Preventative care doesn't save money

https://www.nytimes.com/2018/01/29/upshot/preventive-health-care-costs.html

by richardhod • 8 years ago

71 59 8 years ago

turbohz• 8 years ago

"... but it improves quality of life at a very reasonable price."

laci272• 8 years ago

But of course it saves money.. on the long run. Yes, it does cost more upfront, and yes, people will be using the 'free doctor' more, in the short term, but over the lifetime of the patient, it costs considerable less to prevent, than to 'fix'. Of course, you could say that people who 'suddenly' need fixing will live less, so overall the state will save money cause they will be dead sooner, but i'm pretty sure that's NOT the point of healthcare.

Hermel2• 8 years ago

Of course, there is always a trade-off. For example, it is not worth spending 100$ for a 1% reduction in the risk of getting a disease that costs 1000$ to cure. If you really believe that prevention always pays off, why aren't you wearing a helmet right now?

nolok• 8 years ago

Very poor exemple. Him not wearing a helmet right now has nothing do to with costs, its about practicality and societal norms. Even on construction sites we had to makes laws saying it is mandatory or big fines to get people to wear them.

laci272• 8 years ago

You're right. Like all things in life, one should use common sense when interacting with the world. No one (i hope) wants to spend their budget irrationally. So in your example, I would let the doctor decide if that $100 is spend better on curing rather than preventing. And that 1% reduction you came up as an example is not 1% for the entire population, it may be 1% to me and you, but maybe 50% for someone older, or with a specific condition...

soVeryTired2• 8 years ago

What makes you think I'm not?

kgwgk• 8 years ago

But of course it saves money.. on the long run.

Some of these preventive measures do, and some don’t. In some cases you spend more money and get less quality of life in return. If you think that they are « of course » a good idea by principle and don’t do the calculation you won’t be able to distinguish the useful from the wasteful.

Dwolb2• 8 years ago

I found this to be an extremely interesting point:

In the short term, less smoking would lead to decreased spending because of reductions in health care spending for those who had smoked.
In the long run, all of those people living longer would lead to increases in spending in many programs, including health care. The more people who quit smoking, the higher the deficit from health care — barely offset by the revenue from taxing cigarettes.

So yes, if our goal is to “reduce healthcare spending” letting people die younger, faster would indeed do this.

However if our goal is to “improve quality of life for people at the lowest possible cost” we most likely need to invest in preventative care.

I would like to hear more from the authors on their synthesis.

mjw1007• 8 years ago

Similarly from the linked Robert Wood Johnson Foundation report: «Prevention can reduce the incidence of disease, but savings may be partially offset by health care costs associated with increased longevity.»

Perhaps a useful way of looking at things would be to imagine we had access to a graph of the function from (preventative health care, emergency health care) → life expectancy, and see what it looks like for constant life expectancy.

If you could increase the preventative part by less than you decrease the emergency part, then I think in one sense it's fair to say that preventative care saves money.

robkop• 8 years ago

Letting people die younger, faster makes sense that it would reduce healthcare spending but what doesn't make sense to me is that you loose all future productivity and value that these people create.

They say that the costs are barely offset by cigarette tax revenue but that doesn't take into account all future tax revenue that would be generated by letting these people live.

scarface745• 8 years ago

I hate to sound callous, but on average, how productive are older people? Living longer doesn't necessarily imply working longer. It could just lead to costing more in treating chronic conditions.

soVeryTired2• 8 years ago

Let old people die faster? It sounds callous to frame it in terms of dollars and cents, but allowing people to choose to end their own lives might lift some of the burden on our healthcare systems.

I'm still on the fence about the issue of euthanasia, but I think the Overton window is shifting. In time, I think that debate will make the debate on abortion look cordial.

IIIIIIIIIIIIIII• 8 years ago

Logan's Run [0] (still a great movie even watching it today - especially the cats [1] :-) ) - that society sure had the lowest health care expenses on the entire planet in its fictional universe of a future earth (a statement even more true since it probably was the only one, haha).

