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May 28, 2007
Preventive Care vs. Health Care?
Mark Kleiman, for instance, writes that "[a]ir quality improvement, noise reduction, better parenting practices (which we can purchase publicly with nurse home visitation programs) and changes in the social forces influencing diet and exercise all probably have greater bang for the buck." Don't get me wrong, I'm fully for both preventive health measures and better public health policy. But I wouldn't get too excited over the insight that stripping lead paint from walls is a more efficient way to improve health outcomes than restructuring health care delivery. It's not always true, and, given the politics and emotional realities of the issue, it's not terrifically relevant.
First, the impacts of preventive medicine are often overstated. It's not that cleaning up the air or putting everyone on a gym regimen would greatly improve health -- but people don't follow gym regimens, and business doesn't let you clean air. Furthermore, not all interventions are created equal. Better parenting might be beneficial, but it's unlikely to be more effective -- either on economic or biological grounds -- than the use of statins, or hypertensive drugs, or daily tablets of aspirin. There are a lot of highly effective medical interventions which are very, very cheap. But our system is very poor at incentivizing their use.
Meanwhile, the reason doctors are constantly prescribing statins along with admonitions to exercise and eat better is because using public policy to change diet and exercise habits is really, really, hard, unless you're prepared to be very heavy-handed (i.e, outlawing trans fats in restaurants, setting portion limits, etc). Indeed, part of the problem with preventive health measures is that, rather often, they don't work very well. Like with traditional health care, some things really succeed (stripping lead out of gasoline, giving people antibiotics), and lots of things...don't. And that's to sidestep the weird reality that what drives health care politics is concern over money which, in fact, is quite rational: Folks don't want to go bankrupt, and smart politicians don't want the government to lose all space for spending on other priorities.
In any case, there is no tension between better preventive health measures and health reform -- a more integrated system would encourage preventive health, and every bill you know of that moves us towards universal health care actually has a massive amount of money, incentives, and policies going towards preventive care -- it's something everyone agrees on. But you're never going to get a focus on preventive care in the way you do on acute care: The politics of health care are about financial and medical peace of mind at the point of absolute need. They're not necessarily rational. If they were, we'd already be running laps and eating 5-11 servings of fruits and veggies, the benefits of which are fully available to us now, and which fully rational, forward-thinking beings would be going to great lengths to take advantage of. Sadly, anyone who's ever been offered decent barbecue knows how rational we are. Damn you, Capps...
May 28, 2007 in Health Care | Permalink
Comments
"In any case, there is no tension between better preventive health measures and health reform -- a more integrated system would encourage preventive health"
Indeed - and especially under a single-payer system, that payer would have profound incentives to pay for those preventive measures that could reliably save money over time. Once we have a single-payer system, we can rely on those incentives to take over.
Posted by: low-tech cyclist (formerly RT) | May 28, 2007 12:37:19 PM
This is one area where an deliver system centeted on consumer-directed health has the potential for significant benefits over alternative systems. CDH plans structured appropriately (e.g. with incentives rather than costs for preventive care and cost-effective therapies) and designed correctly (Bush administration's proposals are not close) are the best option to deal with this.
Incenting insurance companies or creating government programs for preventive medicine will only go so far-- the incentives ultimately are most effective with the individuals themselves.
Posted by: wisewon | May 28, 2007 2:29:40 PM
There is a gray area between what is thought to be preventative care and acute care - where LOTS of money and good long-run health outcomes can both be had.
People neglect early symptoms and postpone MD visits for a variety of real (lack of time) and non-real (fear of coming to grips with a problem) reasons. The little growth on the skin that gets postponed until it is spreading wildly. The mild pain in the tummy that may be the first signs of major organ distress. A sugar high that may signal diabetes in the early stages.
Often the problem with pre-or-early-acute issues is simple lack of knowledge. Where are the books or videos that identify problems that are easily and cheaply fixed if caught early (other than female breast self-exams, which are now more common)?
If I had a chunk of money to spend, I'd first spend it on public education on recognizing early symptoms of common diseases (with explanations of why early action can prevent or mitigate major issues caused by postponement or fear.
Posted by: JimPortlandOR | May 28, 2007 3:18:41 PM
damn! comment should read: 'where LOTS of money can be saved'
Posted by: JimPortlandOR | May 28, 2007 3:20:14 PM
Meanwhile, the reason doctors are constantly prescribing statins along with admonitions to exercise and eat better is because using public policy to change diet and exercise habits is really, really, hard, unless you're prepared to be very heavy-handed (i.e, outlawing trans fats in restaurants, setting portion limits, etc).
