Preventative Care Doesn’t Save Money
A longstanding claim---that I myself believed to be true---is that spending money on preventative care like regular checkups would save money in the long run by catching health issues before they become acute. The evidence does not support this.
A longstanding claim—that I myself believed to be true—is that spending money on preventative care like regular checkups would save money in the long run by catching health issues before they become acute. The evidence does not support this.
Aaron Carroll at The Upshot (“Preventive Care Saves Money? Sorry, It’s Too Good to Be True“):
The idea that spending more on preventive care will reduce overall health care spending is widely believed and often promoted as a reason to support reform. It’s thought that too many people with chronic illnesses wait until they are truly ill before seeking care, often in emergency rooms, where it costs more. It should follow then that treating diseases earlier, or screening for them before they become more serious, would wind up saving money in the long run.
Unfortunately, almost none of this is true.
Let’s begin with emergency rooms, which many people believed would get less use after passage of the Affordable Care Act. The opposite occurred. It’s not just the A.C.A. The Oregon Medicaid Health Insurance experiment, which randomly chose some uninsured people to get Medicaid before the A.C.A. went into effect, also found that insurance led to increased use of emergency medicine. Massachusetts saw the same effect after it introduced a program to increase the number of insured residents.
Emergency room care is not free, after all. People didn’t always choose it because they couldn’t afford to go to a doctor’s office. They often went there because it was more convenient. When we decreased the cost for people to use that care, many used it more.
Wellness programs, based on the idea that we can save money on health care by giving people incentives to be healthy, don’t actually work this way. As my colleague Austin Frakt and I have found from reviewing the research in detail, these programs don’t decrease costs — at least not without being discriminatory.
Accountable care organizations rely on the premise that improving outpatient and preventive care, perhaps with improved management and coordination of services for those with chronic conditions, will save money. But a recent study in Health Affairs showed that care coordination and management initiatives in the outpatient setting haven’t been drivers of savings in the Medicare Shared Savings Program.
There’s little reason to believe that even more preventive care in general is going to save a fortune. A study published in Health Affairs in 2010 looked at 20 proven preventive services, all of them recommended by the United States Preventive Services Task Force. These included immunizations, counseling, and screening for disease. Researchers modeled what would happen if up to 90 percent of these services were used, which is much higher than we currently see.
They found that this probably would have saved about $3.7 billion in 2006. That might sound like a lot, until you realize that this was about 0.2 percent of personal health care spending that year. It’s a pittance — and that was with almost complete compliance with recommendations.
One reason for this is that all prevention is not the same. The task force doesn’t model costs in its calculations; it models effectiveness and a preponderance of benefits and harms. When something works, and its positive effects outweigh its adverse ones, a recommendation is made.
This doesn’t mean it saves money.
In 2009, as part of the Robert Wood Johnson Foundation’s Synthesis Project, Sarah Goodell, Joshua Cohen and Peter Neumann exhaustively explored the evidence. They examined more than 500 peer-reviewed studies that looked at primary (stopping something from happening in the first place) or secondary (stopping something from getting worse) prevention. Of all the interventions they looked at, only two were truly cost-saving: childhood immunizations (a no-brainer) and the counseling of adults on the use of low-dose aspirin. An additional 15 preventive services were cost-effective, meaning that they cost less than $50,000 to $100,000 per quality adjusted life-year gained.
Of course, the fact that we don’t see any cost savings doesn’t mean that early care isn’t worthwhile. As Carroll notes, we do see real increases in quality and length of life–things worth paying for.
If you pay $20,000 a year for health insurance and still have to wait 6 weeks to get an appointment, of course you’re going to use the emergency room/urgent care facilities.People are crying about “socialized medicine” and the bad wait times – the US isn’t much better for most parts of the country.
So what I’m getting from this is it’s not that preventative cared doesn’t save money, it’s that other costs remained so high they couldn’t take advantage of them. That’s kind of a non-brainier: if the ER is still the fastest, most convenient and now possibly cheaper way to do this , of course it’s going to see more use! If i’m sick at 11pm at night, why should I have to wait till the morning or possibly days later when there’s a viable alternative available now?