By the way, if we want to "cut costs" we could just blow up the planet and be done with it. No more "costs". What bizarre discussions we are having these days. "Cost cutting" makes sense in narrow(er) contexts, when the goal is clear and various paths to get there are explored, but for societal meaning-of-everything goal setting? If we didn't have health care we would not need to pay for it. That's true for everything ever made by humans. On this planet one person's cost is another persons's income, until we find aliens to trade with.

People already exist (and in huge numbers!) - what do we do with them? They may as well work as doctors and nurses and in the many industries supplying the health care sector. Or they could just hang around and play games, produce meme videos for Youtube, or become insurance agents or financial advisers (but of course, without "costs" somewhere there is not much to invest in... unless we become more of a "virtual society" and just have "money" building and feeding on itself without actual real-world connection).

[0] http://www.imdb.com/title/tt0074812/

[1] https://youtu.be/sax6J8n1AiE

PS: Completely unrelated issue, just for fun search for "Logan's run" on Youtube, filter by "length > 20 minutes", and check out a few of the many results. You can do that for lots of movies, especially popular older ones. Does it seem like Youtube is overrun by millions (must be millions overall, for all kinds of movies) of fake "movies", hours-long fake movies? Doesn't that waste huge amounts of Youtube storage? Why does Google not do anything about it, ML algorithms should have an easy time finding most of those uploads?

paulmd• 8 years ago

This is one of those topics that needs to be addressed but really cannot be because it's just so callous (and because the AARP is such a significant lobby in American politics).

I think assisted suicide should be legal. But even setting that aside, we spend a massive amount of money on prolonging people's lives for a few more miserable weeks at the bitter end. That money would clearly be better used on patients with better long-term prognoses, but this is unfortunately the stuff that gets people screaming about death panels.

BrandoElFollito• 8 years ago

The nature of the discussion is very different, though.

On the one hand you have an entity which is not born yet and which cannot make a choice.

On the other one, you have someone with vast experience deciding about himself (directly or indirectly via a will).

For clarity, I am completely and strongly pro-choice in both cases.

The first one is strongly faith based and weakly science based (when does life starts?)

The second one is way more objective and somehow quantifiable.

windexh8er2• 8 years ago

The assumption that living longer costs more is just that. If Western culture focused more on nutrition and moved away from the Standard American Diet longevity and health would have positive outcomes in the long run.

Preventative health care isn't prescribed by a Doctor in a world not driven by insurance and pharma.

danmaz74• 8 years ago

I'll break some good news to you: Western culture has never been tied to the Standard American Diet. Unless if by "Western" you meant Western US :)

ComputerGuru2• 8 years ago

You missed this part, though:

Of all the interventions they looked at, only two were truly cost-saving: childhood immunizations (a no-brainer) and the counseling of adults on the use of low-dose aspirin. An additional 15 preventive services were cost-effective, meaning that they cost less than $50,000 to $100,000 per quality adjusted life-year gained.

They’re not against paying for things, just not paying uncapped amounts.

It does sound barbaric, but just take it to the extreme. Is, say, $4M of federal taxpayer money for one quality-adjusted year of life gained a good trade off? Someone has to make that call.

gumby• 8 years ago

It's not barbaric, but what I find interesting is different regulatory agencies (e.g. Transportation vs Health vs Defense) assign different economic values to human life.

ineedasername3• 8 years ago

Also, from a view of net economic gain, healthier people are more productive for a longer period of time. So health cost savings may cancel out but the individual's contribution to the economy is higher.

Dwolb2• 8 years ago

Agreed here. Thinking the authors should be rolling up a better view of “health dollars spent per year”.

anon04532• 8 years ago

Yet it is quite different to spend 6 months in a hospital when your kids are 3 and 5, compared to spending the same money and time in hospital when it is your grand children who are 3 and 5.

You cannot put a pricetag on ones health when other lives depend on it.

Gatsky2• 8 years ago

The article says we need to take a wider perspective than just healthcare spending, but gives only one example of this with smoking, which happens to be one of the few 'preventative' interventions which both costs money to implement, and reduces revenue at the same time. As such, I am unconvinced of the entire thesis. It also uses a silly example of emergency room use after the ACA - of course after drasticallly changing the number of people with health insurance, there will not be efficient or ideal use of healthcare services. Many of the previously uninsured people probably aren't even aware of the concept of primary care.

