Perspective
Does Preventive Care Save Money? Health Economics and the Presidential Candidates
N Engl J Med 2008; 358:661-663February 14, 2008
- Article
With health care once again a leading issue in a presidential race, candidates have offered plans for controlling spiraling costs while enhancing the quality of care. A popular component of such plans involves greater promotion of preventive health measures. The first element in Hillary Clinton's plan is to “focus on prevention: wellness not sickness.” John Edwards has stated that “study after study shows that primary and preventive care greatly reduces future health care costs, as well as increasing patients' health.” Mike Huckabee has said that a focus on prevention “would save countless lives, pain and suffering by the victims of chronic conditions, and billions of dollars.” Barack Obama has argued that “too little is spent on prevention and public health.”
Indeed, some evidence does suggest that there are opportunities to save money and improve health through prevention. Preventable causes of death, such as tobacco smoking, poor diet and physical inactivity, and misuse of alcohol have been estimated to be responsible for 900,000 deaths annually — nearly 40% of total yearly mortality in the United States.1 Moreover, some of the measures identified by the U.S. Preventive Services Task Force, such as counseling adults to quit smoking, screening for colorectal cancer, and providing influenza vaccination, reduce mortality either at low cost or at a cost savings.2
Sweeping statements about the cost-saving potential of prevention, however, are overreaching. Studies have concluded that preventing illness can in some cases save money but in other cases can add to health care costs.3 For example, screening costs will exceed the savings from avoided treatment in cases in which only a very small fraction of the population would have become ill in the absence of preventive measures. Preventive measures that do not save money may or may not represent cost-effective care (i.e., good value for the resources expended). Whether any preventive measure saves money or is a reasonable investment despite adding to costs depends entirely on the particular intervention and the specific population in question. For example, drugs used to treat high cholesterol yield much greater value for the money if the targeted population is at high risk for coronary heart disease, and the efficiency of cancer screening can depend heavily on both the frequency of the screening and the level of cancer risk in the screened population.4
The focus on prevention as a key source of cost savings in health care also sidesteps the question of whether such measures are generally more promising and efficient than the treatment of existing conditions. Researchers have found that although high-technology treatments for existing conditions can be expensive, such measures may, in certain circumstances, also represent an efficient use of resources.5 It is important to analyze the costs and benefits of specific interventions.
A systematic review of the cost-effectiveness literature sheds light on these issues. We analyzed the contents of the Tufts–New England Medical Center Cost-Effectiveness Analysis Registry (www.tufts-nemc.org/cearegistry), which consists of detailed abstracted information on published cost-effectiveness studies through 2005. Each registry article estimates the cost-effectiveness of one or more interventions as the incremental costs (converted here to 2006 U.S. dollars) divided by the incremental health benefits quantified in terms of quality-adjusted life-years (QALYs). Low cost-effectiveness ratios are “favorable” because they indicate that incremental QALYs can be accrued inexpensively. An intervention is “cost-saving” if it reduces costs while improving health. Poorly performing interventions can both increase costs and worsen health.
Our analysis was restricted to the 599 articles (and 1500 ratios) published between 2000 and 2005 that properly discounted future costs and benefits. We classified 279 ratios as preventive because they refer to interventions designed to avert disease or injury; all 1221 other ratios pertain to treatments, a category that includes both “tertiary” measures (designed to ameliorate the effects of a disease or condition) and “secondary prevention” measures (designed to reverse or retard progression of an existing condition), such as the use of implantable cardioverter–defibrillators in patients with myocardial disease.
The bar graph
Distribution of Cost-Effectiveness Ratios for Preventive Measures and Treatments for Existing Conditions. shows that the distributions of cost-effectiveness ratios for preventive measures and treatments are very similar — in other words, opportunities for efficient investment in health care programs are roughly equal for prevention and treatment, at least as reflected in the literature we reviewed. Moreover, both distributions span the full range of cost-effectiveness. The table
Cost-Effectiveness of Selected Preventive Measures and Treatments for Existing Conditions (2006 Dollars). shows the cost-effectiveness ratios for selected interventions of various types (a more detailed table appears in the Supplementary Appendix, available with the full text of this article at www.nejm.org).These results are consistent with earlier reviews but cover a larger sample of studies and quantify benefits in terms of QALYs. Some preventive measures save money, while others do not, although they may still be worthwhile because they confer substantial health benefits relative to their cost. In contrast, some preventive measures are expensive given the health benefits they confer. In general, whether a particular preventive measure represents good value or poor value depends on factors such as the population targeted, with measures targeting higher-risk populations typically being the most efficient. In the case of screening, efficiency also depends on frequency (more frequent screening confers greater benefits but is less efficient). Third, as is the case for preventive measures, treatments can be relatively efficient or inefficient.
