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August 08, 2007

A Free, Preventive Lunch

David Leonhardt has a smart column on health care spending today, in which he takes on the idea that preventive care will actually save us money:

The actual savings are also not as large as might at first seem. Even if you don’t develop diabetes, your lifetime medical costs won’t drop to zero. You might live longer and better and yet still ultimately run up almost as big a lifetime medical bill, because you’ll eventually have other problems. That would be an undeniably better outcome, but it wouldn’t produce a financial windfall for society.[...]

Intermountain Healthcare, a network of hospitals in Utah and Idaho that has saved money in recent years by reducing hospital infections and drug errors. Intermountain hospitals have also largely stopped inducing child labor for the sake of doctors’ or parents’ convenience. The hospital induces birth only for medical reasons — and the number of babies that spend time in the neonatal intensive care unit has fallen.

It’s this last example that holds the real key to cutting medical costs. I realize many people will react to the notion that preventive care usually costs money by saying, “So what? We should do it anyway.” And we should.

But by describing it as an easy win-win solution, the presidential candidates are gliding over an important part of the issue. Preventive care saves real money only when it replaces existing care that is expensive and doesn’t do much, if any, good. There are plenty of examples of such care — from induced labor to many lumbar surgeries and cardiac stent procedures.

The problem is that the people getting this care typically don’t consider it wasteful. We all like to believe that other people are the ones getting the unnecessary care. We, on the other hand, are probably not getting enough treatment.

This is all true. To be sure, in a perfect world, I could probably dream up a set of policy initiatives that, if broadly implemented and competently carried out, could reduce health spending off the bat. But the world continually disappoints with its stubborn lack of perfection. Instead, the more achievable goal is to move towards a universal system that's more cost-effective, which is, in fact, very much the same thing as saving money, and towards an integrated system that readies the ground for tougher cost control mechanisms down the road.

August 8, 2007 in Health and Medicine, Health Care | Permalink


It's the structural impact of truly integrated care that is more important than the cost projections: that is, developing a culture where people aren't encouraged to put off doctor visits by the hanging threat of having the scarlet letter P (for pre-existing condition, if you have to ask) hung around their necks.

Getting people into the doctor's office means that actual medical professionals are in a position to advise on potential risks or screening opportunities, as opposed to the current system's implicit emphasis on self-diagnosis and self-medication. Are there any good numbers on how much gets spent on sheer quackery in the US?

Posted by: pseudonymous in nc | Aug 8, 2007 9:18:36 AM

Post something about the health care dude at the debate.

Posted by: John Kerry | Aug 8, 2007 9:25:05 AM

The problem is that the people getting this care typically don’t consider it wasteful.

I'm so sick of this. It's a tautology: people who have been told that something is necessary tend to believe that it's necessary. So it's not that the ones getting the care think it's necessary merely because they're getting the care, but because they were told, often by more than one health professional, that the care was necessary for them.

Right now I firmly believe that for me to get a heart stent would be incredibly wasteful and even stupid. But if a cardiologist were to tell me that I needed one, then I would fairly quickly change my mind. Not because I'm selfish or because I just looovvvve me some surgery, but because a (supposedly) highly educated and trained professional made a diagnosis (supposedly) based upon my individual medical condition.

Since I read Ezra's writing I might ask a lot of questions about why the doctor thinks it's necessary, but in the end I'm going with the doctor's opinion.

Yes, I do believe that every person, insofar as they are able, needs to take charge of their own health and healthcare. But the ever-present bullshit like the quote above is about shifting responsibility, nothing more. People say that in order to make it seem like our healthcare cost crisis is nothing more than a character flaw, a problem of insufficient moral fiber on the part of those doggone people who go around, gobbling up medical care for no good reason at all.

If lumbar surgery doesn't work, where has this information been put? Has it been in all the newspapers, on all the news channels? When we go to the doctors' offices, do we see large, brightly-colored posters from pharmaceutical companies that tell us how lumbar sugery doesn't help anything? Or is this information that has been in journals, on some websites and maybe hit a newspaper or two somewhere between "regional news" and "international headlines?"

Because if it's the latter case, then don't blame me if I have lumbar surgery for the stupid reason that some surgeon told me I needed it.

