Even worse, unhealthy habits such as tobacco smoking may actually save money in the long run as people who smoke die earlier and use fewer health care dollars. "This doesn't make sense," you say, "Smokers are less healthy than nonsmokers." That may be true, and smokers do use up to 40 percent more medical care while they are alive. A recent study from Holland showed that, on average, smokers die at age 77 and save $100,000 in lifetime medical care costs compared with non-smokers who die at 83.
The same is true for people who are obese. While obesity-related conditions such as Type-2 diabetes, high blood pressure and heart disease are associated with high medical expenditures, the costs that are saved by preventing obesity will only be offset later in life by diseases unrelated to obesity that accompany living a longer life. In the Dutch study, obese people die at 80 and save $50,000 compared with non-obese people who die at 83.
In fact, a recent study showed that for all preventive care, 19 percent saves money and 81 percent costs money. What is going on here? Just like the argument about quality care (discussed in last month's column), prevention is absolutely the right thing to do. It improves quality of life and increases our life span. But it doesn't always save money.
Consider the case of high blood pressure. Currently, of the 43 million Americans thought to have high blood pressure, 23 million are treated and only about half of them are controlled -- a quarter of the total. Patients with high blood pressure have higher rates of stroke and coronary heart disease and lower life expectancy. In preventing high blood pressure, the costs involved include screening the entire population, a very expensive undertaking, and then physician follow-up.
Once diagnosed, treating a patient with high blood pressure requires physician visits, lab tests and medications. But there are other costs as well, such as inadequate blood pressure control, not complying with therapy, and lack of follow-up care. So, in evaluating the costs of treating high blood pressure, we would have to add up the costs of general screening of the population, the treatment costs of those identified as having high blood pressure, as well as the costs of those who were hypertensive but who never knew it and became ill as a result of their condition.
The cost savings in treating high blood pressure depend on how high the blood pressure is and the risk of having a stroke or a heart attack, and appear to recover only about 27 percent of the cost of the treatment. Therefore, as you can see, the cost of prevention is about three to four times the cost of the diseases caused by high blood pressure. But that's not all. In that period of time, patients will contract another disease, and it is likely that the disease they die from will be as expensive as the one prevented. So, from an economic standpoint, prevention would save the cost of dying from diseases related to hypertension, but ultimately would contribute to more costs over time.
But, you might say, what about the economic value of living longer? Shouldn't we save money because those extra years of increased health are productive? After all, that is what prevention and quality health care are all about -- keeping people healthy longer. But, as in the case of preventing high blood pressure, the 10 years one gains over those with high blood pressure are years that mostly occur when people are retired and are receiving Social Security and Medicare. Although a person is extremely important to his or her family as a grandparent and to life-long friends, there is little money going back into the system after retirement. This type of calculation weighing the economic benefits and costs of prevention to society seems very cynical, but it makes the point that we control diseases like hypertension to add years of life and to promote health, not to save money. In the future, as people remain healthier until right before death, prevention will save the overall system money -- but not now.
Some investments in prevention can actually save money. Measles vaccination is a case in point. The measles vaccine was licensed in 1963, and its effect was quick and dramatic: In 1964, there were about 450,000 cases of measles, and within a year, the number had dropped by almost half. By 1986, the number of measles cases was reduced almost 99 percent. In all, from 1963 through 1982, 52 million cases of measles were prevented, 5,000 lives were saved, and more than 17,000 cases of mental retardation requiring long-term care were avoided, with a savings to the medical care system and to society at large of approximately $5 billion. This is clearly a case where spending money on prevention yields cost savings later. However, the cost saving is due to the avoidance of a complication that would not kill the patient but would require very expensive long-term care.
Is there a business case for prevention? From the perspective of employers, prevention saves money as long as the patients stay fairly healthy while they are working or until the age of 65, when Medicare pays for the diseases that prevention delayed. For example, employers should certainly pay for mammograms, since paying for advanced breast cancer treatment is significantly more expensive. In one study, when a large employer with 24,000 employees nationwide reduced the co-pays for certain medications that would help manage their employees' asthma, hypertension and diabetes, their health costs per employee dropped 20 percent below those of comparable employers.
Consider this argument: The employer doesn't want to pay for prevention because it is unlikely that the person will be working there long enough to see the benefits of the prevention. Why should the employer worry about lowering a worker's cholesterol if that prevents a heart attack 10 years from now, when the employee will be working for someone else? At first glance, it appears there is not a strong "business case" for prevention, but there could be if the business case encompasses all businesses together instead of as individual companies. After all, cardiovascular disease alone costs $142.5 billion a year in lost productivity. If the first employer had worried about the worker's cholesterol for the last 10 years, the second employer would benefit, as the worker would probably use less medical care while under their employ.
Extend this argument even further: As our country continues to move toward consolidation of major insurance companies, over time there may be only a handful of health insurance companies in the United States covering virtually all people who have employer-based coverage. No matter who the employer is, the insurers would clearly see that it would be to everyone's benefit to cover prevention since they, as well as the patients and employers, will all eventually benefit in terms of staying healthier and having decreased absenteeism. So, prevention does save money for the employer as long as the employee is working because that particular worker, as well as all workers, stays healthier and is more productive. In a study that reviewed 73 worksite health promotion programs over four years, the benefit of prevention was clear: For every dollar spent on keeping employees healthy, $3.50 was saved in reduced absenteeism and health care costs.
The big picture, however, remains the same. From the standpoint of the expense to the entire medical care system, from cradle to grave, prevention does not save money except in certain cases, such as measles vaccination. Fluoridation of drinking water is another example.
Sometimes prevention can help buy healthy years of life, particularly during one's working years. But while prevention is an important way of improving public health, it is not a cure for increasing health expenditures, and it will not produce the cash needed to fix some of the problems of our health care system, such as covering the uninsured. The true value of prevention is not in its cost-saving ability, but in its potential to improve the quality and length of life -- very important goals.
