Any debate discussion involves establishing premises. Hopefully, the premises are accepted by all parties and the subsequent discussion involves attempts to build a logic chain from them. If a premise is flawed, then any subsequent logic chain whether accurately constructed or not will be questionable. When a premise is not accepted by all parties in a discussion, that discussion will likely degenerate into arguments making little progress. As in any debate, before engaging in argument, it is important to assess the premises.
One premise in the health care cost debate in the United States is “Preventive Care is less costly than waiting for a disease to emerge and then treating it.” Many accept this premise and, upon it, assert that less costly health care will involve screening for disease, immunizations, and, in some cases, surgical intervention in seemingly healthy individuals. For some time now, some of us have questioned whether this premise is accurate. Regardless of your position on the Affordable Care Act (ACA), this premise deserves deeper analysis than simply accepting it. There are several components that supposedly support this premise including the following paragraphs.
Keep people out of the emergency room will allow for less expensive care. Estimates are that between 20 and 55 million US residents do not have sufficient health care coverage to seek primary care in a private setting so they seek care in emergency rooms. This means that care is very expensive (several thousand dollars in the ER versus one to two hundred in a primary care office). It is also fragmented (ER staff tend to address only the condition for which a patient presents and not the total health of that person thus chest pain will be worked up and treated but no attention paid to the severe arthritis or obesity). Cost effective analysis of providing primary care in an office rather than in an ER is fraught with variables that cannot be controlled. If all those underserved persons descend upon existing primary care facilities, there will be a major expansion in cost of primary care (for example 30 million persons at $200 a year would cost $6 billion). How many ER visits would be obviated? In my opinion, the benefits of primary care in a primary care office are clear cut and worth any increase in overall cost that may occur. This support of the premise appears to be correct in my opinion.
Cancer Screening When the Pap smear was developed, this became a “gold standard” of preventive care for women. The test was inexpensive, non invasive, quite accurate (not, however 100 percent accurate), and could lead to relatively inexpensive, effective care that would cure what was otherwise a devastating and fatal cancer. Virtually all physicians accepted this preventive care as a less costly form of care than waiting for the cancer to occur and treating it. The keys to this success were an inexpensive test leading to an effective and inexpensive curative procedure for a predictably deadly disease. Soon, other cancer screens were added and touted as being similarly successful. Chest xrays in smokers, mammagrams, PSA blood tests, stool blood tests, annual skin exams, and others. Several aspects of these tests led to failure in both cost effectiveness and disease management lack of efficacy:
1. If positive, the therapeutic intervention was not a less invasive or less costly means of treatment. For example, a positive mammagram is treated in pretty much the same manner as a mass felt in the breast. Unless one can prove that that treatment is more efficacious when initiated early, there is no advantage from the screening tests.
2. False positives lead to expensive and, potentially dangerous confirmation tests. For example, a positive stool blood test can result from several causes other than cancer. Thus the finding must be followed by colon xrays and/or colonoscopy. These are costly and may not be definitive. This screening test becomes costly and entails significant chance of complications by the time false positives are evaluated.
3. Cost effectiveness of the test requires that the total cost of screening, treating false positives, and treating true positives be less than waiting for the disease to emerge and treating it. Several studies have found data to not support this being present for stool blood tests, chest xrays for smokers, PSA, and several other “preventive” studies.
4. In some cases, there is evidence that “early” discovery has not led to better survival from the disease being screened. For example, mammagrams in 65 year old women do not affect life expectancy. Mammagrams in 40 to 55 year old women do appear to provide a modest improvement in life expectancy for that group. This does not mean that the overall cost of care is less, even then. That analysis becomes extremely complex and findings are easily affected by the bias of the “investigator.
So, the bottom line is that screening for cancer is not particularly cost effective except in a few, specific cases (such as the Pap smear) or in high risk populations (e.g., colonoscopy every five years for persons with ulcerative colitis). The premise is only occasionally correct when applied to screening. Despite scientific evidence calling into question cost effectiveness and efficacy of such screening, most persons advocating heath care reform include the “advantages” to be achieved from increased screening as a preventive measure.
Immunization Care. Immunizing against diseases can be effective in preventing that disease and, therefore obviate completely cost of treating the disease. Success has been seen through complete eradication of small pox and near complete eradication of childhood scourges such as measles, chicken pox, diphtheria, and polio. In some cases, success has been such that some now question whether the risk of the immunizations exceeds the risk of the diseases. I have made my view clear on this elsewhere so will not go into it here except to say that death or disability from these diseases is inexcusable in a modern society. Recently, new immunization technology has emerged making it possible that there may be a much larger group of diseases that can be prevented with this technology. In the interest of full disclosure, I will state that I have invested part of my IRA in a company that is working on immunization technology. So far, my investment has only lost about 70 percent of its initial investment. Some problems with assumption of cost effectiveness for new vaccination interventions:
1. Again, cancer of the cervix was one of the first. Cancer of the cervix is highly related to infection by a group of viruses. Immunization for those viruses prevents subsequent infection making it likely that the cancer will be prevented. The cost issue seems to be significant. This is an expensive vaccine. The Pap smear is relatively inexpensive. Additionally, taking the vaccine does not obviate need for periodic Pap (or equivalent) testing. It will be difficult to establish that receiving this vaccine will save overall cost versus continuing classical management. I am not up to the math of estimating cost effectiveness of these vaccines. However, if the disease might affect 1 percent of the population at a cost of $500,000 per case and the vaccine costs $250 per person, the cost benefit of immunizing would be $425,000 per case. However, cervical cancer affects a smaller group than that and, with early detection, costs a lot less to treat. My best guess is that the cost effectiveness is close to a wash. There is evidence that some oral cancers may be preventable with the same vaccine which would add to the cost effectiveness of the vaccine.
