Does Prevention Save Money?

There is a significant difference between something saving money (net reduction in total expenditure) and being cost-effective (requiring less cost per outcome than something else). Sarah Kliff from the Washington Post takes on this question by discussing Louise Russell’s chapter 3 in Menzel’s and my edited text, Prevention vs. Treatment: What’s the Right Balance? Doug Kamerow also addresses this question in more layman’s terms in his new text, Dissecting American Health Care, Commentaries on Health, Policy, and Politics (RTI Press, p. 29).

The argument Kliff looks most at is related to the table Russell shows (figure 3.1) by Joshua Cohen, et. al. that appeared in the New England Journal of Medicine in 2008. According to Google Scholar this article has been cited 195 times since its publication.

It seems to me there is one problem with Cohen, et. al.’s article: it lumps together apples and oranges in its comparison. To compare all well-defined studies of prevention with all well-defined studies of treatment ends up comparing such disparate items as genetic screening for inborn errors of metabolism and surgery for elderly men with prostate cancer. On a macro basis this may be the best we can do when asking the economic question of prevention vs. treatment. But such comparisons seem besides the point when mixed together. I’d rather see comparisons of like-minded prevention and treatment. For example, how does preventive statin use compare with coronary artery bypass surgery? Or more broadly, how does screening and reduction of risk factors for heart disease compare with treatment of preventable heart disease?

A discerning eye can see that prevention cannot impact all types of heart disease, e.g., already established unexplainable congenital heart defects, or right heart failure due to hereditary chronic lung disease. Many (perhaps most) diseases we find in medical textbooks do not have easily defined causes which can be short-circuited by prevention maneuvers. Just as we cannot prevent a disease in a non-at-risk population (i.e., a population that cannot get the disease in the first place – men don’t get ovarian cancer; women who’ve had total hysterectomies cannot get uterine cancer), we cannot prevent a disease for which we do not know predisposing risk factors or causative agents.

[Let me be clear that this doesn’t mean we can’t prevent disease without knowing its proximate cause. Scurvy was prevented in sailors without knowing about vitamin C per se; it was prevented by an observation of the relationship of the lack of citrus fruits and the profound spread of scurvy among sailors. In this case citrus fruits were a surrogate for the active vitamin C ingredient. There are many other such examples in the history of preventive medicine. See, for example. Burt Gerstman’s Epidemiology Kept Simple, 2003, p 290]

One other problem with the cost-effectiveness analyses typically done: they discount the value of future lives. This almost automatically puts prevention at a disadvantage because by definition the effects of prevention are in the future, while the effects of treatment are usually gained in the short-term. So for every life saved in treatment this year, we would need two or more lives saved in the future through prevention if we discount lives. This has interesting ethical implications, the most obvious of which is: why is a life in the future worth less than a life right now? Menzel explores this issue in detail in chapter 11 of Prevention vs. Treatment and I won’t recount his discussion here other than to say that the economic rationale of discounting monetary value most likely doesn’t hold for the value of life, especially when an ethical analysis is done. Because we make health policy including not just dollars but also values, this may hold a very telling modification of the policy implications of Russell’s analysis.

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Medical Management and Executive Leadership

In 1983 I became medical director of a staff model health maintenance organization in Lexington, KY. I practiced half-time in the clinic, while spending the other half-time re-organizing the health care system and hiring/replacing personnel. The HMO had been founded as a non-profit for poorer residents of the area.

One of my first challenges was to encourage staff that their key concern had to be the patients. Many of the employees were more interested in their own concerns. In other words, they were not customer focused. They had come to see our patients as a problem (non-adherent, poor health habits, less important than their own priorities), not their service client. Over the first year we changed that by instituting intensive training programs, customer satisfaction surveys, and performance evaluations. Employees who couldn’t make the switch were asked to leave. 50 of the 55 of them did.

Also we had to train the physicians to understand the concept of comprehensive, coordinated, integrated care. This was not just our primary care physicians who worked in the clinic, but also our specialists to whom we referred patients. We needed to train the specialists that we weren’t just referral sources; we were partners in the health care of our patients. We wanted to maximize convenience and quality care for patients, which often meant providing service to patients at one visit in the location they knew – the primary care clinics. And we wanted all non-emergency decisions to be made in partnership between the primary care physicians and the specialists.

Changing physician practice patterns is not easy. It takes daily review of practice habits by questioning medical leadership. It needs to be done collaboratively, and at the same time with a firm managerial hand. It requires training physicians to think differently from the way they are trained in residency. It requires a bit of humility on the part of physicians – they need to understand that they can continue to learn new competencies while they are practicing; they need to rely on their colleagues who may have complementary skills; and they need to broaden their creativity skills.

At the same time we needed to provide the physicians and staff with a feeling of personal control. While we implemented strong and strict performance standards for patient satisfaction (and quality control), we also provided the physician staff with greater control over their workday patterns – providing schedule flexibility and teamwork models to increase workflow efficiency.

All of this is in saying that the November 2 Atlantic Monthly article, “The Quiet Health Care Revolution” was a pleasure to read. Finally there are some places getting it right.

The danger is, of course, that once the larger insurer, Wellpoint, gets its hands on it it might be corporatized without the ability for continuing intrapreneurship. I say this with some experience. For several years in the late 1980s and 90s I was medical director at Aetna, where I also headed a strategic investment unit. We looked at acquiring certain companies that might have let us do this same kind of work but without the medical ownership. My supervisor at the time was a wise man who had been with Aetna for a long time. He nixed more than one potential acquisition of an innovative and creative company of entrepreneurs because of his fear that “Aetna will destroy this” by requiring bureaucratic policies to be implemented that would stifle competitiveness and innovation in efficiency and effectiveness of care.

Alan Hoops is a smart fellow. I hope he’ll be able to avoid too much corporatization of CareMore, and will recognize that the essence of improvement in the health care system requires strong and close physician management and creativity.