overall society.
16
Cleverly mixes up the two issues with healthcare in the US. Life expectancy, child mortality etc can be improved with preventative care. The US really does need to improve on that even if it does cost money. The fact that the US spends almost double the amount that any other country does on healthcare is due to the prices charged and the huge profits being made and that is what needs to be addressed as a separate issue
5
The article's ending is well worth repeating:
"There are many good arguments for increasing our focus on prevention. Almost all have to do with improving quality, though, not reducing spending. We would do well to admit that and move forward.
Sometimes good things cost money."
4
Everyone’s health would likely improve if each human were truly valued in society as much more than a profit and loss centre for business, including the business of healthcare!
7
It's going be harder and harder to value humans in society when there are so, so many of us - and there will be exponentially even more of us in a short time.
3
Well, yes and no. Tell the parents of the child who recently died in Florida at age 12 that a flu immunization wouldn't have helped (he didn't have one). Or tell the programs that monitor people's weight that losing it (and providing an incentive with lower premiums) wouldn't decrease the number of people with Type 2 diabetes (the disease accounts for about one third of all medical costs). Or tell the plans that require monitoring and medication of patients with HIV that it's cheaper for two weeks hospitalization (at at least 200K) that regular testing and medication (at 40k per year max) isn't more cost effective.
So perhaps we should all die and decrease the surplus population. But what does end-of-life treatment cost? Because that's where most of the money goes.
65
Have any vaccinated folks died of flu? I'll wait...
3
Statistics for that will come at the end of the season. But if it's like past seasons, roughly 90% of those who die from flu have not received a vaccination. That must be why the CDC recommends one.
While I am a "pro vaxxer" and have had a flu shot, and usually benefitted from it....in fact, this year the flu shot was very ineffective. That tells people who did not get it that they made "the right decision" (even if they got sick).
Unfortunately, some people who got flu shots this year still got sick. It is not 100% clear that the child in Florida would have lived, had he gotten the shot. He might have died anyways.
Programs that tell people to lose weight are stunningly ineffective, with a 98% failure rate (!!!!) and so they are not "preventing" much diabetes at all -- furthermore, diabetes is not CAUSED by obesity. In fact, it is the other way around: the metabolic changes of Type 2 diabetes cause patients to be ceaselessly hungry and overeat, plus they cause greater storage of body fat. Losing weight MAY help with diabetes symptoms, but it is not a cure-all. You either have the genes to develop Type 2 (it is highly heritable) or you do not -- 80% of fat people never get Type 2 diabetes.
End of life treatment is not the big problem here. It's treatment for the frail elderly, those over 85 (approx) who get multiple health issues -- cannot care for themselves -- break hips and end up in nursing homes -- where they swiftly run out of money, due to the obscene (FOR PROFIT) costs -- then end up on Medicaid. This is just a huge, massive problem and it is not being addressed.
1
When we change the dynamic - the convenience factor - stop going to the ER for NON emergent issues we will see a shift. The combination of access to care and taking responsibility for one's health takes time - it is not instant. Societies that have this have generations to see this play out, not a decade.
So many things are not addressed in this article: social determinants of health - if I counsel my patients to exercise but they live on a highway without any shoulders (very common in this rural area) and DOT has not even repaired the road in decades how can they safely do it? If they do not have a car or money for gas to travel to a safe place? Now CMS wants to cut the funding that gets them rides to doctors' appointments - this will only further the dependence on emergency rooms.
Primary care does save money when it is used and when a relationship exists - but like all relationships it needs to be built. That takes time which is not reflected in short term studies and when the marketplace keeps shifting.
96
As an acupuncturist, I was hoping you would talk of the preventative complimentary care and how that impacts the cost of more expensive western care.
2
Talk about half truths. Our regional hospital did a comparison study of unrecovered costs 3 years prior to the ACA and 3 years after the ACA and the drop was 40%. Who pays for unrecovered costs? The rest of us with insurance. Further, teaching people to use an urgent care clinic or a regular clinic (both for insured patients as well as previously uninsured patients) further reduced overall costs. An ER visit is more expensive than a clinic visit. It saves money. As to preventative care, most studies do not look at a long enough time frame over an entire lifetime. Lastly, why would the author state "Prevention improves outcomes. It makes people healthier. It improves quality of life. It often does so for a very reasonable price." if it was not less expensive to have preventative care available. Sorry, not buying his argument.
16
In Nova Scotia, we spend billions every year treating chronic illness; various forms of heart and vascular disease, cancer, obesity related conditions, etc. The majority of these disease states are related to poor lifestyle choices, specifically poor diet and lack of physical activity. Preventing chronic illness - and by extension reducing the associated financial burden - doens't have to involve costly medical interventions. In fact, successful preventative care is a life-long, multi-generational endeavor, starting with early childhood education about proper nutrition, physical activity. Healthy lifestyle attitudes are formed early and, with some positive reinforcement along the way, will last for life.
What is the cost? Very little. Improve school curriculum to put more emphasis on nutrition and activity. Provide low income parents with the resources to partake in programs that might otherwise be unavailable to them and their children.
The payback? Fewer healthcare dollars spent on treating lifestyle-related illnesses and a healthier, happier, more productive community, with decreased crime and less spending on social services.
In a "for profit" healthcare system, this is bad for business. But otherwise, it makes perfect sense.
7
True prevention should not be about diagnosing an illness early on so we can prescribe a medication to prevent further symptoms. Prevention should be about be exercise and personal nutrition. Looking at the diet as a true preventive. Until we get big Pharma out of the picture and change the out dated direction of the AMA we will never have a cost efficient healthcare system. Functional Medicine is the answer.
3
Treatment doesn't save money either, but we do it.
3
It seems that the author, in his goal to be contrarian for being contrarian’s sake, is cherry-picking information and removing it from its context.
His focus on cost-saving analysis largely neglects the prospect of health improvement or life enhancement, which is much harder to place a value on. Something might make your health better and your life better but doesn’t really save any money, but from a public health perspective (and from the individual’s perspective), that’s still a big success.
His analysis of what happens outside the healthcare system is also a bit self-serving. He points out that smokers who quit smoking end up costing money with other health problems later on. But that doesn’t mean it isn’t cost-effective: if those former smokers cost roughly the same amount of money but live longer, then there is indeed a savings on per-life-year.
This should spark a conversation aimed at looking at prevention (and not just physical health but crime, mental well-being, etc., etc.). The problem that the people spending money on prevention are often the same people receiving the financial benefit of that prevention. That’s one reason insurance companies before the ACA had no real incentive to improve health, and it’s a reason we need to go to a public system.
3
This article focuses on near-long term effects in an area where change is slow and it takes a very long time to fully measure outcomes.
ER visits might not have declined right away, because people who haven’t had insurance likely don’t have PCPs and might not have access to urgent care. It will take education and access for people to break the habit and establish non-emergency points of care. I suspect that ER visits will decline in the longer term.
Smoking prevention may lead to higher costs for those smokers living longer, but then that generation will pass and there will be fewer living people who have ever smoked, which will significantly reduce costs. The idea that smoking cessation and prevention raises costs is ridiculous - just look 10-15 more years out.
This article is misleadingly short-sighted and fails to consider the bigger picture for the data.
4
Has anyone studies the preventive model being used by Kaiser Permanente? As both an insurance program and a medical provider, Kaiser offers exceptional care (particularly primary care) at relatively low insurance rates. As a Kaiser member, I have seen firsthand their emphasis on prevention and investment in services that support patient wellness. I can’t help but wonder if, in this closed system where insurance and medical care are one business, Kaiser is able to offer such low rates because they are seeing some kind of return on investment for holistic preventive care.
2
"Emergency room care is not free, after all. People didn’t always choose it because they couldn’t afford to go to a doctor’s office. They often went there because it was more convenient. When we decreased the cost for people to use that care, many used it more."
Another reason emergency rooms get used is because of, well, emergencies. When I came down with Lyme disease last summer, for which there is a very narrow window for more-effective treatment, I couldn't wait three weeks to get into see my regular doctor.
2
There might be another explanation for uptick in emergency room visits for people with insurance. Just because you have insurance does not mean you have a doctor. It can be very hard to find a physician who takes low reimbursement insurance, and sometimes the waiting period to be seen as a 'new' patient can be many, many months. Emergency room becomes the only option.
3
Fortunately this does not apply to dental health. Oral health is easily obtained in two ways: Primary prevention, as applied in the article, is achieved by preventing the formation bacterial colonies on the teeth and gums and that is done through daily home care. No major costs there. It is terribly effective from the start, saves tons of cash both front end and for years to come, and will have additional cost savings by reducing the contamination of the body by oral pathogens and the associated costs therein. The second most important primary preventive protocol which does not cost but actually saves money front end is to control sugar intake. Sugar is so amazingly damaging to the teeth, it puzzles me how we are still succumbing to the sweet taste allure it provides. I only wish it could be labeled an addictive substance as with nicotine. These two protocols would dramatically reduce dental expenditures by themselves with no costs.
Secondary prevention fits more in line with the article but it does not have to break the bank either. There are solutions at every cost level all of which can endure through years of service.
Put these together, throw in the improvements in quality of life, which are immense and go beyond pure dental applications and can affect the entire body, add the psychological benefits that emanate from it and the 'costs' of prevention are so worth it.
Medical care needs to apply the same protocols.
2
This is a very pedantic article that appears interested only in the cost ratio rather than the health ratio. I have had serious health problems found because I had good insurance that covered wellness visits. I also prevent dental problems by twice a year dentist visits. Aside from healthcare, I keep my car running in good condition by having recommended checks and changing the oil. My HVAC system works well because I have it checked twice a year. Whether you are maintaining a body or a mechanical device, it pays to have wellness checks. It isn’t all about the money!
5
I guess eating right and exercising wouldn't save health costs in the long run...huh?
3
Another in the Frakt, Carroll health care series that tells us to sit back and enjoy our corrupt, price-gouging American health care "system" because things could be worse or at least not much better. Trust us, we're doctors.
2
Uh... these studies don't necessarily support your claims.
In fact, the authors of the MA study admit "(w)hether this was due to the elimination of financial barriers to seeking care in the ED, a persistent shortage in access to primary care for those with insurance, or some other cause is not entirely clear and will need to be addressed in future research."
In fact, one of the problems still being addressed as of this 2015 report is, in fact, access:
https://bluecrossmafoundation.org/publication/2015-massachusetts-health-...
However, the factoid you plucked from this study has nothing to do with preventive health; likewise, the CBO report on increasing cigarette taxes addresses models of economic incentive and doesn't address at all the cost of uncompensated cardiac, COPD, and emphysema care - except to say that if people live longer because they no longer smoke, they end up using more health care. That is, in fact, the last paragraph of your article, which is true - people who live consume resources - but not at the same cost.
The RWJ 2009 study even states that it considers no preventive measures outside the clinical setting, does not take into account reduced cost of modern screening, and compares expensive screenings like sigmoidoscopy to no screening.
The CDC seems to find some value in other, cheaper preventive measures:
https://www.cdc.gov/diabetes/prevention/employers-insurers/manage_costs....
Please do science better or not at all.
10
Your last sentence says it all. Sometimes good thongs cost money. This is a critical concept that needs to be applied to almost everything we consider in the public sector.
3
I’m founder & CEO of a Medicaid managed care company, Trusted. Main question-how can costs not be saved if managed care companies are profitable?!
Costs ARE saved, but the system does not demand the savings to be passed back to tax payers. If the ACA demands insurers spend @ least 85% of their revenue, the costs will Never go down. Where’s the incentive to do so?
The primary thesis-prevention doesn’t save money-is misguided. It mentions that post ACA (referencing Medicaid) ER visits have not declined. At Trusted, our ER visits are down 14%. How? 80% of total healthcare costs are borne out of the ER. IP admissions account for 60% of costs & 80% of IP admissions come from the ER.
75% of wasteful ER & IP utilization is caused by Social Issues. Not clinical.
3s’: Stable housing; stable income; substance abuse
For mayors nationwide, abuse of ambulances responding to 911 calls for ETOH (alcohol abuse) by homeless people is killing budgets & threatening the entire 911 system.
Just giving people insurance will not save costs. Neither will blanket wellness programs. What saves both is Engagement.
We’ve demonstrated a 24% reduction of overall costs of our members comparing their total costs 12 months pre-face to face meeting with a nurse case manager vs. 12 months post. We have reduced non-emergent ER visits by 7% & inpatient readmissions by 15%. Controlling the first ER and/or IP visit is difficult, but through quick & personal engagement repeat visits are avoidable. Costs come down.
5
“An additional 15 preventive services were cost-effective, meaning that they cost less than $50,000 to $100,000 per quality adjusted life-year gained.”
“Cost-effective.” Seriously?
The US per capita GDP is about $55,000 ($52K in 2016 - https://tradingeconomics.com/united-states/gdp-per-capita - or $55-56K in 2018 assuming 3% growth since 2016).
The US per capita income is about $33,000 ($31K in 2016 - http://www.deptofnumbers.com/income/us/#household - again assuming 3% growth).
If your yearly “starvation prevention” costs (what everyone but a health care economist would call the cost of food) were several times your annual income, you would reasonably fear starvation.
What these numbers say to me is that our society might be able to afford preventative medicine, but only if we all agree to be homeless, hungry and naked. (And the medicine would still need to cost half as much as it actually does.)
1
I suspect this article is mostly correct IF one accepts the premise that health care (and health insurance) should be for-profit private industries and NOT the right (as compared to privilege) of every citizen.
10
The American College of Sports Medicine appreciates the article's point that numerous prevention efforts are not cost effective, even though there are other benefits like quality of life improvement. But the article does not address the key fact that some prevention efforts are profoundly cost effective. For instance, the Diabetes Prevention Program (DPP) for Medicare enrollees identified a savings of $2,650 over 18 months for those enrolled in the DPP compared to matched members who did not enroll in the program. The DPP is the best example ever of healthy lifestyle interventions around diet and physical activity. Not all prevention efforts produce cost savings, but do yield other benefits important to individuals and American society. And some prevention programs, like the Diabetes Prevention Program, produce extraordinary cost effectiveness, and should be noted in the discussion. Especially since the American College of Sports Medicine is in Indianapolis as is Dr. Carroll, we look forward to discussing this important matter with him. Thanks for the opportunity to comment. Jim Whitehead, CEO, American College of Sports Medicine, Indianapolis, Indiana.
7
Patients actually have to follow the physicians' orders in order to have impact. How many people are told to eat better and exercise and how many actually comply?
4
Early screening saves lives. Taking action before a condition gets out of control saves lives. The premise of this article is irresponsible and raises questions about the credibility and motives of the author.
3
As former Complex Care MD and someone who took care of Medicaid and Private Insurance patients, Medicaid, under- and uninsured patients have always had trouble finding care other than Clinics w limited available hrs. In addition, it takes time to change "habits" and evaluations of the ACA and expanded Medicaid predicted "increased initial costs but significant costs savings over 10 yrs". I experienced and concur w these comments though the changes I saw were more rapid, likely because we were available after hrs and had a smaller population...
1
Do wonder if you get an overall economic improvement if you take into account increased productivity from healthier people due to the spending.
Overall it's most definitely something I support regardless, because it makes peoples' lives better. But usually this kind of thing leads to positive economic outcomes (e.g. higher lifetime wages) that more than offset the costs.
3
I think the idea that if you prevent someone from dying now they are only going to cost you more later is somewhat specious. After all, by that logic gun violence is a good thing - think of all those future medical costs we have avoided!
7
And rather cold hearted!
1
I have to take issue with the emergency room usage issue. Anyone who has insurance knows there is a fairly high cost for using the emergency room and tries to avoid doing that. Some plans are broken in that they discourage the use of cheaper urgent care by not covering them in an attempt to get you to go to your primary physician. This seldom works when you are very sick and your doctor can't fit you into their schedule quickly so then you end up at the emergency room.Most people don't go to the doctor until they are fairly sick so that becomes a problem resulting in more trips to the emergency room. This is not an unsolvable problem.
