Preventive scare

Charles Krauthammer is a doctor, the kind of doctor an insurance company would love:

How can that be? If you prevent somebody from getting a heart attack, aren't you necessarily saving money? The fallacy here is confusing the individual with society. For the individual, catching something early generally reduces later spending for that condition. But, explains Elmendorf, we don't know in advance which patients are going to develop costly illnesses. To avert one case, "it is usually necessary to provide preventive care to many patients, most of whom would not have suffered that illness anyway." And this costs society money that would not have been spent otherwise.

Think of it this way. Assume that a screening test for disease X costs $500 and finding it early averts $10,000 of costly treatment at a later stage. Are you saving money? Well, if one in 10 of those who are screened tests positive, society is saving $5,000. But if only one in 100 would get that disease, society is shelling out $40,000 more than it would without the preventive care.

In the very abstract, of course, that's not a ridiculous claim.  I think he's right to make the claim that preventive care is not the high road to lower health care costs (no one he cites seems to argue for that particular claim). He is also right to grant (as he does, a few paragraphs later) that there is a moral reason for preventive care–to limit suffering.  Nonetheless, I think there are two objections one could make here.

First, the economic calculation is the very one the insurance company makes–which, if I am not mistaken, is the problem.

Second, while Krauthammer is not wrong to say that preventive care is economically different from any other medical procedure (he does have an MD after all), he's allowing you to think that preventive care means everyone gets a series of costly tests every year, no matter how irrelevant or unnecessary.  He writes:

That's a hypothetical case. What's the real-life actuality? In Obamaworld, as explained by the president in his Tuesday town hall, if we pour money into primary care for diabetics instead of giving surgeons "$30,000, $40,000, $50,000" for a later amputation — a whopper that misrepresents the surgeon's fee by a factor of at least 30 — "that will save us money." Back on Earth, a rigorous study in the journal Circulation found that for cardiovascular diseases and diabetes, "if all the recommended prevention activities were applied with 100 percent success," the prevention would cost almost 10 times as much as the savings, increasing the country's total medical bill by 162 percent. That's because prevention applied to large populations is very expensive, as shown by another report Elmendorf cites, a definitive review in the New England Journal of Medicine of hundreds of studies that found that more than 80 percent of preventive measures added to medical costs.  

On the cost of an amputation, I'd say the surgeon definitely does not make that, but I think Obama means the total cost–which has to be somewhere around there (but I could be mistaken). 

But the "large populations" claim strikes me as odd, because not everyone will be a candidate for every preventive measure.  Besides, not every preventive measure is a 500 dollar test (which seems to be the basic idea of preventive care in the CBO study):

During a press briefing Tuesday, Thorpe said “the CBO focuses on one type of prevention, which is trying to detect disease through screenings. And some of those types of disease screenings can actually reduce costs, as in the case of colorectal cancer. And a lot of it is really not designed to reduce cost, it’s designed to get people medical intervention earlier,” he said. “So the intent of disease detection is not to save money, it’s sort of a straw man.” [Sorry for the format, but the original is behind a pay wall].

Finally, he is also assuming the present (inflated) cost structure as a baseline.  Some have argued recently that the cost structure and the medical practice we are the problem.  Others have argued that the metric of the CBO study leaves out what really ought to be measured in the first place.  While neither of these demonstrates the cost-effectiveness of preventive care–they do at least point out that we should be minimally circumspect about the CBO's study.


3 thoughts on “Preventive scare”

