Does Preventive Care Save Money? Health Economics and the Presidential Candidates

[NGinpa]

Interesting free article in the NEJM about whether preventive medical processes will actually save money! Summary below suggests mixed results, although this says nothing about whether this allows a better quality of life for many. It is just that when presidential candidates say we can pay for a new universal system with prevention, be skeptical!

Our findings suggest that the broad generalizations made by many presidential candidates can be misleading. These statements convey the message that substantial resources can be saved through prevention. Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not. Careful analysis of the costs and benefits of specific interventions, rather than broad generalizations, is critical. Such analysis could identify not only cost-saving preventive measures but also preventive measures that deliver substantial health benefits relative to their net costs; this analysis could also identify treatments that are cost-saving or highly efficient (i.e., cost-effective).

[ayeshahaqqiqa]

1. interesting

of course one must define what is meant by "preventative care". Does that include yearly checkups and screenings, or more than that? My MD, a holistic physician, gives her patients blood tests and takes extensive health histories to determine if they have food sensitivities, for example. She then gives patients an eating/supplement plan so that they can remain at their healthiest. I don't know that this is commonly known as "preventative care", but for me, at least, it has proven to be most helpful.

[Celebration]

2. Plus if you are fat

you actually save the taxpayers money, by dying early.

This is just business as usual for presidential campaigns.

[supernova]

3. Don't know that money-saving from patient care

should be the primary endgame of a universal healthcare system. Access to care and ease of use by the patient should be the primary aims, IMO.

I've never believed that there was all that "fat" so to speak on the use of the healthcare system. I don't think people use too much healthcare. Yes, there are hypochondriacs, but the MDs offices know who those individuals are in their patient populations. For the most part, people use only what they need.

Where there are cost savings to be made, and where a universal system and a single payer system are superior IMO are in administrative costs. You have very little. Right now, I think our system has about a 15% overhead. In single payer and universal systems that is lowered to about 5%. That is roughly the admin costs for even our medicare/medicaid system, and that's without being fully funded the way it should be.

If you want to trim the fat out of our healthcare system, look to remove the insurance companies, not the docs and nurses, nor the patients they serve.

[NGinpa]

4. Overuse due to ineffective care

I tend to disagree with you that people only use that healthcare which they need. To put it bluntly, I think only about half of what our system does has been proven effective, so from an effectiveness point of view, much more can be done to increase efficiency. Even in single payer countries like Canada, they are having healthcare cost problems due to effectiveness and efficiencies issues. Look at my post about British Columbia and you will/may see the future even here!

http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=222x31881

[Warpy]

5. Obviously, there has to be some rationing

Liver transplants for actively drinking alcoholics don't work, neither do heroics on newborns weighing less than a pound.

However, the delivery of care should be the objective, not the containment of costs.

We've been entirely focused on cost containment for so long that the insured are doing without needed care and even accepting it because that's what some bean counter has told them.

A complete paradigm shift in medicine is needed in this country. What we have now is inhumane, to say the least, and the cost of delivering profit to upper management and shareholders is becoming more and more unbearable in human terms.

[chicagomd]

6. I agree.

But how do you quantify what can be rationed without looking at an analysis of the cost? Cost control will always have to be a major objective if we are going to provide the best care to the most people.

There is a clear difference between cost containment for purposes of maximizing care vs. containment for maximizing profit, but my concern is how people in this country are going to respond to a system that when it tells them "No" there is really no room for discussion. As you said, a complete paradigm shift, but not only for the industry.

[supernova]

7. Effective Therapies

I think we certainly can and should continue to look at what therapies provide the most benefit.

For example, if you do a study and the results are: 50% all strokes/heart attacks could be prevented if the majority of of folks 50+ would just take a baby aspirin every day, why not do that? Aspirin is dirt cheap and you don't have all those expensive complications and need for ongoing rehab are clogging up the system in the coming years because everybody would be taking their aspirin.

But that's a vastly different strategy, and outcomes based on clinical research, from blaming people simply for going to the doctor too much.

I"m all for the former, not the latter.

[Celebration]

8. well, it's too bad

It is a small minority of people who actually do go to the doctor "too much," (I really can't relate to doing this), but they can still cause huge headaches. A friend of ours who is a doctor complains a lot about people making appointments when they don't need to see him--it may not be a majority of people in the community, but it is a majority in his waiting room. He says they are trying to get excuses not to have to work. I'm not sure what to do about that other than have high enough co-pays to discourage this. But then you get to the issue of people that actually need to go to the doctor not being able to afford the co-pays.

