What do the campaign platforms of Sens. Hillary Clinton, John McCain, and Barack Obama have in common? Preventive medicine, and the belief that prevention saves money. But does it?
Our "health-care system" is primarily a disease-care system. Last year, $2.1 trillion was spent in this country on medical care, or 16.5 percent of the gross national product. And 95 cents of every medical-care dollar went to treat disease after it had already occurred. At least 75 percent of these costs were spent on treating chronic diseases such as heart disease and diabetes that are preventable or even reversible. A RAND study projected nearly $81 billion in annual national health expenditure savings due to prevention and disease-management programs.
Incentives are often perverse. For example, insurance companies pay more than $30,000 to amputate a diabetic foot even though most amputations are preventable by scrupulous foot care, which is usually not covered by insurance. When I lecture, I often begin by showing a slide of doctors busily mopping up the floor around an overflowing sink, but no one is turning off the faucet. Similarly, Dr. Denis Burkitt (who discovered Burkitt's lymphoma) once said that raising money to pay for ambulances and a hospital at the base of a cliff is not as smart as building a fence at the top to keep cars from falling off.
It's important to treat not only the problem but also its underlying causes. Otherwise, the same problem often recurs (for example, bypass grafts or angioplastied arteries often clog up again), a new set of problems may occur (such as side effects from medications), or there may be painful choices.
Our research at the Preventive Medicine Research Institute (PMRI), as well as the studies of other investigators, have shown that your body often has a remarkable capacity to begin healing itself, and much more quickly than had once been realized, when the underlying causes of illness are addressed. For many people, the choices we make each day in what we eat and in how we live are among the most important underlying causes.
Hillary Clinton's health plan calls for a "focus on prevention: wellness not sickness ... Insurers must cover high priority preventive services that experts agree are proven and effective. This focus on prevention will improve health and lower costs in the long run." John McCain states on his campaign Web site that "We can improve health and spend less, while promoting competition on the cost and quality of care, taking better care of our citizens with chronic illness, and promoting prevention that will keep millions of others from ever developing deadly and debilitating disease." Barack Obama's health plan states, "This nation is facing a true epidemic of chronic disease. An increasing number of Americans are suffering and dying needlessly from diseases such as obesity, diabetes, heart disease, asthma and HIV/AIDS, all of which can be delayed in onset if not prevented entirely." Also, Sen. Ron Wyden has sponsored the Healthy Americans Act, which emphasizes prevention and has bipartisan support.
Given this consensus, many people were surprised by some recent articles questioning the value of prevention. As David Brown wrote earlier this month in The Washington Post, "Studies show it's often cheaper to let people get sick ... Even when prevention greatly reduces future cases of a particular illness, overall cost to the health-care system typically goes up when lots of disease-preventing strategies are put into practice." For example, he questioned the value of taking cholesterol-lowering drugs:
Even if this analysis were true--and there are several fallacies in his calculations--it ignores the fact that most people can significantly lower their cholesterol levels and blood pressure by making comprehensive lifestyle changes that are free rather than by taking a lifetime of drugs that are costly. In our research, we found that improved nutrition, moderate exercise, stress-management techniques and social support caused a 40 percent average reduction in harmful LDL-cholesterol levels in men and women during the course of a year without drugs. Last year, more than $20 billion was spent in this country on cholesterol-lowering drugs, so the potential cost savings would be significant if more people made comprehensive lifestyle changes in lieu of drugs.
A similar but somewhat more balanced perspective was published two months ago in The New England Journal of Medicine. The authors wrote, "Sweeping statements about the cost-saving potential of prevention, however, are overreaching. Studies have concluded that preventing illness can in some cases save money but in other cases can add to health care costs ... In general, whether a particular preventive measure represents good value or poor value depends on factors such as the population targeted, with measures targeting higher-risk populations typically being the most efficient."
I agree that cost savings can be greatest and can be seen most quickly in those who are at highest risk or who have chronic diseases. For example, my colleagues and I at the nonprofit PMRI conducted a demonstration project in collaboration with eight hospitals to determine if comprehensive lifestyle changes could be a safe and effective alternative to bypass surgery or angioplasty in those who were eligible to receive it. After one year, almost 80 percent of people were able to safely avoid heart surgery or angioplasty, and Mutual of Omaha calculated saving almost $30,000 per patient in the first year. In a second demonstration project with Highmark Blue Cross Blue Shield, these comprehensive lifestyle changes reduced total health-care costs in those with coronary heart disease by 50 percent after only one year and by an additional 20 percent to 30 percent when compared to a matched control group.
The rapid growth of companies offering personalized genetic testing such as Navigenics, 23&Me and deCODE Genetics, makes it possible to identify people who are at highest risk for chronic disease and to tailor prevention prescriptions to those who most need it. Finding out you're at higher risk for illnesses such as heart disease or diabetes is a powerful motivator for making comprehensive lifestyle changes. Also, those at high risk are more likely to show cost savings from prevention. A Senate bill that would prohibit discrimination based on genetic information is expected to pass this week, so the use of genetic testing is likely to escalate.
Prevention is also cost-effective in healthier people, although the cost savings per person are not as high. For example, three years ago, Steve Burd, the CEO of Safeway, realized that health-care costs for his employees were rising past Safeway's net income--clearly, not sustainable. We discussed redesigning the corporate health plan for his employees in ways that emphasized prevention and wellness, provided incentives for healthful behaviors, and paid 100 percent of the costs of preventive care. Overall health-care costs decreased by 15 percent in the first year and have remained flat since then. Many other worksite wellness programs have shown cost savings, as well as a happier and more productive workforce.
In each of these studies, significant savings occurred in the first year--medically effective and cost-effective. Why? Because there is a growing body of scientific evidence showing how much more dynamic our bodies are than had previously been believed.
When you eat a healthier diet, quit smoking, exercise, meditate and have more love in your life, then your brain receives more blood and oxygen, so you think more clearly, have more energy, need less sleep. You may grow new brain cells. Your face gets more blood flow, so your skin glows more and wrinkles less. Your heart gets more blood flow, so you have more stamina and can even begin to reverse heart disease. Your sexual organs receive more blood flow, so you may become more potent--the same way that drugs like Viagra work. For many people, these are choices worth making--not just to live longer but also to live better.
In other words, the debate on prevention often misses the point: the mortality rate is still 100 percent, one per person. So, it's not just how long we live but also how well we live. Making comprehensive lifestyle changes significantly improves the quality of life very quickly, which is what makes these changes sustainable and meaningful.