In the Balance

Interactive

Where the Candidates -- And You -- Stand

Preventing those heart attacks is expensive because everyone fitting the risk profile needs to get the intervention. Why? Because there's no way to know in advance who the 1-in-4 unlucky men or 1-in-9 unlucky women are.

If the prevention strategy is taking a statin -- a very effective cholesterol-lowering drug -- it will cost $160,000 for every year of life saved among men with the above-described risk profile. For women, it will be even pricier: $240,000 for every year of life saved, according to a study published in the Annals of Internal Medicine in 2000. (That total bill includes the cost of physician visits and lab tests).

It seems like a lot to pay. But who among us would choose 1-in-4 or 1-in-9 odds of having a heart attack if the alternative is to reduce the odds dramatically by taking a pill every day (especially if you don't have to pay for the pill yourself)?

In the answer to that question lies both the appeal of our increasingly prevention-oriented health-care system and the reason why prevention tends to drive costs up over the long run.

Calculating the Odds

Prevention can be expensive even when it doesn't involve taking drugs or undergoing procedures. Even giving information can be uneconomical. That's because giving information takes time, and the yield in terms of behavior change that leads to less disease is very low -- as anyone who has been told to eat less and exercise more knows.

For example, Australian researchers tried out a program in which general practitioners watched a video and read a booklet about how to help their patients lower their heart attack risk. The patients were then given a series of videos and a self-help booklet on the same topic.

How cost-effective is this instruction? When it is provided for women at low risk of heart disease, $9.8 million has to be spent for every year of life saved in the prevention of premature heart attack deaths.

Of course, there are situations in which prevention is the economical choice, even if it still adds to the total spent on health care.

Take smoking.

Smoking cigarettes is probably the most unhealthful legal thing a person can do. Nevertheless, most lifelong smokers will make it to age 70 without paying the ultimate price. This was borne out in a study published two years ago.

Medical researchers in Norway observed the experience of 50,000 Norwegian men and women over a 25-year period. Of the men who smoked more than a pack of cigarettes a day the entire time, 41 percent died between age 40 and 70. Among similarly heavy-smoking women, 26 percent died. (For people who never smoked, the mortality was 14 percent for men and 9 percent for women). Even for heavy smokers, the odds favor survival.

Nevertheless, doing almost anything to help people quit smoking is likely to be a good investment. That's because even though most people get to age 70, lots don't -- but might if they didn't smoke.