Not really true at all. The way to promote healthier lifestyles is to make the economic incentives for unhealthy behavior high.
For example, higher gas prices will actually make people walk more, and subsidies to mass transit will have the same effect, because people tend to walk more to get to the bus or the train station
Posted by: enigma_foundry | May 28, 2007 5:41:29 PM
If a hefty gasoline tax -- which may well be a great idea -- doesn't count as heavy-handed regulation, I don't know what does.
Posted by: Ezra | May 28, 2007 6:16:14 PM
Yes, but....a lot of the things we can do outside the healthcare industry to improve health outcomes have other benefits.
Walking more may be a slow way to better health. However, if it means less use of automobiles, more money in the pocket of the walker, and less spent by communities on roads, the benefits start to add up.
Secondly, normally when you get a health benefit from "healthy living", the payoff starts early and lasts as long as you keep that clean-living profile.
As for getting a focus on preventive care, I'd say we already have it. People with money try to get regular exercise and eat small portions of really good food, and the more money people have, in general, the more they pursue those healthy goals.
Part of our problem is that, as with acute care, the provision of preventive care is skewed towards the rich. Sure, it's a lot more impressive to save the life of a gang member perforated in a drive-by shooting, but that doesn't mean that rich people hang around poor neighborhoods to get their moneys-worth from the dollar they spend on well-being.
Rich people spend aggressively to get the right kind of paint and the right kind of air to breathe, and I'd be very surprised if this wasn't reflected in actuarial tables.
Posted by: serial catowner | May 28, 2007 6:23:07 PM
One thing all this illustrates, and a thread at MattY's blog also shows this, is that public health and health outcomes have almost no presence in the public debate or arena.
Creating universal single-payer would create such a presence-a corporate body on a national scale with a large budget and appropriately-sized concerns about the origins of expenses.
In turn, such a presence would soon be in some degree of conflict with other, already-existing bodies, such as the mechanical agriculture industry, the suburban home-building industry, industry in general in relation to safety equipment, etc.
Now, not so much. Medicine visibly saves lives, but there is less recognition of the people who save their own lives by healthy living- except from their friends, who all envy how long they'll probably live.
The confusion around the issue is reflected, for instance, when Ezra says "Doctors prescribe statins because public health is really hard." No- doctors prescribe statins because they are doctors. Public health is hard because we spend most of our money on doctors. Spend as much, per capita, on public health as you do on doctors, and it would be really easy.
Posted by: serial catowner | May 28, 2007 6:37:40 PM
Ezra/Enigma,
To emphasize the CDH point. This would be heavy-handed regulation as a tax, but would be much better received as a "credit" on a CDH plan, i.e. eat well (measured by LDL/HDL levels and ratio, for example) and received x% off your premium/deductible/yearly contribution, etc.
Posted by: wisewon | May 28, 2007 7:33:43 PM
Your assertion that there are a lot of effective medical interventions not being used cries for documentation. You mention statins. I understand that has been no decrease in cardiovascular death rates since statins went on the market. In addition studies show that statins are of NO benefit to the elderly or women, in terms of total mortality. They do appear to have modest benefits for high risk men, though with substantial and often serious adverse effects. That's it. See thincs.org for more.
Any reform of the health care system that does not directly challenge the medical model of health will achieve little in improving outcomes.
Posted by: chaim | May 28, 2007 8:17:07 PM
Chaim,
Mortality is too crude a measure to be used for outcomes measures. Something that addresses for quality-of-life differences, such as QALYs are much more comprehensive-- including both mortality and moribidity effects.
Given that statins are going generic, the cost-effectiveness of statin use is undisputed-- the projected $/QALY is excellent, even for cohorts that benefit less, such as low-risk young women.
Posted by: wisewon | May 28, 2007 9:12:38 PM
If a hefty gasoline tax -- which may well be a great idea -- doesn't count as heavy-handed regulation, I don't know what does.
Well, I did not actually say anything about a hefty gasoline tax, just higher prices. One way to achieve the higher price, would be to fold the actual costs of the gasoline--in terms of the increased defense spending, and the costs to the environment--into the actual price of gasoline. The most obvious way to do this, it is true, is through a gasoline tax.
When Anderson proposed a gasoline tax back in 1980, it was viewed as crazy, but it made a lot of sense then and does now, too. The sooner the economy starts getting price signals that reflect the true risks associated with gasoline, the sooner the economy will begin to make the painful transitions.
It is interesting, though how very often sustainable priorities fold into other issues, and give us new policy directions on those issues, too.
Posted by: enigma_foundry | May 28, 2007 9:22:41 PM
The sooner the economy starts getting price signals that reflect the true risks associated with gasoline, the sooner the economy will begin to make the painful transitions.