Doctors really need to consider affiliations with aftercare places – Dr So-n-so is affiliated with AfterCareUltraPlus and if you go there, you get a discount. Dr gets a kickback, company gets a new customer and the patients not in the ER.
I was curious about one line though regarding the wellness programs – that they were only effective if “discriminatory”. Having seen this in action, I call BS. My company offers insurance discounts for wellness programs like weight loss, attending the on-site gym, going for a walk on lunch and even drinking more water during the day! They offer cash and other goodies as well. There’s over a dozen programs that are completely volunteer designed to fit a number of different needs and medical concerns. We consistently win awards for healthiest workplace due to the sheer number of options.
Yet there’s always someone – who would really benefit from these things – throws a fit because “it’s not fair they don’t get the discount for not participating” . They don’t want to disclose their weight or go on a diet, they don’t want to hit up the gym even for some stretching, they don’t want to quite smoking, they don’t want to do anything to try and live a healthier life. I’m perfectly fine with them taking on the full price of their choice, no discounts for no effort. It’s their choice to be unhealthy – it’s NOT their choice to get it at discount rates!
I never believed this particular hype. The truth is medical science – aside from immunizations – can’t really do much to prevent illness. The science ain’t there.
We need to take a step back and look at the reality of American medicine. The greatest single medical threat we face as a species is drug resistant bacteria. Why do we have drug resistant bacteria? A medical system that threw antibiotics at people just to shut them up. MRSA? A resistant bacterium that escaped into the general population as a consequence of poor medical practices. The opioid epidemic? It started with doctors handing out opiates like candy. And the simple act of requiring doctors, surgeons and nurses to wash their hands and practice elementary hygiene saves tens of thousands of lives a year – or, to reverse that, medical laziness kills tens of thousands every year.
The worst medical issue I’ve had (so far…) is a staph infection that tried to eat my neck – an infection I picked up from a doctor performing a ‘check-up.’
The American medical system costs us multiples of what other developed countries pay while delivering results that are either worse or no better. They are bankrupting the country with mediocre services. And their ‘preventative’ care has mostly amounted to lecturing fat people to lose weight, drunks to stop drinking, lazy people to exercise, and smokers to stop smoking. There is not a single fat, lazy, alcoholic smoker who does not already know they’re behaving badly, and nothing doctors can say or do really tips the scales (heh) one way or the other.
So, yeah, not surprised by these findings. I get a check-up every year, and med checks more frequently. In the last 20 years I’ve had three prostate biopsies (all neg), three colonoscopies, (all neg), a heart CT (yeah, I have a heart) which was negative, a stress test (neg), a head MRI (also have a brain it seems) and enough blood drawn to keep a vampire well-fed, and the number of illnesses all this expensive activity caught in the early stages and remedied by swift medical action remains: 0. Probably $100,000 in ‘preventative’ care which has thus far prevented nothing.
Number of diseases stopped by preventative care: 0
Number of diseases contracted while receiving prevatative care: 1
I’m old enough to remember when saying this meant you were a tool of the insurance industry. But it was always true and always fairly obvious. It’s cheap to get sick. It’s cheap to die. It’s getting well that’s the expensive part. Someone dropping dead of a heart attack is way cheaper than someone being on statins for years.
(I would also note, as Michael Reynolds did, that the efficacy of preventative care is often dubious. Research has shown, for example, that routine mammography is a waste of money except for high-risk women. But Congress specifically acted to make sure it stays a part of healthcare packages because otherwise you hate women and don’t care about breast cancer. Yearly checkups are of dubious value. Prostate checks are of dubious value. Some preventative care is useful, but the best preventative care is usually a lifestyle change.)
Romneycare saw the same things: ER visits went up because now people had insurance; utilization went up because now people had insurance; preventative care went up but was expensive. The idea that insuring more people was going to save money was as silly as the idea that tax cuts pay for themselves. There is no such thing a fiscal perpetual motion machine.
@KM: While overall I support more socialized healthcare, my main complaint has always been that I would be paying for people who don’t even try to take care of themselves. So yes, I may be self-righteous and discriminatory, but I support wellness programs.
