Enough With the Fruit Salad Already

David Harsanyi is back at it, going on about how preventive care doesn’t save money. The problem is, of course, that, just like before, he’s combining apples, oranges, and kiwis. Makes a nice fruit salad – healthy! – but a bad argument.

So, again, let’s try to set the record straight.

One of the most glaring errors that Harsanyi makes, as do many others, is they completely misunderstand how prevention models would fit into health care reform.  No one involved in the debate is talking about parachuting prevention into the existing system.  For modern prevention strategies to work, how we deliver health care must change.  Incentives must be realigned to promote wellness and structures to support physicians - including better coordination of care for patients with chronic disease - must be developed.  That’s what the conversation in Washington is about.  Also – as I mentioned in my first reaction to Harsanyi - prevention is not just about detecting disease, or prevention of the worsening of disease  – it is absolutely about preventing the onset of disease in the first place. 

As to Harsanyi’s  blanket contention that no studies show widespread saving, I call it flat-out wrong because there is plenty of evidence. Policy should be based on facts, not bullheaded belief.

In the Huffington Post piece I co-wrote with my Emory colleague, Lydia Ogden, we cited some studies showing prevention’s effectiveness, which Mr. Harsanyi conveniently ignored. The evidence of widespread savings is incontrovertible, no matter how many times he denies it. Here (again) are some examples:

  • Research examining community-based lifestyle interventions (primary prevention) shows savings ranging from a short-term return on investment of $1 for every $1 invested rising to more than $6 over the longer term. An investment of $10 per person per year in community-based programs tackling physical inactivity, poor nutrition, and smoking could yield more than $16 billion in medical cost savings annually within 5 years – an ROI of $5.60 for every single dollar spent, without considering the additional gains in worker productivity, reduced absenteeism at work and school, and enhanced quality of life. (You can see the full report here.)
  • Research examining smoking prevention and cessation programs is particularly strong. An intervention targeting junior high school students found at $20:$1 ROI, counting just averted medical costs. Economic evaluation of programs to assist people to stop smoking found that each smoker who successfully quits reduces medical costs associated with heart attack and stroke by an estimated $47 in the first year and $853 over the following seven years. That study didn’t count other medical costs and it didn’t count the savings that accrue to employers when people aren’t off the job because of illness. Economists generally agree that indirect costs swamp direct costs of health care, by as much as 4:1 – so both these studies actually understate prevention’s true savings. (Here are the citations for these studies: Wang LY, Gutin B, Barbeau P, Moore JB, Hanes J, Jr., Johnson MH, et al. Cost-effectiveness of a School-Based Tobacco-Use Prevention Program. Archives of Pediatrics and Adolescent Medicine. 2001;155(9):1043-50 and Lightwood JM, Glantz SA. Short-term Economic and Health Benefits of Smoking Cessation : Myocardial Infarction and Stroke. Circulation. 1997 August 19, 1997;96(4):1089-96.)
  • Worksite health promotion programs post positive ROIs.  A scientific review of more than 50 studies found strong evidence of WHP program effectiveness in specific areas: reducing tobacco use, dietary fat consumption, high blood pressure, total serum cholesterol levels, and days absent from work due to illness or disability, as well as improvements in other general measures of worker productivity. At Citibank, for example, a comprehensive health management program showed a return on investment of $4.70 for every $1.00 in cost. A similar comprehensive program at Johnson & Johnson reduced health risks, including high cholesterol levels, cigarette smoking, and high blood pressure, and saved the company up to $8.8 million annually. [Goetzel RZ, Ozminkowski RJ. The Health and Cost Benefits of Work Site Health-Promotion Programs. Annual Review of Public Health. 2008;29(1):303-23. Ozminkowski RJ, Goetzel RZ, Smith MW, Cantor RI, Shaughnessy A, Harrison M. The Impact of the Citibank, NA, Health Management Program on Changes in Employee Health Risks Over Time. Journal of Occupational and Environmental Medicine. 2000;42(5):502-11.