2
Quoting the American Medical Association (AMA, "Patients Before Politics". The author as well as the publisher seem to be the puppets of a known source. Many are aware of the previous predicaments, of the NYTs with publishing inaccurate information. Putting to "press" the inaccuracies of this article, is a deliberate attempt to sway the readers. Through negative publicity the author/NYTs gets the readers, shame that it now leaves many wondering who exactly dictated this article and go to press. Now, more than ever, the AMAs stance & commitment to "Patients Before Politics" is loud and clear.
1
Starting with a error. Preventative care would reduce medical costs. Emergency care isn't preventative care, nor is it more convenient to sit in the ER for 24 hours instead of waiting until the next day for a PCP appointment. Easier access drives the cost up because people are idiots and ER rooms can't turn people away like they should be able to. Every level should be able to dismiss patients that aren't in their purvey. Not an emergency? Kick them out. Very few things are emergencies, and your cold isn't one of them.
3
Agreed. The article puts preventive care together with emergency room use inappropriately. They are different problems. If someone shows up at ER with a cold (or any other non-emergent medical problem) sign them up for a future medical appointment. Don't reward them with treatment for the non-emergent problem.
2
Birth control and sexual health? There is no way those don't save money long term. No. Way.
9
pretty tight circle, doc. a bit more global epidemiology might enlighten the conversation….
Glad you wrote this, Dr Carroll. I have been saying this for years. Look at all the people in nursing homes who would have died years ago but are still alive now. They cost society a lot of money.
That said, as a doctor, I believe in preventive care because it decreases suffering and puts off death. Colonoscopic screening for colon cancer saves a lot of lives.
But here's the thing: Politicians, including in the Obama administration just a few short years ago, fed us all this rubbish about preventive care saving money when it was pretty obvious to us in the business that most people get very sick or very old or both before they die. Unless you get run over by a wheat combine or something, which isn't that great either.
What's the way out of this mess? There is no way out, folks. You die young and save your country the cost of your health care and general maintenance, or you die old and maybe hit yourself, your family, or your society with a big bill. Choose your poison.
5
I read the article and then look around the world and see most other developed countries that have way lower costs and higher life expediencies than the US and most of them focus on healthy lifestyles, are you telling me this is just a coincidence?
Of course if we really wanted to save healthcare costs, we could follow Shakespeare's advice: "First thing we do, let's kill all the lawyers." - Henry VI
6
Inherent in "preventive care"-- immunizations, health screening, wellness classes, etc., is a 'care-giver' (provider) doing something for the patient/client/public. The patient is essentially passive, except for maybe taking a baby aspirin. No surprise that kind of "prevention" doesn't work too well. Lots of people just want a pill/potion/procedure to make them feel better while they get back to drinking, smoking, eating junk while sitting on their couch.
Real disease prevention requires action on the part of individuals (as everyone knows). If every American did not smoke or drink (excessively), ate only fresh fruit and veggies, nuts, grains and dairy products, ate no junk food and exercised vigorously 5 time a week you better believe we'd be healthier and vastly reduce our medical costs.
Of course, nobody knows how to get all Americans to eat right and exercise regularly. But here's a start: make the cost of drinking, smoking and eating junk food so preposterously expensive (thru taxes used for healthcare costs) it would gag even the wealthy.
7
If we included the social determinants of health - things like socioeconomic status, access to affordable housing and good education, and a healthy physical environment - these numbers would look a lot different. Why don't we consider these factors part of preventive care? Poverty is the worst thing that can happen to a person's health.
11
The experiment isn't over. Look at the cost over their lifetimes of children who grew up under the ACA and received preventative care for decades Including safe water, living environments, etc.) vs the relative costs of previous, uninsured generations who didn't get it.
4
Preventive care also takes the form of clean water, vaccinations, antibiotics and dentistry. The cost benefits of these 4 components of medicine are well documented.
6
But as long as insurance companies continue to put unreasonable obstacles in the way of people getting the care they need when they need it we will spend more on care than necessary. It is less expensive to treat a sinus infection that hasn't spread than one that has gone untreated because the patient can't afford insurance, can't afford the co-pay or the full fee, cannot afford the prescription if it's needed, and lets things go. It's also less expensive to give adults tetanus shots every 10 years and include diphtheria and pertussis in them but we don't do that in America. Why? It's too hard for doctors to keep track of their patients and given the way insurance companies set up who we're allowed to see and how it works, doctors are correct.
If we want to have better health care we need to ensure that people can see doctors when they need to wherever they are instead of wherever the insurance company deems it convenient.
2
This is a good point. The reason to seek a healthy population is not to save money. If all we wanted to do was reduce the total cost of health care, we'd make cigarettes free to anyone over 10.
2
We have to decide as a society what we worship. Money and the laws of commerce or a manifestation of Humanistic Ethics (or some other entity with a different goal). If we were a Christian nation, we would not elect leaders who choose commerce of the common good whenever they come into competition. If we were remotely an ethical nation, we would choose to have compassion despite it costing more than neglect. Our national motto should not be "Am I my brother's keeper?"
Also, if we must use selfishness as our motivator, I wonder if these models take pandemics into account. Ask the people of California who are fighting a war against resurgent hepatitis what the cost of ignoring a segment of society's health is.
What would the cost be if fewer people were getting olsetamivir this winter? What happens if we don't discover another anti-viral before olsetamivir no longer works?
1
Why was anyone surprised?
My uninsured brother-in-law went with undiagnosed and untreated hypertension. At 400+ pounds, he also was very likely diabetic. Aside from a single emergency room visit for stiches from a dog bite, he'd never so much as spoken to a doctor after getting his last required immunization in childhood. He dropped dead suddenly of a heart attack at 50. He also smoked.
My beloved and very well insured Aunt has, at 90, consumed a lifetime of preventive care. And she reaps the rewards. Diabetes, Heart Disease and Cancer were prevented (or maybe they were never going to happen). Alas, nobody is sure how to prevent Alzheimer's. The custodial cost of her care in a shared room is $175,000 annually.
8
You are so right, you can always only have at most two out of the three:
1. Cheap healthcare
2. Great, effective healthcare
3. Universal healthcare.
That's because great healthcare by definition will prolong the lifespans of people, so they can grow older and eventually come down with a really expensive incurable illness
1
As others have pointed out here, the author's assertion that saving lives will increase overall healthcare costs because surviving people will consume health care over a longer period of time is, at best, narrow-minded. But what it does begin to shine light on is the extraordinary amount of resources our country, and our culture, demand for end-of-life care. 30% of all Medicare expenditures are attributed to the 5% of beneficiaries that die each year, with 1/3 of that cost occurring in the last month of life. Somehow we need to come to grips with how to allow people a death with dignity that doesn't consume highly disproportionate resources.
2
It's not narrow minded. It is 100% true. People are chasing a pipe dream to think that cheap healthcare, universal healthcare, and effective healthcare can all exist at the same time. It can't. Just do a simple logical test in your head. Effective healthcare by definition will prolong people's lives so that they can grow older until they develop a different and incurable and very expensive illness. At that point, the cheapest healthcare for that person would be NO HEALTHCARE, euthanasia, in other words, to tell them that it is just too expensive to treat their incurable illness, even if it means they will live a years longer, and that they should just have the decency to go and die and not cost any more money.
What if that old person doesn't WANT to just die, to get out of your way, so you don't have to spend money on them?
Will you simply shoot them? Or force them into euthanasia, as they do in the Netherlands?
2
Follow the logic. I am not advocating that we shoot old people. I am just pointing out what should be obvious. ANY kind of effective healthcare that keeps people alive longer will just increase total healthcare costs because those people will just live longer until the day that they get sick from something that healthcare cannot cure or prevent, i.e. any number of long term disabling and very expensive diseases that we can give palliative care and treatment for but cannot cure or prevent. Cancer, Alzheimer's and other neurodegenerative disorders, cardiovascular disease, etc.
Go back and READ MY POST. You cannot have cheap healthcare, universal healthcare, and great, effective healthcare all at the same time. PERIOD.
Saving money includes the ability of healthy people to work and contribute to the economy. I conclude that this was not considered in the "research" performed for this article. When a sick person dies, is that good for the economy and the country? This is the effect being seen in the article. When sick people die, they cease to use healthcare services. When they don't die, they can work. This must be included in any research on the effectiveness of preventative healthcare.
5
"When sick people die, they cease to use healthcare services." AKA, the GOP approach.
3
Preventive care may both cost money and also harm health.
The clearest example that comes to many people’s minds is prescription medication. About 60% of Americans are on at least one prescription drug, and many of these drugs are given to people without disease in the belief that they will prevent some disease or other.
The clearest and most costly example is statin drugs. It seems to be the case that statins are of benefit (lowering future heart attacks, strokes, etc.) for secondary prevention—for those who’ve already had a heart attack or stroke.
But most statins seem to be prescribed for primary prevention, and there is still hot debate as to whether they are of any benefit. (The November 15, 2016, issue of JAMA focuses on this debate.) What is not under debate is that statins cost tens of billions of dollars a year. They’re real “blockbusters”!
Crazy as it sounds, no one seems to know how many get statins for primary vs secondary prevention. Even crazier is that no one is required to report adverse effects: not our doctors, no one. One can call the FDA or the CDC to quickly confirm all this. And adverse effects can be extremely costly!
We’re not 13th in the world in longevity for no reason, and I think over-prescription of drugs is a big cause. OxyContin is the ugliest bit of business, but it’s certainly not alone. StatinVictims.com
5
Report adverse effects here: https://www.fda.gov/Safety/MedWatch/HowToReport/ucm053074.htm
1
Yes, thank you. Those who've been devastated by the adverse effects of prescription drugs are, of course, the least likely to report. The F.D.A. will confirm that there is consequently massive under-reporting.
This article highlights how off track we have gotten. Why did ER visits and costs spike after access to care was provided? Hm, maybe because there was such a backlog, with folks having been without care for so long. The intention of a medical system isn't to save money--it's to provide medical care, which we are doing insufficiently. More egregious however is the misuse of "preventative" applied to everything from screening mammograms and well visits for adults, to healthy food and exercise. The former have been shown to be overused, the latter essential to well being. The issue with "prevention" isn't that we don't know what works; it's that we are ignoring how few people have access to the foundations of health--food, exercise, sleep, emotional well being, safety.
6
The only way to know if preventive care saves money is to evaluate it over the entire lifetime of recipients.
5
I get it. Smoking leads to an early death.
The government then saves money through reduced spening on Social Security and Medicare.
So hope they die of a quick heart attack, and not a prolonged cancer.
7
Stupid Dr. Carroll. He should embrace the anecdotes and good sense of those commenters here who reject the evidence he cites. Instead, the silly doctor relies on multiple studies from multiple sources. The kindred-spirits of climate-change deniers are present in this forum.
And please read again the doctor's closing paragraphs:
"But money doesn’t have to be saved to make something worthwhile. Prevention improves outcomes. It makes people healthier. It improves quality of life. It often does so for a very reasonable price.
There are many good arguments for increasing our focus on prevention. Almost all have to do with improving quality, though, not reducing spending. We would do well to admit that and move forward."
10
This is an excellent article on a complex issue, and despite being written by a subject matter expert is one of the better examples of unbiased news that I have read on NYTimes in many months.
2
I think of Soylent Green when I read this article. I see it has sparked discussion.
1
I would like to see the Upshot invite another expert review this article, e.g. Dr. Ezekiel Emanuel.
I am not an expert, but, for example, I have read that people often live for a long time with diabetes, unaware until it becomes symptomatic, and some damage is done already. So it seems that early attention and preventive steps would be cost effective.
1
I have two questions that are related, but beyond the scope of this article and its research. First, to what degree was the uptick in emergency care services simply a cultural response from people who have little to no experience with any other kind of medical care/intervention? If you only ever to the ER, then when you get insurance you might not start going to a PCP, you might just go to the ER more. This could even out over time as we train people in how to use medical services.
Second, healthcare is a market. Furthermore, as Atul Gawande and healthcare economists have written about, healthcare functions as a demand-driven market. That means doctors can prescribe more tests, services, surgeries, etc. to keep the profit of a hospital or group practice steady. They usually don't even realize they're doing this. That could also course-correct to erase any gains from preventative care.
I'd love to see future research that tries to control for these factors.
3
This article defines the cost of health care within a limited system, just the cost of health care. As a family doc I recommended all my patients who were teachers get flu shot. That saved the school districts money because they didn't have to hire subs when teachers had flu. Saving the life of a mother of young children saves on possible/probable mental health care, addiction treatment, and criminal justice for her children. Abandoned children do not do well. And whether a mother dies of physical illness or drug addiction the child is still motherless.
But the big elephant in the room is the huge consumption of health care in the last few months of a person's life and in the personal care of the elderly in nursing homes. Bathing, feeding, providing food and beds etc for elderly whose families cannot or will not care for them, or who have no family, is assessed against the health care system when, in fact, it is personal care and has only a small component of "medical" care, such as giving medications. We have a political culture that values the desires of the individual over the needs of the nation. This is currently measured in tax rates. But it could also be measured by family care of the elderly, or by individuals recognizing when medical intervention costs more in suffering and money than is gained in a few more days of life. We fool ourselves into thinking that health care can solve the problem of death and disability.
4
You are mixing apples & orangutans.
The costs avoided by regular screening for colon (colonoscopy) & uterine (PAP) cancer not to mention immunizations (flu & pneumonia vaccines) for the elderly are significant. The type & methods used to provide preventive care also influence outcomes.
The best bangs for prevention bucks are those that have an impact on large segments of the population -think seat belts & fluoridation. Large scale public health prevention measures have been demonstrated to have a hefty return on investment. An article in a medical journal found a mean ROI for public health prevention activities to be 14.3 to 1.
http://jech.bmj.com/content/early/2017/03/07/jech-2016-208141
5
My health insurance will pay for a pneumonia vaccine when I turn 65. Clearly, the insurance industry has calculated that treating those who get pneumonia costs less than giving the vaccine starting at age 50. However, my personal cost-benefit analysis is the $200 cost of the vaccine is trivial compared to having pneumonia. I paid for the shot.
3
Years ago, a colleague whose research focus was preventive health wryly said to me, though they may live better, when people live longer they ultimately use more health services. I think Dr. Carroll is correct—improved quality of life is a worthy outcome even if we don’t save costs overall.
6
In 1948, Aneurin Bevan, the British Health Minister, introduced the National Health Service with the promise that a system of health care with emphasis on prevention would reduce the overall costs to the country. The budget of the NHS has increased every year since 1948.
2
This review is truly misguided because preventive services are not the same. They also apply to wide disarray of different conditions. For instance one case of paralytic polio could cause a lifetime of increased expense.
4
I don't believe this. Diet, exercise, no-smoking and little drinking are the biggest single contributor to disease prevention of many kinds and they don't cost the health care system anything - all the necessary information is freely available and it is OUR responsibility as individuals to live a healthy life-style. If most people did this we would see huge reductions of expenditures on curative medicine and the management of chronic diseases.
7
Yes but the only way that is likely to happen is for there to be a combination of positive and negative incentives for people to practice good health. So far we are mostly unwilling to do that under group insurance. As a person who has fought their weight for as long as I can remember I will tell you that simple weight control is anything but simple. Exercise is great and we can almost all do something about that but it dosn't change the need to keep the weight in check. That for most Americans apparently is very difficult, even our current president. People who smoke are addicted, they know it will likely do them serious harm but they are addicted, even if they quit they often start again because a weak moment and a few cigarettes while under stress will start them back up.
There's a few things this article doesn't address. First of all, the Oregon study only ran a few years. When patients who have not seen a doctor in decades enter the medical system, they are often very expensive to treat initially. You can't undo the kind of damage that uncontrolled hypertension and diabetes can do, you can only prevent it. You won't see cost savings from that kind of preventitive medicine for decades.
Second, there is a severe shortage of primary care doctors. Many rural areas have wait lists to get into a doctor's practice. Depending on the area, medicaid may pay less than the cost to provide the care so many doctors don't accept it. Patients had insurance, but they didn't have healthcare. The still couldn't access preventitive care.
These studies did not show that good preventitive medicine costs more. They only showed that giving people insurance but limited access to preventitive care doesn't work. We need enough primary care doctors and a few decades to undo all the damage our current system as done.
