Correspondence

Does Preventive Care Save Money?

N Engl J Med 2008; 358:2847-2848June 26, 2008

Article

To the Editor:

In the Perspective article by Cohen et al. (Feb. 14 issue),1 a narrow construction of what constitutes prevention leads to erroneous conclusions about its potential impact and cost-effectiveness. The authors do not address preventive interventions that occur outside the doctor's office. These include basic public health services and many other policies that bear directly on health (e.g., seat-belt laws and smoke-free policies). Health gains achieved through population-based approaches often exceed those that can be accomplished clinically, and these approaches are often cost-saving or highly cost-effective.2

Even if one considers only prevention in clinical settings, many high-value services are substantially underutilized. For example, less than 50% of the target population receives smoking-cessation services, counseling about aspirin use, colorectal-cancer screening, and influenza vaccines. Increasing use of these four services to 90% would save more than 100,000 lives annually.3

Policymakers should support investment in prevention for the right reasons — namely, to improve health at an acceptable cost, even if the services will not reduce overall spending. If reduced spending is the goal, then policymakers should discourage use of low-value services, both therapeutic and preventive.

Jonathan E. Fielding, M.D., M.P.H.
Los Angeles County Department of Public Health, Los Angeles, CA 90012

Corinne G. Husten, M.D., M.P.H.
Jordan H. Richland, M.P.H., M.P.A.
Partnership for Prevention, Washington, DC 20036
chusten@prevent.org

3 References

1. 1

   Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money? Health economics and the presidential candidates. N Engl J Med 2008;358:661-663
   Full Text | Web of Science | Medline

2. 2

   Task Force on Community Preventive Services. The guide to community preventive services: what works to promote health? New York: Oxford University Press, 2005.
   

3. 3

   Preventive care: a national profile on use, disparities, and health benefits. Washington, DC: Partnership for Prevention, 2007.
   

Author/Editor Response

Fielding and colleagues correctly highlight community-based interventions as important preventive strategies to evaluate, but they fail to note that our analysis of 1500 comparisons described in 599 articles drawn from the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org) did in fact include a number of community-based interventions. Like clinical preventive services, nonclinical interventions are sometimes expensive (e.g., a ban on cell-phone use while people are driving, which costs $380,000 per quality-adjusted life-year, or QALY1) and sometimes cost-saving (e.g., folic acid fortification of grains2 and condom distribution3). Other interventions cost the health care system more money than they save but generally deliver good value,4 meaning that they cost less than commonly recognized benchmarks for cost per QALY.5

We also agree that, as we stated in our article, “In addition to determining which preventive measures and treatments are most efficient, it will be necessary to identify those that are not yet fully deployed and those that could serve a large population and bring about substantial aggregate improvements in health at an acceptable cost.”

Joshua T. Cohen, Ph.D.
Peter J. Neumann, Sc.D.
Tufts Medical Center, Boston, MA 02111

Milton C. Weinstein, Ph.D.
Harvard School of Public Health, Boston, MA 02115

5 References

1. 1

   Cohen JT, Graham JD. A revised economic analysis of restrictions on the use of cell phones while driving. Risk Anal 2003;23:5-17
   CrossRef | Web of Science | Medline

2. 2

   Tice JA, Ross E, Coxson PG, et al. Cost-effectiveness of vitamin therapy to lower plasma homocysteine levels for the prevention of coronary heart disease: effect of grain fortification and beyond. JAMA 2001;286:936-943
   CrossRef | Web of Science | Medline

3. 3

   Bedimo AL, Pinkerton SD, Cohen DA, Gray B, Farley TA. Condom distribution: a cost-utility analysis. Int J STD AIDS 2002;13:384-392
   CrossRef | Web of Science | Medline

4. 4

   Tengs TO, Osgood ND, Chen LL. The cost-effectiveness of intensive national school-based anti-tobacco education: results from the tobacco policy model. Prev Med 2001;33:558-570
   CrossRef | Web of Science | Medline

5. 5

   Weinstein MC. How much are Americans willing to pay for a quality-adjusted life year? Med Care 2008;46:343-345
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   E. E. Schadt, J. L. M. Bjorkegren. (2012) NEW: Network-Enabled Wisdom in Biology, Medicine, and Health Care. Science Translational Medicine 4:115, 115rv1-115rv1
   CrossRef