Posted by: Stephen | Aug 8, 2007 9:40:51 AM

There are a lot of smart ways to stand on the filibuster and otherwise expose and weaken the GOP obstruction. The Dems do none of them. It's getting harder every day to believe that they are simply stupid or craven. i.e. it was a procedural goof that got the FISA law to the floor? Right.

They're getting something out of this arrangement that benefits them. It's' we - and the integrity of the country - that are getting left out.

Posted by: eRobin | Aug 8, 2007 9:53:35 AM

I'm sorry - that comment should have gone in the Webb thread. I'm not sure how that happened. I'm going to go with procedural goof.

Posted by: eRobin | Aug 8, 2007 9:54:40 AM

I agree with stephen.

Posted by: Phil | Aug 8, 2007 10:00:56 AM

Stephen: that's exactly why we have to work towards a system with less incentives for doctors to prescribe unnecessary treatments, along with incentives for doctors to keep up to date with knowledge about which treatments really work.

Posted by: Meh | Aug 8, 2007 10:25:32 AM

Heh... "inducing child labor?" That's a pretty interesting phrase.

However, inducing labor (in pregnant women, not forcing someone to work) is a problem IMO, and while I mostly agree with Stephen, IME pregnant women tend to be all over elective inductions-- they allow for easy scheduling & getting the relations in town more easily, the controlled environment means they don't have to deal with one minute of labor outside a hospital, and they're sick to death of being pregnant. I'd say that something like two-thirds of my acquaintances who had inductions ended up with c-sections, which are enormously expensive and not so great for either women or newborns. I distinctly remember one coworker, five or six years ago, whose report of the decision to induce horrified me, because it was clearly a sales technique: "I know you're ready to get this over with, the baby's ready, and if we do it Tuesday you can have a new baby for everyone to see at Thanksgiving, so let's go ahead & set it up." She wasn't home for Thanksgiving, of course, because she ended up with an 'emergency' c-section for fetal distress after twelve hours of Pitocin. Imagine that.


Posted by: latts | Aug 8, 2007 10:35:15 AM


That's why I didn't talk about induced labor. I agree that there is a very casual attitude toward it from all parties, and it needs to stop.

But we also need to remember that despite all the talk about it recently, elective c-sections and inducements are involved in a minority of births. Cutting out all the "unnecessary medical care" involved with these things won't do much at all to solve our costs problems.

Posted by: Stephen | Aug 8, 2007 11:44:54 AM

The medical industry is very good at talking about the benefits of a given procedure while ignoring the side effects or downside of any procedure. This leads to many people thinking that taking this pill or having this procedure will be pain and side effect free, when in reality the procedure or pill is anything but pain or side effect free. The medical industry employees thousands of people to extoll the benefits of medical procedures but almost no one is out there talking about the risks and side effects of these procedures.

It seems like the medical industry needs some sort of fairness doctrine imposed upon it, that would require equal time be given to the bad side of medicine.

Posted by: bryce | Aug 8, 2007 12:21:10 PM

Couldn't the savings be greater than some imagine because of the way health care costs are structured? In other words, if we prevent people from getting heart disease and having heart attacks, one of the supposedly big costs in health care, wouldn't that cut down on the amount of money spent? Or would it be almost a wash, because the amount of money getting there would be about equal to treating the people with those problems in the first place?

Posted by: Brian | Aug 8, 2007 12:28:51 PM

As per over-induction of labor, it's part of an constellation of bad birth practices in the US, which are somewhat connected to cost but (in my opinion) a lot more tied to a patriarchal mindset and a fear of liability. The fact that more inductions=more c/secs is a bonus to many OBs, some of whom will even admit they wish all births were surgical, because malpractice juries will usually assume that if he c/sectioned, the OB did all he could, no matter what happened as a result. I'm not sure universal care would help in this as much as in changing our approach to birth in general, but that's another topic.

Posted by: emjaybee | Aug 8, 2007 1:46:26 PM

I don't agree that this is a "smart" article. It cites very little in the way of evidence, and very vaguely. It seems to be reaching for examples to support what the author considers a fresh, contrarian view, but ends up just concluding that health-care reform is really hard and will probably mean lots of rationing - the subtext being "so don't listen to those candidates". It's very much in a John Tierney mode.