Of course, our review reflects a selected sample of studies in the peer-reviewed literature and does not cover all possible opportunities to spend resources to improve health. In addition, there may be inconsistency among the studies in terms of the methods used. Still, our analysis is based on a large and diverse set of studies that used recommended metrics for cost-effectiveness analysis, and we believe that it offers important lessons.
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).
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. Findings that some cost-saving or highly efficient measures are underused would indicate that current practice is inconsistent with the efficient delivery of health care. Other services might be identified as overused, and such findings would underscore the importance of fashioning policies that provide incentives to shift practice toward more cost-effective delivery of health care. In the face of increasingly constrained resources, there is a realistic way of achieving better health results: conduct careful analysis to identify evidence-based opportunities for more efficient delivery of health care — whether prevention or treatment — and then restructure the system to create incentives that encourage the appropriate delivery of efficient interventions.
No potential conflict of interest relevant to this article was reported.
Source Information
Dr. Cohen is a research associate professor of medicine and Dr. Neumann a professor of medicine and the director at the Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts–New England Medical Center, Boston; Dr. Weinstein is a professor of health policy and management at the Harvard School of Public Health, Boston.
- References
References
1
Mokdad AH ,Marks JS ,Stroup DF ,Gerberding JL . Actual causes of death in the United States, 2000. JAMA 2004;291:1238-1245[Erratum, JAMA 2005;293:293-4, 298.]
CrossRef | Web of Science | Medline2
Maciosek MV ,Coffield AB ,Edwards NM ,Flottemesch TJ ,Goodman MJ ,Solberg LI . Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med 2006;31:52-61
CrossRef | Web of Science | Medline3
Russell LB. Prevention's potential for slowing the growth of medical spending. Washington, DC: National Coalition on Health Care, October 2007. (Accessed January 24, 2008, at http://www.nchc.org/nchc_report.pdf.)
4
The role of prevention in health reform. N Engl J Med 1993;329:352-354
Full Text | Web of Science | Medline5
Weinstein MC . High-priced technology can be good value for money. Ann Intern Med 1999;130:857-858
Web of Science | Medline
- Citing Articles (57)
Citing Articles
1
Taryn W. Morrissey. (2012) Health Reform and Child Health: Progress, Cautions, and Future Directions. Child Development Perspectivesno-no
CrossRef2
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
CrossRef3
Jennifer Prah Ruger, Christina M. Lazar. (2012) Economic evaluation of drug abuse treatment and HIV prevention programs in pregnant women: A systematic review. Addictive Behaviors 37:1, 1-10
CrossRef4
2011. Role of Disease Prevention in Health Care Reform. , 57-72.
CrossRef5
Donald A. Redelmeier, Christopher J. Yarnell. (2011) Lethal misconceptions: interpretation and bias in studies of traffic deaths. Journal of Clinical Epidemiology
CrossRef6
Thomas F. Mulrooney. (2011) Health Care in America. Mayo Clinic Proceedings 86:11, 1125-1126
CrossRef7
George Miller, Paul Hughes-Cromwick, Charles Roehrig. (2011) National Spending on Cardiovascular Disease, 1996–2008. Journal of the American College of Cardiology 58:19, 2017-2019
CrossRef8
N. J. Temple. (2011) Why prevention can increase health-care spending. The European Journal of Public Health
CrossRef9
Steven Simoens. (2011) Public health and prevention in Europe: is it cost-effective?. Journal of Pharmaceutical Health Services Research 2:3, 151-155
CrossRef10
Mark Dusheiko, Hugh Gravelle, Stephen Martin, Nigel Rice, Peter C. Smith. (2011) Does better disease management in primary care reduce hospital costs? Evidence from English primary care. Journal of Health Economics 30:5, 919-932
CrossRef11
Sandra L. Decker, Jalpa A. Doshi, Amy E. Knaup, Daniel Polsky. (2011) HEALTH SERVICE USE AMONG THE PREVIOUSLY UNINSURED: IS SUBSIDIZED HEALTH INSURANCE ENOUGH?. Health Economicsn/a-n/a
CrossRef12
David Alan Klein. (2011) Evaluating Social Value: On the Intersection of Mortality and Economics in the Distribution of Publicly Funded Medical Care. The American Journal of Bioethics 11:7, 18-20
CrossRef13
S. Simoens. (2011) What is the value for money of medicines? A registry study. Journal of Clinical Pharmacy and Therapeuticsno-no
CrossRef14
U. Walter, M. Plaumann, S. Dubben, G. Nöcker, T. Kliche. (2011) Gesundheitsökonomische Evaluationen in der Prävention und Gesundheitsförderung. Prävention und Gesundheitsförderung 6:2, 94-101
CrossRef15
Maki S. Kamae, Isao Kamae, Joshua T. Cohen, Peter J. Neumann. (2011) Regression analysis on the variation in efficiency frontiers for prevention stage of HIV/AIDS. Journal of Medical Economics 14:2, 187-193
CrossRef16
Michael E. Chernew, Joseph P. Newhouse. 2011. Health Care Spending Growth. , 1-43.
