The ABCs of prevention

There are three kinds of prevention.

Primary prevention focuses on community-wide efforts to reduce disease in everyone. This is usually called public health. Some examples are mass immunizations, air-pollution controls and public-service campaigns to reduce smoking and other risky behavior. So-called “sin taxes” on cigarettes and alcohol are a form of primary prevention.

Secondary prevention is primarily screening to detect diseases such as cancer and heart disease in their early stages, in an effort to reduce severity. But screening does not prevent them.

Tertiary prevention attempts to keep disease under control after it has developed. This is also known as chronic-disease management, and is the most expensive form of prevention. There is an entire chapter devoted to this subject later in this book.

The bottom line is that most preventive services do not save money immediately. But that might not be the point. Prevention advocates correctly argue that most medical treatment does not save money, and that holding prevention to the different standard is unfair. The larger issue, they say, is to determine the best way to allocate health-care dollars to improve Americans’ health.

 Steven Woolf, a physician and Virginia Commonwealth University professor, argues that health is a commodity, just like a new car or a loaf of bread. They are bought for their non-monetary value – in this case, transportation or nourishment. They are not meant to save money. But they are expected to provide good value.

How much should an additional healthy year of life cost? The rule of thumb seems to be $100,000 or less for what health-policy experts call a “quality-adjusted life year.” It is easy to spend far more than that when disease-prevention efforts include a mostly healthy, low-risk population.

Placing an economic value on life is a tricky business. The Environmental Protection Agency valued an individual American’s life at $9.1 million when it proposed more stringent air-pollution controls in 2010. That is up from $6.8 million, the figure the agency used during when George W. Bush was president. The Food and Drug Administration’s number is $7.9 million, up from $5 million in 2008.

It is likewise difficult to tote up prevention cost-effectiveness. For example, adult cigarette smoking causes multiple chronic conditions and sickens children in the household. Secondhand smoke affects the public in places where smoking is not banned. How do you account for the value of tobacco-cessation programs for the damage not caused by smoking?

Timing can also be an issue. Obese children almost inevitably become obese adults. If the condition could somehow be altered early in life, the personal and societal payoff would be enormous and compounded annually.

How much prevention costs depends on how it is delivered. An out-of-shape, overweight man can transform his health by deciding to change his diet and frequenting a local hiking trail. That cost is no more than an adjustment of the weekly grocery bill and a pair of sneakers, and it stays within the household. He profits by having a longer and healthier life. His insurance company pays less for his medical bills. His employer has a more energetic and engaged employee. Everyone wins, and the cost is peanuts.

If the man is not self-motivated, the costs start to mount and effectiveness becomes less certain. Perhaps his doctor has to spend time counseling him about potential health risks. Or his company has to offer him a cash incentive to work out.

Woolf contends that people often conflate the value of programs with the effectiveness of the behavior. The programs encouraging exercise cost money. But the resulting behavior likely saves money. This confusion can obscure positive public-health messages.

A final, and perhaps more cynical, point is that preventive services account for a tiny percentage of health-care costs. The big money is in treating disease. It is not that the health-care system wishes people ill. But most health-care marketing is about the wonders of medical technology and dealing with expensive conditions.