The link between health and labour productivity only gets stronger as the population ages. Given this, I would need to see some compelling arguments that keeping people healthier for longer does not actually save money, but none are forthcoming in this article.

gbacon• 8 years ago

The point of the ER example is it runs counter to one of ACA’s important justification claims, viz. requiring all manner of preventive care coverage — even from low-premium, high-deductible plans — would reduce ER usage by giving the formerly uninsured the option of primary care. Even though now the ER isn’t “the only place they can go,” the author asserts that some choose to visit the ER as a matter of convenience. Reality isn’t likely to be quite this simple, e.g., another likely factor is a shortage of physicians accepting Medicaid.

The example isn’t silly at all. Central to ACA advocacy was how high American healthcare spending was relative to other countries and that costs would fall with ER-as-primary gone.

Gatsky2• 8 years ago

I still maintain it is a lazy example, and indeed probably just wrong[1]. The last insurance expansion was as recent as 2014, yet there is no discussion of trends over time.

[1]https://m.medicalxpress.com/news/2017-07-impact-patient-emer...

analog31• 8 years ago

In my view the use of emergency rooms was a red herring -- blaming the poor for being wasteful. I've been to the ER a couple times for relatively non emergency care. When you walk in the door, you go to a window, and if you don't have a real critical emergency, they direct you down a hallway into a facility on site that looks and operates exactly like a regular "urgent" or "primary" care facility. It seems no less efficient to provide primary care in the same building as an emergency room, as to provide it in a separate building down the street.

If you're having a heart attack, then you get the real thing: Eight attendants, machine that goes "ping" and so forth.

Now, of course the billing process may be different. With free health care, there would be no billing process.

Sacho• 8 years ago

Reminds me of a section of Dr. Bartlett's talk on sustainability(https://youtu.be/TBtW51D_q2Q?t=860). It is very interesting to see how a government is forced to grapple with the financial implications of well-meaning policies. Perhaps this is why preventative care needs to be billed as a cost-saving measure, otherwise you have to justify it over many other life-improving programs(education, law and order, defense, even other medical care programs).

The CBO report cited in the article also highlights another troubling point, the insolvency of our social policies:

"From about the middle of the second decade onward, however, the effects of increased longevity would outweigh decreases in per capita health care spending, and outlays would rise; but until about the mid-2060s, that growth in outlays would be more than offset by the increase in tax revenues from higher earnings. The largest deficit reduction from the health-related effects — about 0.005% of GDP annually — would occur from about 2030 to 2035. After the mid-2060s, the deficit would be larger than otherwise because the higher outlays would outweigh the health-related revenue increase."

(simplified, the taxes paid by healthier, longer-living citizens are not enough to offset the extra medical care they are afforded).

roenxi• 8 years ago

I'm not actually going to read the CBO report, but this article has a bad taste; it looks like political problems being mis-interpreted by the reporter as technical revelation.

If long-term impacts on the health system are considered, long-term tax & other productivity related payments need to be considered also. If this is net-negative, then that indicates a problem with the tax system (or possibly the healthcare system is to generous in the long term).

That is intensely political ground to say the least. Surely the issues with preventative care are closely linked to the solvency issue.

zbentley• 8 years ago

If this is net-negative, then that indicates a problem with the tax system (or possibly the healthcare system is to generous in the long term).

Given the number of anecdotal and statistical horrors that occur where the US healthcare system denies large numbers of people care that is unambiguously necessary, I suspect that the larger financial issue lies in the tax system.

To be clear: there are huge areas of terrible waste and broken behavior in the healthcare system (to the point that it costs far more than comparable systems in other countries), I just think the missing taxation-responsibility angle is more significant.

jrs235• 8 years ago

People are mentioning letting people die faster and earlier should reduce costs. But that's too simple. It would reduce costs for the initial payers but the costs (capital and labor) would remain the same for the short term meaning costs for services would have to rise for the providers to pay their fixed capital financing costs and to not have to lay off any labor. It's like inflation. How your buying per is affected depends on when/if you get the new money.