Even the most common chronic conditions are amenable to good secondary and tertiary prevention to better manage illness and reduce costs. For example: Researchers evaluated the cost-effectiveness of the Arthritis Self-Help Course — a six-week patient education intervention — in reducing arthritis pain and physician visits for pain. Arthritis is the leading cause of disability in the United States and a common problem among older adults. They counted cost per enrollee, costs for physician visits for arthritis over 4 years, and costs for personal time and transportation for either attending ASHC sessions or making physician visits. What did they find? This intervention could save up to $320 per person per year, reducing individual suffering and doctor visits. [Citation: Kruger JMS, Helmick CG, Callahan LF, Haddix AC. Cost-Effectiveness of the Arthritis Self-Help Course. Archives of Internal Medicine 1998;158(11):1245-9.]

A meta-analysis of peer-reviewed studies — that is, a large review of investigations that pass scientific muster — showed that tertiary prevention to manage multiple conditions among the elderly and, specifically, congestive heart failure (CHF) when appropriately designed produces improved outcomes and savings. Research consistently shows a strong ROI (return on investment) for CHF care management (ranging from $2.72 to $32.70 saved per $1 invested). Most of the savings result from reductions in hospitalizations, particularly readmissions, and emergency department use. Among targeted CHF populations with more intensive interventions, the decline in hospital admissions ranged from 21% to roughly 48%. For asthma/COPD, the decline in hospital admissions or readmissions ranged from 11% to 60%. Reductions in ER use ranged from 24% to 69%. For patients with diabetes, declines in hospitalizations ranged from 9% to 43%. Among seniors with multiple conditions, declines in hospitalization ranged from 9% to 44%. [Meyer J, Smith BM. Chronic Disease Management: Evidence of Predictable Savings. Washington, DC: Health Management Associates; 2008. See this review

Does all prevention work? No, particularly not if it isn’t evidence-based. Are all prevention interventions designed to save money? No. As the evidence shows, primary prevention—preventing disease, getting people to stop smoking, can save money. Other the other hand, the kind of prevention Harsanyi is bleating on about – secondary prevention – is most likely to cost money in the short term, as people are diagnosed and treated appropriately—which is exactly what disease detection efforts are designed to do. Tertiary prevention, too, costs money to implement but can save money in the long run, even for patients with chronic illness. For example, the physician group practice demonstration in Medicare found that better care management for elders with diabetes and/or heart failure could improve health outcomes and save money. Who says? The Government Accountability Office (Medicare Physician Payment: Care Coordination Programs Used in Demonstration Show Promise, but Wider Use of Payment Approach May Be Limited. Washington, D.C.: Government Accountability Office; 2008 February. 

Sometimes you have to spend money to save it. This isn’t a terribly complex concept. Anyone who has a periodic oil change for their car gets it. Do you know for sure if you don’t that you’ll blow the engine? No. Do you know for sure that if you do change the oil you won’t? No again. Do you do it anyway?

Helping sick people not get sicker is the right thing to do (so is preventing illness to begin with), and studies show it saves money in the long-term because it avoids expensive in-hospital care and costly complications (even more expensive than blown engines). So … why wouldn’t we do that? We sure can’t continue what we’ve been doing. Health care is too expensive, too inefficient, and too often ineffective. Integrating primary prevention to avert disease, secondary prevention to find and treat disease at its earliest stages, and tertiary prevention to better manage disease and avoid complications is essential to reducing health spending. It’s not a panacea, as Harsanyi rightly points out. It’s a piece of the larger health care reform effort and has to be coupled with changes in finance and payment in order to reduce overall spending, slow the rate of growth, and increase the value of our health spending. That’s not opinion. It’s fact.

For the record, I must also add that I am not for nationalized health care that rations care—this one Harsanyi just makes up and is unfortunately often used as a polemic by those who have nothing else to say when debating health care reform. And, though flattered that Harsanyi implies I am a medical doctor, I’m not an MD. I have a PhD in public policy focused on health economics.  But more troubling is Harsanyi’s implication that doctors have no role in the reform debate.  Physicians are at the heart of the debate and have a great deal to contribute in terms of ideas for reform.