"studies have shown that preventive care ... usually ends up costing money" [What studies? costing money compared to what?]

"I don't know of any evidence that preventive care actually saves money" [Did he look for any? and what is the role of prevention in the Massachusetts plan he helped devise?]

"a doctor and economist ... estimates that to prevent one new case of diabetes, an antiobesity program must treat five people — 'not cheaply'" [Not cheaply compared to a lifetime of diabetes care??]

"when retirees in California began visiting their doctor less often and filling fewer prescriptions, overall medical spending fell" [These are retirees - they've already had many years of care - if they are able to see the doctor less often now, it's because they've had good care before]

"You might live longer and better and yet still ultimately run up almost as big a lifetime medical bill, because you'll eventually have other problems." [You can assert any damn thing you want as long as you say "might" and "almost".]

Posted by: Hob | Aug 8, 2007 1:48:11 PM

At some point its about the reward versus the cost. I'm not a medical professional, but my understanding is that with something like lumbar surgery, its very costly and there's no guarantee of success. But if I had a back problem I'd want to be able to pursue any treatment that help a positive expectation in results- even if that expectation was low. But that kind of treatment is going to be very expensive in the aggregate. In my ideal world, people would be able to decide up front how much coverage they could get from their health care plan and pay accordingly. The government would provide alternatives and the cheapest plan would be free. I don't like that aspect of national health care where these kinds of alternatives are really going to be limited to all but the super-rich. If I want a slightly better plan, it should only cost me a small amount of money. With a single national plan, I would probably not have that option. But in the current environment, I have very little flexibility in choosing my health care plan anyhow.

Posted by: mpowell | Aug 8, 2007 6:27:48 PM

Also, I want to respond to the article: even if preventative care won't save us money, Leonhart hardly makes an effective case against it. Basically, he's arguing that someone could live a life diabetes free (and longer) for the same cost. Dude, that's a big win.

Posted by: mpowell | Aug 8, 2007 6:29:52 PM

Our experience has been that elective induction is the easiest way to insure that the baby is born with the mother's personal OB/GYN on call. Wait for nature to take its course, and the on-call OB/GYN could be anyone in his/her practice.

Posted by: Joe | Aug 8, 2007 7:09:46 PM

One point the article and subsequent discussion have missed is that preventive care is not all there is to prevention. By "preventive care" people almost always mean clinical preventive efforts like screenings and vaccines. But the vast majority of health care is actually delivered outside of a clinical context...at home, by the affected person and/or his/her family.

Even a patient with a chronic disease like diabetes who comes into the office every couple of weeks will only see a physician for a few hours over the course of a year. 40 visits at 15 minutes each is 10 hours.

When you add in time for lab work, etc., the total annual time could reach a day or two, but almost never more than that unless the person goes to the hospital.

The rest of the time, the person is managing his or her own disease, or doing it with the help of family.

Moreover, the single most important thing most of us can do to avoid disease is to live a healthy lifestyle. And living a healthy lifestyle isn't just about doctors telling patients to do things, like quit smoking. It's about changing what is acceptable behavior in society. It's about changing laws, like no smoking ordinances and increasing taxes on cigarettes, or banning trans fats. I'm also a fan of having employers and health plans provide financial incentives for health.

There are people who aren't motivated to do the right thing for themselves by the prospect of living 10 extra disease free years, but are motivated by the prospect of earning an extra 500 bucks.

Prevention in the broader sense is where we should be thinking about getting our bang for the buck when it comes to prevention. It ain't about more and more exams and doctorly exhortations in the privacy of the exam room, but about public health measures, changing attitudes, and financial incentives. So say I.

Posted by: jd | Aug 8, 2007 7:39:17 PM

Having been in healthcare back when there really wasn't any preventive care for diabetes.......well, you can hardly imagine the difference.

In those days, well, to tell the truth, a youth onset diabetic was lucky to make it much past 30, and adult onset diabetics were- shall we say- most unhappy by age 60.

With preventive care and modern diagnostics a diabetic today is like a normal person. It wasn't always that way.

The smart aleck Leonhardt has set up a straw man and then backed off into qualifiers and imaginings. This is the kind of column we could use a lot less of (but are doomed to get a lot more of) because it not only doesn't provide any real information, it doesn't even offer any good ideas.