Until labor costs go down and we don't have a push for an "MRI on every block" costs won't go down. There seems to be more support jobs today particularly for coding and billing and dealing with insurances which is why single payer is thought to be a way to reduce costs by reducing overhead. It ought to work but then we better be prepared to help those workers who get displaced... Which just shifts the cost(s) somewhere else (sometime needs to pay to retrain displaced workers whose skills and knowledge are no longer needed or possibly even pay unemployment or even welfare to jobless individuals).

danjoc• 8 years ago

These included immunizations, counseling, and screening for disease. Researchers modeled what would happen if up to 90 percent of these services were used

The science is settled. We have a model for proof.

pmontra2• 8 years ago

Preventive, not preventative. Please fix the HN title.

bequanna• 8 years ago

Both appear to be acceptable and share the same definitions.

http://grammarist.com/spelling/preventative-preventive/

pmontra2• 8 years ago

But the title of the post uses the word preventive.

pkilgore• 8 years ago

The key paragraph, with added emphasis:

One reason for this is that all prevention is not the same. The task force doesn’t model costs in its calculations; it models effectiveness and a preponderance of benefits and harms. When something works, and its positive effects outweigh its adverse ones, a recommendation is made.

Aaron (the author) and his partners blog here[1], it's a very good site if this sort of thing interests you.

[1]https://theincidentaleconomist.com

bob_theslob646• 8 years ago

The author, in my opinion,does not do enough to talk about one of things that most Americans can control:nutrition & exercise.

The author also fails to mention that American medical system lives for treating rather than curing because treating makes the health industry makes more money.

Preventive Care Saves Money? Sorry, It’s Too Good to Be True

Why is it that I can find this?

A new study from researchers at Indiana and Cornell Universities looked at the effects of the Affordable Care Act’s (ACA) Medicaid expansion on a specific group: low-income, non-elderly, non-disabled childless adults–folks who wouldn’t normally be eligible for coverage without the ACA. This group is now 17% more likely to have health insurance, 7% more likely to have a personal doctor, and 11% “less likely to report that cost was a barrier to their health care,” according to a statement from the Indiana University Newsroom.

(https://www.fastcompany.com/3067684/one-big-lesson-from-obam...)

Definition of Preventative Healthcare.

Preventive healthcare (alternately preventive medicine or prophylaxis) consists of measures taken for disease prevention, as opposed to disease treatment.(https://en.wikipedia.org/wiki/Preventive_healthcare)[1]

I cannot speak of this for the EU, but in the U.S. does anyone pause and wonder why their is not more education on nutrition?

Does that ultimately have a huge effect on what diseases we may get?

Over the past century, essential nutrient deficiencies have dramatically decreased, many infectious diseases have been conquered, and the majority of the U.S. population can now anticipate a long and productive life.
However, as infectious disease rates have dropped, the rates of noncommunicable diseases—specifically, chronic diet-related diseases—have risen, due in part to changes in lifestyle behaviors.
A history of poor eating and physical activity patterns have a cumulative effect and have contributed to significant nutrition- and physical activity-related health challenges that now face the U.S. population.
About half of all American adults—117 million individuals—have one or more preventable chronic diseases, many of which are related_ to poor quality eating patterns and physical inactivity_.

(https://health.gov/dietaryguidelines/2015/guidelines/introdu...

Other papers and articles that disagree with the author.

(https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2008.0... Use Of Preventive Services In U.S. Health Care Could Save Lives At Little Or No Cost Michael V. Maciosek1, Ashley B. Coffield2, Thomas J. Flottemesch3, ... See all authors AFFILIATIONS PUBLISHED:SEPTEMBER 2010Free Access]

My point is that the answer is quite complicated and to state something as simple as the author does is, disingenuous.

crazygringo• 8 years ago

If we really want to know whether prevention saves money, maybe we should take a wider perspective. Does spending on prevention save the country money over all? A recent report from the Congressional Budget Office in the New England Journal of Medicine suggests the answer is no. The budget office modeled how a policy to reduce smoking through higher cigarette taxes might affect federal spending... In the long run, all of those people living longer would lead to increases in spending in many programs, including health care. The more people who quit smoking, the higher the deficit from health care — barely offset by the revenue from taxing cigarettes.

