In the Balance

Interactive

Where the Candidates -- And You -- Stand

In just one example of dozens of cost-effectiveness studies examining strategies to reduce smoking deaths, a team of British researchers in 2002 calculated that providing brief counseling, nicotine replacement and the anti-craving drug buproprion to smokers would save one year of life for every $1,300 spent -- an incredible bargain.

There are also some disease-preventing activities that save money, although they are relatively rare. Childhood vaccinations are the classic examples.

Many of the infections they protect against -- chickenpox, measles, mumps -- are ones nearly every child would get if not for the shots. Even though few of those cases put children in the hospital or cost much to treat, virtually all that expense (and a few lives) are saved with universal childhood immunization. If vaccines are cheap and easy to administer, the total cost of vaccination is actually less than the cost of treating the cases of illness that would occur in their absence.

Toward the other end of life, providing a single colonoscopy to men 60 to 64 years old also saves money. Even though the procedure costs more than $1,000, it takes such a huge bite out of expensive, painful, life-shortening colon cancer mortality that it costs less to test everybody than to treat the people who would otherwise develop the disease.

"In order to crack this nut [of controlling health-care spending], careful thought and analysis has to go into evaluating what things work, how well things work and how much they cost," said Joshua T. Cohen of the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center in Boston.

And in the Long Run?

Similar to the finding that prevention rarely saves money is the calculation that people in good health probably rack up higher lifetime medical costs than their less-healthy brethren.

The reason? Healthy people tend to live longer.

The Framingham Heart Study has followed more than 5,000 people in a town outside Boston since 1948. An analysis published in 2003 found that obese women smokers lost 13.3 years of life, and obese men smokers lost 13.7 years, compared with normal-weight nonsmokers. This loss of longevity can make a big economic difference because people who miss old age miss the high medical costs associated with it.

In the journal PLoS Medicine last month, Dutch researchers led by Pieter H.M. van Baal used mathematical modeling to compare the medical expenses (starting at age 20) of healthy people, obese people and non-obese smokers.

Up to age 56, an obese person's annual medical costs are higher than a smoker's, mostly because of problems that often come along with obesity, such as diabetes, arthritis and lower back pain. Healthy people have the lowest annual cost.

But over a lifetime, the researchers calculated, healthy people incur the most cost, followed by the obese and then smokers, who die the earliest.

Does that mean we shouldn't try to get people to quit smoking or lose weight?

Of course not, says Louise Russell, the "Is Prevention Better Than Cure?" author who is now a research professor at Rutgers University in New Jersey.

"People are important, their health is important, and we want to make their lives better in a variety of ways," Russell said. "The point of the medical-care system is to serve people. It is not the point of people to serve the medical-care system."

Prevention can be a great investment, but it's still an investment. Nothing in the modern health-care economy is cheap.

Not even health. ·

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