CrossRef17
Grant D. Jacobsen, Kathryn H. Jacobsen. (2011) Health awareness campaigns and diagnosis rates: Evidence from National Breast Cancer Awareness Month. Journal of Health Economics 30:1, 55-61
CrossRef18
I. Lenoir-Wijnkoop, M. Dapoigny, D. Dubois, E. van Ganse, I. Gutiérrez-Ibarluzea, J. Hutton, P. Jones, T. Mittendorf, M. J. Poley, S. Salminen, M. J. C. Nuijten. (2011) Nutrition economics – characterising the economic and health impact of nutrition. British Journal of Nutrition 105:01, 157-166
CrossRef19
M. Malach, W. J. Baumol. (2010) Further Opportunities for Cost Reduction of Medical Care. Journal of Community Health 35:6, 561-571
CrossRef20
Amitabh Chandra, Tom S. Vogl. (2010) Rising up with shoe leather? A comment on Fair Society, Healthy Lives (The Marmot Review). Social Science & Medicine 71:7, 1227-1230
CrossRef21
Alan C. Monheit. (2010) Can Reform's Prevention Incentives Help to Bend the Cost Curve?. Inquiry 47:3, 179-185
CrossRef22
Eran Klein, Jason Karlawish. (2010) Challenges and Opportunities for Developing and Implementing Incentives to Improve Health-Related Behaviors in Older Adults. Journal of the American Geriatrics Society 58:9, 1758-1763
CrossRef23
D. R. Rappange, W. B. F. Brouwer, F. F. H. Rutten, P. H. M. van Baal. (2010) Lifestyle intervention: from cost savings to value for money. Journal of Public Health 32:3, 440-447
CrossRef24
Michael T. French, Jenny F. Homer, Shay Klevay, Edward Goldman, Steven G. Ullmann, Barbara E. Kahn. (2010) Is the United States Ready to Embrace Concierge Medicine?. Population Health Management 13:4, 177-182
CrossRef25
Bobby Milstein, Jack Homer, Gary Hirsch. (2010) Analyzing National Health Reform Strategies With a Dynamic Simulation Model. American Journal of Public Health 100:5, 811-819
CrossRef26
Eduardo J. Simoes, Ciro V. Sumaya. (2010) Protecting and Enhancing Health: Community Engagement, Collaborations, and Incentives for Prevention. The Journal of Primary Prevention 31:1-2, 21-29
CrossRef27
Robert H. Dworkin, Michael P. McDermott, Srinivasa N. Raja. (2010) Preventing Chronic Postsurgical Pain. Anesthesiology 112:3, 516-518
CrossRef28
Jane Hall. (2010) Medicare Select: A Bold Reform?. Australian Economic Review 43:1, 63-70
CrossRef29
TJ Freer. (2010) Contemporary issues in dental education in Australia. Australian Dental Journal 55:1, 20-27
CrossRef30
Weinstein, Milton C., Skinner, Jonathan A., . (2010) Comparative Effectiveness and Health Care Spending — Implications for Reform. New England Journal of Medicine 362:5, 460-465
Full Text31
Lukas Jyuhn-Hsiarn Lee, Chien-Hung Chen, Yu-Yin Chang, Saou-Hsing Liou, Jung-Der Wang. (2010) An estimation of the health impact of groundwater pollution caused by dumping of chlorinated solvents. Science of The Total Environment 408:6, 1271-1275
CrossRef32
N. Marcus Thygeson. (2010) A Health Plan Perspective on Worksite-Based Health Promotion Programs. American Journal of Preventive Medicine 38:2, S226-S228
CrossRef33
K. M. Venkat Narayan, David F. Williamson. (2010) Prevention of Type 2 Diabetes: Risk Status, Clinic, and Community. Journal of General Internal Medicine 25:2, 154-157
CrossRef34
D. Greenberg, C. Earle, C.-H. Fang, A. Eldar-Lissai, P. J. Neumann. (2010) When is Cancer Care Cost-Effective? A Systematic Overview of Cost-Utility Analyses in Oncology. JNCI Journal of the National Cancer Institute 102:2, 82-88
CrossRef35
Prashanth U. Nyer, Stephanie Dellande. (2010) Public commitment as a motivator for weight loss. Psychology and Marketing 27:1, 1-12
CrossRef36