@michael reynolds: Anecdotally, my uncle prefers to stay away from hospitals, because people die at hospitals. He’s 95 and walks 3 miles a day, so his plan is working so far. (His young 87-year-old wife is doing fine, too.) In contrast, my parents always had the best healthcare and took all their pills, and both died in their 70s.
@Franklin:
It’s not self-righteous to expect people to put forth effort to maintain their own lives. Nor is it discriminatory to expect those who don’t will pay more for the outcome of their failure to act. What is discriminatory is broadly apply judgement: we can’t just say all diabetics must pay more but if said diabetic is sucking down several liter bottles of Coke a day, scarfs nothing but McD’s and refuses to exercise, then feel free to charge their fat ass more. Did you smoke after all the warnings came out (so in the last 2 decades)? Guess what – you get to pay more for cancer treatments because we told you this would happen. Do you weigh over 50+lbs from the top of your recommend weight class for no good medical reason? Oops – you should have to pay more for all the extra avoidable complications you are causing and resources you are taking up.
It’s a uniquely American concept to want to divorce personal actions from medical consequences. Sucks that we also happen to have a system that can financially punish said actions easily and ruinously. Either of these two need to change in order for the system to really be effective. To modernize a phrase: You cannot have your Whopper and lose weight too. I don’t expect us all to gym bunnies (lord knows I’m not) but basic wellness and effort should be the norm, not some quickly forgotten New Years pledge.
@KM:
I once worked for a company that banned smoking. They didn’t just not allow smoking on the premises, they included nicotine in the routine pre-employment drug scan and didn’t hire smokers. I almost didn’t get hired because I showed nicotine, three or four cigarettes a day worth from secondary smoke where I was been working. They grandfathered in existing smokers when they implemented the policy, so they had a few smokers. Rather than have them sneak out to the parking lot, they designated a smoking room. I opened the door once out of curiosity, a small, bare room with one couch and an incredible odor.
A bunch of the non-smokers pitched a big bitch about how come the smokers get a break room? No good deed goes unpunished.
I’ve seen claims that a huge junk of spending goes to end of life care. No matter how healthy we are, or how much preventive care we get, we all go sometime. People who don’t smoke and don’t get lung cancer still die from something. But as James and others note, there’s some benefit to living better and going later.
@michael reynolds :
We’re working on that but to be fair, it’s a hospital aka a nexus of sickness and infection. IDK why people don’t go in with the notion they may catch something. literally every surface is a possible infection vector and should be treated as such. When I was working in the labs we had a sign on the elevators “take off your gloves please, whatever you’re protecting yourself from we don’t want either”. When I go into a hospital, I take my own lysol wipes, a bottle of purell and I sanitize the shit out of EVERYTHING, even if I just saw you do it. Anybody that wants to touch me or mine washes their hands in front of me and then uses purell for good measure. Any doctor who gets offended by that? Through them out and ask for a different one – they shouldn’t be offended by it all it and really should be do it as a matter of course.
American healthcare is more expensive than its European counterparts, but the reasons aren’t as clear cut as is often portrayed. Yes, the list price for, say, an MRI is ten times higher in the US then in Europe, but that is only charged to people without insurance. The normal price charged is a fraction of that.
One of the biggest drivers of our costs is the unbelievable level of overhead for adminstering our system. There are millions and millions of people employed in the US simply to administer payments. Insurance companies alone are an enormous expense but also all the people in your average doctors office that predominantly handle billing. And the billing department in your average hospital is one of the biggest departments.
Another reason for American cost is inefficiency driven by profit motive. There is no incentive to rent a low cost storefront in a low income neighborhood and staff it with a few nurses to provide localized, low cost care, because they are not particularly profitable. But in the Netherlands this is common because it is so much cheaper than having people show up in the ER. Especially since the three or four people working in these small centers are all providing care. None are administering payment and insurance.
@gVOR08:
Hah, we had that issue with the one senior employee who still smoked. One of the lesser used conference rooms was designated for it and that lasted for about a month. The room was poorly ventilated and the stink was horrendous. That ended when somebody foolishly decided to hold an interview in there and both got sick. The pregnant head of HR went to investigate, got so sick she had to go to the ER and bye bye policy. Said employee refused to change and got sh^tcanned a week later by an extremely pissed off (and green-faced) HR head. To this day, that room still reeks and I have to explain to the newbies when even though meeting room space is at a premium why that room is the absolute last to be booked… and if you can take the call at your desk, you might want to, just saying.