25
100%
1
As a senior that just had his annual check-up with my doctor, I strongly endorse preventive care. My new doctor, due to relocation, now knows me well and in case anything happens will understand my needs and any care recommended.
5
FASCINATING! ... and/but ... it isn't MY "hobby horse," but income redistribution certainly figures in every $ (or billion) spent by government. One has to recognize that with the big benefit being "improved quality of life" (including longer lives!), the unspoken push back will take the form of "WHOSE LIVES?"
One would have to be life-threateningly naive to think that this question - however "immoral" - doesn't deserve attention.
I won't even attempt an answer, partly because of the word limit here.
I will say that I heard a discussion of the opioid crisis, mentioning Philadelphia, worst of all U.S. cities at this point ... and a Canadian city that lets folks "shoot up" under conditions that make it likely that they will not die. The interviewer was sympathetic, but she felt bound to ask the question "But aren't we 'enabling' a lifestyle we wish they would abandon?"
The interviewee probably has been asked this question more times than he can count, and his answer was similar to the one in this article - "We're keeping them alive. Can anyone really argue that that goal is unworthy?!" (And yes, he said that their ultimate goal is that the users "get to a place in their lives" where they can be drug free.)
That's an extreme example of the preventative medicine discussed here, but it's instructive in that even people who think they're "decent" would - many of them - view any added tax burden with enormous hostility.
2
REAL preventive health care saves money. Mammograms and prostate tests and the like are not preventive health - they are diagnostic tools.
What is preventive health care? Eating whole foods, eating organic. Acupuncture, ayurveda, naturopathy. Yoga, tai chi, chi gong. Herbs. A bath in mineral salts with some lavender oil. Quitting smoking.
All of those are beneficial and compared to what western medicine does, saves you money.
I realize it is anecdotal, but over 25 years ago, a few doses of a homeopathic remedy cured by 3x weekly major asthma attacks. What cure does Western medicine have, and further, one that isn't laden with more problems?
Some pollution control would help too, as well as decreasing gun violence among other things. Get the chemicals out of our lives, that is real preventive medicine. A lot cheaper than treating cancer.
This is so typical NY Times.
5
YES! disappointed with TIMES reporting. Don't smoke. Maintain a healthy lean/fat ratio. Exercise regularly. THAT'S preventative medicine!!!
2
"eating organic. Acupuncture, ayurveda, naturopathy. Yoga, tai chi, chi gong. Herbs. A bath in mineral salts with some lavender oil. "
"a few doses of a homeopathic remedy cured by 3x weekly major asthma attacks. "
Great. "Preventive care" means quackery and an anti-Western medicine perspective.
3
Thank god the NRA is doing its part to reduce overall health spending. As the article pointed out, dead people don't need doctors.
4
... but wounded/disabled ones do.
1
This is the most amazing amalgam of malarkey and playing mischief with research I have seen for some time. While perhaps trying to honor the scientific method, Dr. Carroll has gone seriously astray here. Dr. Carroll relies on research on the costs of preventive medicine to discount it's financial relevance, but when one looks carefully at the research, none of it actually pertains to preventive medicine, even if it is labeled that way. Most of the research pertains to screening tests and suggestions that people modify their behaviors in a more pro-health manner. These actions do not constitute preventive medicine -- they constitute surveys of health and no active intervention other than the already known to fail implementation of a "suggestion".
We already have known for many years that preventive medicine saves money -- the reduced rate of tobacco smoking has led to a reduction in the rates of lung cancer, COPD, and cardiovascular disease due to these factors. Countless patients have reported improved health from losing weight or implementing an exercise program. If there isn't adequate research demonstrating this, this is attestation to the shortcomings of the research, not evidence that these interventions are not cost effective. It is indeed shocking that in this day and age when up to 80% of chronic illness is due to modifiable lifestyle factors, Dr. Carroll can seem to imply that interventions that change these lifestyle factors won't help save health dollars.
10
So it depends on how you define health care dollars. If you carve out care for the elderly with dementia in a skilled nursing facility or other setting, then your supposition is potentially correct.
However, if you decide to include that particular substantial cost, then it turns out that helping people live longer does not actually end up saving money, as those who enter the late periods of their lives end up requiring more and more custodial care, which is often provided in a health care setting using health care dollars (e.g. Medicaid).
I am not disagreeing that preventive care is worthwhile - it is just important to realize that it doesn't save money for the "system" overall.
2
"In the long run, all of those people living longer would lead to increases in spending in many programs, including health care."
So we can save money by having people die younger. Doesn't that same logic apply to anything that saves people's lives? That this is taken seriously is another indication of how far removed from reality our ruling elite has become.
3
The subtitle of the article is:
"Contrary to conventional wisdom, it tends to cost money, but it improves quality of life at a very reasonable price."
Carroll is not a bean counter. In fact, he's saying that cost saving is not a reason to argue for preventative care.
2
I would like to comment here on another area of health care costs. Defenders of such costs being higher in the US than in other developed countries say it is the price we must pay for medical breakthroughs and innovation, which are supposedly lacking in places like Taiwan, where the government controls health care costs. Here is a link to a local report on a breakthrough at a government funded research institute that may lead to new treatments for dementia:
http://www.taipeitimes.com/News/taiwan/archives/2018/01/28/2003686580
If saving money is all that matters get rid of health insurance companies and overpaid hospital administrators.
4
Everything in this country is connected to $$$$. Health care is no different. I'd like to see comparable statistics for other countries who have universal health care. I wonder if those health care systems think in terms of "saving lives (first) versus saving money."
3
Yes. Well put. Sometimes good things cost money! I've wondered so often why Americans don't seem to grasp this. Taxes fund a civilized society; the cost of food and clothes regularly goes up, so why shouldn't the costs - and the taxes - connected with good fire departments, good roads, good sewage infrastructure? We are manifestly not a nation of critical thinkers, and Exhibit A in that regard is this ridiculous profit-driven healthcare system. At 59, I know too much. I eat right, get good rest and exercise and stay socially connected because it's the best way to avoid that healthcare system!
5
There is a large elephant in the middle of the room called huge profits by the health care industry. Can we just admit that everything else is nonsense until this fundemental problem is addressed? Of course "preventative" medicine lowers costs- but not in our system, becuase when profits decrease in one area, new sources of income generation sprout up- becuase it is legal and what shareholders want.
6
It's not costs. It's PRICES. Set by the medical industrial complex.
1
In contrast to "Preventive Care" (whatever that is) Primary Care saves money and saves lives. Dr. Starfield and coworkers at Johns Hopkins showed this for many populations across the world. Yet, due to Medicare-led payment policies, primary care in the US is struggling to survive.
The US (CMS) has tried to replace primary care with checkboxes and formulas, insisting that more regulations and paperwork can replace clinical judgement. Yet their own creature (MedPac) urges junking MIPS, the most recent bureaucratic quality/value scam.
Other countries spend half as much as we do for health care and get better health. They spend twice as much on 'social services,' which is true prevention. They house the homeless. We pay for hospital care when they get sick from living rough. They pay for primary care, which improves health and reduces costs. We pay for more and more expensive hospital/specialty care. They decriminalize drugs and pay for treatment. We spend billions on cops'n robbers, and let people die.
Formulized health care doesn't work, including blind recommendations for preventive care. Bad policy kills.
Good primary care and sensible policies save money and lives.
5
Everybody dies. If you don't die from one thing you will die from another. So everyone is going to end up casting the health care system money unless they happen to drop dead in their tracks before they make it into the health care system. That's in essence a fixed cost.
However, the longer you live without entering the health care system the less demand you place on the resources. So in the simplest thought experiment preventive care saves money. BUT, you have to integrate the costs of use of the system over the lifetime of the individual and normalize for the length of time that each individual is economically productive.
Are there any studies that actually take this approach? If not, then you are looking at the whole problem the wrong way.
3
To use the argument that an increase in cigarette taxes increases government costs to support this thesis is ludicrous! Certainly if we don't dissuade people from smoking, more of them will contract lung cancer later in life and die prematurely, thus costing less in social security payments and medicare costs. But it's a really off-base argument to make in discussing the cost-effectiveness of preventative medicine. Makes one wonder how well reasoned or supported the rest of the arguments here are.
1
While prevention might not save the government money your analysis didn’t mention the benefits to the economy as a whole due to reduced worker sick days, increased worker performance because they are healthier. This benefit could be enormous.
4
to Aaron Carroll,
What this op-ed is doing is only creating more rhetoric in favor of furthering capitalism at the cost of human lives by diminishing the worth of someone with failing health. The human body is cash crop in America. It does not matter that preventative care is just as costly as the current health insurance infrastructure. It matters that you write pieces that overlooks the fact that capitalism kills the ailing bodied and the poor. It is inhumane. This individualistic society is going to continue to be a cancer to everyone, crabs in a barrel. This op-ed was not needed.
1
It's very deceptive to lump all preventive medical care under the few examples cited. Preventive care runs the gamut from patients taking the initiative to end dangerous habits like smoking, excessive drinking and other addictions with the help of programs, to altering a diet based on the genetic pre-disposition of such illnesses as diabetes 2 and heart disease by taking part in dietary education programs to more unconventional methods of altering one's mental state including hypnosis and meditation.
Dr. Mark Hyman has pioneered the field of nutrition by demonstrating how eating correctly can eliminate, prevent or reduce illness of all manner. One of his patients was Bill Clinton whose health he improved greatly. To say that preventative medicine is neither effective nor financially sound based on limited anecdotal evidence is dangerous. But I guess that's all we can expect from conventional doctors with limited imaginations.
The problem is not preventitive medicine, it is the manner in which they have been implemented.
2
This only matters if we, as a people, actually care about the health and happiness of our society. And we lag other first-world countries substantially on our social nets.
1
Well, preventive, or rather EARLY care works for me, and I would bet the majority of readers. It comes down to awareness, execution, and probably having more skin in the game for an ER visit versus an Immediate Care visit.
I've been using Immediate Care centers for many years, they have gotten more convenient, e.g., late hours, more locations, etc. Recently I went for an intestinal infection, an antibiotic cleared it up in a week. Physician said, if I'd waited, it would have meant surgery. What's more cost effective and expedient (didn't miss any work)?
The reports this article are based on are old! 2009? 2010? Aside from which the article does not cover one of the most beneficial of preventative health care measures that Medicaid, Medicare and most plans don't cover without an extraordinary additional cost: dental care.
In my non-scientific observation, the poor and elderly have the worst teeth. People with bad teeth can't eat foods that are tough to chew - vegetables, meats, etc.
Better dental care could lead to overall better health. It's insane that basic dental care isn't covered. To deny that preventative health care for heart conditions, stroke, etc., are ineffectual is irresponsible.
Nothing in this article is persuasive that preventative health care does not saves lives. It is, however, good fodder for those who would deny health care to those needing Medicaid and Medicare; i.e., Republicans.
It did sound too good to be true, and I'm sorry that it's not. It takes away a good argument for the ACA, but as the author said, there are still good reasons to support preventive medicine. I can more comfortably make my arguments for the ACA and universal healthcare with the facts. I'll leave the myths to the other side.
If the ACA had a provision in it that more preventive care would be provided, I can see how its passage would relate to increase or decrease in emergency room use. But no such provision was included. What it did do is provide insurance coverage to more people, making them feel they could actually afford to treat conditions when they occurred. Unfortunately, many conditions are noticed first when it is difficult to go to a primary care doctor, and many people are just used to doing the easy thing and heading for the ER. So, yep, passing the ACA increased ER use. But that doesn't look like anything like an argument for preventive care increasing costs.
I wonder what you think of the current state of preventative care, though, and whether if we improve it, with better interventions for lifestyle diseases specifically, whether the projections would improve. Especially since it is early days for the ACA (in the scheme of things), and since universal care might alter costs and access to care etc much more, I'm not sure it's fair to say definitively yet that preventative care won't save money in the long run. I'm also not sure the 'if people live longer they'll cost us more' is the best argument to use-- there might be a 'cost per year' amount that could compare someone who currently smokes to those who quit, which, per year, would likely be less expensive. From your reasoning there it's a short leap to: "people should die earlier because it's cheaper." Which, clearly not.
Dr. Carroll: Your assessment makes perfect sense and none of this is really a surprise. Aside from the rising cost of healthcare services, the single most important reason that preventive care is not saving money is due to poor doctor-patient communication which leads to very expensive medical errors. When basic healthcare issues are not addressed in the practice setting, illnesses linger and go untreated until they become very expensive chronic conditions leading to increased morbidity and mortality --- at no fault of the patient. Are there records that show outcomes? I've hardly known doctors to ask about outcomes, so how can they report them? And, what percentage of patients actually have their medical concerns properly addressed? I would guess very few. And, we wonder why medical care is so expensive.
1
If we make mandatory to give everyone turning 40 a pill that would kill them instantly, health care costs would most certainly drastically drop. Will this achieve any goal? Probably not.
A true measure of health care policy effectiveness, is how much lifespan and quality of live it increase, for each added year of life. Obviously it's going to cost more if people live longer, and more as people get older. The economy question is how efficiently we can add each new year of life (while factoring in the increased economic output of individuals). The policy one is how much are we willing to pay as a society to extend life
2
Ok...so let me make sure I understand; we shouldn't fund prevention because people used more emergency rooms? Since when is an emergency room considered preventative medicine?
4
I find this pretty misleading. First - the editorial begins by diving into increased use of emergency room care. An article about increased preventative care should actually test what happens when the use of preventative care increases, not presume that increased access to preventative care will not result in an increased use of preventative care. If the author is arguing that increased access to insurance does not reduce emergency room visits, that's a different argument.
Second, $3.7 billion may be .2% of national health expenditures, but that's not really germane to the reduction in costs. For instance, national health expenditures includes personal spending on over-the-counter medicines like Tylenol and Motrin. Increased preventative care would not be expected to reduce these kinds of expenses.
Given that the goal of increasing preventative care would be to reduce the federal taxpayer expense for emergency room visits, one must compare that 3.7 billion to the total amount of money the Federal government spent on emergency room visits not covered by Medicare/Medicaid.
Also, how much money would be saved if the government directly negotiated rates for everything? How much money would be saved if urgent care facilities were streamlined with preventative care clinics, so patients could be routed more efficiently on an ad-hoc basis?
4
Some of the lack of impact by ACA plans on lowering emergency room use is that many bronze plans have high deductibles--$5000 or more. Many people with bronze plans probably delay care until they have to get it in the E.R. This needs to be factored in. So many plans now have high deductibles.
4
In southwestern Washington, (Vancouver, WA area), ERs are saying not to go there unless the condition is life threatening. But it can also take 5 to 7 days to get an appointment with a primary care physician. Let's go to the ER.
Urgent Care centers are popping up like mushrooms for everything else. I have gone once with very good effect. When I lived in Cupertino, CA, there were several Urgent Care centers there that I frequently used.
1
So an ounce of prevention is worth an ounce of prevention?
A friend of mine comments:
This I know from experience: If a woman ignores having routine ("preventive") mammograms
for 4 or 5 years, and ends up with Stage 3 breast cancer, the cost of treatment of that disease
will be well over $100,000.00. Had the woman had a mammogram earlier, chances are good
that the tumor would have been discovered far sooner, would have involved less intrusive
surgery, less costly follow-up treatment, and overall would have saved insurance about two-
thirds of the $100,000 figure.
1
John Ahlstrom's friend has clearly not followed studies in this field for over a decade. First, there are many false positives with mammograms. The unnecessary operations wipe out the savings that friend described, which is what this article is based on. Second, and this has easily been shown in a number of excellent population studies, mammograms do not result in fewer deaths from cancer. Patients are told their cancers were successfully removed, but there is no significant difference in whether or not they die of cancer. Perhaps the operation or radiation treatment is sometimes itself harmful.
5
More precisely, for 1000 women 50-70 having or not having mammograms over 20 years, the net effect is 2 more women dying of something else, and 2 fewer dying of breast cancer. (Loberg, 2015)
Presumably, overdiagnosis and overtreatment causes the extra deaths in the screened group.
An individual anecdote does not outweigh the fact that it costs more to screen tens of thousands of women for many years just to find that one little anecdotal woman.
