the economics of preventative health care

From David Brown in the Washington Post (hat tip: Linda Christiansen)...

This is reminiscent of many things studied by economists where the benefits are obvious and the costs are larger but subtle-- and so, people have a difficult time weighing the costs and benefits appropriately.

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....

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.

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.

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....

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....

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

Toward the other end of life, providing a single colonoscopy to men 60 to 64 years old also saves money....

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....healthy people incur the most cost, followed by the obese and then smokers, who die the earliest....

Prevention can be a great investment, but it's still an investment. Nothing in the modern health-care economy is cheap. Not even health.