@KM:
The PCP had just come from doing rounds at the hospital, came back to her practice, did not wash her hands, did not put on gloves, and palpated my freshly-shaved neck. She was just lazy and careless, and I paid the price. Had I had a compromised immune system she might well have killed me. Staph eating into skin a millimeter from your jugular is not good.
Just spent the last 3 months in battle with a different PCP over testosterone replacement. She listened to nothing I had to say. When I said, ‘the science you’re citing is not settled by a long shot,’ she angrily insisted it was. So I went to another GP, same bullsh-t. So I see an endocrinologist who, in the course of five minutes, validates everything I suggested to my PCP. Yep: badly-constructed studies, short duration, correlation not causation, and mutually contradictory. Basically my Googling trumped two relatively young, well-educated GP’s.
This bothers me. This shakes what little confidence I have left. Occasionally while debating politics I point out that I should not be right about about some things, should not win some arguments so easily for the reason that I have virtually no formal education. It should not be easy for a high school drop-out kid book author armed with 15 minutes of Google time to do better analysis of a medical issue than the doctors.
@KM: There’s also this recent article from Vox: An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay
A woman thought she might have appendicitis, so she went to the ER. It turned out to be ovarian cysts, and since her insurer decided that wasn’t a true emergency, they won’t pay.
@michael reynolds: I had had pap smears every year since I turned 19, and starting at 40, I was told that I should do colonoscopies and mammograms every other year due to family cancer histories. I was dutiful in these, until in my mid-40’s, I went through a period of 2 years uninsured. When I got insurance again, I eschewed all these tests.
I turned 50 last year, and was told it was time again by my doctor, so I got all 3: pap, colonoscopy, and mammogram. All clear. To my relief, my doctor then said that the new recommendations are, you can wait 5 years before having to do them again if they’re clear.
Wasn’t it always expected that increasing access to health care would cause a bump in utilization and a short term increase in costs? The savings are longer term — at least five years.
This study also appears to be weirdly multi-topiced, stretching across wellness programs, greater access to PCPs, etc. For me, this raises a lot of red flags — it seems like someone who starts with a conclusion and is seeking places to apply it.
This is also an early study. There will be others. But the early study gets the news cycles, despite the lack of confirmation.
@MarkedMan: I also read an article about how European countries spend less on healthcare because they spend more on “social determinants of health” — the other areas of life that can affect our health outcomes, such as housing and education.
@Gustopher: Are there studies about long-term cost savings (or not) from Massachusetts, which has now had Romneycare for more than a decade?
Uwe Reinhardt put it best: it’s the prices, stupid. We pay more for simple, routine procedures than people in other countries do. As long as that’s the case nothing will save money. When you shove the bulging side in, something else will bulge out.
Alternative perspective: the medical cost savings / increase is not the true cost savings / increase. If the preventative measure (going on statins / following Weight Watchers / testing blood glucose levels before each meal) increases my work productivity and quality of life, which means that I take less sick time, don’t end up on Disability, and overall more effective at whatever tasks I’m prioritizing, then there are likely cost savings on a macro level even if medical costs increase.
@michael reynolds: eit
In all likelihood neither do the docs you’re talking to. They’re not educated; they’re trained, like seals.
Let me emphasize that it is not their fault. It’s the health care system. They’re intelligent men and women who got where they are by producing the expected answer on demand. They might call it “standard of care” but it’s reproducing the expected answer. When you get outside their area of expertise, their knowledge decreases rapidly.
And specialization being what it is today they’re not experts at all of medicine—just their own specialty with a smattering of ignorance beyond that.
@Franklin: I had a teacher in Jr high that did exactly the same thing. He would run every morning before going to work and such. He died my senior year from a heart attack. No family history or any indication it was coming since he never went to the doctor.
@Dave Schuler: Doctors are the best trained monkeys in the world.
But often not their confidence.
@Dave Schuler: @gVOR08: can you provide an example of a profession that is educated rather than trained so I can understand how you see the difference between education and training?