1
Our current system is guided primarily by its profiteers. As Cris
Rock said about HIV 'there won't be a cure. There's no money in a cure. The moneys in the come-back'.
Prevention is more than what's on your list. It includes enhancing a person's sense of control (their ability to pay), their sense of understanding (what they know about their condition) and, their sense of meaning. These all play into what Antonovsky called a sense of coherence that marked his group of healthy people.
More currently Steve Cole at UCLA has found that healthy genes are preferentially expressed by altruistic behaviors. That too is preventive medicine.
The goal of medicine should be increasing the quality of life and then the quantity of life will increase and be more worthwhile. Being disabled by dementia, chronic pain, severe shortness of breath, or paralysis should be prevented as well as death.
Living forever is and always will be impossible.
Insurance should be for unaffordable expenses such as a house burning, a severe accident, or chronic disease.
Emergency rooms have very high overheads, with much staffing and equipment ready to handle anything 24 hours a day and to fill all the gaps and the medical system. The average bill is now $1800. ERs are not cost effective unless the disorder is life or limb threatening .
1
Health insurers have long known that tend to neglect their health in other ways as well - and that their tendency to go to the doctor less often than more health conscious people saves them money. Which would explain why they weren't investing in smoking cessation programs and should make obvious that insurers interest are not always aligned with patient health.
But all this analysis simply takes into account savings from the gov't and taxpayers point of view, and not by costs borne by individuals and their families. Do economists measure the costs for families of having a chronically ill loved one, or of growing up without a parent who died early due to untreated illness, or the impact of addiction on the health of the rest of the family?
One thing economists are not interested in discussing is the morality of profiting by ignoring some people's suffering. Prof. Reinhardt commented often that it was not his job to dictate the priorities or levels of compassion of the American people, yet I would assume and hope that he and many economists would have balked at engaging in analysis of whether slavery or apartheid or the practice of selling daughters into marriage, or euthanizing the mentally ill had a net positive or negative effect on the economy.
The fact that we do so regarding healthcare, not to mention the election of Trump signals the extent to which we are now amoral.
2
O.K. then, spend extra money on prevention. End of story. The extraneous quibbling in this piece doesn't make much of a case for the failure of Prevention to save money nor improve lives - in the sense he confusedly uses it - and why the hard-edged interest in saving vs spending money, anyway, when you're talking about improving people's lives?
You say it's worth it to "spend more" (something that was hardly proven necessary in this scant article) but it sounded pretty grudging to me. And "spend more" is not the same as spend more wisely, something to consider.
4
The one subject about universal healthcare or "medicare for all" I have almost never heard and do not hear in this article or opinion responses is the possible result from the rapid increase in total population health EDUCATION from cradle to grave combined with all the rest of the arguments about savings, not just quality of life. Visiting a doctor, getting regular health examinations always leaves a person (at least it does me) a bit more educated. The only time trickle down actually works! We talk about the powerful effects of "herd immunity" regarding the real goal of vaccines? Well, What about "herd healthcare" education?
The pro and con arguments I see here (everywhere) regarding preventative care saving resources doesn't take into account the effect of this education to the whole healthcare system. It will take a decade or more to see the effects but I do think that when we provide heath "care" and the attitude toward that goal, not health "insurance" which is a misnomer, we will be on the right track toward a massive increase in "herd healthcare" education.
When taken into account the education and preventative care we take for ourselves which will happen BEFORE we need a doctors will save a tremendous amount of resources decades from now compared to if we do not.
6
We need to start widening our definition of "prevention" beyond the medical setting. I have an MPH and one of the most striking things you learn early on is that health CARE only impacts about 20% of a person's overall HEALTH; social determinants of health (e.g. stable housing and income, healthy food, family and community cohesion, etc) along with personal habits account for the rest. The government doesn't even consider social determinants in risk adjustment algorithms that set reimbursement rates for Medicare and Medicaid. Something else you learn is that when you combine health care and social spending in the US, we spend about as much per capita as our developed country peers---we just spend a disproportionate amount of the total on health care despite the relatively small impact it has on health.
I'm glad the author eventually pointed out that there are also meaningful benefits to PEOPLE from routine preventive medical care, regardless of whether the savings are significant.
Finally, the main practitioners of preventive care, primary care docs, are among the best positioned to bend the cost curve of pricey specialist and inpatient care and over prescribing. They are burnt out and in short supply and the last thing we need to do is poo-poo the value of their work. We need way more of them, with much smaller panels so they can get to know their patients again and, with luck, start practicing a more holistic kind of care that addresses health beyond the physical body.
11
If cancer is caught early, it may just be a minor surgical procedure. The cost of treating one person in later stage cancer can run into the millions. Cancer is one of the leading causes of death in the US. I guess I am wondering how exactly these conclusions are reached at a detail level?
11
There is a major problem baked into this argument, evident from the start.
There are only two ways to reduce health spending. One is to improve the efficiency of how funds are spent. The other is to reduce services offered.
It is delusional to think that putting more money towards preventive services would have a major impact on health spending if nothing is done to reduce wasteful spending elsewhere. A case in point comes from paragraph 2 of this article: if the Affordable Care Act increases funding for both preventive and acute care (emergency) services, clearly costs will go up. Moreover, another obvious point is that if preventive services reduce the incidence of one costly health problem (i.e. lung cancer from smoking), these people will develop other problems that will still cost a lot.
The solution seems obvious then, but it can only be arrived at by stepping back from the myth that there is any simple cure-all to healthcare spending. Instead, we need to go back to first principles.
Health care costs will undoubtedly go down if funds are shifted from acute care services and expensive, hospital-based interventionist services that disproportionately affect those near the end of life, yet provide only modest benefits, to community-based and evidence-supported preventive services. And, in the US, you will need to gut the wasteful administration-heavy private insurance racket that increases costs by at least 50% above anywhere else in the developed world.
6
A third way to decrease spending is decrease usage.
The dirty little secret in health care is that those who can least afford service (the poor) have the highest utilization rates.
The poor smoke and are obese in much higher numbers than those of other socio-economic demographics. Both of those are the top two behavioral issues related to health.
1
The poor do not have the highest health care utilization rates.
Does the fact that the $3.6 billion saved by preventative care is "only" a fraction of annual health care costs mean it's unimportant to save that money or the suffering in disease it represents treatment of?
6
Saved? Well where is this money Anima? Perhaps you mean $3.6 billion in expenditures were avoided. Big difference.
What's not in these studies is the effect income inequality has on the cost of non-preventive treatment. Preventive care looks costly in comparison because so many can not afford the cost of subsequent treatment, so they choose not to have it... and bingo, the total cost of this treatment is now less.
As long as this treatment remains expensive and out of reach of most with sub-standard or no insurance, it will remain highly profitable, and political incentive for preventive care will remain weak.
2
Preventative care is not a commodity. It is misleading to make blanket statements about all types of preventative care or disregard the competence with which it is carried out.
My fully insured partner made 6 trips to the ER, and spent almost three months locked psychiatric hospitals because the preventative care practitioners failed to administer helpful tests, failed to diagnose her conditions, and prescribed "preventative care" that actually contributed to her psychiatric symptoms.
It turned out that she had genetic abnormalities that led to nutritional deficiencies and sensitivities to some supplements and drugs that were being prescribed. Most doctors know very little about nutrition, do not adequately test for nutritional problems, and are hopeless when it comes to how genetics and common foods and supplements can lead to extreme symptoms in a small but significant portion of the population.
She also had a neuro-Lyme infection that went undiagnosed for decades. Again, most doctors know little about Lyme, and much of what they think they know is wrong, thanks in part to misinformation and suppression of information by the CDC.
Eventually, we sought the genetic, nutritional, and Lyme testing on our own, figured out most of what to do about it on our own, and got some necessary help from an extensively educated naturopath not paid for by our insurance. No more expensive ER visits or psychiatric symptoms, now -- no thanks to conventional "preventative care."
2
His premise is sound. We have been told (repeatedly) that preventive care and access to care will make things cheaper and reduce costs. This is false. You can't have more use of services and expect it to be cheaper. Chronic disease (diabetes, heart disease, obesity) do not go away because blood sugar is monitored or a nurse calls to ensure adequate coordination of care. Those with diabetes found earlier will still need optometry appointments, screening for other comorbidities. Diet and exercise will most likely fail (see why many physicians are gaming their panels in light of new rules for "quality" versus "quantity" of services for reimbursement) and the patient will be started on expensive medication to get decrease the A1c. The only real prevention is diet earlier in life. Unfortunately, the major food conglomerates donate heavily to the American Diabetes Association and others.
My point is that other health care systems ration based on access to care. The US rations based on ability to pay. If we spent our money on vaccinations, prenatal care, and reduced that spent on end of life care, we would still need more money, but it would be better spent.
No one likes forking over their money to insurance companies as currently mandated by the federal government in exchange for access to care on paper. Medicaid is costing more money than originally estimated by many fold. We as a nation must decide whether we want access to basic services for all, or access to all for a few.
2
We faced this same question prior to the adoption ACA. We, the people, must decide whether we want access to basic services for all, or access to all services for a few. Will the question finally be resolved when a majority of our fellow citizens choose access to all services for a few, even when they are not part of the few and against their best interests? Many would shoot down their own medical care so that "others" won't have any care either.
1
What is the value of improved quality of life and the increased productivity associated with it?
I'm sure it depends greatly on how much improved your quality of life is, from what level it's improved, and how many more years of life it gets you (and if you're working or retired). There's probably no way to do the math, and even if you could, it varies from person to person, based on their situation.
The authors seemed to have glossed over the quality issue. They didn't provide any statistics or measures of quality. That s because quality of life is very difficult to measure.
From my experience as a MD, there are two kinds of patients, the ones who love going to the doctor, receiving an exam, preventive tests and education, sympathy and hand holding. The others hate going to the doctor and only go when sick, in which case they might use the ER or urgent care, but hopefully will be able to see me, because I am not wasting time doing physicals.
I can't stand the first group. Just come to me when your sick or notice that something isn't right with your body and I will take care of you. If you have a chronic condition I will take care of you by seeing you regularly and keeping an eye out for complications or new problems. Your quality of life will increase.
Stop wasting your doctor's time just so you can hear you're healthy. The only beneficial screening measures are fasting blood sugar, weight and blood pressure, which are rated A by the USFPS. Those can be done at home or by a nurse annually. If one or more is abnormal, then come see me. Saves money and time all around.
2
This seems reasonable to me, a nurse of 30+ years. And I know that the conclusion, that there are substantial quality of life benefits in preventative care, is definitely true.
3
An interesting take on this topic. It's sure to generate lots of heated debate including "single-payer" diatribes. Anyone who thinks the Emergency Room is convenient hasn't been on a Monday evening waiting hours. This for care from a physician you've never met who might (if you're lucky) have access to your medical record. I've experienced single-payer with my family in Canada, the UK, and Germany. They generally save money by delaying care, decreasing customer service, and generally discouraging use of services. The important point lost in all this is ACCESS to timely care. The ER is popular because it is accessible, and can bring tremendous resources together to take on a problem. But this is expensive (but might actually be more efficient). Hopefully technology working with professionals can bring access to medicine in a more convenient way through email and videoconferencing. Now we just need the pay/incentive system to catch up.
Lots of correlations and associations here, but not much examination of cause. For example, emergency room utilization rates across all insured categories were increasing before the ACA, during the ACA and after the ACA. The ACA has little to do with that. Instead, it is in practice increasingly difficult to see a physician quickly and so people across the spectrum of all ages and insurance coverage go to the ED. As for the idea of "prevention", it is well-known in the healthcare industry that utilization is inversely correlated to wealth and is a function of "social determinants". In short, the average Medicaid recipient of any given age uses twice the medical resources of the average commercially-insured of the same age. Fix the social problem and you fix the medical problem.
10
So true! Folks newly insured will likely not have had a primary care physician. And it seems that many if not most physicians will insist on a routine physical for an initial visit. For such there can be a waiting period of months.
An interesting concept presented here: the more that healthy behavior is achieved, the longer we live. And thus the more we end up costing, in geriatric needs. Maybe we should have a "use-by" date. Beyond that date, all bets are off.
1
Except that life expectancy has grown massively over time, and not just because of better medical care - things like basic sanitation or vaccines have dramatically transformed care and made us live longer without requiring us to spend thousands of dollars on pills. My point is, who's to say our "use-by" date is as high as it'll go? And who's to say that someone at the end of that date will require a lot of care? Or someone who isn't, won't?
3
This is already happening. Seniors ARE being denied life saving treatment, because they are not viewed as full human beings.
1
You missed my tongue in its cheek...
Vaccination is at the core of preventative medicine and has been one of the biggest success stories in modern history. Preventing disease is always more economical than treating it, though it's true that many educational programs are not successful. We should redirect our efforts toward farm-aid reform (eliminating subsidies for corn products that fuel obesity).
6
It is not "too good to be true" but rather false in most instances. It also is not really true that it improves life so much at a low cost either for everyone. Those that monitor their health and make changes do benefit, many won't be changing their habits that much and at a very large cost.
There are ripple effects, positive or negative from access or lack of preventive h/c. Affordable, consistent preventive care affects family income and living standards.
Family bread winners are less likely to die or become disabled from ongoing untreated conditions.
If become disabled, another family member may have to quit a job to stay home and care for the disabled person.
Family economic security is reduced, with negative effects on childrens' lives.
The family may have to go on welfare, instead of working and paying taxes.
Sustaining the health of a population has many secondary effects on economic independence of individuals.
8
It would be very helpful for Dr. Carroll to write a column based on "quality adjusted life years" which is a more appropriate metric than costs. So it's not only how long you live, it's the quality of those years. I find the reductionist argument that people's living longer because of prevention-oriented lifestyles is bad for the bottom line particularly offensive.
14
Only offensive to people like you, everything has a cost and defining quality life is very subjective.
3
He did - 3 years ago. Follow the "cost effective" link in the 4th to last paragraph.
1
The purpose of health care is NOT to save money. It's to help people lead meaningful lives not crippled by illness and pain.
If you want to save money, simply shoot anybody who has an expensive illness or a condition that may produce such an illness.
Diagnosed diabetes or kidney disease leads to long-term treatment. Undiagnosed, these will knock the patient off soon and we won't have to pay for them.
Finally, some alternative to the ER - clinics in people's neighborhoods that are adequately staffed - will reduce visits to the ER when there's no need for immediate high-level care. Such a clinic makes the ER work better for really serious cases. No guarantee that it saves money. Again, that's not the point of health care.
33
The analysis is flawed, and I wonder what the motivation is for clearly failing to address the larger picture of our healthcare system. Yes, preventive health care measures cost money! Yes, quality of life matters. But pay attention: behind "quality of life" there is indeed a long term savings of medical expense. People who have higher quality of life don't end up on disability, miss less work days, and have less need for the type of emergency care that eats up money. Some of the examples the author gives on how the ACA ends up costing more are based on limited data. Emergency room use on my ACA Florida Blue policy costs me $500.00 each time I visit. I am unlikely to go to the emergency room if it is not an emergency. If medical care is available at cheaper cost, consumers will use it. But is medical care available? Not everywhere. This is a flaw in our overall medical delivery system and the example cannot be used to simply put down preventive care. Our for profit medical care system favors solutions that profit pharmaceutical companies, device manufacturers, labs, radiology and imaging centers, and even to hospitals that operate as non-profit organizations. True preventive health costs money, but doesn't bring in a large enough profit margin for the players in our system. The bias--often unconscious--finds its way all the way to the level of the scientists doing basic research, who need grants and patentable products.
12
Perhaps one helpful nuance would be to not lump all people together. As examples, maternity and well-baby checkups are cheap and very effective, I expect the same is true for people with diabetes. Whereas little in the short term is going to help or hurt a healthy 20 year old. P-care is probably extremely cost effective for some segments, and less so for others.
6
Another aspect of preventative care that would cost a lot of money but I think would be well worth it: Public Health sponsored, free or very low cost, widespread, long term educational programs for people on a variety of problems such as diet/nutrition/obesity/healthy low cost meals/exercise for all different ages/stress/anxiety/depression/addiction/pregnancy/infant care and safety/early childhood development etc etc.
