Economics and Disease Prevention

In a brief, less than 3-page commentary in the February 4, 2009 JAMA, (“A closer look at the economic argument for disease prevention”),[1] Steven Woolf systematically, succinctly, and thoroughly addresses the breadth of issues surrounding assessment of prevention methods and their cost, and the comparison to treatment. It is a “must read” for anyone interested in health, prevention, medical care, or health economics. I have nothing to add to this excellent presentation, but for any readers who cannot get JAMA, I will attempt to identify and summarize some of the key points, below.

· Framing the question as “whether preventive strategies save money” is incorrect. Some may, indeed, but for others, as for any goods and services we purchase, the question is what value we, as individuals or a society, get for our expenditure (cost-effectiveness), particularly in comparison to other options (most commonly disease treatment). Often this is measured in QALYs (quality-adjusted life years; see post January). “Services ordinarily are considered to have reasonable cost-effectiveness if they cost less than $50,000 to $75,000 per [QALY], but payers routinely cover treatments that cost more than $100,000 per QALY.”

· Many preventive measures have been demonstrated to be very cost-effective – “Among 25 recommended preventive services 15 cost less than $35,000 per QALY and 10 services cost less than $14,000 per QALY”, while others actual do save money – “childhood immunizations, smoking cessation, and aspirin prophylaxis among patients at increased risk for cardiovascular disease”. However, some are not: “…offering services to low-risk patients, frequent rescreening, and pursuing aggressive targets (e.g., reducing low-density lipoprotein cholesterol levels to <100mg/dL).”

· Some services can be shown to be cost-effective in comparison to doing nothing, but are not when compared to an alternative intervention. This is parallel to the requirement that new drugs only need to be shown to be superior to placebo to be approved, not to alternative existing therapies (my comment, not his).

· The adoption of behaviors by individuals (such as smoking cessation or exercise) may be of great benefit and cost-effectiveness in themselves, but programs to induce such behaviors may or may not be. For example, physician counseling to patients to stop smoking is cost-effective (<$5000 per QALY) but physician counseling for patients to exercise is of uncertain effectiveness and cost/benefit.

· Econometrics doesn’t capture everything; “Even if prevention and treatment cost the same per QALY, patients prefer the former to avoid the ordeal of illness.” Of course, but not always considered!

· What level of effectiveness are we looking at and, importantly, who pays? “…some community…preventive services (e.g., tobacco taxes, immunization requirements, seatbelt requirement) offer low cost per QALY or net savings.”, but may not be as important to, or even considered by, physicians, hospitals and health plans concerned with medical care, and require social or governmental intervention. “Community interventions may outperform clinical interventions, on both effectiveness and economic value. Opening a new cardiac center may cost more and do less for the health of local citizens than banning smoking in public places.”

· While prevention only accounts for 2% to 3% of health care expenditures, preventive interventions are (rightly) scrutinized for effectiveness and cost-effectiveness, treatment interventions (wrongly) rarely are. “Policy makers will rightly deny coverage for cancer screening until trials demonstrate an effect on mortality, but they readily extend coverage for new diagnostic tests simply because they boast greater accuracy or are advocated by specialists….The question that dogs prevention – will it save money? – is rarely posed for a new imaging device, a new antibiotic, or a surgical procedure.” Woolf persuasively argues that, whatever the origins of this “double standard” may be, it must disappear if we are ever to control health care spending. “The same questions posed for prevention must now be applied to disease treatments: does the intervention improve health outcomes, and how strong is the evidence? If the intervention is effective, is it cost-effective (a good value)? Can other options achieve better results, or the same results at lower cost?”

I have quoted extensively from the piece because it is so well-written and clear. Although based on the work of many researchers, it provides an outstanding expostulation of the issues it covers. It should be read and pondered by all health systems, providers, and policy makers.

[1] Woolf SH, “A closer look at the economic argument for disease prevention”, JAMA 4Feb2009; 301(5):536-8.