In yet more disappointing news for Democrats pushing for health care reform, Douglas W. Elmendorf, director of the Congressional Budget Office, offered a skeptical view Friday of the cost savings that could result from preventive care -- an area that President Obama and congressional Democrats repeatedly had emphasized as a way health care reform would be less expensive in the long term.Elmendorf's conclusions are based on several published academic studies. You know, the kind of research that President Obama trumpeted that would be the foundation for decisions in his administration. I guess that explains why the Democrats are bashing the CBO for the conclusions it has reached on the costs of the Democrats' proposals.
Obviously successful preventive care can make Americans healthier and save lives. But, Elmendorf wrote, it may not save money as Democrats had been arguing.
"Although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall," Elmendorf wrote. "That result may seem counterintuitive.
"For example, many observers point to cases in which a simple medical test, if given early enough, can reveal a condition that is treatable at a fraction of the cost of treating that same illness after it has progressed. In such cases, an ounce of prevention improves health and reduces spending — for that individual," Elmendorf wrote. "But when analyzing the effects of preventive care on total spending for health care, it is important to recognize that doctors do not know beforehand which patients are going to develop costly illnesses. To avert one case of acute illness, it is usually necessary to provide preventive care to many patients, most of whom would not have suffered that illness anyway. ... Researchers who have examined the effects of preventive care generally find that the added costs of widespread use of preventive services tend to exceed the savings from averted illness."
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Monday, August 10, 2009
Don't count on those purported savings from preventive care
The CBO has, once again, thrown a dash of reality onto the debate over paying for health care reform. As ABC reports,
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I came across a review of the scholarly work done on this topic a while back. Louise Russel, the author of the review, summarized the data this way:
"Over the four decades since cost-effectiveness analysis was first applied to health and medicine, hundreds of studies have shown that prevention usually adds to medical costs instead of reducing them. Medications for hypertension and elevated cholesterol, diet and exercise to prevent diabetes, and screening and early treatment for cancer all add more to medical costs than they save. Careful choices about frequency, groups to target, and component costs can increase the likelihood that interventions will be highly cost-effective or even cost-saving.
It's understandable that we'd all like to see preventive medicine be the cheaper solution, and maybe it's better policy even if it is more expensive, but the data is overwhelmingly disappointing on the issue of cost.
Ugh, I shouldn't look on blogs when take my morning coffee break... see posts I want to provide a counter to in depth and won't have the time until later this evening.
Suffice to say, the CBO analysis fails to point out that its entirely dependent on the approach. Focusing on medication and supplements as a primary mechanism of prevention would be costly and basically stupid. Exercise included as a source of cost?!!?!? How does one arrive at that? Are we to assume we would each have to run out and hire a private trainer? Better diet? Maybe, because McD's, Mac&Cheese and processed anything are wonderful at being initially very cheap but can't hold a candle in nutritional value to a proper diet. I imagine you'd have to factor in the cost of (gasp) actually preparing a meal with (shudder) raw ingredients.
Betsy seriously, I realize you are not in favor of the proposed ideas on health care reform but this as a flaw in the President's efforts to change the system? I would be interested in your thoughts on an alternative, as while I really do want it 'fixed' I'm not sold on what I've seen as yet. Do you really think a move to preventive care, which by the way, includes educating the average American to take personal responsibility with their decisions and how they may (near and long term) affect their health, isn't a component of cost containment? Do you see the latest (panic) health report regarding vitamin D? Kids suffering bizarre conditions (at least for childhood), all linked to a low vitamin D levels. The new report focused on diet and supplements, which as a means of prevention would add, not subtract, costs. However, were the kids to say, I don't know... go outside once a day for 15 minutes of sunshine... presto!, normal vitamin D levels, with no risk of overdose, as with some supplements. Folks who live north of say Cincinnati, get an extra meal of wild fish a week between October and April. This is prevention.
Yes, take better care of yourself and you may well prevent some health issue.
And yes, it may cost more and/or lead to "unintended consequences" of various types.
Anyone else remember the first few years of HMOs? Or why there aren't many still around and those which are do not resemble the original model[s]? Expect the government to respond to any problems in as little as a few years? Heck, in the last week a court castigated the IRS for continuing to collect a tax (long-distance telephony) it had admitted years ago it should not.
stubedobedu,
Are you still advocating government direction of lifestyle choices such as diet and exercise? How does that happen but more importantly, where does the intrusion stop?
I had the same reaction to stu as tfhr. Who doesn't already know about the benefits of exercise? Do you really believe that if the feds provide this kind of information, that will change people's decision to exercise or not? Also implied in stu's response are regulations (bans?) on certain "processed" foods and mandatory fish diets for people in certain parts of the country.
stu, do you know what a statist is?
Oh dear god,
Seriously equitus, do you basically wait to read between the lines, past the lines, to the coffee stain to review what "I really meant" like a rorschach test?
I did not say, nor have I ever posted anything, banning or regulating certain food to change behavior.