There are many many people out there who simply DON'T know how to take care of themselves, they haven't the $ or knowledge. What used to be covered in basic education is no longer. We have a public health crisis of lack of knowledge and support. Look at the obesity crisis, the opioid crisis, children arrives to kindergarten completely unready for learning. Look at maternal mortality rates! We need an extensive public health initiative (and I also believe single payer all inclusive system to access health).
4
We already have such around here. Single payer will only spend even more money to little to no benefit.
1
As a physician and public health practitioner, I am troubled by the author’s application of data in framing the message.
Although the author supports improved outcomes via public health prevention, he invokes a discussion around its economic impact. However, his cases are rather myopic. By pointing out tobacco prevention results in decreased mortality, actually costing the system more money in the long run is perniciously confounding. By this logic, from an economic perspective, we do not need doctors or hospitals. Why spend $ preventing and treating childhood asthma if it prolongs life?
Furthermore, by conflating multiple complex issues, the author actually fails to achieve his point. His examples are not all under the specious bucket of ‘prevention’, they have distinct, very broad categories – each deserving a serious editorial discussion. Namely, economic impact of health policy+financing, insurance & access, public health campaigns around smoking and nutrition, community wellness programs and collective impact, and health care delivery reform. Let’s make it clear, Medicaid is a right, it is not prevention. By cherry-picking the preventions that did ‘not’ achieve economic benefit, he confounds the issue and misses the point. For every example he chose, there is an example to counter. Given the increasing polarizing discussions around ACA, this would be an auspicious opportunity for The Times to open up the discussion and bring it to public discourse.
52
Concluding that “Sometimes good things cost money,” Aaron Carroll suggests that, though we thought we were saving money under Affordable Care, emergency room use increased and that preventive care still isn’t cost effective. But Carroll doesn’t mention that Affordable Care isn’t good enough at keeping us healthy. Why does the Upshot not examine a plan that might both save money and extend life: the NY Health Act or Improved Medicare for all New York residents? Under the NYHA, every New Yorker will receive primary, preventive, and specialty care; hospitalization; mental health; reproductive health; dental, vision, and hearing; prescription drugs and medical supplies. NY Health will save 98% of taxpayer expenses because it will cut 30% of costs which currently give profits to insurance companies and big pharma, allowing physicians to focus on patients who will see that they get real prevention: care that prevents diabetes from being crippling, high blood pressure from causing strokes, cancer screening that will stop advancing diseases before they cause us to die?
6
What on earth is the NY Health Act or "improved Medicare for all NY residents?" I am a resident of NYC and on Medicare. Not only do I receive no dental, vision or hearing benefits, I receive little preventive care (unless I want to pay $300 - $400 for an annual physical), as no doctor (including my own large group practice) or academic medical center geriatric practice (including NYU and Mt. Sinai) will accept Medicare reimbursement for Medicare's "annual wellness visit." Hence I not had an annual physical in 4 or 5 years as I have been busy paying annual 5-figure dental expenses.
I think one big reason why preventive care doesn't reduce medical expenses is that by diagnosing illnesses earlier rather than later it often produces higher rather than lower bills. For instance, if someone doesn't have regular preventive care and doesn't see a doctor until their cancer is stage 4, there is a good chance there will be few treatments available and the person will die sooner than if heavily treated with early diagnosis. I'm sure this is not lost on insurers.
2
I have had good and crappy insurance coverage and always done an annual physical. At my age most men are taking multiple medications but I take none and have no diseases other than getting older and new aches and pains. Why do I get a physical? You never know, especially at my age what will crop up. The new urgent care model is much less expensive than emergency rooms and I have used them a few times for minor injuries. There are reasons and ways to save money, but many of us do not take the time to even get an annual physical or else go the ER at the slightest indication of something wrong, which costs a lot. Good article.
2
The wellness portion of this -- employers want to make employees happy whether they like it or not, or they fine them for not participating -- is largely a scam.
Vendors are unregulated, unlicensed, unsupervised and largely unscrupulous. Indeed, the winner of the award for the country's best wellness program last year actually harmed employees.
https://www.statnews.com/2016/09/27/workplace-wellness-award/
As a result, employees hate wellness, according to the most recent survey.
https://theysaidwhat.net/2018/01/20/quiz-which-industry-has-the-worst-ne...
1
Preventive care that works--Care for yourself. Diet, exercise, weight control, reduce stress, avoid risky vices, avoid careless behavior that is know to disproportionately lead to accidents.
If people cared for themselves in reasonable ways, system costs would plummet and sufficient funds would exist for those random and/or genetic misfortunes that can strike any of us.
At 73, I have yet to draw $1 of reimbursement from medicare or private insurance. Completed a 15K race on Sunday in 94 minutes.
Self care not a sure fire preventive measure, of course. But it does increase the odds in your favor.
3
Congratulations on good habits. Surely, good genetics is working in your favor, as well.
1
Depends on what 'living longer' means. If it means someone gets more productive working years in, the preventative care could make sense even in strictly financial terms (more taxes paid). If it means more years in retirement, than the argument holds up - strictly financially speaking, of course.
1
Apparently, many commenters don't read the entire article. Consider at least reading the opening paragraphs and the last 3 paragraphs if you're pressed for time. The author's point is that preventive care adds to health care expenditures rather than reducing them. Buying something worthwhile still costs. The author does not argue against spending for it.
5
Of course P-care doesn't save money in raw dollars spent. But, it saves ME money. If more people pay for preventative care (or, in fact, any care) or any form of insurance, I am paying less in taxes that go to support safety net services. If someone doesn't pay for any form of insurance and uses the ER, trust me, someone pays for it. And in the end, IT IS ME.
6
Public health prevention interventions are proven to save lives and decrease morbidity. Prenatal care, clean drinking water, adequate sanitation, birth spacing using modern contraceptives, condoms to prevent sexually transmitted diseases and hand washing are some of the most cost effective public health interventions available. Studies that only look at services provided by health facilities miss the point of what preventive services are. Public health interventions are often overlooked and undervalued as indicated by the headline to this article.
10
The conclusion of this article is weak. The US healthcare system is based on reactive care (after the fact), not on preventative care. A preventative care system -- a universal healthcare system, not based on a market -- comprises of a collection of individuals whose beliefs and practices are fundamentally different than the long-term beliefs and practices that it's taken to sustain a reactive, market-based, capitalistic, health care system. The long term harm and consequences of capitalism doesn't lose force with the piece meal implementation of preventive healthcare reforms. The two system are underpinned by different philosophical paradigms. If you want to improve human health (and health care), get rid of capitalism -- an inhuman system of private ownership and profit for the rich.
7
The most important part of prevention is a healthy lifestyle. Yes, low-dose aspirin for adults. (I have high cholesterol in the family, not caused by diet), so I take low-dose aspirin, but not a statin. I was in a Boston-area study for statins in the past, and it did greatly reduce my cholesterol. I have been mostly a dairy plantatarian since age 19, which was 1970. I have ham, turkey or roast beef on holidays, but rarely at other times. Some chicken, more fish, mostly salmon.
I have about 20 plants a week, either in homemade chili, other homemade soups, or in combinations of brown, wild rice, barley,spices, tomatoes, celery, tomatoes, homemade fruit salads or huge Romaine salads with 10 cold vegetables and bits of apples/oranges/lemon juice. Add daily meditation, 9 hours of sleep, a nap, a social life in real life and online, and exercise. My cholesterol is not harming me. My mitral valve prolapse is fine. I get enough sleep so I don't get bronchitis or pneumonia -- my main risk factors.
THAT is what I consider preventive medicine -- self-care so you don't need doctors often. When I was of child-bearing age, I did go more often.
I smoke nothing, and have not smoked cigarettes since I was a teen. I drink about 1 glass of wine or beer or a shot in mixer a week, at most. Coffee is a delight. Tea, also. Eating fresh fruits and vegetables keeps our taste buds natural.
3
Nothing is free, not even the air we breathe...if we do not take preventive measures to avoid fouling the environment (such as removing sensible regulations for polluting industries taking responsibility to clean their 'act'...before it affects our health and productivity). And that costs money via our taxes and to industry. The famous adage "an ounce of prevention is worth many times over one pound of foolish contamination of air and water" is absolutely true...but not in terms of not costing money; besides, whenever we are offered something 'gratis' (for free), our appreciation sinks. But, like all things in life, the cost of prevention may become a burden as well, if misused or abused. As an example, we surgeons used to remove gallbladders whenever we found stones on a routine ultrasound, even when no symptoms were there. A study by a gastro-enterologist in Ann Arbor, Michigan showed that, unless symptoms were present, or there were gallstones in a diabetic patient, removing this organ preventively didn't make sense...other than us sending a bill, plus the potential complications of any surgery. Since then, we stopped that unnecessary surgery, to everybody's contentment. Remember the gastrectomies we used to do so often for gastro-duodenal ulcers, before we found out the symptoms were due to a bacterium (H. pylori), easily treated with medications? Things do change, and usually for the better. So, prevention is good but it must be based on empiric evidence.
2
Introducing better prevention within the context of the current healthcare system cannot reduce costs because it also produces greater access to and usage of expensive and unnecessary services, witness the use of ERs and such things as routine stress testing. Further, the rate of progress in emergence of new preventive approaches has been very rapid in recent years and is not reflected in data available to date. Witness the new diabetes agents that reduce cardiovascular risk(yes, another cost problem to solve) and the impact of substituting coronary CT angiography for inaccurate and expensive stress testing and high hospital dwell time of chest pain patients who do not have risky coronary disease.
I agree strongly with the premise here. But the writer overlooks an essential point Because of a very different emphasis in physician and other provider training, and lack of longditudinal care, ER is inferior to dedicated primary care and family practice for our most expensive care; chronic diseases such as pain, addiction, heart failure and diabetes. The US health care industry undervalues and under-reimburses primary care to the extent that access to primary care is severely limited compared to other countries. No-one with acute back pain or a cough, or poor blood sugar control, or worsening shortness of breath, can or should be expected to wait 2-3 weeks to see a PCP - so of course they head to the ED. There they will inevitably receive less appropriate and more expensive care and be referred on for unnecessary specialist opinion. Building better primary care access for everyone may or may not not save money - likely not - but would vastly improve quality of care and quality of life for all Americans
11
Why hasnt anyone tried giving incentives (lower insurance premium just like for nom-smokers) for people to maintain a healthy weight. Obesity is rampant and a major cause of most illness. The only way to change behavior is to impact the pocketbook.
4
In the <65 population, there is virtually no evidence that anyone except for employees at BOTH extremes cost an employer extra money. Plus, employees cheat on weigh-ins, in ways that can be harmful.
https://theysaidwhat.net/2018/01/22/at-schlumberger-today-is-take-your-s...
1
Punishing is counter productive -- they simply will not seek medical care until there is a costly crisis requiring hospitalization.
Further more, medical science has no real treatments to offer overweight people, as diets provably do not work for long term weight loss.
There are so many benefits to being thin, that no fat person would EVER choose to be fat on purpose -- giving up respect, romance, nice clothing, etc. -- there is no "upside" to being fat!
So it comes down to "For what would you like to pay?"?
And "Do you want to pay for surgery, ICUs, harrowing and sometimes heroic procedures? Or longer lives with better outcomes and the costs those entail?"
I think most would go with the longer lives.
However, I would like to see a flat-out research project conducted over 25 years instead of yet another meta-data survey.
1
This perspective is possibly not considering the long term benefits of preventive care. It takes many years for the effects of cigarettes and poor diet to show up in the emergency room. Programs that enhance health may very well show a cost saving in the long run. And the benefits may not be all in dollars and cents. Healthy people have a better chance to be happy people and better citizens.
5
If it is true that the 10% of patients who are the oldest and most frail account for 90% of health care spending in the US, then this Upshot leads to a false conclusion regarding the proportionate savings of preventive care for those patients most likely to benefit from preventive care: the 90% who are not already gravely ill.
Another point: An annual exam, as a matter of public health, might not be cost effective. But as a matter of risk mitigation for an individual -- say myself or my dad -- be a worthy expenditure indeed. This personal benefit is reason enough for me to support preventive health care programs at the policy level.
4
So if cost is everything why bother with anything? Preventive care does make sense and saves money. I have done annual physicals while a resident of Japan as well as since returning to the US and will continue to do so regardless of what this doctor says. I don't believe him. He is only concerned about money which is typical of the American medical system. And it is worthwhile - the cost should not be a a red herring.
3
For people who have health insurance for the first time, there is a learning curve to figuring out the type of facility they should go to for care when they need it. The linked study indicates there was increased use of emergency room care for conditions better treated through primary care. Did those who came for these basic care needs get charged a significant co-pay amount, as our insurance would? Since EMTALA does not mandate non-emergency care in the emergency room, just stabilization, were they turned away and referred to their primary care givers? People who are used to popping in to emergency rooms because they don't need an appointment and can't be turned away need to be educated on how the health care system works, and the availability of urgent care clinics. If there is no disincentive to using an expensive system that gives ready access when it isn't necessary, we won't see the cost benefits of using less costly care.
6
There is also a problem with not enough PCPs, they may not be able to get a PCP or if they get one be able to get an appointment in a reasonable timeframe.
1
"Preventive Care Saves Money? Sorry, It’s Too Good to Be True"
Wasn't access to preventive care a key cost lowering component that was used to sell Obamacare? Why yes it was.
As with "like your doctor, keep your doctor", another too good to be true statement from the Obama folks.
4
Isn't it mostly important because it saves lives?
4
Not to money-obsessed Republicans. They stick to their argument that health care is a privilege, not a right.
2
"...They often went [to the ER] because it was more convenient."
Really? The last time I went to the Emergency Room, I waited five hours among sick and contagious people in an overcrowded space to see a doctor for about 15 minutes. Is that how ERs are perceived by the public? I wonder what other medical realities the public is uninformed about.
10
The last time I went to an ER, it was on a Sunday morning; my daughter had an issue that could have easily waited a few hours, but likely not the day-and-a-half it would take to get her in at her doctor's office (not open Sundays, and lucking into a Monday morning appointment was unlikely). The ER was empty and she was out in under an hour. Probably depends on the ER and doctor's office in question (and time of day).
3
When my late mother was still alive, it was routine for her to wait 8-12 hours to be seen in the ER at the NYC hospital that proudly proclaims it is ranked "#1 in New York, # 6 in the Nation!" In one case it was 24 hours, and as night turned to day my mother encouraged me to leave, knowing I had to go to work (to a job I later lost, in part because I was missing work for things like docs calling me to take my mother to the ER, hospital calling me and asking me to go to my mother's apt. and look for a medication she took as hospital didn't want to have to pay for it). She was usually told to go to ER because her doc had decided she needed to be admitted and, after waiting a day or two to be notified a bed was available, the doc threw up her arms in despair and said "just go to the ER; they'll have to take you there."
3
Everything has a cost, and a value. Too often, we (all) focus on just the cost of this or that. "OMG!! This or that is SO expensive!!" While ignoring or often at least inadequately weighing the offsetting value of this or that. As this article infers/points out, "value" is the total of what you gain from whatever overall "cost" you spend. And that value is often significantly higher.
3
Ted, can you talk to "Un," the poster whose piece is just above yours? I think he needs to hear what you have to say. Thanks.
2
The ACA has failed. Costs have not dropped for insurance. Coverage has decreased. Prices have increased. And people did not have the option of keeping their doctors. Worst of all, life expe cries are decreasing and more people are being denied medical care options unless they pay out of pocket. The insurance companies were the big winners along with the democrat lobbyists.
Now that the horrible Obama years are history, I am glad to see the Times is willing to publish data. Trump has his work cut out for him.
5
Recall that insurance prices were increasing at a rapid clip previous to the ACA and that coverage has in fact increased. There are more people insured than before the ACA and the insurance they do have covers much more of the basic needs than the bare bones cheap plans available before the ACA.
Trump's actions so far will result in paying more for less health insurance for most people.
4
This piece desperately needs other voices responding to the author's assertions.