Of course, the sooner the economy starts making the transition, the more gradual and less painful it will be. If we wait for the 'free market' to catch up to what we should know, we could be in for another oil shook, just like the 1970's.
The way to avoid this is to start feeding the economy price signals, now...
Posted by: enigma_foundry | May 28, 2007 10:14:55 PM
The most powerful and effective force for preventative health is culture. Mking it K00L to be a non-smoker, non drug user, non-drinker, etc.
Now, to change the culture, you will need some incentives. Oh, that's right....you don't think anything should be stigmatized or ridiculed such as being fat.
How the hell can you change the culture for better health when nothing is a cultural sin??
Posted by: Fred Jones | May 29, 2007 7:52:57 AM
The most powerful and effective force for preventative health is culture. Mking it K00L to be a non-smoker, non drug user, non-drinker, etc.
Now, to change the culture, you will need some incentives. Oh, that's right....you don't think anything should be stigmatized or ridiculed such as being fat.
How the hell can you change the culture for better health when nothing is a cultural sin??
Posted by: Fred Jones | May 29, 2007 7:52:57 AM
The most powerful and effective force for preventative health is culture. Mking it K00L to be a non-smoker, non drug user, non-drinker, etc.
Now, to change the culture, you will need some incentives. Oh, that's right....you don't think anything should be stigmatized or ridiculed such as being fat.
How the hell can you change the culture for better health when nothing is a cultural sin??
Posted by: Fred Jones | May 29, 2007 7:52:57 AM
The effect of ethanol subsidies is supposed to drive up food prices. If ethanol merely offsets the price of oil then we should see a slimming of the population. So hooray (tongue-in-cheek) for those swing farming states and the fact that food purveyors further "downstream" are not as well organized or as regional.
Posted by: Steve | May 29, 2007 9:15:31 AM
"To emphasize the CDH point. This would be heavy-handed regulation as a tax, but would be much better received as a "credit" on a CDH plan, i.e. eat well (measured by LDL/HDL levels and ratio, for example) and received x% off your premium/deductible/yearly contribution, etc"
LDL/HDL is often depends on one's heredity. There are plenty of people who exercise and eat well, weight at the lower part of normal range (myself included) and barely manage to have LDL/HDL fine. In fact, I am quite sure that the moment I stop HRT (that I take because I have POF) around the age of 50, my ratio will go to hell, in spite of my BMI of 22. There are fat people with normal ratio, and there are slim people whose ratio is bad. My slim former-competitive-runner father has much bigger problem with cholesterol than my 174-pound obese mother (who gain weight after the menopause). If you use the resulting ratio as a measure, you'll be penalizing people with bad genes.
Incidentally, it is very difficult for some women to keep weight off after the menopause. The only reason I manage to is that I eat about 1400 calories a day.
Wisewon - are you confusing cost-effectiveness with cost-savings? Cost-effectiveness simply means that the cost of quality-adjusted life year is under 50K. While I don't doubt that it is worthwhile, it is not the same as cost savings for society. If you look at statins for PRIMARY PREVENTION, you'd see that they are not really cost-saving. Neither are most chronic desease preventive measure. Even with exercise,you have to factor in the cost of injuries. And by the way, please do, show us some convincing evidence of statin benefit for primary prevention in women.
Posted by: Kitty | May 29, 2007 10:58:16 AM
Kitty,
LDL/HDL was an example of something you could measure if someone is eating well, not THE answer. I'll leave it to the nutrition and CV experts to determine the best metrics, but you could certainly ensvision a number of things that could be collected: HDL/LDL, BMI, visits with nutritionists, credit for diet programs, etc. that could enable people to earn that eat well "credit." The point is to incentive behavior, not make a scientific determination of who is eating well-- could be meet three of the 5 criteria and you achieve it-- so those that HDL/LDL isn't accurate due to hereditary/medical issues could still achieve it other ways.
On the cost-effectiveness vs. cost-savings point. I made an implicit assumption: that if we cut out (or in CDH terms, de-incentivize) the non cost-effective measures (even at a level of let's say $200K/QALY) we would have sufficient cost savings to the system as a whole. If we actually lived in a health system that there were so many <$50K/QALY interventions that the total cost of covering them would still be prohibitive, we could then fall back on other measures to choose between them, such as absolute cost-savings.
On the primary prevention point. I didn't claim that women CV death rates are impacted by statins. My larger point was that outcomes measures involve more than mortality. Health care isn't just about how long you live, but the quality of life as well.
