Last week, I stated that prevention very seldom led to direct cost savings:
Some prevention efforts may lead to higher net costs (however we have determined them). And that can be okay if we think that the improved health is worthwhile. Prevention is mainly about preventing bad outcomes and not about saving money. Saving money sometimes is an intended goal but the goal of improving mortality or quality of life even at a net increase in expense is also a legitimate goal.
Prevention should be judged on what it is seeking to be doing instead of expecting it to prevent disease and other negative outcomes while also saving money.
This week a great paper in Health Affairs came out by Cutler et al that shows a massive exception case. Preventative services for cardiac diseases for Medicare beneficiaries improves mortality and lowers costs:
Decomposing spending by condition, we found that half of the spending slowdown was attributable to slower growth in spending for cardiovascular diseases. Spending growth also slowed for dementia, renal and genitourinary diseases, and aftercare for people with acute illnesses. Using estimates from the medical literature of the impact of pharmaceuticals on acute disease, we found that roughly half of the reduction in major cardiovascular events was attributable to medications controlling cardiovascular risk factors. Despite this substantial cost-saving improvement in cardiovascular health, additional opportunities remain to lower spending through disease prevention and control.
A lot is going on. Half of the cardiovascular savings were due to the prolific prescription of effective risk management drugs. These drugs have become increasing affordable over time for several reasons.
1) Medicare Part D made drugs more affordable over time
2) Quite a few of the first generation drug classes went off patent with significant generic introduction
3) Continued push by providers for prevention
There is still a lot of space for improvement as the low cost generics are still very low cost but not prescribed to every one who is at elevated risk.
There may be a few other areas where the combination of effective prevention treatments with very low costs after a reasonable number needed to treat (NNT).
This is very much in line with my own experience– I was diagnosed as hypertensive in my mid 20s, so I’m all in on these points. I’ve always suspected that early diagnosis and treatment of hypertension makes a big difference.
It would be interesting to see if -early- diagnosis of hypertension and hyperlipidemia also have a big payoff.
I can attest to the difference in both lifespan and quality of life due to controlling hypertension. My maternal grandparents both died in their 50s from cardiovascular/cerebrovascular incidents. In contrast, my mom worked until she was 72 and at 81 has had her hypertension and various endocrine issues under control for decades.
I’ve been on meds for thyroid and hypertension and I have to admit, it makes all the difference. I don’t get as fatigued as I did 15 years ago (long before WarriorGirl was born), and my headaches now are from sinuses, nothing else.
Controlling for cardiac risk, according to my doctor, is the easiest thing to do. Family history gives the big “heads up” for which thing is likeliest — for me-n-siblings, it’s don’t smoke and expect that you’ve got an aneurysm somewhere, so keep your BP down.
And since the study was of Medicare subscribers from 1999-2012, the news may be even better now that Ocare has increased coverage of other age groups (assuming the earlier the cardiovascular intervention the better for long term outcomes- for Medicaid spending- and for overall spending if not for the immediate private insurers.)
Did they specify the meds?
Are we talking blood thinners or beta-blockers or statins or what?
Every one in my family tree kicked it from heart attack or stroke. At roughly my age. So this is kind of a sore point for me.
@oldster: They included all major medication classes that are associated with controlling blood pressure, cholesterol, diabetes, and associated conditions, including aspirin. They do not suggest that there were any great innovations in any of these categories during the time period, rather, they suggest that prevalence of treatment increased, resulting in fewer hospitalizations. They also concluded that cost for medications in these classes did not rise because so many important drugs went off patent.
Question about the Unexplained bar— How much of that savings is due to decreases in smoking behaviors?
@Wag: Probably a good chunk of “unexplained” is smoking cessation.
@FlyingToaster: I’d love to ensure my hypertension is really under control. 3 meds, 1 3x, 1 1x and 1 24hrs to get an average of 127/83. For no damned reason. No family history. Then again, I have no family history that I know of since we’re not the type of family that talks to each other. I keep an eye on it, but I resent how early, pernicious and mysterious this whole thing has been.