7
The claim that preventative care reduces medical care costs overall is an easier political sell in our $-oriented society that the truth: that it improves life. I have argued vs. this fallacy for decades, but it persists. --retired MD
6
I'm going to go out on a limb and argue that flu vaccinations do save money because fewer people end up in the hospital if they have been vaccinated.
2
As many commentors have noted this article is very flawed.
For example it tries to look only as health care money spent or saved and ignores that living longer while healthier leads to many valuable results - working longer, supporting yourself and your family, paying taxes, happiness in your life.
This reminds me of the direction of medicine that is also short sighted- reducing treatments to algorithms (cook book treatments) and linking payments to these outcomes.
Medical people are losing (or have lost) the art of listening to their patients, performing detailed physical examinations, evaluating possible diagnosis that are not on a chart, and planning diagnosis and treatments that are tailor made for their patient - the science of medicine. This is being lost and patients suffer for these changes.
Don't think a chart can guide you. Use your experiences and education if you are old enough to remember those days in medicine.
When you hear hoof beats, think zebras, not horses.
9
The "evidence" presented in this article leads with the increase in emergency room use after Obamacare. I don't see the relationship with preventive care. Likewise many of the other examples are not about what most people think of when you talk about preventive care. What about screenings? What about medicating people with high blood pressure? What about vaccinations? These are real preventative care, but are ignored.
8
The AMA discourages the annual physical but that doesn't stop people from smugly bragging they went for theirs. It is a huge waste of money and time for the exam and unnecessary tests for mostly healthy people. On the other hand, there are not enough places to go for urgent care. Our local hospital used to claim their urgent care was in the emergency room but that was never true.You don't need a relationship with your doctor to go in to check if you have strep because you have had it before and know when you need treatment. Hospitals should have convenient urgent care departments to take care of the walk-ins who are not emergency cases.
When people are insured they think care is free but its overuse causes all of us to pay the price. When universal health insurance started in Canada, my mom had a poorish friend who had a cold and wanted to go to the doctor. Why? Because she was entitled. In the US people also think they are entitled to overuse the system because they are spreading the true costs on the rest of us.
6
Just one question JL: If say your teenage daughter came home from college with a moderate fever, a sore neck and headache during flu season would you council her to "Tuff it out, its just the flu"? Or, would you want to make sure that she had not possibly contracted meningitis B in her dorm (which after all is a common vector site for this illness- And which illness can, of course, prove fatal in as little as 24 hours after developing symptoms)?
So no,lately people like you and our GOP Congress have become perdictable with their self righteousness when wanting others to buck-up and tuff it out, after the rest of us ask about access to quality health insurance. When it comes to taking your own advice ,however, you are all too willing to shift the costs of your own gold plated private insurance plans onto the shoulders of the rest of us (by lowering the average and low income person's access to decent moderate coverage) and then preaching about-"Tuffing it out".
1
Dr. Carroll presents a flawed argument. If we accepted it, we should stop taking medicines like statins, we should stop doing exercise (which is among other things preventive care), we should take up the pleasure of smoking again, and we should not get vaccinated for flu or small pox.
Indeed, it is a nutty argument.If we took it seriously,we should shut down Schools of Public Health, Departments of Preventive Medicine, and even State and County Health Departments. Perhaps we should stop testing for water safety and for tuberculosis.
The argument doesn't take into account that by living longer and healthier lives, people can make more contributions to society. Could Dr. Carroll at least make a calculation of the benefit of that?
I wonder whether the Times should be farming out these opinions to people who are not expert in statistics and health economics.
23
The fact that Diogenes seems unaware that smallpox was eliminated from the wild almost 40 years ago, and that vaccines for it are only available for a small number of researchers who study it, means that his or her criticisms of other health researchers can be safely ignored.
3
The human mind is an inference machine. Unfortunately, it is not a reliable one.
Arguing that we just need to accept that preventative care is expensive is like saying that your ‘72 Cadillac gets bad gas mileage so we just need to pay for the gas.
Unfortunately, in addition to delivering worse health outcomes per dollar spent than other developed nations, our medical establishment isn’t designed or incentivized to keep people healthy. Worse, Americans aren’t incentivized either. My physician’s wellness pitch must compete with a daily barrage of Big Mac ads in a culture that values immediate gratification and personal entitlement. It would take a serious cultural shift for America to become healthy. However, we should still work to provide better value care. For example, if less costly clinics with more convenient locations and hours would appeal to patients that would otherwise use the ER, building those clinics is a part of less costly preventative care. If creating a national health record data exchange would establish better coordination among providers and prevent medical mistakes and overutilization, doing so is a part of better value preventative care. Simply throwing hands up and declaring that preventative care can’t be done more efficiently isn’t helpful.
7
Craig Eaves: part of the solution will begin, when people like you stop claiming that the sole cause of all health problems in the USA are "Big Macs" -- a HAMBURGER! with about 600 calories -- it's not Oxycontin or black tar heroin, for gods sake.
This is such a simplistic article. Isn't quality of life more important, or at least as important as saving money?
Dr. Atul Gawande, in his book "Being Mortal" writes: We've been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reason one wishes to be alive. Those reasons matter not just at the end of life, or when debility comes, but all along the way.
If Mr. Carroll is going to bundle preventive care with prevention, at least lump the dollars that are use for these vs. health care? Investment in preventive approaches are estimated to be less 3-5% of health care costs or less? Do we even given prevention a reasonable chance? Mr. Carroll, have any of the evaluations even factored promoting well-being and preventing mental emotional and behavioral disorders? At the least Mr. Carroll could have talked about the limitations of the evaluations - what is missing and why.
3
The use of the ER rather than urgent care clinics or doctor's offices points to a need for more of the latter rather than any bad choices on the patients' part. If the ER is the more convenient choice, that says something systematic about how healthcare is set up in an area.
I would expect there to be some bumps on the road as more people get insurance, there always are when things change. We do have a shortage of primary care doctors, that's well known, and we also have a shortage of good mental health providers. Now that more people have insurance, there will be a higher demand for them, but it will take a while for medical schools to adjust to the new environment and so there will be a long lag. It would help if insurance reimbursed primary care docs better too.
3
the big fallacy in this whole debate is that the cost of much of the medical "care" we receive is fictional.
Consider the $1,000 or so average "cost" that someone runs up if they visit an Emergency Room. Most of that cost would be there whether I visit it or not -- the folks there are paid their salaries whether a patient visits or doesn't, after all. So that $1,000 is really my averaged cost of covering the overhead, not the cost my sickness actually runs up.
Most medical costs are like this -- our share of the whole system. And why does the system cost so much? Because medical suppliers can charge whatever they want -- this paper's excellent series looking at that tallied it up very neatly, but even the paper's own writers seem to ignore it.
Why does an Epipen cost $800 when it was only $50 two years ago? Because someone discovered that he could raise the price that much and nobody could stop him, that's why.
Make medical care cost what it really costs by getting the greedy "capitalists" and their government protection out of the way, a lot of this problem will go away.
50
Wasn't the executive who raised the price of Epipens actually the daughter of a US senator or congressman?
1
chas: yes, she was the daughter of US Senator from West Virginia, Joe Manchin -- and here's the kicker....he is a DEMOCRAT.
The 4th to final paragraph notes that people living longer means that we spend more on their health care. This hints at an central point to this analysis: the best way to save money on health care is to die at birth, thus saving the health care system from any future expense on your behalf. So maybe a model that only looks at cost - and ignores the economic benefit that healthier individuals tend to provide - misses something important. Preventive care may well be a net economic gain if we can also look at how a healthier, longer-living population creates economic gains.
8
"In the short term, less smoking would lead to decreased spending because of reductions in health care spending for those who had smoked. In the long run, all of those people living longer would lead to increases in spending in many programs, including health care. The more people who quit smoking, the higher the deficit from health care — barely offset by the revenue from taxing cigarettes."
This study omits a critical analysis: those people who are living longer because they stopped smoking aren't just sitting around consuming health care and other programs. They're also living productive lives -- working, paying taxes, and benefiting society in countless other ways.
If the ONLY consideration were minimizing the cost of future health care, the best solution would be to let people die of any disease they get, or perhaps to kill them off at birth. Then they'd never consume any health care at all.
12
It's impossible for the reader to confirm or disprove the assertions in this piece, so we're dependent on the author to be fair. With that in mind, it feels like the conclusion was pre-ordained and data selected to support it.
It feels like the title was selected to be provocative, since it flies in the face of everything we experience in our lives about the cost of prevention vs cure.
Cuba is reported to have roughly the same life expectancy as America at roughly 10% of the healthcare costs. Perhaps the author could study that and report back....?
32
Multiple studies have shown that for every one dollar the government spends on family planning services, between $5-$7 is saved. Not only do family planning programs provide people with the education and tools they need to prevent unintended pregnancies, they also help reduce the incidence of STIs and resultant infertility.
So - I’d have to say that that's one preventative service that more than pays for itself! Not to mention that making reproductive health care universally accessible is the right thing to do.
10
The question is whether this would change over time as preventive care becomes more available to more people (assuming the Republicans' gutting of health care doesn't stop everything). One might expect that in the short term, emergency room use and demand for medical services might increase as those who did not seek medical attention because of a lack of insurance start using it. The question is whether demand would shrink as more people take advantage of preventive care over an extended period of time, thus potentially reducing emergency room demand for those types of disease/illness where preventive care addresses issues before they become acute - and turn into emergency room visits.
6
Preventative care produces expensive false positives. For instance, I'd like to know how many angiograms show no blockages after being prescribed because an electrocardiogram changed.
1
Who classifies an angiogram as "preventive" care? Should fall under diagnostic procedure.
I agree on the false positives... uh, wait, no actually my angiogram detected 2 blockages approximately 17 years ago, which were successfully treated via bypass (bad genes will hunt you down). I've been able to contribute to society and raise my boy, who likely would not have known his father absent the angiogram.
How callous we are to think of health care ONLY as a dollar sign, like buying a new truck or dining out. I've an Idea, maybe YOU should skip the angiogram if your ekg turns up abnormal; as someone who knows better, I wouldn't recommend it.
This is truly an instance of knowing the cost of everything and the value of nothing.
80
Why in the world would an emergency room be "more convenient"? Only because those still using it routinely don't have a primary physician, or other logistical reasons that could be taken care of if the healthcare system was better integrated.
As for smokers living longer costing more in other areas - what about the additional taxes they pay over their longer lives? What about their other societal contributions? Do those not count positively somewhere?
Such a one sided analysis would have us believe that we are all simply a net drag and therefore should die as infants to save the taxpayer money.
10
A better use of funds would be on "social determinant" type public health interventions - like permanent supportive housing for chronically homeless - strategies that actually work and truly save money.
5
Dr. Carroll skips analysis of the most important “preventive care:” a long term relationship with a primary care provider, which has been shown to decrease cost and improve longevity.
10
That should have been captured in the data. Perhaps the ability to maintain a long-term relationship with a physician is correlated with other characteristics that lead to better long-term health outcomes.
3
Look for a forthcoming article on Hot Spotter reports and medical redlining. Most ACA insurance carriers are state contractors that don't simply sell ACA policies. They handle claim processing, along with Medicaid and "self insured" products. They assemble and SELL medical records. In Oregon, virtually all of the OHP patients without primary care doctors are victims of medical redlining. This true of Ohio and several other states I have audited. The federal government, in the face of whistleblowing for years, has done nothing. The NYT, The Fourth Estate, needs to step into the breech and report on this. If you want to save the ACA, Medicaid and Medicare, you will cut fraud and abuse. If you want to kill those programs, you will do nothing....as we have been doing.
2
A wonderful analysis.
Talking about emergency room visits - unaffected by insurance - I am no doc or a statitian or a scientist - but my recent stay in UK might illuminate.
In UK, they have this so called NHS - a single payer I.e. government program that covers all. No ibe lijes it but they are mighty proud of it. No questions asked when you visit your designated hospital or care giver facility or a doc.
Yet, during my stay, all I read was how over crowded so called A&E (accident and emergency) facilities were - impossible to get into. Folks lying in corridors and all horror stories.
This study presented here appears directly applicable in UK. Here is a true example.
A friend of mine waited six months to get his torn tendons repaired - all paid for. While waiting for an operation, he kept going to A&E for temporary relief about which he complained to no end.
So, UK could be a poster child to support thesis presented here.
I am forwarding this article to my buddy in Yorkshire - if nothing else, he may learn that visiting A&E might have given him relief but in the end it was very expensive.
Thank you.
2
I feel this is misleading and designed to make a sensible group of advocates (doctors, nurses, social workers) appear as liars.
When people talk about saving money by mitigating expensive medical interventions, the fact that people will also live longer because they are healthier is not accounted for, most likely because that itself is considered a social good, as long as it isn't an unhealthy long life. But hey--who needs a death panel when we can save money by taking care of people so poorly they never live past 80?
The thing this article is missing is nuance about what different groups are measuring when they are talking about "saving money in the long run." Whose money, and at what point? In my view, quality of life is what is being bought and should be bought, and advocates for better care are not messing with that.
10
This is a misleading article. The author misuses the term preventive care and then seeks to undermine it.
Sorry but using the using medicaide money for emergency room or treating disease is NOT preventive care. Healthy life style and primary care including coordinating care so that unnecessary tests or duplicating services is preventive. It works to keep people healthy and save money. I can tell you that from over 25 years of medical practice.
Prevention is preventing disease before it manifests.
I am not aware of an auto manufacturer that tells its customers not to change their engine oil so that their car will last longer or be cheaper to maintain in the long run.
Mark Hoch, MD
54
Money vs. People.
Why, when we compare the cries of people for a better life with money, too often money interests win and people lose? See
https://www.legalreader.com/republican-racketeers-violent-policies/
Thanks, Dr. Carroll for distilling the latest health economics study results re preventive medicine.
If we are to have meaningful discussions about health care budgets, the myth of preventive measures as cost reducers (sans immunizations and ASA) must be swept away.
Now let's crack a harder nut: how about a rigorous economic analysis of the benefits of NIH cancer research?
1
Why no mention of Innovation in Preventive Care? CMS (Ctr Medicare/Medicaid) has tested Diabetes and is moving forward with reimbursement for Diabetes Prevention Programs (DPP), taking a pro-active approach to disease. This will focus on Nutrition, Exercise, Coaching and other lower costing lifestyle changes or adjustments. In doing so, many new and innovative approaches to DPP have sprung up, making Preventative Care more and more efficient. The plan is to start with Diabetes and move into other Chronic Condition (where Preventive approach can have impact). This is where Population Health meets Precision Health.
1
This is surprising. Fir a few years NYT published numerous articles promoting Obamacare, and one of the arguments mentioned many times was savings due to fewer visits to the ER and due to preventive care. I remember that conservatives strongly disagreed with this prediction.
Should we expect the NYT to do a postmortem on this topic, and explain to the readers why conservative experts are better than liberal experts in predicting results?
3
The biggest problem with the ACA and Medicaid is fraud. I worked as a DBA for a state program and saw, and have records of, an unbelievable amount of fraud. The fraud occurs at the claims administration level, where (usually private) state contractors supposedly enter, vet, and process claims. What they do, however, is invent duplicate claims, unbundle claims, sell medical records to doctors, which gets patients dropped by doctors, forced them to ER’s with no one to monitor hypertension, opiod pain medication, the fueling of the failure of our medical system. It’s simple to fix, too. The press needs to report on and expose those corrupt state-state contractor syndicates. Get rid of the fraud, which will cut 30to 40% of costs.
3
There are lots of talking points that are completely wrong. I'll save readers some future shock: The benefits of a college education are grossly overstated. College is a huge waste of money because it often does not teach skills. The degree is a signalling device.
I also recommend that my fellow readers not question too much of the Narrative, or else they risk inadvertently swallowing a bitter (red) pill.
2
Hmm. When you consider the narrow window of "preventative care " (immunizations, for instance), OK, well that supports the conclusion -- but it misses the main point -- Americans are overweight, eat horrible foods, and don't exercise. Diabetes and a host of other diseases caused by overeating and sedentary lifestyles are a substantial cost to the heal care system. End of (main) story.