  1. Obama clearly misspoke, but it’s an understandable mistake, consistent with the way a lot of people talk about their total bill from a hospital or clinic – as coming from either the “hospital” or from the doctor who performed the procedure, as opposed to reciting an itemization of separate fees from the surgeon, clinic, anesthesiologists, nursing staff, etc. Krauthammer has identified an actual mistake, as Obama did state “the surgeon is reimbursed” instead of something like “the total cost of the surgery”, but it’s a nitpick – Obama did correctly state the total cost of the surgery.
    What follows establishes, at least to me, that Krauthammer has absolutely no interest in the truth – quite the opposite. Having scored a petty rhetorical point he implies that the total cost of the surgery is in the neighborhood of $800, despite knowing Obama’s figure to be accurate in terms of that total cost even before we consider additional, long-term costs. Although the journal is available online only to subscribers, I have read that a 2007 article in the Journal of the American Podiatric Medical Association (JAPMA) estimated the cost of a lower extremity amputation at $30,000 to $60,000, with subsequent care over the next three years to add another $43,000 to $60,000.
    The Journal, Circulation, makes most of its articles available online. So far, I can’t find the article Krauthammer is referencing ( although I’m sure it’s there somewhere), but I see a lot that seems to weigh strongly in favor of preventive care. I am skeptical that the article comes to the same conclusion as Krauthammer – judging from other medical literature on the subject, I suspect that he cherry picked the quote while deliberately omitting the study’s conclusion. Which, for Krauthammer, would be quite typical.

  2. A more substantive discussion:
    So now I’d like to completely shift gears from the past to the future. And let’s suppose that we make a discovery and from some date onward, we have a 10 percent lower death rate from cancer. We estimate that a discovery that reduced cancer death rates by 10 percent has a present value of about $5 trillion. That’s a big number—it’s less than half but more than a third of a year of GDP. That’s a lot of value.
    So now let’s think about a program designed to try to capture that $5 trillion gain. Let’s say we’re going to propose a big National Institutes of Health budget increase to try to work on the new War on Cancer. Say we spent $100 billion on our new War on Cancer. $100 billion is a lot of research money. If you talk to people, they’d say, we can do a lot with $100 billion; there’s a good chance we can achieve that 10 percent reduction in the cancer death rate.
    You might be tempted to think, well, isn’t this a no-brainer? I spend $100 billion, and even if my chance is one in 10 of being successful, I’m going to get $500 billion in expected value. So what a great return on your money, a five for one, even with a one in 10 chance.
    But what’s left out of that equation? What’s left out is the cost of implementing whatever cancer treatments I discover. If it costs $10 trillion in present value to implement these new treatments that generate the $5 trillion gain in life expectancy, we’ve lost money. The discovery has negative value, not positive value. On the other hand, if it costs only $2 trillion, well, we will end up with a $3 trillion net gain.
    In this calculation, what matters? Does the $100 billion invested by NIH matter? What would happen if I made that $200 billion? Or I made it $50 billion? The answer is it does not matter much. Even the probability of success does not matter too much.
    What really does matter is the cost of treatment. If treatment costs are $10 trillion, the project has a negative net present value even if the research is free. With $2 trillion in treatment costs, the net gain from success is $3 trillion, so that we would get a good return even if the probability of success was one in 30. So when you think about research, it’s not the dollars you spend that matter—what matters is the cost of implementing the treatment that might be discovered. The downside to research is not failure, but unaffordable success.
    I think the following message comes out of that exercise: Cost containment and health progress are complementary. That is, if we can control costs, that makes research a much more attractive option. That’s the most important lesson I learned from doing this work.
    When you go to Washington and talk to people at NIH, what are they excited about? They’re excited about that $5 trillion number. They’re excited that, boy, we could do something that could generate tremendous value for people. We can cure disease and lengthen lives, both of which make people much better off. The work that Bob and I did quantifies that number; it says it’s huge, $5 trillion for that 10 percent reduction in cancer.
    You walk across the street and talk to the guys who have to pay for it, and they’re terrified that people are going to come up with more new medical treatments that they’re somehow going to have to finance. So, to me the bottom line is those two people have to work together. That is, we have tremendous ability to create value for people. We also know that health expenditure is a very important part of the equation. What we need to do is focus our research on finding affordable treatments.
    And if we can do that, we can put more money into health research knowing that we’re going to end up creating net value for people—gains in longevity and health that exceed the cost of investment.
    The question of should we have a bigger NIH budget is not a question of whether we would be wasting the money. The question is, what are we going to get out of it? If we’re going to get affordable treatments, a bigger NIH budget sounds great. If we have no cost containment, it’s a much more dicey equation. We need to work together on, one, cost containment, and two, increased and better research.