David, what thoughts do you have on insulin costs? I know of type 1’s who are crowdfunding it. Is a legal crackdown on drug companies likely)
I, too, would like for Mayhew to tackle why insulin is so expensive, and is becoming UNAFFORDABLE for those who need it.
My mother was a insulin-dependent diabetic for years, but it seems, in the time since her death (2008), the price of insulin has skyrocketed, which makes no sense to me, since medicine has to have made advancements in it. Insulin is a LIFE NECESSITY for millions of diabetics.
I’m highly annoyed with my HMO because I was diagnosed with moderate sleep apnea at the end of 2017 and they’ve done NOTHING to get me a CPAP or APAP despite my doctor sending them the prescription.
Apparently they would rather have me take statins because my “good” cholesterol is too low and steroids because my asthma is getting worse rather than give me the goddamned machine that will improve both of those things simultaneously. Argh.
Rikyrah, I know there was some mention of Congressional inquiry, but that’s a long way from action!
Does anyone know the price of insulin in Canada?
Since my pons stroke in the fall I’ve been on mild statins and low dose aspirin. I’m liking the health monitoring my new Apple Watch does with heart.
Does your insurance let you get tested for sleep apnea? It turns out that there are a whole host of health problems that can be caused or worsened by sleep apnea, and high blood pressure is one of them.
Dorothy A. Winsor
When I was in cardiac rehab, they said only about a third of the people for whom rehab is recommended do it. It’s usually 3X/week for 12 weeks so time can be a factor is someone is working or something. But cost is also a factor because if there’s a co-pay, it can add up for 36 sessions. I felt really lucky because Medicare plus my AARP supplement covered it.
I read a story about a young man who was diagnosed with Type 1 diabetes when he was 23 or 24. He died once he got kicked off his mother’s insurance and had to buy the insulin himself. They believed he died because he was rationing his insulin. I was stunned at the prices that I was reading in that story. I handled picking up and ordering all my mother’s medicine, so I am very aware of all that entails with an insulin-dependent diabetic. These companies are literally pricing out people and sentencing them to DEATH.
They did say in the story that insulin was far more affordable outside of the USA.
What a pain. Wonder what their problem is. A relative did the sleep study, got diagnosed, and then got the machine and all necessary masks, etc pretty quickly. I got the impression that this was pretty standard when appropriate.
The info about cardiac diseases is very encouraging.
Cool, cool. In that case, I’ll just take handfuls of each.
@rikyrah: Both really good questions and really outside my area of knowledge.
@ruemara: We’re lucky in that at least some of the extended family would talk to my parents, so we have the past 3 (my great-grandparents, grandparents, and parents) generations of “what they had and what eventually killed them”. Since either the current ones won’t talk to me, or I won’t talk to them, I suspect that WarriorGirl’s descendants will have to rely more on DNA testing.
In absence of family history, your own personal history does help your doctor. My PCP noted that I had BP spikes for years (which I blamed on driving into Cambridge), but it wasn’t a worry until it stayed up during the last week of my pregnancy. And the stats from that told her I’d be on BP meds in under 5 years, and that it’d likely take several tries to find one that lowered my BP without massive side effects (ankles the size of watermelons, for instance). Expect that if you and your doctor don’t like the results you’re seeing, you’ll get to try a different med. And so it goes.
“(ankles the size of watermelons, for instance)”
You should have that looked at — you may have Congressman Steve King Disease.
It’s good to hear positive news about some preventive medicine regimes, because over the last year I’ve mostly seen stories about how preventive medicine doesn’t have an impact on overall health/healthcare costs (*cough* early annual mammograms *cough*). It looks like there are certain health conditions which do lend themselves to preventive care and certain conditions that don’t.
There’s also a lot of contradictory information: I could swear I’d read that a study concluded low dose aspirin regimes did NOT prevent heart attacks in any statistically significant sense, and yet people are still taking them as preventive care…? Is this a case of “It couldn’t hurt”?