4
The mismatch between the "industry" and those it supposedly serves is never more apparent than in the belief that expanding coverage will reduce the use of emergency departments. Even when you have a doctor you think of as "my doctor" the likelihood that doctor will be available to see you on a weekend after you fell down the stairs and are concerned you might have broken a bone or when your kid begins vomiting violently at 11:00 pm is, basically, nil. And you can forget about getting a reasonably timed visit when you experience symptoms of the flu or a twisted ankle and so on. Yet, when you show up at the only place that is open and available to you the stern health economists accuse you of "wasting their time and resources." The minute clinic movement has taken some of the stress off of emergency rooms, no doubt, but the underlying problem is an industry that has set itself up to serve problems it wants to to work on but that occur on a less frequent basis, to the exclusion of problems that people actually need answers for.
4
It's also what gets paid for, and what gets well paid. Emergency visits (insured) generally get paid, at about $1800. A primary care visit might be paid at $60-100. Insurance company profit is about 5-10% of the gross. Which visit would they prefer?
(Remember when costs go up, insurers get rate increases.)
He who pays the piper calls the tune.
Primary care doctors would generally prefer to be paid to do comprehensive care, like people get elsewhere. But spending more on primary care would save money overall, and that would be bad.
So I guess the prudent goal of a government healthcare program should be for every American to die as early in life as possible, to save costs??
3
Although it is heartless and cruel.....in a purely economic sense, yes. The old, who do not work but only consume medical care and tax dollars, are "useless eaters".
Until, of course, YOU get old or sick or frail and than suddenly it is all very different.
The longer you live, the more that ages, wears out, gets injured, or becomes diseased. Paying for it all by working one third of a lifespan is increasingly problematical.
3
Steve Bolger: OK, so how ELSE would you pay for it? By working starting at age 6 or 7? or by forcing 70 year olds back into the work force, despite the fact that employers do not even wish to hire or retain workers over FIFTY!!!
Even if you wanted to work after age 62-67....good luck finding employers who will hire you, short of as a Walmart greeter!
This demonstrates, yet again, that the pronouncements of experts are sometimes wrong and should always be taken with a grain of salt.
I wonder if the authors of the study ever interviewed any of the people using the ER as their primary care. I have never been to an ER without spending less than 6 hours sitting there, waiting my turn. And, one of these visits was because I had a chlorine burn on my retina due to negligent use of pool chemicals at my local gym.
1
Lets make this complicated article more simple.
If I go to the dentist regularly and keep my teeth clean, I won't need more expensive fillings and perhaps crowns.
In this case, preventive care saves me money.
If we all do this, then the need for dentists declines. To keep their incomes up, they start marketing "smiles" and white teeth and orthodontics. Because - - well, marketing, advertising and the media all help sell these things which have nothing to do with healthy teeth and all to do with the dentist's income stream.
Does this mean that the money spent on checkups and preventive care doesn't save money? I guess it all depends on whose money you are talking about.
9
Preventive dental care HELPS but I've had excellent dental care all my life -- twice yearly visits -- x-rays -- plus I was blessed most of my life with "good teeth" simply due to lucky genes.
But since turning about 55...I've had to get two crowns and two onlays ($$$$)....insurance only covered a small part of this....plus probably looking at some peridontal work in a few years.
My dentist shrugs and says "your teeth were only designed to last 50 years, because that is how long people used to live! nobody ever though people would live to 95 or longer!"
Things like teeth whitening can be done at home and they never made up a huge part of dental practices. Orthodontia? it's done by specialists, not regular dentists.
Dentists never lack for work; they don't have to do fake stuff to "gin up" more patients!
1
If a person is diligent about tests such as colonoscopies, mammograms, prostate etc, they shall live longer should anything be found. Take care of yourself as no one else will.
2
The writer talks about the preventive medicine on the national basis as the public wellness policy. On the individual basis, preventive medicine saves money. I have been studying preventive medicine over 4 years from specialists, clinicians and researchers, thanks to internet. I follow my health checking on various bio markers such as homocysteine,vitamine D, high sensitive CRP, A1C, insulin, ferritin, testosteron in addition to regular annual labo tests. I don’t take any medicines and have been surviving by nearly zero medical expenses. I do daily detoxification by diet and vitamin C trying to keep mitochondrial health best. I also run and move my body often so that I can sleep better. I drink water purified by reverse osmosis. All the foods I eat are organic, grass-fed, small fish, local shrimp etc.
1
That's nice but you are either genetically very lucky or just young -- I have known fit, athletic, slim people who were vegetarians and non-smokers, and they still got sick and died.
I think the issue is more complicated. Preventative care like education, occasion visits to doctors office etc. can work but the problem is they are abused all along the line.
1-Hypos. Yes I know you don't like to here it but especially women who have insurance will live at their doctors office 24/7 with unneeded visits.
2-The medical honchos and yes doctors who have gotten use to it will give you every unneeded test in the book to make money.
3-Outright crooks who will take advantage of the programs and directly scam it.
4-People who get wellness visits but smoke, overeat, don't exercise and lead couch potato lives.
3
Once again, this basically says Americans know the monetary value of everything and the worth of nothing.
3
If we consider reducing obesity a form of preventive care, we get a 50% reduction of most major diseases. Cancer, stroke, heart attack, diabetes, Joint problems, endocrine diseases, etc. This article is very misleading. It focuses on expensive conventional medical preventive procedures instead of cheap cultural and life style measures to promote health.
3
Dave from Shandaken: except medical science has absolutely no effective treatment for obesity, except gastric bypass surgery (at $35,000 each, and ONLY for morbidly obese patients!).
Simply telling people "diet and exercise" is not going to get 180 million people to all lose weight. Not to mention, they have all likely heard this 1000 times in their lives and it never worked before!
It seems to me that another way of summarizing the conclusions in this article is that reducing access to healthcare saves money by causing people to die sooner.
6
let's see.........preventative care makes people live longer. living longer is more expensive (or comparable in cost) to having them die earlier from disease. so your argument is....what is the point since the cost is the same? seriously?
3
“Not everything that can be counted counts,
and not everything that counts can be counted.” (Einstein)
Value is seldom reflected in a profit and loss statement yet that's about all this country uses to calculate "costs." We are so much poorer because of this mindset.
4
We're still left with the problem of explaining why European countries with Universal healthcare have better health and mortality rates.
In the case of the Oregon experiment, ER usage did go up, but anecdotal evidence was that low income patients could not take time off from work, and so went to the ER at night or on weekends, when their PC physicians were not available.
If you want to know whether preventive care works, study it in Europe. The US has a Frankenstein medical system; which is dysfunctional in so many ways, that trying to find "benefits" out of "chaos" is not informative.
3
What we SHOULD HAVE learned is that people need access to clinics or some sort of "urgent care" 24/7 -- that poor people with chaotic lives and NO SICK LEAVE, cannot easily make appointments and keep them.
We also should have been educating people -- perhaps with public service TV ads and posters -- about what conditions merit a hospital visit (like chest pains) and which are a stupid waste of everyone's time (a bad cold or scraped knee).
It's not surprising that ER receives more patients after ACA. I know a lot of people who work in hospitals, from nurses to technicians to doctors, and the biggest thing they see is that (1) a lot of people don't have primary care physicians so they're using the ER as primary care; and (2) for those with primary care, sometimes their PCPs are so backlogged that it takes 3+ weeks to get an appointment and it's actually faster at the ER. The entire medical system in this country needs to change--people's first instinct shouldn't be to go to the hospital unless it's an actual emergency.
Also, I think the article missed the biggest preventive care --exercising and eating healthy. Given the percent of Americans who are overweight or obese (71% of the population according to the CDC), this is by far the biggest area that could save money. But, as other NYT articles have pointed out, doctors are reluctant to speak to their patients about their weight because there's such a strong movement in society to accept all body types, regardless of whether they're healthy or not. A doctor telling someone to exercise and eat healthy is not the same thing as people making fun of others for their weight and yet, a lot of people feel they're the same now. How much money could we save if 71% dropped to below 30%? or even 40% or 50?
9
hanxueying: and people should also save money, and never drive about the speed limit or lose their temper.
Eating healthy is great, but it is no guarantee you won't get fat. I know fat vegans and fat vegetarians.
So far....NOTHING in medical science has offered a "cure" or even effective treatment for obesity....except gastric bypass, which is risky major surgery and only available to the morbidly obese. For other overweight people, there is no real medical help -- just fad diets and quackery.
So for doctors to nag people over their weight is POINTLESS. It is like yelling at someone for getting the flu. Also, doctors really DO tell people to lose weight, exercise and eat healthy -- but it often falls on deaf ears. If you nag and shame patients.....they won't follow medical advice and worse, they won't come for medical assistance until they are deathly ill -- who wants to hear shaming or a lecture, when you have the flu?
Do you seriously think that just TELLING people to lose weight will cause half of more to actually lose weight?
What are the additional 15 preventative services that were deemed cost-effective?
3
Please avoid the term “preventive care.” With few exceptions, these steps reduce risk and allow early detection which may or may not make a difference. Avoiding one disease can make room for another. In particular, elders who avoid dying of heart disease often go on to get cancer or dementia.
5
Definitely -- my dad had heart disease most of his adult life. By 72, he required a quadruple bypass -- he was in such bad shape, his cardiologists said that "sewing his arteries was like trying to sew wet kleenex!" -- nonetheless, he came through with flying colors and went on to enjoy several happy, healthy years living independently -- but in the end, he got cancer and that killed him.
If the quadruple bypass did not exist -- or had excluded him on age -- dad would have died of heart failure years earlier.
So the question is: what is the value of 6-7 years of happy, healthy old age -- enjoying retirement -- watching your grandkids grow to adulthood and attend college? Put a price on that.
A question unanswered by the article is whether or not preventative care affects a person's ability to perform productive work, or work that provides some sort of benefit to society.
That gain in productivity or societal improvement, if it exists, could more than offset the cost of preventative care.
8
As we enter a demographic period where there will inevitably be more people “on the wagon” boomers-then pulling the wagon-millenials- the longer we extend boomers lives (where each additional year lived cost Medicare and SS more than the retireecontributed into the system) the net loss expands.
1
That's implied by their definition of breakeven at a cost of $50K-$100K per life adjusted year gained, so yes, that's is most certainly baked into their assumption.
John Whitc: but that is NORMAL -- all populations ebb and flow -- we had a halcyon period for years, where boomers "pulled the wagon" for their parents and grandparents -- now it is the boomers turn! the millennial generation is BIGGER than the boomers! the real problem will occur when millennials reach 65.
You cannot give up on Medicare, simply because of demographic changes. The system can flex and adapt to changes in population.
For some specific populations, preventive care does save money. Particularly for those individuals who are high utilizers of health care, persons with multiple health conditions or persons with disabilities, accessible preventive care can reduce hospitalizations. But remember that emergency department visits go up when hospitalizations go down in a specific group of patients. If a patient goes into the emergency department and gets discharged home, it is counted as an emergency department visit. If that patients gets admitted to the hospital, the visit to the emergency department disappears. And as expensive as emergency department visits are, if they prevent a hospitalization, they are cheap.
2
People visit the er when the outpatient clinic suggests that move. They're trained to stoke the fear of dying by further recommending an ambulance ride to the er. Severe dehydration can cause some pretty frightening symptoms. A couple thousand dollars later ( because the ACA plans most folks can afford don't cover ambulance service or er care), you realize preventative care is something you can only do for yourself - like drinking enough water. A very expensive and embarrassing lesson completely paid by the policy holder.
Eating nutritious foods, avoiding processed foods entirely, especially with added sugar is the best prevention we can do for ourselves. The very best thought you can run through your head to stay well is -"My government could care less about my health", so any recommendation they suggest is actually more about some big industry - Ag, Pharma, Food Processors, Energy, making money for their shareholders. Mammograms don't prevent breast cancer, or other invasive testing do not prevent disease.
In many communities hospitals hold health fairs where you can get your fasting bloodwork done for $40. The results are sent to you with an explanation of the levels so you can take these to your doctor or nurse practitioner on how to proceed. This knowledge will assist you on making better decisions for your wellness than any "preventative" test.
Look at our government policies and see how many take into account its citizens health, physical or mental.
1
No, they're not "They're trained to stoke the fear of dying by further recommending an ambulance ride to the ER." They're trained to protect themselves from the parasitic lawyers.
2
Eating nutritious foods is great, but it won't prevent the flu....it will not prevent dehydration in frail elderly people....it will not prevent cancer or heart disease or diabetes. You can overeat very nutritious food, there are other ways of getting fat than "sugary snacks".
The idea behind mammograms or other tests is to catch such illnesses EARLY -- and treat them successfully -- not "prevention". A lot of breast cancer is caused by genetics! how do you "prevent that"?
One problem we have as a nation -- keeping us from solving this health care dilemma -- is how badly we want to shame & blame other people for their sicknesses -- but self-congratulate ourselves on how wonderful we are! ALL OF US are only one step away from the hospital or a cancer diagnosis -- arrogance in this regard is simply pathetic.
In the early 1970s I received a copy of an internal study performed by a consortium of large employers. It found that increasing the life expectancy of employees by improved access to medical care would increase their costs for providing benefits to retirees. It went on and concluded that providing health insurance to employees would increase costs to the Federal government because Social Security and Medicare costs would increase.
It has been a goal of conservatives for nearly 50 years to reduce or eliminate public or private funding for medical care for everyone - to return us to the situation before World War II.
This essay contains one of the fundamental errors inherent in medical care economics: the sooner that a person dies, the lower the lifetime medical and retirement costs.
37
This is not an error-its a fact, as they author concedes.
2
Consumption of resources, even by a retired person, increases the strength of the general economy.
2
5barris: while I am a strong supporter of Medicare...that is not true. Retired people consume modestly -- they do not shop for recreation -- they do not run out and buy the latest iPhone -- and their medical care is very costly and they consume a LOT of it.
The highest cost is the last 5 years of life, when multiple hospitalizations occur -- rehab -- physical therapy. And the biggest cost of all is MEDICAID NURSING CARE, which is tens of billions of our budget.
As a cardiologist, I have always doubted that preventive care saves money. It can hopefully improve quality of life, but medicine in this country is expensive, and almost everyone eventually develops a chronic end of life illness..money saving suggestions? Single payer, more effective obamacare where no-one is uninsured, and perhaps some sensible rationing, overseen by local impartial ethics committees
12
Single payer does not provide any guarantee careless people will take any better care of themselves, eat more nutritiously, etc.
3
Well, you can try that -- in Canada, "elective procedures" like knee surgery or cataract surgery are "rationed" and people must wait for years to get them.
Ask affluent, privileged Americans if they would be willing to wait 4 years for a knee replacement....so that poor people (those awful deplorables in red states) can get basic health care at a reasonable cost....my guess is they would all say "no way".
Your analysis misses many important costs and savings. Mostly those relating to the fact that we are not discrete individuals but are a broader community. Even if we as individuals wanted to, we cannot exist separate from society. Therefore when my neighbors do not get vaccinated or get regular check ups, I live in a sicker community with more infectious disease, which makes me more susceptible to illness, and makes my health care costs go up. The US has a problem with individualism and flawed cost accounting gone amok that will kill us all. It's the same flawed logic that makes us think that it's too expensive to stop the cause of global warming and instead spend billions on sea walls, relocating sand, flood insurance, and wildfire fighting that won't work and just gets more expensive every year. We need more innovative thinking in economics not more of the same flawed logic displayed here.
16
So what we are saying is that the entire *economic* justification for Obamacare just went out the window, and that if we want to provide health insurance for everyone, we would have been better off simply having tax dollars pay for private insurance or medicare/Medicaid, rather than upending the entire medical care market.
7
Essentially, yes.
Obamacare was a kluge -- a huge mess, designed to give fake insurance to millions (an insurance "card" but no access to CARE, because of HIGH DEDUCTIBLES) and to get even that, Big Insurance had to be placated -- and they demanded millions of new customers and no caps on raising prices!
NOTHING in Obamacare ever was designed to hold down costs -- moderate high pay for execs -- get rid of million dollar bonuses for Big Insurance execs -- control pay for medical professionals -- educate MORE AMERICAN DOCTORS and nurses to avoid shortages.
It took a miserably bad problem and made 100 times worse.