2. Immunizing for hepatitis B can prevent that illness. The vaccine is relatively expensive. However, hepatitis B is a potentially lethal illness and, in its chronic form can lead to liver cancer. The cost of treating hepatitis and liver cancer are very high and, it appears likely that this vaccine is cost effective. I have not seen any analyses of that so cannot prove it to be accurate. My “intuition” sense tells me that this is a valuable vaccine and I have received it.
3. In the pipeline vaccines include several for hepatitis C, several for HIV, malaria, and a host of other illnesses. It appears very likely that, in the future, health care will need to assess persons for risk of incurring illnesses and deciding if the risk and cost of vaccines are worth the investment. For example, malaria vaccine would not be recommended for persons living their entire life in the continental US. Much like cancer screening, vaccination will often be directed toward susceptible populations rather than universal. HIV vaccine would be cost effective for persons with potential for multiple sex partners but not for persons likely to be celibate or lifelong monogamous (yes, there are a few of these still in the world).
Screening for Early Detection. The “honored” annual physical examination. Included here are blood pressure, pulse, weight, blood sugar, urine analysis, cholesterol, and a host of other tests. Numerous investigators have questioned the alleged value of these procedures. Certainly, some are of minimal to no benefit, at least in a doctor’s office setting. I won’t go into the details of cost analysis here other than to agree with those who assert that an “annual physical” is pretty much a waste of resources. Weight monitoring can and should be done by ones self. It should also be part of every visit to a physician’s office. BP measurements are readily available at multiple sites for no cost (accuracy may be an issue) and should be taken at every visit to a physician’s office whatever the specialty or reason for the visit. Blood sugar measurements are probably important if you are more than 25 percent overweight and/or have a family history of type II diabetes mellitus. The list of diseases for which screening is recommended continues to expand at a rate exceeding capability of establishing or disproving cost effectiveness. Screening for depression, dementia, autism spectrum disorder, vision (in children), hearing, coronary artery disease, chronic obstructive pulmonary disease, and so forth are all possible. Given a three or four hour primary care visit, your physician and staff can screen for all of these. You tell, me, is it worth the investment?
Screening for congenital diseases. A simple blood test at birth can screen for a number of diseases that are rare but have devastating impact on children afflicted with them. Some of these can be treated with diet management (glycogen storage disease), others are treated with medication (hypothyroidism), and other modalities. Congenital hypothyroidism is a special case in that treatment, ideally is initiated prior to birth since there is evidence that afflicted children will have lower IQ than normal if only treated after birth. I do not know if there is yet a prenatal screen at this point in time. Recently, genetic testing of fetal blood in the mother’s blood stream (i.e., screening for genetic disease by a blood test of the mother) has become possible. At this time, that testing is prohibitively expensive. However, genetic analysis methodology is evolving rapidly enought that it seems likely that such testing will become affordable within ten or fewer years. The question will then become, “is it cost effective to diagnose genetic conditions prior to birth?” If the answer is no, it is not cost effective, there will still remain the question of “Is it of sufficient value to justify the investment for such testing?” Here, my best guess is that identifying these illnesses at birth or earlier can lead to relatively inexpensive and effective treatment thus saving millions of dollars per person in life long care and loss of productive livelihood.
Summary. There are numerous cases in which “preventive” care is neither less expensive nor more efficacious than routine management of illnesses as they emerge. There are, however, several instances in which “preventive” care is both cost effective and efficacious. Many of these do not necessarily involve health care as such. Pasteurizing milk helped stop intestinal tuberculosis as well as some other conditions. Careful sterilizing of preserved foods has made botulism a rare disorder. Refrigeration has led to significant cut in salt consumption and may be the single most effective prevention of high blood pressure implemented. Most industries have dynamic safety programs in recognition that injuries prevented save money and resources. On the medical intervention side, few US citizens have ever seen tetanus, or for that matter, polio, small pox, whooping cough, and a host of other illnesses due to effective vaccinations. In my humble opinion, vaccination for those diseases clearly preventable on a cost effective basis should be made universally available at minimal to no cost. These include polio, measles, whooping cough, tetanus, diphtheria, hepatitis B, and a few others. When I was in practice in New Mexico, the state provided childhood immunizations at no charge through county nurses. As a physician, I sent all my patients to that source and simply counseled them how important the shots were and monitored that they were obtained.
This is a long discussion of whether Preventive Care is cost effective and therefore should be included in health care coverage. My answer is that the instances in which preventive care is clearly cost effective are limited. The exceptions are severe enough that they make this particular premise not valid in affirming the prevention clauses in the ACA as leading to significant savings.