I just started taking an ACE inhibitor. If you read the instructions that my pharmacy didn’t give me, they say to avoid any non-steroidal anti-inflammatory drugs, including aspirin. Last time my Dr. did a test for signs of inflammation, it didn’t show any, so I stopped taking any supplements that are supposed to be anti-inflammatory. My cholesterol is good due to exercise. What I really need to do is lose weight, but that’s not easy.
@Mnemosyne: No sleep apnea. I only even snore if I get rip roaring drunk which is hard to do on certain liquors but easy on others – which my system burns off very quickly.
@FlyingToaster: Yeah, this current level of medicine took about 3 years to get ok results. Last time, I was on meds for 2 years until my obgyn for presurgery pointed out that the entire class of meds is not recommended for black people because we don’t respond to it. Whoops.
Before one doctor fucked up my system with horrormones, I had good results with DASH & TCM + acupuncture. To the point of not needing meds. The body is a very interesting & strange thing.
@Eric U.: Eric, weight loss is a lot easier with modern technology. Download a calorie tracker (the free versions are fine), choose a modest rate of loss, and be patient. You don’t have to make huge lifestyle changes, exercise for hours or cut out every last food treat to lose weight. Read this.
@Pogonip: What a big pile of nothing.
@Pogonip: I am most suspicious of Pelosi on her relationship to big money and corporate influence, and how that influences her positions like financial reform, health care and corporate governance. But, come on… It’s an open question whether a rapid Medicare for All policy is the best approach right now. Even a solid progressive like Brown thinks incremental approach of lowering eligibility age and slowly expanding coverage is best, and see how private insurance reacts. Swiss have a much better system that uses a private insurance industry, though it is regulated much more heavily, with much much stricter enforcement than anything dreamed of in the US. And the Swiss insurance industry hates the system with the heat of a thousand suns.
And of course, top tactical and strategic politicians ALWAYS say exactly what they really mean deep down in their hearts to important stakeholders. And very obviously approved leaks like this NEVER have an ulterior motive.
Let’s wait and see how hearings and legislation develops. Nothing happening in the next two years anyway. It will all be House Dems getting their plans ready for after 2020.
@jl: Interesting! I had no strong opinion about the article myself.
Good post, and link to another good post by David. Good news. I’ll read the article with interest.
I think David’s link to the issues involved in evaluating the cost-benefit of prevention and other health care is too deep in the weeds, and leaves too much hanging for the average reader. I’ll volunteer my opinion on some important points that were left hanging.
For social efficiency, the perspective of society and the patient are the bottom lines. The others matter only in figuring how to get socially and patient-wise beneficial stuff done.
The discount rates used are often way too high. You read these cookbooks on cost-benefit and cost-effectiveness analysis that clinicians and ‘policy’ PhDs often use, they recommend things like 3% to 5% real. I think way too high from societal perspective. For vast majority of people, investing in extended life is a fairly save bet, so should be same as for long term treasury bill or life cycle return on residential housing, so 2% to 2.5% max, from perspective of average person in society, Research showing much higher discount rates for patients is low quality methodology, and the estimated discount rates mix up a lot of different issues, that involve evaluating real options, timing of decisions. Standard one-shot, now-or-never simple present value analysis cannot handle the issues involved. I’ll be interested to see how discount rates were treated in this research.
Costs: need to distinguish real economic costs from expenditures, transfers and monopoly rents. Increased health care costs for things that extend life mean nothing unless you compare them to increased personal income and tax revenue if you can keep a person in shape to work, or they can live longer to enjoy their savings (which is easier to handle in a pay as you go social security setting, whatever that thought it worth).
So, my two or three cents.
@Pogonip: Sorry, I didn’t mean to atttidinalize towards you. Some venting in that comment that I should have toned down or labeled as such.
