Wednesday, June 24, 2009

How Much Is That Ounce Really Worth?

David Harsanyi has a piece on the myth of preventive medicine as a cure-all for our health care woes:

Surely, for some, preventive health care is worthwhile. And no one is stopping you from eating an apple. But unless policy changes have the power to stop the Grim Reaper--rather than only postponing his arrival--it will make health care more expensive.

Let's begin with the morbidly obvious. The longer people hang around the longer they utilize the health care system. End-of-life care is often the most expensive. Old folks just love doctors. (I know I plan to unleash septuagenarian fury on MDs regularly.) As studies on Medicare have proven, easy availability to services at the tail end of life translates into lots of needless services.

Second, a government policy that prods people into incessantly visiting medical offices for checkups, screenings and tests will only raise costs even further. According to studies, preventive medicine thwarts little, though it does mean early diagnoses for relatively harmless ailments--and treatments for them.

As H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy, contends, "recent expansions in the definitions of diabetes, high cholesterol and osteoporosis defined millions more as suddenly needing therapy. A new definition of 'abnormal bone density'...turned 6.8 million American women into osteoporosis patients literally overnight."

There is another vital aspect of preventive health care that many health professionals and bureaucrats simply refuse to accept: Some of us can't be helped.

Or maybe more accurately "don't want to be" helped. The unsettling thing about the government becoming increasingly obsessed with preventive care is that we may not have much of a choice in the matter.

In Saturday's WSJ, Dr. Abraham Verghese--himself a proponent of government driven health care reform--also weighed in on the myth of prevention:

It is true that if the prevention strategies we are talking about are behavioral things—eat better, lose weight, exercise more, smoke less, wear a seat belt—then they cost very little and they do save money by keeping people healthy.

But if your preventive strategy is medical, if it involves us, if it consists of screening, finding medical conditions early, shaking the bushes for high cholesterols, or abnormal EKGs, markers for prostate cancer such as PSA, then more often than not you don't save anything and you might generate more medical costs.

Prevention is a good thing to do, but why equate it with saving money when it won't? Think about this: discovering high cholesterol in a person who is feeling well, is really just discovering a risk factor and not a disease; it predicts that you have a greater chance of having a heart attack than someone with a normal cholesterol. Now you can reduce the probability of a heart attack by swallowing a statin, and it will make good sense for you personally, especially if you have other risk factors (male sex, smoking etc). But if you are treating a population, keep in mind that you may have to treat several hundred people to prevent one heart attack. Using a statin costs about $150,000 for every year of life it saves in men, and even more in women (since their heart-attack risk is lower)--I don't see the savings there.

Or take the coronary calcium scans or heart scan, which most authorities suggest is not a test to be done on people who have no symptoms, and which I think of as the equivalent of the miracle glow-in-the-dark minnow lure advertised on late night infommercials. It's a money maker, without any doubt, and some institutions actually advertise on billboards or in newspapers, luring you in for this 'cheap' and 'painless' way to get a look at your coronary arteries. If you take the test and find you have no calcium on your coronaries, you have learned have no calcium on your coronaries. If they do find calcium on your coronaries, then my friend, you have just bought yourself some major worry. You will want to know, What does this mean? Are my coronary arteries narrowed to a trickle? Am I about to die? Is it nothing? Asking such questions almost inevitably leads to more tests: a stress test, an echocardiogram, a stress echo, a cardiac catheterization, stents and even cardiac bypass operations--all because you opted for a 'cheap' and 'painless' test--if only you'd never seen that billboard.

Obviously preventive medicine is a net good for society. Living longer and healthier lives because of technology and testing is one of the great achievements of modern medicine. But we should not expect it to be the panacea to pay for the costs of President Obama's transformative health care plans.

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