Based on the United States having the highest rate of obesity in the world, yeah... I'd have to say folks don't know about exercise and or good diet.
The point of my critique was that to suggest preventative medicine was more costly is wrong headed. As with anything, its how its implemented. According to the CDC (as of 2005), 75% of all health care spending goes to chronic conditions (diabetes, cardiac issues, back/shoulder pain, allergies, etc). Most of which is preventable. Translation: if the patient deals with the issues that create the condition, treatment is either not needed, not needed as greatly, or delayed until much older. If instead we treat preventative medicine as more pills, supplements, etc... yes, its going to add, not subtract, to health care costs.
Look, no matter how health care is addressed, if the public has no ownership of cost containment, you will not fix it. I'm am completely in favor of folks eating and living as they choose, but I'm not in favor of being responsible for their choices. Not to keep picking on obesity, but isn't not reasonable to suggest that if a person eats themselves into a higher risk group, then suffers the effects leading to chronic conditions requiring regular treatment and medications (which consumes the shared pool of insurance money), they should experience a higher cost? What is wrong with setting up the system that a) educations them on the effects of these decisions and b) creates incentives for choosing alternatives?
It kills me that I'm catching grief for the view of putting more of the burden on those who act in ways that will require more health care spending. This is generally seen as a right-wing concept, and my liberal friends are constantly abusing me (and the economists who advocate it) for it.
tfhr,
I think government can do a better job of educating the public on the economic benefits of good diet and exercise. They currently focus on the lifestyle benefits with general information on positive health effects. However, I usually do not see any 'marketing' of the direct/indirect costs of poor choices. Its usually in statistics, which I find folks very rarely look at and say, yup... I bet I'm part of that 36%...
I think health care reform will require some effort to place the burden of the cost of preventable conditions on the individuals who elect to make lifestyle decisions that will increase their risk of these conditions. This could be integrated into the regulatory reforms that would presumably address the support of eliminating the ability of insurance companies to deny coverage. Secondly, this could be done by altering the incentive system, so that doctors and hospitals are encouraged to essentially get you out of their office in a more permanent fashion, through education, etc. Because, again, I think the evidence suggests that while I want the individual to be free to choose how they want to be cared for, most simply do not have an understanding of the system or their own well being.
I also think this could be integrated into Tort Reform. For me, Tort Reform is both changes to compensation and also what is done with the results of the malpractice suit. If these lawsuits were integrated into the system, so that clinicians, insurance and regulatory agencies involved could treat them as events, they could speed modification of treatment standards to avoid future incidents. They could also be more quickly disemminated to all clinicians so that everyone can more quickly learn of a specific change in practice, etc. I strongly suspect that this would also identify patient behaviors that contribute to patient safety events, that in turn could be used to modify insurance requirements.
stu, I admit I will take sketchy statements to their (il)logical or unsavory conclusions, if only to encourage the writer to make a clarification (or to retract - fat chance).
Your point is a bit more clear now. I'm still of the mind that education along the lines of "being fat is bad for your health" is not effective and throwing billions more into that is a waste. I'd bet the great majority of the gravitationally challenged will admit they know that already, but either are unwilling or unable (willpower, psycology, etc.) to change.
But education such as "being fat will cost you money" could be a better incentive. But is it the feds who recoup this cost? That's statist. The insurance companies? Don't they already factor in such lifestyle risks in individual policies (not group)? In any event, I can't imagine a lot can be done about this via public policy. This will require deep cultural changes of the kind government is intrinsically ill-suited to carry out.
I'm glad to hear somebody speaking up on tort reform. But I'm not sure your integration/adaptation model will lead to much more than more defensive medicine, which is wasteful. I don't have many specific idea of my own, other than caps on punitive awards and major changes in attny compensation rules to discourage frivolous and/or outrageous claims.
equitus, I don't think it has to cost billions. A good example would be the annual letter from the Social Security Administration. Before they started that I got to listen to more or less a generation of discusisons (basically the two circles of my father's and uncle's friends) complain seemingly constantly how much they put into the system via taxes, how they were going to get screwed (based on the size of their parent's check), etc. Any conversation about prepping for the future (IRA, savings, etc) were pretty much nonstarters. Almost immediately after they started sending out that letter and I've never participated or witnessed that conversation since. I have had several folks ask me about recommendations for IRAs...
That letter only costs a couple of million (don't recall where I read this) annually but has done a lot (IMO) of educating a public inclined to not think about these things until its entirely too late.
As to how to make the 'penalty', I'd be fine with there being a slightly higher 'flat' rate for our premiums (whether public or private, it doesn't matter for this item) and discount it for folks who meet measurable conditions.
stu,
The letter you speak of presupposes that there will be funds available to back Social Security when your turn comes. I think I'm probably older than you and I do not factor Social Security into my planning, other than for setting a tentative final retirement date. But by then, by the time that date does arrive, the equivalent of drawing benefits at age 67 will be age 103!
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