Maybe not exactly what you had in mind with preventive care but may I suggest early childhood education. Certainly improves school and economic outcomes; my guess it that it may also have good effect in reducing health care spending. Is there any data on this?
3
J Clin Sleep Med. 2009 Jun 15;5(3):240-5.
The economic consequences of narcolepsy.
Jennum P1, Knudsen S, Kjellberg J.
CONCLUSION:
The study confirms that narcolepsy has major socioeconomic consequences for the individual patient and for society. Early diagnosis and treatment could potentially reduce disease burden, which would have a significant socioeconomic impact.
Preventive care certainly saved a ton in my case... I'd guess that if medical care, preventive or otherwise, were available outside of most work hours, the ER's might get less traffic? As it is we have to get "time-off" (without pay?) to go to the doc and then wait for an hour because they are never on time.
18
Doctor's hours (like banker hours) are scheduled for the DOCTOR'S convenience....not the patient. The doctor wants to work a regular day job, then go home to his family -- and all doctors in the US are relatively wealthy compared to other workers, and have incredible job security -- he does not wish to work nights of weekends. Those lousy hours in our society are reserved to low wage, unskilled work -- retail stores, restaurants, 2nd shift factory jobs.
But that is when people NEED medical care -- and when they can go -- because most of them work days too -- have little or no sick leave -- must arrange child care if they see a doctor.
People need to see the doctor evenings and weekends, but that is not when doctors want to work.
1
Almost everything that improves quality costs money. For instance, take child safety seats & seat belts. Americans spent $200 million/year on various devices for kids ages 2-6. But a 2006 study by Doyle & Levitt (the Freakonomics guy) suggested that they only prevented $72 million/year in injuries, which suggests that we "waste" $128 million/year!
Does this mean we shouldn't buy child safety seats? Most parents will tell you no since the value of child's life and safety can't be measured solely by money.
By the same notion, all preventative health care costs money. It becomes a question of how much VALUE we get for the amount we spend. Unfortunately, to get the ACA passed, Obama had to make a deal with the GOP to prevent the US from using cost-effective analysis to decide on what to cover. As a result, the US makes health care purchases guided only by health outcomes WITHOUT any regard for cost.
10
It is generally the case that it costs money to keep people alive. How much one should spend to do so is a difficult question to answer.
5
Yes ERs are convenient. Especially after regular working hours. What do you do if you have a medical issue that isn't life threatening, but needs to be taken care of and evaluate after 5 PM, weekends, and holidays. This has happened to several people I know, including myself.
Maybe the health care delivery system should consider 24/7 clinics and urgent care centers to handle these types of emergencies.
27
Interesting, if only that every hospital in our area has a regular clinic and urgent care clinic either attached to the hospital or very nearby including ones in major malls.
5
Freestanding Urgent care facilities are expanding rapiusdly, BUT they often don’t take insurance and can refuse to see patients. For hospitals, it makes little sense to capitalize an urgent care facility close to the Emergency Departememt they already have staffed 24 hours a day.
You don't have urgent care clinics? I live in a rural area and the urgent care clinic is closer than the hospital plus there's an urgent orthopedic clinic about the same distance as the hospital. Very nice when my kid fell off the bike and cracked his wrist, a much shorter wait time and they knew exactly what to do.
I would have expected that a place as dense with patients as NYC would have them everywhere.
5
Unfortunately what is often classified as "preventive" is actually disease detection and not prevention.
For example, mammograms and PSA for prostate cancer detect disease after it is present and may allow treatment to begin earlier enough to make treatment effective but in no way prevent disease. And alcohol abuse screening detects abuse but doesn't prevent it from occurring in the first place.
In fact, most physicians provide few preventive services. Immunizations certainly are as are colonoscopies. But the real ones such as counseling on diet, exercise, smoking, drug use, and improving mental health are rarely provided by physicians as they don't get paid much money to do so and if they do provide it, it is done as quickly as possible.
If we ever really focused on true prevention of disease, I don't know if we'd spend less money (sadly, considering how much money is wasted on unnecessary tests such as the tens of billions of dollars for MRIs on people for low back pain that provide absolutely no benefit for them, lowering costs in our current pay for services system is probably impossible) but we'd have much healthier people who no doubt would be able to make greater contributions to the economy.
44
Real public health measures do not involve doctors. Clean water, clean air, sanitary systems, immunizations and public health education that tells people not to smoke, not to over eat and to get some exercise would not only save a lot of money but would also make peoples lives happier and healthier.
7
My take away is that anti-smoking efforts have been passed deceptively. I miss a society that smokes, not only was quality of life higher, but it saved all of us money.
12
I had to laugh at the idea that going to the emergency room is convient. Let's all just pop into the ER for a three hour wait. Maybe the problem isn't health insurance and people living longer, Why aren't doctor's offices open at night?Does everyone really need a colonoscooy or a yearly mammogram/prostrate screening? Why are seniors often on multiple presciptions? Does everyone really need to take a statin or high blood pressure medication? Why aren't we investing in infrastructure projects that encourage people to walk? We know that walking is a highly effective exercise at decreasing risk of a bunch chronic diseases, but in many places walking is unsafe. Why does the government subsidize the manufacture of junk food with subsidies for sugar, grain and soy but does not subsidize the price of fruits and vegetables. I don't think that the concept of preventative medicine is flawed as much as how we go about implementing it.
149
You are right. Guess who gets to live in walkable neighborhoods in metro regions? Those who can afford the luxury condos/apartments. Those people are already pretty healthy and can take advantage to gyms, have access to better grocery stores and farmer's markets. The low income folks live multiple mass transit modes away from their jobs, have convenience stores for food, and have neither the time or money to "maintain a healthy lifestyle."
6
Lots of fallacies here. “Everyone” doesn’t take statins--and besides, they are incredibly cheap. Likewise, most BP meds.
Old people take multiple drugs because they have multiple medical problems.
People are free to eat healthy food--they tend not to. Why blame subsidies? How about advertising--especially to children?
Recommendations for screening are based on the best scientific consensus, so your question is just, sorry, silly.
3
Using money to measure some things devalues the thing we are measuring and reveals the values of the person performing the measure. In this case, money is more important than someone else's health.
9
Not a surprise. Insuring more people and providing more care costs more. I don't know w how we can tell if providing more care will make people more productive by some objective measurement on the economy, like GDP .
It certainly improves quality of life, which I think is not solely individual , but community-wide effect. If we had universal health care, it would take a few years to track the results.
I worked in a civil service job and had good health benefits. Judging from my peers, they made a lot of use of them - much more than anyone who was not well covered. That's anecdotal - but people are people. And we also actually have a society which drums into our heads that we should see doctors - probably more often than necessary. So if they are covered -and if the copays and deductibles are not too high - they will go.
For most of the chronic diseases of modern society, it is behavioral choices which are implicated in many - food, exercise, weight, smoking, alcohol and drug use. There isn't any convincing evidence that preventive care actually works to inspire the behavioral changes that are needed to change those trends.
It really IS about what sort of society we want.
8
Sorry, but this is just wrong. If you do preventive care properly, over a long period of time without countermanding disincentives, it will work. You can't blame history or an ineffective system for your conclusions.
26
"Sometimes good things cost money", thanks Doc. The medical establishment is committed only to increasing profitability. Treatment options are evaluated and decisions are made to benefit the physicians pocketbook and not the patient's health.
Preventive care is cheaper than treating the outcomes of medical neglect.
Doctor's are millionaire's now and providing preventive care is somehow beneath them.
2
Your opinion about doctors seems very cynical. Yes, doctors get paid a lot, but they also spend 4 years of college, 4 years of medical school, plus an additional 3-5 years of residency working for $13/hr ($55k/yr, 80 hr/wk) while accruing an average of $166k in debt before graduating.
I don't fault doctors for seeking specialization and possibly higher compensation.
The real driver of health care costs are (1) drug companies, (2) medical device manufacturers, and (3) overuse of hospital-based care.
Most modern medicines don't cure disease - only control them. That translates to a lifetime of drug costs. The top 12 drug companies made $1.05 trillion in profits in 2011.
Medical devices get approved by the FDA with a minimum safety review. Device failure oftentimes does not get detected until they've been in widespread use for years, sometimes with devastating results.
But the big driver is hospital use. Consumer need to start deciding how much is too much. Performing complex surgeries on 80 year olds? Giving chemo to advance-stage cancers in the elderly? Artificially prolonging life in actively dying patients with no realistic hope for survival? These are tough ethical issues with real financial consequences that Americans don't want to think about.
7
NYC Commuter: I'm gonna bet you are pretty young and in your prime working years.
Let's check back and see how you feel about "not giving complex surgeries to 80 years olds"....when you are 79.
In fact, many people today ages 75-85 are leading active lives and will live into their 90s or beyond, and many surgeries to improve their lives are very valid.
What is YOUR life worth to YOU? how old is too old to get chemo or radiation, that might save your life and give you extra years to spend with your grandchildren? what is the value of surgery or medical treatment that reduces pain -- or keeps people out of nursing homes?
BY FAR the greatest cost to our entire system is "broke elderly seniors who end up in Medicaid nursing homes" -- it runs many tens of thousands of dollars per year -- so yes, if having knee replacements done at 80 means you can live independently another five years -- it has a very real value to society.
I worked for a large insurance companies in the mid 1970s. The company made 2 innovative health innovations that paid off: free flu vaccine by a company nurse in office time every fall and free exercise programmes with professional trainers available for an hour at any time of the day in a newly converted large gym in the company basement. I still remember fondly "marching around the gym" to the upbeat tunes from Saturday Night Fever.
Sickness days off dropped. But, the real "payoff" was that staff turnover plummeted. People stopped leaving because they enjoyed work more. That saved real money.
81
Of course. The problem with these studies is that they don't/can't measure the 'ripple effect'. The PCP I use underwent a change to what's known as a "patient-centered medical home". For example, they run group wellness programs to help patients reduce their risk factors by making changes in their lifestyle; the have a nutritionist/dietician and psychologists on staff,etc. I'm healthier and in better shape, fitness-wise than in decades. I'm also a better, more informed patient and participate with my providers in making my health care decisions. How do quantify all that?
8
If we model the comparative costs and cost savings of prevention versus amelioration, we should also model the cost of doing neither. We would probably find that this saves the most money, especially with respect to people in whom society has not invested very much. States like Kentucky have perhaps done this analysis.
If we want to decrease health care costs dramatically, we could discourage spending money on marketing products that are not new or different. The relative efficacy of various medical products should be determined by clinical evaluations; if these evaluations are inconclusive or impossible to do (measuring pain relief is tricky), marketing is a waste of resources from a medical standpoint. From a business standpoint, of course, it is not, and medicine is, in this country at least, a business with money as the product and health as a byproduct.
12
the author needs to consider the increased productivity of a healthy american workforce compared to one that is in and out of the hospital, or the cost-savings associated with preventing drug addiction versus treating it. increased access to preventive medicine has economic effects that reverberate well beyond the health care sector.
5
Carroll seems to be missing out on the capture of greater economic benefits -- the ones that accrue elsewhere outside of the health system. It's true that extending a person's life might lead to more costs down the road, but that calculation misses all the economic output we'll get from their continued existence -- years of work, childrearing, etc.
37
No doubt the figures are correct. Emergency room visits have always been a cost driver.
People who didn't have insurance, didn't go to the doctor, until it was very bad. Under the ACA, they still didn't go until it was bad, and they went the Emergency.
The problem seems to be one of education. When I think of preventive care, it means annual physicals and keeping up with vaccinations, etc.
It appears that the problem is people haven't been educated on how to get the most out of their health care. They instead are following old bad habits.
11
Aaron Carroll artfully dodges the crux of this issue, which is that it's not HOW MUCH we spend on health treatment - it's HOW relatively LITTLE VALUE we get for what we spend.
Emergency room visits, for example. Carroll notes (triumphantly?) that ER visits went up following ACA's implementation. Ok, fine - did the total RESOURCES spent per visit go up as well?
Let's ALL visit clinicians 5x more, so long as our aggregate health treatment outlays diminish by 10, 20, 30+ percent
18
I fear that your scenario above is just wishful thinking.
There is no evidence that increasing the number of clinician visits would decrease overall health costs.
And I say this as a primary care physician.
4
a typical ER visit costs about five times (some studies say 9x) the cost of a regular office visit - the math is pretty daunting.
3
Steve RR: about 10 years ago, I was in an accident and went to the ER -- I had lacerations and was bleeding heavily. I looked like an extra from a horror film, covered in my own blood. I had to wait in the ER for 7 hours to see a doctor. The doctor saw me for maybe 30 seconds. He told me "you have some pretty bad lacerations in your face and mouth; you'd better see your regular physician in the morning". His nurse put some dabs of Bacitracin ointment on my cuts from a large, common tube (USED). Then I was sent home.
For this magnificent medical care, I was billed $4400 -- less than 30 seconds consult -- no actual care. The amount billed for the dab or two of Bacitracin -- again, a large COMMON tube that was open & USED -- was billed to my insurance for $75 (!!!). A similar tube at the drugstore runs about $3.
My insurance covered this, but I had a 20% copay, so I had to shell out $880 of my own money.
Wouldn't it be fair to state that improving quality of life is a worthy goal? And if that's the case, wouldn't it be fair to add that the best way to bolster quality of life is through comprehensive health insurance reform in which a single payer option is available to every person, at a much lower price than the current profit-driven system we, of all Western nations, don't have?
77
Hospitals, doctor's offices, other health professionals work in environments where costs are fixed, and require a certain amount of revenue to maintain them. Preventive care will not reduce these expenses. Expenses continue and increase over time because of wage and equipment increases, 20% of the population make up 80% of the cost and care will continue in various medical settings. Finally preventive care allows people longer survival, and the older you are, the more illness will require intensive services. However if people can live longer and in better health they will be more productive, content employers and employees, and be able to more fully enjoy life. Just as the extra layout for roads, communications, and education enhances everyone's existence, so too preventive care falls into such categories.
17
You make a very good point - a recent study of a sample hospital revealed the total budget was $429.2 million, of which $360.3 million (84%) was fixed and $68.8 million (16%) was variable.
4
I suspect that a large number of people clamoring for preventative medical care here neither exercise regularly nor watch their diets closely. What they want is a preventative pill that absolves them from many of the lifestyle choices they've made.
Those who stay in shape and watch their diets often find that their need for preventative care is negligible at best, because they've covered most of it with their lifestyle choices.
11
This is a modified form of blaming the victim. What about mammograms? Does jogging prevent breast cancer? Breast cancer may be slightly more prevalent in the overweight, but it doesn't spare those with healthy lifestyles.
Many diseases are the same. Risk might double for an unhealthy lifestyle, but a healthy one doesn't eliminate your risk.
11
SAO, although I agree with you that the above poster is over simplifying prevention (and overestimating diet and exercise impact), your example of breast Ca and exercise may not advance your argument.
Many studies have demonstrated that exercise decreases the risk of breast cancer. One is linked below.
http://radonc.wdfiles.com/local--files/part-2/RANZCR_Stats_1996b.pdf
What about mammograms? They are not and have never been "preventive care." They are a screen. And when they find something, it must be further explored and treated. That costs money. The hope was that early treatment would save lives and reduce costs. Very few lives are saved and costs exploded.
From your observations I gather that we save money on some patients because they die earlier than normal i.e. smokers. But we spend more on people who live longer by paying expected old age health requirements.
20
Yes, BUT...there was no effort to understand that relying on an ER for one's health needs also concerns their children---children who are being taught a reckless way to live. Children who will pass on this way of living to their children, and so on as they forego thinking about prevention or better ways to manage their medical needs.
1
You have the math exactly right. My loved ones who did not smoke and escaped the cancer that killed their siblings in their 50's are now in their 90's about a half-decade into Alzheimer's but otherwise, healthy. That time period between 60-90 included broken hip, broken wrists, perforated bowel from a colonoscopy, melanoma diagnosis & treatment, appendicitis and the routine screenings and monitoring than are typical of anyone in mid and late life. It's expensive. And we simply don't have the resources anywhere for everyone to live into their 90's.
8
So, when is it appropriate to die? Is 60 too early? How about moving the average age of death back to 65? Who votes for that?
1