R ecent articles in Newsweek and the Washington Post, based on research published in the peer-reviewed literature, report that most measures to prevent disease might not save money. 1 Further, they note that according to recent research, the presidential candidates who advocate increased use of preventive services as a cost-saving device are misguided and setting false expectations that prevention can cure the ailing U.S. health care system. 2
Stepping back, it seems heretical that anyone would be opposed to prevention. Were we not raised with the adage of “an ounce of prevention is worth a pound of cure”? The naysayers in this debate point out that in many instances, preventive measures do not save money, when compared to the cost of treating the disease that would otherwise have been prevented, because screening costs for healthy people far outweigh treatment costs for the few who develop the disease.
They are absolutely right in that respect. Providing certain preventive services, mostly in clinical settings, does not save money. But, then again, neither do most medical treatments. The issue relevant to this debate is how much value is achieved for any given preventive or treatment service. Instead of debating whether prevention or treatment saves money, we should determine the most cost-effective ways to achieve improved population health, and where to focus scarce resources to get the “biggest bang for the buck.”
I argue that, as a broad philosophy, prevention and health promotion can provide high value to society because lives are improved at a relatively low cost. Further, drawing from my twenty years of experience evaluating corporate health promotion programs, I present evidence that in nonclinical settings (such as the workplace), health promotion/disease prevention can improve population health, reduce health risks, and save money for businesses that sponsor these programs. In short, pitted against the costs of medical treatments, prevention offers a good return on investment.
What constitutes “prevention.”
First off, it is important to define what is meant when we say “prevention.” In health care, prevention is a broad term encompassing a wide range of interventions aimed at reducing the incidence of disease and disability, or slowing the progression and exacerbation of illnesses. Prevention can include such diverse and far-reaching initiatives as providing childhood immunizations, raising taxes on cigarettes, limiting employees’ exposure to toxic substances, mandating seat-belt use, screening for cancer, restricting alcohol sales to minors, building bicycle paths, and eliminating sales of sugary beverages in schools. This list purposely draws from many individual, organizational, and societal actions aimed at improving health and preventing disease or disability. The examples further highlight the wide array of potential interventions that individuals, clinicians, organizations, and governments can use that fall under the broad umbrella term of prevention. Given this long list, is it any wonder that proving that prevention, per se, can save money is complicated?
Screenings versus preventive services.
This problem is most pronounced when lawmakers and ordinary citizens talk about prevention in health care. In their minds, prevention means getting mammograms, colonoscopies, Pap tests, prostate screens, and full body scans. Although these are called preventive services, they are actually screenings for disease in early stages of development. The screenings may prevent having to treat the disease at a later time, and in a more serious form, but they do not prevent the disease. So, when lawmakers discuss providing access to and funding for prevention, they usually mean reimbursing for clinical screenings performed in a doctor’s office.
Health promotion versus disease prevention.
In any debate about the relative merits of prevention, it is important to clearly define that term. Many years ago, Lester Breslow observed that health is not merely the absence of disease, and health promotion is not the same as disease prevention. Being healthy, Breslow wrote, means “being able to move about freely, enjoy food and sex, feel good, remember things, have family and friends.” 3 Michael O’Donnell more broadly defined health promotion as “the science and art of helping people change their lifestyle. …Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behavior and create environments that support good health practices.” 4
In short, when one is discussing prevention, the main emphasis should be placed on avoiding disease and promoting good health practices through primary prevention. This involves obtaining proper immunizations, managing one’s weight, being physically active, eating a healthy diet, not smoking, drinking moderate amounts of alcohol, getting enough rest, surrounding oneself with family and friends, driving safely, managing stress, and, in general, living what most would agree is a healthy lifestyle. Very few of these behaviors require the services of medical personnel, but their adoption can reduce a population’s proclivity to contract chronic and debilitating diseases, and their concomitant costs.
Value of secondary prevention.
To be fair, health promotion also includes elements of secondary prevention directed at people who are at high risk for contracting diseases but who might not yet be sick. Interventions in this category target people with high-risk lifestyle practices (for example, smokers) and those who have elevated biometric values sometimes through no fault of their own (such as high blood pressure, high cholesterol, high blood glucose, and being overweight). For these people, secondary prevention includes hypertension screening and treatment; smoking cessation and weight management programs; and lipid-lowering medications. It is here where the debate about cost savings is most pronounced. Although these interventions rarely save money, certain ones offer high value in terms of adding quality-adjusted life-years (QALYs) at a relatively low cost.
Evaluating effectiveness and safety.
As critics have observed, paying for secondary prevention services is expensive when offered indiscriminately to all comers. New and exotic screening tests are introduced regularly, many with little incremental value, especially when directed at “healthy” populations. Deciding which preventive services are effective and safe and therefore recommended is left to the judgment of unbiased, independent panels such as the U.S. Preventive Services Task Force and the Task Force on Community Preventive Services.
Although these task forces do not routinely evaluate the cost-effectiveness or cost-benefit balance of alternative preventive services, other bodies do. Most notably, the economic and societal benefits of clinical preventive services were reviewed by the Partnership for Prevention. 5 Its analyses, which considered the effectiveness, impact, and cost of preventive interventions, led to targeted recommendations for expanded access to services that would improve health outcomes for large population segments at a reasonable cost.
