Disease prevention not just screenings

This weekend, the Congressional Budget Office (CBO) sent a letter to Rep. Nathan Deal and other Congressmen regarding the scoring of prevention, in response to a July 16 question by Deal on the subject. Faithful to CBO’s previous statements, the letter said that investing in prevention won’t yield cost savings to the government, though some forms of prevention can be cost-effective.

What CBO says is true, depending on how you define prevention. Prevention is a continuum of care that works in three different ways: averting disease (primary prevention), detecting disease (secondary prevention) and managing disease (tertiary prevention). Much of CBO’s letter is devoted to secondary prevention efforts, i.e., screenings and tests for disease, which they call “medical preventive care.”

“For example, many observers point to cases in which a simple medical test, if given early enough, can reveal a condition that is treatable at a fraction of the cost of treating that same illness after it has progressed.”

But if you look at studies on cost savings from prevention, it’s really primary prevention – averting disease in the first place, eating healthy, exercising regularly and avoiding bad habits like smoking -- that has shown to yield cost savings. Tertiary prevention also shows good potential for savings per dollar invested. For instance, the fact that $100 billion to $300 billion is lost every year because people don’t follow their doctors orders on managing disease is a big problem – and a big opportunity for realizing value through better quality care. Secondary prevention is most likely to cost money in the short term, as people are diagnosed and treated appropriately— exactly what detection efforts are designed to do.

Part of the issue with CBO’s findings on prevention is that it evaluates these efforts within a 10-year window, which many prevention advocates argue is too short (by about 5-10 years) to truly capture the extent of savings. The other issue is that CBO looks only at savings to the federal government and not at the additional savings to the economy (through less lost productivity, lost work days) that studies have shown would come from investment in prevention.

Both the White House and Congress have rallied behind prevention as a cost saving mechanism and a path to health improvement, and I commend them for their efforts on this. However, CBO’s letter underlines a yet-to-overcome hurdle that prevention advocates must surmount if they want prevention included as a sustainable element of health reform, and that’s making sure everyone (CBO, the American public) knows exactly what we mean when we say prevention (and it’s not just disease detection and screenings).