Dorothy A. Winsor
A couple of days ago, the Pod Save America guys talked about health insurance. They hoped the Ds wouldn’t get bogged down in pro or anti-Medicare for All arguments, but would focus the discussion on how to make sure people have good, affordable health insurance at a lower cost to the country than we currently pay. There are various ways to do that. Focusing only on Medicare for All is like discussing immigration reform by focusing only on pro or anti-Wall.
They also said surveys show Medicare for All polls very favorably but if you throw in the abolition of private insurance, support drops precipitously. And the issue is inevitably political. Insurance companies will fight like crazy to avoid being abolished. Any policy discussion needs to take that into account in planning how to achieve the end goal.
Kinda deep in another set of weeds, but interesting stuff.
Dorothy A. Winsor
Also, as someone who’s on Medicare, it’s not clear to me exactly what Medicare for All means. I get part A free and pay some for part B, depending on my income. That’s designed to cover something like 80% of costs. So I buy a supplementary policy from a private insurer. I also buy dental and vision care from a private insurer. And Medicare part D (drugs) is managed by a private insurer too. So is that what we’re talking about?
@Dorothy A. Winsor: It’s also the case that a lot of beneficiaries currently receive Medicare through private insurers, and nearly ever beneficiary has supplemental private insurance from an employer or that they purchase on their own.
Dorothy A. Winsor
@Barbara: Yes, exactly. As we found with the ACA, the devil is in the details.
@Brachiator: It’s like the joke about the accountant who only sees costs and never sees benefits. With regard to prevention of cardiovascular disease, you incur a cost of $10,000 to prevent a heart attack, that reduces expected future costs of heart failure and other diseases attributable by $1,000 to the heart attack, and the expected future income (aka social productivity) of the person who did not have the heart attack (because they are alive instead of dead, or healthy versus crippled in the future) is $11,000, you have a win-win. The person and society and the gummint is up on the deal over the person’s life cycle by $2,000.
That is a simple hypothetical example. But you can only see that total picture if you take societal and patient perspective into account, with a time horizon of the person’s life cycle, use a sensible discount rate for the safe investment of an extended life of a now healthy person, and separate real costs from corporate gouging when the charge for simple preventive services, like behavior therapy (exercise), and some blood pressure pills. And you have to include non-medical costs and benefits as well as medical.
Hate to be downer, but I think safe to say majority of research ignores one or more of these issues in the US, and frankly, is not worth much.
@Dorothy A. Winsor: @Barbara:
Given that so many people with Medicare end up getting supplemental insurance, it seems unlikely that private insurance will go away. At least not anytime soon.
I’m all for the Swiss system. I think The Netherlands has the same system or a similar one. Private insurance but highly regulated. Keep costs low. Everyone is covered and people can decide how much extra they want on top of that.
@Yarrow: Some conservatives in the US point to the Swiss system as a model for Obamacare improvement. But it is a bait and switch. Regulation and enforcement is much much heavier in Switzerland than anything even contemplated so far in US. As Krugman has said, they want the Swiss system for the US, and then take out everything that makes it work. To Go Swiss!, you need universal mandatory coverage, uniform basic policy, supplemental insurance must supplement not substitute coverage, basic mandatory policy has to be offered on non-profit basis with regulated management fee for the ‘profit’, only supplemental policies can be sold for profit. Soft price band price regulation. Uniform fee schedules across providers for the same service. All produces and services provided in federal system must meet a cost-effectiveness and cost-benefit test (Death Panel!). Community rating based on residence and age. The systems is swamped with nurses and health techs to make provision cheaper (docs stick more to stuff only a doc can do). A LOT of public provision compared to US: child health through schools, pregnancy and neonatal, young people up to age 25 (very heavy public subsidies to make it cheap for them access).
I doubt corporate pharma, labs, hospital chains, clinics would stand for it. We may go Medicare for All simply because corporations and professional interest groups will not accept half a loaf instead of a whole loaf, and in the end the people will demand a system that gives them no loaf. For society as a whole, you can get almost same results with a good Medicare for All system (Go Australia!) as you do with Go Swiss! But very different in terms of how much money goes through private insurance, and private provider system.