Posted by: Wisewon | May 29, 2007 11:51:50 AM
"Indeed, part of the problem with preventive health measures is that, rather often, they don't work very well."
But they do! I feel so much better when I can spend my efforts telling you how to change your life rather than trying to change my own.
--ml
Posted by: Martin Langeland | May 29, 2007 12:39:44 PM
"Smoking" is the one-word refutation of this post. Meanwhile, NYC just banned trans- fats from restaurants, New Jersey just banned soda and candy from schools, etc. I realize you want to strengthen the case for health care reform, which is great, but saying "it can't be done" about things that have been and are being done quite successfully is the wrong approach.
Posted by: lemuel pitkin | May 29, 2007 12:47:50 PM
Longman's piece is yet another blow to those obsessed with the idea that the key to improving the health and longevity of Americans is systematic reform of the nation's health care system. As Longman painstakingly documents, health care interventions actually have very little to do with improving health and increasing lifespans. To the extent and in the ways that the citizens of other first world nations tend to be healthier than Americans, it's mainly because they have better diets and get more exercise. The presence or absence of "universal health care" has little or nothing to do with it. And whether health care is funded primarily by the government or primarily by private sector has even less to do with it.
Posted by: JasonR | May 29, 2007 2:07:42 PM
"On the cost-effectiveness vs. cost-savings point. I made an implicit assumption: that if we cut out (or in CDH terms, de-incentivize) the non cost-effective measures (even at a level of let's say $200K/QALY) we would have sufficient cost savings to the system as a whole. "
Maybe. And reducing waste such as unnecessary expensive testing is likely to save money. But there are really very few cost-saving measures, at least not in chronic deseases. Just pick a few common preventive drugs/tests and check out the NNT. Then, factor in side effects or drugs, extra office visits, etc, and you'll see your savings evaporate. Even obvious lifestyle measures - non-smoking or being fit are far from clear. Runners or gymnasts, for example, have high injury rates. Non-smoking is probably the most effective preventive measure by far, no drug or anything else comes close. But smokers die sooner on the average, so is the cost of their lifetime care is really more expensive? For an employer, definitely, since the employer doesn't care what happens after you are no longer employed. But over the lifetime? I am not sure. HDL/LDL is largely impacted by genes; and keeping the weight off after the menopause is an ongoing battle. Everything is great in theory. In practice, coming up with these good metrics is very difficult.
"On the primary prevention point. I didn't claim that women CV death rates are impacted by statins. My larger point was that outcomes measures involve more than mortality. Health care isn't just about how long you live, but the quality of life as well."
True as a larger point, but since your comment was made with regard of women and statins, could you show studies that statins actually improve quality of life of otherwise healthy (no diabetes, no heart desease) women? If anything, having to take a drug that may have side effects in order to maybe slightly reduce one's 10-year risk of heart attack (say from 6% to 4%) is going to adversely impact one's quality of life. No, I am not against statins - my father is taking them - but the case for primary prevention in women is less than clear.
Another post: Lemuel, don't you think that before we applaud the trans-fat ban we should have some evidence that it does any good in terms of improving public health or at least reducing obesity rate? For all we know, this measures could prove about as effective in reducing obesity as the Prohibition was in reducing violence.
Posted by: kitty | May 29, 2007 11:13:06 PM
Kitty,
I'm not saying the procedures themselves would be cost-saving: anything with a positive dollar per QALY clearly does cost money. The cost savings would be from stopping coverage (or deincenting) the least cost-effective procedures, such that less procedures are done overall. That's where cost-savings comes from.
I'd suggest your standard of procedures as needing to be cost-neutral or cost-saving as too strict. We generate wealth as individuals and as a society, with the ability to spend it on something. What better than improving one's health (within reason, hence the limits on $/QALY)?
On the statins point-- you've clearly studied this more than me. I was following on from Ezra's original post, so I'd suggest you take up this point with him...
Posted by: wisewon | May 30, 2007 5:16:20 PM
Thank you Ezra Klein. As a family physician, I learned years ago that the more a doc actually deals with real patients on a day-to-day basis, the less enthusiastic that doc is about preventive care. The easy stuff like immunizations has already been done. Further improvements in lifespan and health, given the current state of medical technology, could theoretically come from people changing their own health habits. Unfortunately, docs' interventions is this area are generally ineffective, except for the subgroup of people who are already health-conscious. Quite simply, physicians have no effective way to make people take good care of themselves. It sounds simple, but many with uninformed views of preventive care neglect this absolutely crucial fact. So why does the medical system focus on diagnosis and treatment instead of on prevention? Because we know how to do it and it's what people want.
Posted by: JRossi | May 30, 2007 5:34:22 PM
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