There just isn't a perfect answer to all this.

Aspirin has its own set of problems--stomach problems, plus I don't think it has been shown to be effective for all types of things. But maybe we should all be on Omega 3 fatty acids.

[supernova]

10. I disagree

with you that the focus should be on getting all the "nervous Nellies" out of the waiting room to contain costs.

Just like there is a segment of the population at any given time that needs maternity care, or vocational rehab, or any other patient cohort, you are just going to have anxious people who need a lot of hand holding. Some people cope very well with health issues. Others, not so much. Maybe they didn't get hugged enough as kids, I don't know.

The paradigm shift that Warpy mentioned earlier needs to include not punishing people for being human.

It's the same mindset that looks askance at a seemingly able-bodied person who has a handicapped placard and parks in a handicapped space. The truth is, you don't know what that person is going through. You don't know what their story is. This story actually did happen to a friend of mine. She, like me, has congenital heart disease and got the placard to avoid being tuckered out before she even walked inside the store to do her business. Finally she got so mad at one haughty onlooker, she flashed him, showing her scarred chest!

[Celebration]

13. the result, though, is

Long waits for the rest of us, including really ill people. Seriously, it is really annoying to have to wait for appointments for the doctor when the doctor is seeing the nervous nellies, or the malingerers. Plus it could be to the detriment of the health of everyone that has to wait. We only have limited resources, including doctors, and I am not sure that we want to pay doctors to hold hands, if the system is continually abused by the same minority of people. I actually like the model of at least having nurse practitioners screen these out.

As far as evidence based medicine goes, don't something like 80% of problems clear up on their own, without going to the doctor? So how do you handle that? I mean, if that's the evidence (I forget what the actual statistic was) shouldn't everyone just stay home and try to get well on their own?

[supernova]

14. You're needlessly pessimistic

:D

You are basing a universal healthcare of the future based on what you see now.

Right now we DO have clogged waiting rooms in ERs. However, that's because so few of us can afford a GP to go to for routine care. Problems that start out as minor become acute problems over time so that when you arrive in the ER, you are much sicker than you otherwise would be and require greater intervention.

If everyone had a GP to ask about routine matters and visit as the need arises, I expect the ER clog would be greatly reduced over time.

You haven't convinced me that the nervous nellies are the main problem. There are many chronic and deadly conditions that require ongoing monitoring, for appropriate med levels, repeat diagnostics, and so on. The practice of medicine isn't a one shot, in and out deal.

"don't something like 80% of problems clear up on their own, without going to the doctor?"

Well, the body has a natural inclination toward optimal health, but 80% a statistic out of thin air.

In what discipline does your doctor friend practice?

edit: There is also an issue with physician distribution. Rural areas and lower income urban areas are underserved by the medical community for a lot of reasons. A lot of it having to do with the need for MDs to make a lot of money. There's a whole other conversation that needs to be had about the cost of a medical education and where it would be the most useful for MDs to be.

[Celebration]

18. he's an otolaryngologist

I admit I was surprised by what he said. First of all, I cannot relate in the least to people who want to go to the doctor. He says a lot of the people on our stat's plan have manual labor jobs, and if they are a little tired and don't want to go to them, they get off to go to the doctor. I mean, that is sad. But meanwhile he can't see people that are really sick with something---he has to put them off until he has an available appointment. He is not a happy camper about this situation, but other than refusing to write excuses for people for getting off work (when there is nothing wrong with them), he doesn't know what else to do.

The eighty percent figure was about right with what I read at one time, but since there is no way I can find it, you are right to question whether I pulled it out of my hat. I didn't, but it could have been anywhere between seventy five percent and ninety percent. Anyway, it is a substantial amount, and anyone who promotes evidence based medicine should try to figure out what the actual percentage of people is that would get well on their own, instead of going to the doctor. Even now there are studies that show that most sinus infections should not be treated with antibiotics. Why? Because they last the same length of time with antibiotics or without antibiotics.

One thing that I like is all the Walmart clinic type places. I like the idea of minor med places that are open 24 hours per day. The ones around here are closed at night and on Sundays. That fills up emergency rooms at those times.

