Ben Franklin estimated the cost-effectiveness ratio of prevention to treatment at 16 to 1: an ounce of prevention is worth a pound of cure. We now know in medicine that the ratio of savings varies from several-fold to infinite. Two familiar examples are immunization against incurable poliomyelitis and reductions in dental cavities by fluoridating the water.
After you measure the additional savings from reduction or elimination of suffering, disability, and dependency that accompany all illness and injury, trivial or serious, it becomes hard to imagine where prevention, if applicable, would not pay dividends. If there's no disease or accident, there's no doctor, no hospital, no time lost from school, work or play. Prevention is the ultimate in cost-containment.
Instead, most predictions about the future of the health care system now focus on the high cost of high volumes of high-tech diagnoses and treatments.
The alternative is giving prevention a try as a low-tech strategy for reducing some of the need for the numbers of high-tech treatments.
Skeptics say, "Yes, but prevention isn't always a panacea. Prevent cancer, you'll probably die of heart disease or stroke. Sooner or later the piper must be paid." Apparently not, according to recent studies. The longer it takes to develop a serious disease, the less costly is the inevitable, final episode. The cost of dying before age 65 is much greater than after 65, and the cost to Medicare of the last year of life in an 85-year-old is only slightly more than half that for a 67-year-old.
Why, then, if common sense and recent evidence both make the case for prevention, is there no big push for a "prevention services" system? The answer is in part related to the attitude of physicians.
Prevention is boring to many physicians who are trained to diagnose and treat. It is hard to get very excited by an event that doesn't take place.
Another problem is the abstract nature of prevention: prevent something from happening and how do you know for sure whether it would have happened if you hadn't prevented it?
Finally, the lack of attention by physicians is certainly related to the fact that prevention strategies, at least most of them, really don't require the hands-on involvement of physicians; many are nothing more than home remedies, where the patients can take responsibility, such as eating properly, exercising, sleeping, breast self-examination and using seat belts.
Nonetheless, the physician is the key needed both to unlock the potential of prevention and make the system work. People trust their own doctors and tend to look to them for advice. Many people are not even aware of their own risks: high blood pressure, high blood cholesterol, overmedication, inheritance. And the primary-care physician knows how to appraise these factors and suggest prevention strategies.
It all sounds good, but there is a serious impediment: who pays for the appraisals?
Since its inception, Medicare has prohibited reimbursements for preventive services, although there are signs that Congress is about to change that policy. Private health insurors have not included preventive services as covered benefits, though some are reconsidering.
Many large corporations have moved ahead of the health insurors by mounting worksite wellness programs, although these programs have usually not been aimed specifically at "prescriptions" for individual workers and their risks.
Most physicians agree now that there is great potential value in the preventive health risk assessment approach; there is no disagreement that lack of insurance coverage discourages participation by physicians and patients.
The time has come to remove this deterrent and it should not cost very much to do so (somewhere around an average of $70 per visit per person is probably a reasonable guess -- much lower in children and perhaps twice as high for those over 75).
Taking into account that not all would choose to avail themselves of this service even if it were "free" and, most important, that an average of much less than a visit per year per person is required, perhaps $10 billion to $12 billion would cover the cost of the appraisals each year. In the context of the daily expenditures for our health services of well over $1 billion now and counting, the add-on for comprehensive preventive appraisal would be trivial. In any case, the outlay should be viewed as an investment . . . in better health and correspondingly in lowered costs for therapeutic care.
It is time to get on with it. Here are three recommendations:
*Medicare law should be amended to remove the prohibition against reimbursement for preventive services and should pay for the appraisal package for all Medicare beneficiaries on an age-adjusted schedule. An "entrance exam" when one becomes eligible for Medicare has considerable rational appeal.
*State and other local governments -- already providing more and more care for those without insurance -- should provide preventive assessments for citizens who are already at highest risk for illness. A minuscule increase in sales tax on nonessential items might meet the modest additional expense and over time the savings from the stitch in time should recoup the modest additional investment by the public in the health of some of their less fortunate neighbors.
*The cost for all the rest of us should be met through Blue Cross, the private health insurors, and self-insured corporations as a new benefit. If offered as an option, it might be surprising how many employees would select a prevention package over others.