Of course you won't see any big savings on preventive care, especially if you start by providing it to 50 million people who weren't getting it.

But that kinda goes with the territory, because the kind of care we're talking about is preventive.

That's right, Mr. slow reader Leonhardt, the savings come later.

Posted by: serial catowner | Aug 8, 2007 8:07:07 PM

I can't get over how dumb that guy is. A 'better outcome' doesn't produce a financial windfall for society?

Baloney. Healthy people generate financial activity- even if they themselves do not make any money. Financial windfalls come from things that happen financially and one of the sure things in finance is that if you increase your population of healthy people the financial machine gets bigger and cranks out more.

I know- amazing stuff. Even better, most healthy people are productive, and if their health is maintained in the cheapest possible way......well, you see where I'm going with this.

Posted by: serial catowner | Aug 8, 2007 8:15:34 PM

Americans wont accept healthcare rationing on behalf of the federal government. Thats why the HMO capitation move in the early 90s has been abandoned. Patients sued their HMO at a far higher rate when their plan used rationing and restricted a far higher number of interventions/procedures than insurance companies do today.

Under a govt run system that wont change. For socialized medicine to work, you have to give the govt sovereign immunity so that people cant sue them everytime they dont like a decision to ration care. Give them some kind of appeals process, but you have to take it out of the courts.

What are the odds that Congress, legislatures, and courts will allow that kind of shift of power away from lawyers and the courtroom in favor of administrative appeals processes instead? About the odds of me scoring wtih Halle Berry tonight.

Posted by: joe blow | Aug 8, 2007 8:36:17 PM

You might live longer and better and yet still ultimately run up almost as big a lifetime medical bill, because you’ll eventually have other problems.

But wouldn't you also be more productive, therefore making lifetime medical bills a smaller fraction of lifetime earnings, and national medical costs a smaller fraction of GDP?

Posted by: Consumatopia | Aug 8, 2007 10:46:05 PM

But wouldn't you also be more productive, therefore making lifetime medical bills a smaller fraction of lifetime earnings, and national medical costs a smaller fraction of GDP?

Possibly, but not necessarily.

The best example is cholesterol monitoring, and the various cholesterol-lowering drugs. They definitely extend lifespans, but they almost certainly greatly increase the cost of health-care; dying of a heart attack in your early 60's is a cheap way to die.

Posted by: SamChevre | Aug 9, 2007 9:21:20 AM

After looking at this again, I think most of our complaints are beside the point. True, the guy doesn't make a good case against the importance of preventive care, but that's not really what the article is about. If you look at how it starts and ends, it's basically political water-muddying, like this:

"Sure those Democrats sound good with all their fancy health care reform ideas, but really they don't have a clue what they're talking about, because they're saying it'll be all rainbows and ponies and it really won't! So let's ignore the substance of their proposals and all other proposals, until everyone becomes very thoughtful and serious like me, by admitting that any change is bound to involve big big spending. Really big. Trust me, it'll be awful. Not that we shouldn't try anyway! But still... wow. Those poor, naive Democrats, little do they know."

I'm not saying Leonhardt really meant to praise the status quo or support the Republicans, but he chose to accept a set of assumptions and a rhetorical style that aren't well suited for any other purpose. The result is much like the endless op-ed refrain, "Sure the Iraq war is a mess, but all those liberals are against it for the wrong reasons! They all think ending the war will be all rainbows and ponies, and it's not..." etc., etc.

Posted by: Hob | Aug 9, 2007 10:29:18 AM

It's really appalling how often you can read the excerpt, click on the link, and you don't even need to wait for the page to load.

Oh- it's the NY Times- the business page.

JD, above, comes closest to getting it right- it's about public health, not medicine. Letting the med schools rule as the BMOC has been a big-time mistake.

To put it in terms most of us can understand, public health are the guys who make sure the oil is changed regularly and you don't drive under the influence. Doctors are the people who replace blown-up engines and straighten crumpled bodywork.

Hob is right too- it's a puff piece for hurried businessmen who want to quickly reinforce their existing prejudice against national healthcare.

Ezra should take a second look at whatever attitudes of his made him think this was a smart article.

Posted by: serial catowner | Aug 9, 2007 11:48:26 AM

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