If we are going to have universal coverage, I think we need to start educating thousands of nurse practitioners. Most people do not need to see someone who has had the advanced training of an MD. They can be referred to MDs if necessary, of course. If we don't do this, our system is going to become very strained very quickly.

[NGinpa]

11. Evidenced-based medicine must come to the forefront

Especially in a universal system, we must stop doing the 50% of medical care that is mostly ineffective and a product of either outright greed or habit. That is the key! Why are we doing something and does it work??

When the poster says that most people go to the doctor for what they believe is needed care, that perception may be true enough, but is there systematic proof and accountability that what is being done does work?? In any system, we just cannot get to the point where we spent 100% GNP on healthcare and especially if we have little to show as a result!

[supernova]

12. I agree with you about evidenced-based medicine

And the pharma companies need to stop supressing research that doesn't show experimental drugs in the best light either. If a drug doesn't work or doesn't do as much as anticipated, then they need to publish that fact and get on with business. Not cover it up, put it on the market and act like it's the second coming of Jesus.

[Warpy]

9. You look at a lot of things besides cost. You also

have to look at risk versus benefit. The first procedures rationed would be like the ones I describe, high cost heroics with little to no chance of success.

Cost analysis is more applicable to decisions like when to start expensive colonoscopy screening for colorectal cancer instead of yearly stool guaiac tests for blood. It could also be applied to risk groups for breast cancer, with the higher priced imaging being started younger in women with genetic markers for familial, early breast cancer.

The problem is that we have plenty of cost analysis to work from, but it's being used more and more to deny care when care is needed the most.

Insurance companies make money 3 ways: denying coverage, denying care, and denying payment for any care that falls outside a computer model. That computer model is the current cost containment model.

We need to reassert the emphasis on the delivery of prompt, appropriate care. We don't need more cost analysis. We need to put our attention elsewhere as the current system is the most cruel, inhumane system in the world.

Nothing is worse than the promise of something denied at the last minute. Consult the myth of Tantalus to find out why.

[chicagomd]

15. Oh, I am on board with you.

Insurance companies are the bane of my existence right now, both personally and professionally.

But I wonder how people are going to respond when (and at this point it is truly a matter of when, not if) rationing starts to occur.

Take for example the infant born at 23 weeks gestational age. Most, if not all, neonatologists would council parents against any type of resuscitative measures, but that line is constantly being re-drawn when institutions and physicians push the limits of viability at the demand of either the parents or their own egos. How are parents going to act when the answer to their request to resuscitate the baby because they read about a miracle on the internet is an unqualified "no".

How is the media going to respond to Congress when they try to come up with a list of uncovered (and in the case of single payer/socialized medicine, not performed) procedures? What groups are going to have a strong enough lobby to get something they want passed? The nuts and bolts of the whole thing just seems to be so ugly, I wonder if it every really going to happen.

[Warpy]

16. Experimentation on neonates at university allied hospitals

that is written off as research and not as a health care cost could still be done with the consent of parents who are grasping at straws to save an extremely premature infant. The risk/benefit equation would need to be fully explained, however.

The "no" other parents get on equivalent infants at less well equipped hospitals where research is not being done should be explained on the basis of lack of ability to provide such heroics plus an explanation of the life long disability such heroics are likely to inflict on a child if they're "successful."

Costs would be contained while the envelope of viability could still be pushed.

I've seen families running on false hope told "no chance" many times before. It can be done. Most times, it has to be done.

Otherwise, you end up with Terri Schiavo.

[chicagomd]

17. Can you come talk to the nurses I work with?

"The "no" other parents get on equivalent infants at less well equipped hospitals where research is not being done should be explained on the basis of lack of ability to provide such heroics plus an explanation of the life long disability such heroics are likely to inflict on a child if they're "successful."

If more people in the medical profession were able to communicate this concept as effectively I think we would be in good shape. Or at least better shape.

[Warpy]

19. I worked trauma

and dealt with unrealistic hope a lot. I was pretty good at deflating it, but was far from the best.

It seems like such a cruel thing to do to people, but all you have to consider is what false hope did to the Schindlers.

Neonatal is a whole different ballgame, but it's still somebody's kid, whether it got born too early or got drunk too early and drove its car into a bridge abutment.