What about those peoples' economic productivity as they work for another decade? What about the other jobs they help maintain by spending the money they make from their productivity? What about the care they provide to their grandkids?

This article takes an incredibly myopic view. If we're sticking to pure economics, the metric shouldn't be to decrease lifetime health care costs... the metric should be to decrease the ratio of lifetime health care costs to lifetime economic productivity, broadly measured.

boxed• 8 years ago

Even if they did take economic activity into accounting that seems besides the point. The same argument would make it a really good idea to introduce the death penalty for reaching retirement age! If you optimize for something stupid you get stupid results.

gutnor• 8 years ago

There is a bit of a nihilist nature to it too.

Current modern society only achievement is making people live better, longer. There is no scientific, objective reason to do that. It is only the arbitrary (slightly helped by biology) value we put on human life that makes us do that.

You can look at about everything, be it healthcare, government, defence, or even economy and money and the only cold logical conclusion is that it serves no purpose.

Makes me think we better be careful with AI. Overly survivalist AI can kill all humans, the opposite is one that eventually find out that killing all human now is the fastest way to help humanity reach its natural conclusion.

crb002• 8 years ago

Cutting sugar, not being wholly sedentary, and having life long friends is 90% of preventative care.

bpicolo• 8 years ago

I imagine it does for dentistry

polskibus• 8 years ago

Did they analyse European preventative care programmes too? Maybe preventative care can save money, just not in the US ?

cryoshon• 8 years ago

here is a fallacy that is frequently made: everything needs to be profitable. no, not everything needs to be profitable. we accept that things that are for use by the general public as essential to their life are not held to the standard of being profitable. this is why we offer food stamps and control the rates for water delivery and electricity delivery very strictly.

healthcare doesn't need to be profitable, it needs to increase people's longevity and their quality of life. full stop. anything else-- anything less-- anything more cruel in the conversation is completely unwelcome and hopelessly off-base.

it's like the people who try to argue that public transit needs to make a profit. no, it's a public utility. it needs to not bleed the public's money dry, sure, but its primary objective is providing a service rather than making money. making money isn't even a tertiary goal. once again, it's a public service.

flagged this article for being too stupid to be on HN; other people in the comments have already pointed out the article's glaring methodological flaws, poor rhetoric, and its malicious moral standpoint.

reasonattlm• 8 years ago

Leaving aside for a moment the issues of healthcare being wrapped up in a system of regulation and entitlement that makes a healthy marketplace impossible, and growth in demand harmful rather than beneficial. Putting that to one side, the reason why present day preventative care does little to the numbers is that (a) most costs occur due to age-related disease, and (b) present day medicine can produce only marginally positive outcomes at great expensive when it comes to aging and its consequences. It is still outperformed in many areas by lifestyle choices.

Sufficiently good preventative medicine will save money, because it will address the root causes of aging and thereby reduce risk and severity of age-related disease, while lengthening healthy and overall life span. It doesn't even have to be cheap. It just has to be less cheap than the cost of attempting and failing cope with aging.

But in practice it will largely be cheap.

Senolytic therapies to clear senescent cells are a pharmaceutical approach to age-related conditions that improves the situation for near all individuals and pathologies of aging, cost-effectively. Those tested to date reduce inflammation, partially resolve loss of regenerative capacity, turn back atherosclerosis, restore loss of tissue elasticity to some degree, effectively treat osteoarthritis, effectively treat fibrosis, clear out many forms of bad immune cell, remove a contributing cause of Parkinson's disease, and so for for a much longer list. The reason it will be so much better is that it targets a root cause of aging, a form of damage, and directly repairs at least some of it (25-50% of senescent cells destroyed in some of the measured tissues for some of the approaches).

One of the candidate therapies, dasatinib/quercetin, costs ~ $30-100 / dose. Take it once every few years.

Preventative care doesn't save money

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