These analyses even pointed to some preventive services that are cost-beneficial, meaning that they save more money than they cost (for example, certain vaccinations and colonoscopy screenings for targeted patient groups). However, many other preventive services offer high value because the cost of adding an additional QALY is very low (for example, under $200 for providing certain newborn screenings and targeted smoking cessation programs). The analyses also pointed to certain preventive services that offer little value (for example, screening people age sixty-five for diabetes), but the same can be said for certain treatments (such as inserting left-ventricular assist devices). In both examples, the cost of adding one QALY was valued at more than a half-million dollars. So, although some preventive services are expensive (that is, they cost more than $100,000 for every additional QALY gained), many more are bargains. Among the Partnership for Prevention’s strongly recommended preventive services, twenty-five cost less than $35,000 and ten cost less than $14,000 for each year gained.
The economic benefit of tertiary prevention, often mistakenly referred to as health promotion but really disease management, is still in dispute. Although these programs aim to ameliorate a disease or slow its progression, there is scant evidence that they save money in the short run.
Relevance of venue.
Also relevant to this discussion of cost savings is where prevention takes place. Having physicians counsel patients to lose weight or quit smoking may be effective, but it is not cost-effective. Most physicians lack the time, skill, or motivation (personal and financial) to provide ongoing, sustained, and effective counseling. Besides, most people spend too little time with their doctors to be influenced by their counsel.
If we expand the number and types of settings (such as homes, schools, and work-places) where prevention can occur, new opportunities for behavior change emerge. It is in those settings that environmental, policy, regulatory, normative, and other “ecological” measures can be introduced to improve population health at a relatively low cost per unit.
Examples abound. Steven Woolf offers several options for reducing obesity. 6 These include labeling the nutritional value of food at restaurants, supermarkets, school cafeterias, and vending machines; developing walkable communities and parklands; building bicycle lanes; removing soda machines from schools and requiring daily physical activity by students; and supporting effective media campaigns that counterbalance the marketing of high-fat, low-nutrition food products. Meaningful changes in social norms can be achieved through coordinated efforts involving multiple stakeholders (for example, urban planners, food growers and distributors, educators, government officials, civic leaders, and health care professionals) without relying exclusively on expensive medical personnel for improving health.
Innovation in the workplace.
One setting where major innovation is occurring is the workplace. Over the past twenty years, my colleagues and I have studied the health and economic impacts of health promotion programs at several large organizations. 7 Workplaces represent a microcosm of society since they contain concentrated groups of people who share a common purpose and culture. Although today most U.S. employers do not provide comprehensive and evidence-based programs considered “best practice,” such programs are thriving in a growing number of workplaces. Data supporting the success of these culturally engrained initiatives have been reported in peer-reviewed articles, compiled in literature reviews, and made available on Web sites. 8
Why bring employers into a debate about the economic benefits of prevention? If you think about it, employers have a built-in incentive for keeping people healthy. If employers’ health promotion efforts are successful, workers use health care services sparingly, they have lower absenteeism, disability rates decrease, worker safety improves, and productivity is improved. When done right, this presents a “win-win” for employees and employers. Employers’ experience in providing health promotion programs can inform others of the value that prevention offers in achieving long-term improvements in the health and well-being of Americans.
Rebuttals to arguments against prevention.
One pervasive argument against prevention is this: people have to die of something—all prevention does is postpone the time of eventual death and introduce new and more costly diseases that are the consequences of aging. As Woolf points out, the aim of prevention is not to replace one disease with another, but to compress the time one is sick or disabled before one’s ultimate demise. Over the past thirty years, Jim Fries and others have presented evidence supporting the compression-of-morbidity theory positing that while the human lifespan cannot be prolonged beyond a certain age, the period of illness and disability before death can be curtailed for those leading a healthy life. 9 Others have supported Fries’s conclusions that adopting healthy lifestyles, even in later years, can lead to longevity and a healthier old age. 10 In a landmark analysis of Medicare claims data, James Lubitz and colleagues found that elderly people in good health at age seventy live almost three years longer than those in poor health, but their cumulative Medicare spending is no greater than the spending of those who die sooner. 11
Another argument against prevention is this: it is really hard to change people’s health habits, especially those set in their ways. The experience over the past four decades contradicts this assertion. During that period, smoking rates were cut in half, while obesity rates doubled. Smokers quit because of new clean-air regulations, no-smoking policies in workplaces, increased taxation, bans on advertising, and a reversal of social norms, which previously supported smoking as “cool” and a natural rite of passage for adolescents.
Conversely, changes in physical activity and eating habits in the past few decades have sharply increased the prevalence of obesity. Causes for this dramatic rise in obesity include more driving by Americans and less walking and bicycling; new labor-saving appliances in the home; increased consumption of ready-made foods and larger portion sizes; increased television viewing, use of computers, and playing of video games; and more sedentary occupations. These changes in social norms and practices have altered our health and health habits, both positive and negative. Changing behavior is possible—it has been done before, and we can do it again.
Some sobering statistics.
In 2006, U.S. health spending exceeded two trillion dollars, with three-fourths of that spending directed at treating chronic diseases. Almost two-thirds of the growth in spending is attributable to Americans’ worsening health habits, particularly the epidemic rise in obesity. 12 The U.S. care delivery system favors paying for treatment of chronic diseases rather than preventing them in the first place. For the United States to continue to be an economic leader worldwide, supported by a healthy and productive workforce, more attention needs to be directed toward health promotion and disease prevention. Prevention is a key element of a comprehensive health reform strategy aimed at improving the health of Americans and reducing the social and financial burdens imposed by preventable illnesses.
Ron Goetzel ( [email protected] ) is a research professor and director of the Institute for Health and Productivity Studies, Rollins School of Public Health, at Emory University in Atlanta, Georgia, and vice president, Consulting and Applied Research, at Thomson Reuters in Washington, D.C.
The author thanks Enid Chung Roemer, Rivka Liss-Levinson, and Dan Samoly for their help in editing the final manuscript.
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