@gVOR08: There’s in fact a cliche among General Aviation flight instructors–the “doctor in a Bonanza”. Basically doctors who purchase their own planes (a Bonanza is a rich man’s airplane, what with the wood panelling and all) and insist on learning how to fly. Flight instructors dread such students (or at least the two flight instructors I had did.)
@grumpy realist: Haha yeah I’ve ran into that one a few times too. Teaching people who are professionals in other fields how to fly can be extremely taxing. They tend to think they are experts in everything…..
EDIT : Wanted to clarify that I’m not a flight instructor BUT I have talked with several people who are and ALL of them had at least one story….
@Erik: It’s not so much the education as the orientation, or rather the education reflects the orientation. In a field such as my own field of engineering, or say, economics, the idea is to teach basic knowledge, theory, and methods and apply those to analysis of specific problems. Medicine is more a matter of rote. Other fields rely more on critical thinking, medicine on application of trained responses. This is appropriate for medicine. We don’t want individual doctors improvising and experimenting.
The classic story, perhaps apocryphal, is that in their early days NASA realized they’d need people cross trained in medicine and engineering. As med school takes longer than engineering school, they did the obvious and hired several doctors and sent them to engineering schools. After some time, they gave up, hired engineers, and sent them to med school.
That said, Pareto’s Rule applies and about 80% of engineers, and I expect economists, operate on rote rules. Hence all the econ types who said deficit spending in ’09 would produce huge inflation in ’10. Analysis said otherwise (look up Zero Lower Bound). And they never changed their opinions as inflation continued to fail to materialize. And there are many doctors who do creative research.
@grumpy realist: I’ve heard the doctors and Bonanza line. I also saw a car salesman write about how he loved to sell to doctors – only someone as intelligent and discerning as yourself can appreciate the qualities of this Mercedes. There’s also a line about why high caste Hindus tend to be arrogant, like doctors they’ve been surrounded by lower class staff whose job is to make them look good.
@Mu: More importantly, when I call the office of my PCP, before I even get to the telephone tree asking how my call should be handled I get the following message:
“If you are having a medical emergency or need care today, please go to the emergency room.”
I plan to live forever…so far, so good.
The ” emergency” room is very misused with people showing up for colds, hangnails,hangovers, and minor injuries. And the related problems this brings: people with more urgent, true emergencies often have to wait; the waiting rooms are crowded since a lot of people tend to want to bring three relatives, four kids, and some of the neighbors resulting in a lot of noise, and of course the litter from their fast food bags and drinks.
A lot of people could be sent on their way after a quick exam and told to go see a doctor the next day or better yet stay home and take aspirin.
@gVOR08: it sounds like the trained seal label belongs not so much to a profession then as to type of work one does. If your work tends toward recognition of a specific problem and then applying a well proven technique to address that problem that would be a more “trained” approach, whereas if more creativity is required to determine the nature of the problem and/or create a solution that would solve the problem that would be more what you initially labeled “educated.” Is that a fair reading? If so, applying the parado principle as you suggest, the majority of economists, or even engineers, should be lumped with the doctors. And on the other hand, doctors who need to apply basic anatomical principles, or basic physiology, to perform their specialty might be “educated” vs those doctors that look in an ear, say “your kid has an ear infection” and respond by prescription of the antibiotic that they learned is the one that works best.
Does the definition of preventative care include never smoking (surgeon general’s warning) regular exercise and staying within your ideal BMI?
Because my doctor says if you do/have done all those things, (factoring out inherited predispositions) most boomers will live into their 90s.
@the Q: Living a healthy lifestyle isn’t “preventative care” in the context of this research question.
@KM: “It’s a uniquely American concept to want to divorce personal actions from medical consequences.”
It’s an even more uniquely American concept to believe that I deserve benefits because I am a good person, but all THOSE people don’t deserve them because they are beneath me morally. Sometimes the “those” relates to race, sometimes to class, sometimes to religion, and sometimes to self-righteousness about lifestyle.
@Tyrell: I delivered to multiple ERs in my city and never once did I see someone there for a hangnail, hangover, etc. You’re so disconnected from reality it’s astounding.