  3. Doctor Krauthammer’s article, Prevenention as Cost Cure All is just a Myth, 8-17-2009 Investor’s Business Daily basis his thesis on material primarily from medical periodicals projecting costs.  The CBO is cited as supportive of Krauthammer’s thesis based upon NEJM publication February 14, 2008 358: 661p663. Does Prevention Care Save Money? The authors of this publication stated, “That sweeping statements about the cost saving potential of prevention are overwhelming. Yet, there are oppertunities to save money and improve healthy by prevention. ”

    My professional experience as a pathologist has been directed toward the importance of the earliest diagnosis and subsequent treatment of disease. Since Hippocrates’ time, it has been a basic principle of Medicine that the earliest diagnosis provides the oppertunity for treatment with the greatest chance of cure.

    Cardiac deaths are the leading cause of death in the U.S. Diabetes is the number one contributor. Those with cardiovascular disease not identified with diabetes are simply undiagnosed.

    There are estimates of many millions of undiagnosed diabetics worldwide. According to The International Diabetes Federation and The American Diabetes Association, the number of people suffering from diabetes has skyrocketed in the past two decades. These estimates are only the tip of the iceberg.

    In 2002, awarness that the pathology of diabetes was not limited to those with clinical diabetes, but also occurred in those with impaird sugars or fasting blood sugars considered normal, prompted a panel of The Department of Health and Human Services and The American Diabetes Association to make recommendations for physicians to begin screening for prediabetes and diabetes. This was to be by fasting blood sugars or oral glucose tolerance tests, particularly, in overweight people 45 years of age or older. They cited prediabetes as impaired glucose tolerance and impaired fasting glucose as a serious condition treatable by early diagnosis. The panel emphasized that most people develop type 2 diabetes within 10 years with risk of heart disease by 50%.

    In 2006, The Expert Committee of  The American Diabetes Association confirmed their previous views and further recommended that individuals under 45 and over weight with any other risk factors for diabetes should be tested. Also, children and youths at increased risk should be tested.

    How early should diabetes be treated? This may appear to be a ridiculous question and that it is. The question of greater urgencey is how early should diabetes be diagnosed? The earliest diagnosis of diabetes is a mandate to arrest the worldwide epidemic of diabetes. The insulin assay with the oral glucose tolerance provides the earliest diagnosis.

    The oral glucose tolerance has been an established procedure for the diagnosis of early diabetes since 1921 based upon glucose determination alone. The oral glucose tolerance with insulin assays became a routine at St. Joseph Hospital, Chicago Illinois in 1972. The test  provided the earliest diagnosis of prediabetes and diabetes even when blood sugars considered normal. In 1974, the oral glucose tolerance with insulin assays demonstrated that the increasd insulin response (hyperinsulinemia) is type 2 diabetes. This was not only a major diagnostic finding in those with diabetes mellitus tolerance (DMGT) but also in those with impaired glucose tolerances and was most noteworthy in those with normal glucose tolerances. These findings were concurred in the 14,000 + examinations acquired in the subsequent years up to 1998.

    In our data  base of 14,384 oral glucose tolerances with insulin assays acquired at St. Joseph Hospital, from 1975 – 1998, 40% of 2011 diabete mellitus glucose tolerances had fasting blood sugar less than 110 mg/dl and 20% were less than 100 mg/dl, the current fasting normal blood sugar since 2004.

    Current application of the oral glucose tolerance with insulin assays is detailed in a 2008 publication: DIABETES EPIDEMIC & YOU, Trafford Publication, Victoria, B.C., Canada (  and 
    ISBN: 142516809-4

    In addition, a publication DIABETES A SILENT DISORDER is pending, October, 2008, Comperhensive Therapy: The American Society of Contemporary Medicine, Surgery and Ophthalmology.

    Until the earliest diagnosis of type 2 diabetes becomes a standard operating procedure, the worldwide clinical silence of diabetes will continue to remain an enigma of Medicine. The silent diabetes epidemic will be arrested and then reversed when physicans and patients demand the earliest diagnosis and treatment for diabetes. The clinical benifits with incalcuable long-range cost savings by the earliest diagnosis of the pathology of diabetes is self-evident and not a “myth.”

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