Tracy A. Lieu, G. Thomas Ray, Ismael R. Ortega-Sanchez, Ken Kleinman, Donna Rusinak, Lisa A. Prosser. (2009) Willingness to Pay for a QALY Based on Community Member and Patient Preferences for Temporary Health States Associated with Herpes Zoster. PharmacoEconomics 27:12, 1005-1016
CrossRef37
Hiroko Nagase, Kensuke Moriwaki, Maki Kamae, Shinichiro Yanagisawa, Isao Kamae. (2009) Cost-Effectiveness Analysis of Oseltamivir for Influenza Treatment Considering the Virus Emerging Resistant to the Drug in Japan. Value in Health 12, S62-S65
CrossRef38
Peter J. Neumann, Chi-Hui Fang, Joshua T. Cohen. (2009) 30 Years of Pharmaceutical Cost-Utility Analyses. PharmacoEconomics 27:10, 861-872
CrossRef39
Evrim Didem Güneş. (2009) Modeling time allocation for prevention in primary care. Central European Journal of Operations Research 17:3, 359-380
CrossRef40
Ephrat Levy-Lahad. (2009) Population-based BRCA1/BRCA2 screening in Ashkenazi Jews: A call for evidence. Genetics in Medicine 11:9, 620-621
CrossRef41
Callahan, Daniel, . (2009) Cost Control — Time to Get Serious. New England Journal of Medicine 361:7,
Full Text42
Monte Malach, W. J. Baumol. (2009) Opportunities for the Cost Reduction of Medical Care. Journal of Community Health 34:4, 255-261
CrossRef43
Joseph Menzin, Lisa M Lines, Jeno Marton. (2009) Estimating the short-term clinical and economic benefits of smoking cessation: do we have it right?. Expert Review of Pharmacoeconomics & Outcomes Research 9:3, 257-264
CrossRef44
Timothy L. Hunt, Bryan R. Luce, Matthew J. Page, Robin Pokrzywinski. (2009) Willingness to Pay for Cancer Prevention. PharmacoEconomics 27:4, 299-312
CrossRef45
Michael Chernew, Mark Fendrick. (2009) Clinically Sensitive Cost-Sharing for Prescription Drugs. Medical Care 47:5, 505-507
CrossRef46
Anthony Keech, John D. Horowitz. (2009) Cost-effectiveness Considerations of Cardiovascular Therapeutics. Heart, Lung and Circulation 18:2, 118-122
CrossRef47
Nick Bansback, Carlo A. Marra, Axel Finckh, Aslam Anis. (2009) The economics of treatment in early rheumatoid arthritis. Best Practice & Research Clinical Rheumatology 23:1, 83-92
CrossRef48
Sungwook Kang, Chang Hoon You, Young Dae Kwon. (2009) The Determinants of the Use of Opportunistic Screening Programs in Korea. Journal of Preventive Medicine and Public Health 42:3, 177
CrossRef49
Bruce Siegel, Holly Mead, Robert Burke. (2008) Private Gain and Public Pain: Financing American Health Care. The Journal of Law, Medicine & Ethics 36:4, 644-651
CrossRef50
Roger Zoorob, Vincent Morelli. (2008) Disease Prevention and Wellness in the Twenty-first Century. Primary Care: Clinics in Office Practice 35:4, 663-667
CrossRef51
TANYA G.K. BENTLEY, RACHEL M. EFFROS, KARTIKA PALAR, EMMETT B. KEELER. (2008) Waste in the U.S. Health Care System: A Conceptual Framework. Milbank Quarterly 86:4, 629-659
CrossRef52
Deborah Stone. (2008) Protect the Sick: Health Insurance Reform in One Easy Lesson. The Journal of Law, Medicine & Ethics 36:4, 652-659
CrossRef53
Gordon K. Norman. (2008) Disease Management Outcomes: Are We Asking the Right Questions Yet?. Population Health Management 11:4, 183-187
CrossRef54
(2008) Does Preventive Care Save Money?. New England Journal of Medicine 358:26, 2847-2848
Full Text55
H. Schmidt. (2008) Bonuses as Incentives and Rewards for Health Responsibility: A Good Thing?. Journal of Medicine and Philosophy 33:3, 198-220
CrossRef56
Isaacs, Stephen L., Schroeder, Steven A., . (2008) California Dreamin' — State Health Care Reform and the Prospect for National Change. New England Journal of Medicine 358:15, 1537-1540
Full Text57
George Miller, Charles Roehrig, Paul Hughes-Cromwick, Craig Lake. 2008. Quantifying national spending on wellness and prevention. , 1-24.
CrossRef
- Letters
