It has become fashionable to assess the ‘value’ of medical care with a financial metric: Is this test cost effective? Does that intervention save money?
In this environment, it is not a surprise that some are suggesting that preventive care is important and should be part of universal coverage because it saves money. The problem is, it doesn’t save money. The people who take this position are confusing the concepts of cost and value. These are not the same, and are often totally unrelated. A simple example should make this clear: the air you are breathing while reading this costs you absolutely nothing - but it is incredibly valuable to you. Without it, you would die in minutes.
Let’s be clear about our definitions:
- Cost is what you have to pay to obtain something.
- Value is what something is worth, how important or useful it is, what benefit it provides.
In medicine, cost matters but value often matters more. Another simple example should make this clear: if one has pneumococcal lobar pneumonia with a 1 in 10 chance of dying, treating it with tap water costs next to nothing, but most of us would opt instead for the much more expensive treatment with antibiotics and oxygen in a hospital. High value trumps low cost.
With this preamble, let’s turn our attention to the issue of preventive care and consider two questions:
- Does it save money? (Sometimes phrased as, is it cost effective?)
- Is it valuable?
Spoiler: my answers are NO, YES.
Do preventive services save money?
Despite the hype, pretty much everyone who has examined the data carefully has come to the same conclusion: preventive care does NOT save money overall. It may save money in a narrow sense: the colorectal cancer screening (CRC screening is usually a colonoscopy in the US) that discovers Mrs. Smith’s early colon cancer costs less than treating her for advanced colon cancer. However, when the total costs of screening the entire at-risk population for CRC, including prep, time off work, false positives and false negatives, complications of treatment is compared to the total costs of NOT screening, colorectal cancer screening is not a money saver. The only two preventive services that have data to support cost savings are childhood immunizations and explaining to adults when they should take low dose aspirin to prevent cardiovascular (CV) disease. (Note: these are both very low cost interventions!)
One of the best summaries of this issue can be found in a recent NYTimes column by Aaron E. Carroll, MD.
Are preventive services valuable?
While I cannot argue for preventive care as a cost-effective for society to save society money, I am a strong proponent. Why? Because I see preventive care as having huge value. What do I mean? Let me count the ways.
Preventive care is traditionally (and arguably, optimally) done in the setting of a long-term relationship with a primary-care clinician. In this setting, the patient-clinician dyad learns over time what each other’s values are and how best to communicate with each other. The clinician learns about the patient’s context, things like education, family, work, support, spirituality, resources, goals. In a long-term primary care setting, the patient-clinician team gets to practice evidence assessment and decision making.
There are also specific benefits that may accrue to individual patients, though this value is certainly not evenly distributed. Screening for hypertension and treating when the risk of cardiovascular disease warrants treatment can prevent cardiovascular events and allow a longer and more productive or fulfilling life. Counseling and education can help engaged and motivated patients with lifestyle issues like exercise, diet, sleep, stress, or safety. Regular scheduled preventive visits are an opportunity for clinicians to do ‘anticipatory guidance’ by helping the patient understand what health challenges they may be likely to encounter going forward: birth control and reproductive decisions, aging challenges, risks related to lifestyle or activities.
In short, the potential value to the individual patient is independent of the financial value (cost savings) for society.
Having finished writing this, I am going to go out and use my fairly expensive DSLR Nikon to take photos of my grandchildren. My camera is not cost effective. It has not saved me money. But is of great value.