Dutch system is halfway between Obamacare and Swiss, and shows milder forms of corporate gouging and gaming and instability that Obamacare has under hostile administration of hostile congress and executive.
@Yarrow: Swiss regulation of drugs would be considered financially genocidal to $ interests of US big pharma, though gives more access to drugs than in US.
Yet Swiss pharma business and exports a growing sector of their economy. Hasn’t killed off their big pharma at all. Swiss economy has been reindustrializing in wake of their forced abandonment, or at least scaling down, of their very sketchy international money laundering industry.
I see your point, but I think you over-complicate some things, so that it makes it harder to do reasonable comparisons. You offer a different and useful picture, but not a “total” one. But you raise a lot of good points that add to the discusssion, and that’s what it’s all about, right?
The fun thing is, we have a lot of models to look at in trying to decide what might work the best for us.
Ran across this fun, brief page about the Australian System, complete with a short video. The healthcare system at a glance
@Dorothy A. Winsor:
My general take on M4A is that it works better as a slogan than as a policy. Basically, Medicare is a messy program that’s grown up as an agglomeration of different parts designed to deal with specific problems. We probably don’t want to expand that to everyone. But the basic idea of Medicare For All- everyone gets health insurance paid for by the government- is a reasonable one.
Their real goal is to keep the status quo or, since Obamacare was actually passed, to go back to what we had before. Every Republican proposal on universal healthcare is made in bad faith. They just realize that they need to have some kind of counter-proposal so they don’t look like complete obstructionists. If they actually wanted a Swiss-style system, they could have passed it when they had complete control of Congress and the White House. That the only proposal on universal health care they’ve ever taken when they were in position to enact their plans was to try repealing Obamacare should tell you everything you need to know about their real goals.
@jl: The ACA is modeled on the Swiss system (the second most expensive health care system in the world), however all Swiss health insurers are non-profits. The Cons were big fans of the Swiss system until it got adopted for the ACA, then it fell out of favor for some reason …
@Juice Box: Whether Swiss is second or third or fourth depends on how you count the cost. Norway, Luxembourg and Switzerland have all been taking turns at being the second most expensive in the world, depending on how you want to measure it.
I think most useful measure, that avoids lots of complications, and reflects burden of healthcare system on whole economy, is percent of GDP that runs through the health care system. And there, Swiss is not particularly expensive compared to Medicare for All Australia, even after adjusting for some differences in national accounts. As for dollar costs, important to remember that Swiss workers are highly paid compared even to other countries in Northern Europe and even Nordic countries.
Swiss health insurance organizations can be for-profit or non-profit. the crucial thing is that any insurance organization in the basic heath insurance market must offer the basic uniform mandatory health policy on a non-profit basis for a publicly negotiated management fee. Many for-profit insurance companies sell the mandatory policy on a non-profit basis and also sell supplemental policies on a for-profit basis on a separate and much less heavily regulated market.
I 100 percent agree with your last statement.
Are cardiac drugs really prevention of heart attacks or treatment of hypertension & cholesterol buildup?
Maybe just words, but I’m curious about definitions.
@Downpuppy: I’ll answer in case you check back, Hypertension and cholesterol plaque buildup, and poor diet, obesity and lack of exercise, are part of the causal chain that leads to cardiovascular disease, including heart attack. If you intervene in one or more of those in a beneficial way, you reduce chances of heart attack, or stroke. Statistically, whether you want to skip over the links of causation and go directly from the preventive measure to its effect on, say, heart attack, or examine each causal link depends on what you are studying, doesn’t change the final answer much on whether a pill or behavioral therapy reduces heart attacks. Technically, the changes in hypertension or cholesterol plaque buildup are called ‘mediating variable’, and for the simplest analysis of a very large clinical trial, you would want to try to estimate the effect of the pill directly on the incidence of heart attacks and skip over the mediating variables. But, you also need to look at the mediating variables too, for various reasons. A good research study should try to do both.