In the Balance
Tuesday, April 8, 2008
An ounce of prevention may have been worth a pound of cure in households down through the ages, but in the world of health economics the adage, alas, is not true.
An ounce of prevention is sometimes worth more than an ounce of cure (although rarely worth 16 times as much, or the equivalent of a pound). Usually, an ounce of prevention is worth considerably less. Often it is worth (to mix measures) only a gram of cure. Or even just a milligram.
This is a seemingly illogical truth. Most of us naturally assume that preventing a disease is cheaper than waiting for the disease to appear and then treating it. That belief is especially dear to politicians, who often view prevention as an underused weapon in the battle against health-care costs.
The campaign Web site for Sen. Hillary Clinton (D-N.Y.) notes that her health-care plan is "targeting the drivers of health-care costs, including our back-ended coverage of health care that gives short shrift to prevention." Rival Sen. Barack Obama (D-Ill.) asserts that American families can save up to $2,500 a year each if five cost-containing strategies are implemented, one of which is "improving prevention and management of chronic conditions." (The presumed Republican nominee, Arizona Sen. John McCain, generally has not pushed prevention as a way to control expenses.)
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. This is usually true whether treating the preventable diseases is cheap or expensive.
Taking the Long View
In 1986, a health economist named Louise B. Russell published "Is Prevention Better Than Cure?," in which she concluded that prevention activities tend to cost more than they save. Since the book's appearance, her observation has been borne out by studies of hundreds of interventions -- everything from offering mammograms to all women and prescribing drugs to people with high cholesterol to requiring passenger-side air bags in cars and shortening the response time of ambulances.
On closer look, this isn't so surprising. Nor is it reason for despair. After all, you get something from prevention -- less disease, for starters -- which is worth a lot even if it doesn't come cheap.
There are many reasons prevention usually doesn't save money. Perhaps the most important is that prevention activities target many more people than will ever come down with the disease being prevented. The reason (thankfully) is that people tend to stay healthy for most of their lives, no matter what they do.
Take the example of lowering cholesterol to prevent heart attacks.
The vocabulary of cardiac risk uses such terms as "normal," "high" and "very high." But in reality, most people even in the "very high" risk category don't suffer heart attacks over quite long time horizons.
Consider a 50-year-old male smoker whose total cholesterol is in the "high" range (over 240); whose HDL, or desirable cholesterol fraction, is "low" (below 40); and who has untreated moderate hypertension. Sounds like a walking time bomb!
It turns out his chance of having a heart attack in the next 10 years is only 25 percent. For a woman with the same profile, the chance of having a heart attack is 11 percent. Almost nine out of 10 such people will dodge the bullet by . . . doing nothing.