Does Prevention Really Lower Health Care Costs?

Preventive care sounds like a win-win—conventional wisdom says it makes for both healthier patients and lower health-care costs. It's a favorite topic of politicians, even more so than usual this year. Sen. Barack Obama's campaign links "disease-management programs" to smaller price tags for health care, and Sen. John McCain's says that "by emphasizing prevention … we can reduce health-care costs." But wait, can we? A recent paper in The New England Journal of Medicine says the conventional wisdom is wrong: preventive-care programs usually result in higher payouts, not lower ones. So will the candidates' preventive-care plans add even more dollars to what we already pay? NEWSWEEK's Mary Carmichael spoke with two of the paper's authors, Peter Neumann and Joshua Cohen, both health-policy researchers at Tufts Medical Center:

CARMICHAEL: Why do politicians like preventive care so much?
COHEN: Because it sounds like common sense. We've all heard "an ounce of prevention is worth a pound of cure."

NEUMANN: It also sounds painless. It's a way to talk about health care without talking about cutting payments or limiting choices. So it's a great message, even if it's a very broad one.

Too broad, according to your paper.
NEUMANN: The blanket statement that prevention will save money and improve health is too simplistic. Sometimes it saves money, sometimes it doesn't.

What's an example of preventive care that does save money?
One is childhood immunization on the recommended schedule. The problem is that a lot of kids are already on that schedule—we've gotten the bang for that buck. Another is the use of aspirin in middle-aged people to decrease their risk of cardiovascular disease. If you target the right people, you could actually save money and make people's health better.

But only 19 percent of the preventive interventions you looked at ended up saving money. Some cost a lot more.
NEUMANN: One example is prostate-cancer screening. It seems to be inefficient.

You have to spend a lot to catch the few cases that threaten people's health.
NEUMANN: And you might intervene medically when it wasn't necessary. So you get better health at very high costs, or you possibly get even worse health.

COHEN: Savings claims for smoking cessation programs are also controversial.

Really? McCain's plan specifically calls for more of those programs.
COHEN: They're probably the most complicated of all the programs I've looked at. If they work and people live longer, you prevent illness in the near term, but you extend life in the distant decades when people are older and their care is costly. So it depends on how you do your accounting.

NEUMANN: It's also easy to say "more people should eat well and exercise and not smoke," but will people adhere to that advice? If they don't, we're not going to get a big return on our investment in health-education programs.

Is there a general rule about what kind of preventive care government should pay for?
It's usually more efficient to target high-risk populations.

COHEN: You also want to know how many people you have to screen or treat to prevent one case of disease and how much each screening costs. Checking my blood pressure is pretty inexpensive. Doing an MRI is going to be much more costly, perhaps by orders of magnitude. And it's good to look at the nature of the disease that's being prevented. Let's say hypothetically I have a medication that prevents Alzheimer's. That could cut way down on the years people spend in a disabled state, and those years eat up a lot of money. On the other hand, if I have a medication that prevents something that kills rapidly with little disability, it may save lives but it won't necessarily save money.

Prevention also isn't very precise. Once a person is sick, we know he needs help—
NEUMANN: Whereas it's not always clear who's going to be a train wreck in the future. When you intervene early you pick up train wrecks, but also people who were slightly at risk or weren't at risk at all. Also, part of what advanced medicine helps us do is detect small risks, and we're going to pay for that. As we gain more ability to detect small risks and intervene when we find them, costs will go up.

Are you saying it's sometimes cheaper to treat a sick person than it is to keep him healthy?
NEUMANN: Some advanced treatments are more efficient. But I think we have to be careful with "cheaper." The cheapest thing might be do nothing and let the person die. The goal is not to save money—it's to improve health and get the best value from our spending.

COHEN: If we claim we want to do prevention because we don't want people to have a particular disease, that's fine. But if we claim we're doing it because it saves money, that's not always being honest.

Obama's plan says we need to study which health-care strategies work best. In light of that and also your work, what do you make of his plan? And McCain's?
If a politician is going to go through these measures carefully and find the ones that do in fact deliver, that would be great. But it's something to ask them both about at the debates. "You claim this will save money. How?" I'm sure they'll have an answer. At least I hope so.