The prevention dilemma - disease prevention and health preservation - Column

"Since both in importance and in time, health precedes disease, we ought to consider first how health may be preserved, and then how one may best cure disease."

-- Galen, circa 130-200 AD

Prevention is not a new idea, nor an especially complicated one. Promoting healthy lifestyles was embraced in antiquity as heartily as it is today. But implementing this simple notion has always been problematic. Human beings don't tend naturally to do everything that is good for either their bodies or their souls.

But in modern times, the dilemma has deepened, and not just because there are more sybaritic temptations. Some complex issues lie hidden behind the promise and pursuit of prevention--and these are becoming more evident and painful as we develop better prevention tools.

The goal of prevention is three-fold: 1) to forestall illness; 2) to decrease morbidity and premature mortality and reduce human suffering; and 3) to save money. The success of prevention strategies in the public health domain has been well documented. For example, ensuring that drinking water is clean clearly achieves these three goals. Providing safe work sites also translates into lives saved and prolonged, productivity gained, and health costs contained. Regular preventive dental care has dramatically reduced the incidence of dental decay over the last 25 years.

But other prevention goals are harder won or illusive, and the cost savings are less clear-cut. For example, a company that adopts a smoking-cessation program can expect perhaps only 20% of its smoking workers to stop, and many will do so only after repeated tries. Quitting is certainly worth the effort for those who will have a reduced risk of illness over the long term. But the company may not see any immediate benefits, apart from some reduction in absenteeism. The reason for that today is largely demographic. Statistics show most of those workers will move on to other jobs before they either don't get sick or don't die in their mid-50s from a heart attack or stroke. Thus, individual companies (especially those with high employee turnover) may not view smoking-cessation programs--in strictly economic terms--as worth the effort.

But what if all employers had smoking-cessation programs--or covered their cost? Well, the theory goes, then the benefits would accrue to everyone in this age where workers switch jobs, on average, every seven years. The number of smokers would gradually decline, bringing large cost savings in medical care down the road.

Or would it? The truth is no one knows. Smoking has declined dramatically in the last 20 years but there has been no easily measurable impact on costs associated with heart disease and cancer. Moreover, it's not clear if and when the cost of universal smoking-cessation programs would reach a point of diminishing returns--when they wouldn't be getting that many more people to quit permanently and when the cost would exceed the benefit.

The same dilemma applies to a host of other prevention, wellness, and early disease detection programs. The number crunchers have not yet been able to assign them a clear societywide benefit, in purely economic terms.

Prostate cancer tests serve as another example. Most doctors urge men over 50 to get a yearly blood examination, called a prostate-specific antigen test, to detect prostate cancer early. But studies have not proven that it reduces the death rate from prostate cancer, and some studies indicate that it could add to health care costs by increasing the number of men who have prostate surgery--perhaps unnecessarily, since the cancer often grows slowly and is non-fatal in many older men.

Other biomedical advances pose similar problems. Genetic techniques can be used, for instance, to identify people at risk of disease. The Nebraska Supreme Court ruled this year that a health insurer, Blue Cross and Blue Shield of Nebraska, must pay for the surgical removal of a woman's ovaries because a genetics expert had assessed that the woman had a family history of ovarian cancer. Her mother and an aunt had died of the disease in their 40s. The expert testified that the surgery was a medically indicated "preventive" procedure. The Blues plan had refused to pay, arguing that the surgery was not medically indicated.

In essence, says George Annas, a specialist in health care law at Harvard University, the court adopted a standard that a genetic predisposition to a disease may in fact be a disease. itself and warrant treatment under most insurance contracts. If such a definition gains further weight in other court opinions, it would significantly broaden the scope of preventive interventions, and potentially add billions to the nation's health care tab, Annas says.

The most profound prevention dilemma is this: Keeping people alive costs money, too. Getting a 55-year-old, sedentary, overweight male steak-lover and smoker to adopt a healthier lifestyle may keep him from having a fatal heart attack at age 60. But after that, his employer--and later the government (and taxpayers)--will have to pay for his health expenses. Perhaps he lives to be 75, and his health care costs $200,000 over those additional 15 years. Well, you say, these things can't be measured in this cold-blooded way. The man may be a husband, a father, a grandfather.

But the federal government, aided by the Congressional Budget Office, "scores" prevention interventions in the Medicare program in a way that projects the added cost of keeping people alive. In fact, preventive interventions among the elderly have come under renewed suspicion lately. A batch of government-funded studies presented at last month's meeting of the American Public Health Association found no measurable improved health or reduced expenditures due to prevention programs among about 10,000 Medicare beneficiaries. The lone exception was flu shots.

One study, for example, divided 4, 195 Medicare beneficiaries into two groups, one that received preventive services and one that did not. At the end of four years, hospital lengths-of-stay, health care utilization, and the number of hospitalizations were about the same in both groups.

Of course, some preventive programs do appear to have payoffs. A recent review of 28 prevention studies in the New England Journal of Medicine concluded that pregnancy care programs to prevent premature births and programs to improve people's management of their own chronic diseases both yielded documentable savings in just a few short years.

In addition, companies that continue health promotion efforts over time claim tangible rewards. In 1983, The Quaker Oats Co. in Chicago began a wellness program that offered employees, among other things, cash incentives to quit bad lifestyle habits. The company attributes savings of $1.4 million last year to reduced utilization of health services by a healthier work force.

It was programs like this that put prevention on the health reform agenda this year. But a funny thing happened on the way to shaping the final legislation; preventive measures were scaled back. They made the benefit package too rich, said the actuaries.

That's been a problem for years. Only 47% of large employers cover the full cost of screening tests; 41% cover all immunizations; and only 33% offer on-site fitness facilities or subsidize health club memberships.

Some have called this pennywise and pound foolish. But now the experts aren't so sure.

So, beneath the rhetoric and wholesome embrace of prevention lie some murky and distinctly unpleasant issues. As a society we haven't faced them squarely yet. We don't even know how to weigh fully the costs and benefits of prevention; clearly they can't be measured in purely economic terms. No doubt prevention will remain a widely accepted goal, and an idea that makes intuitive good sense. But adoption of it in real life will continue to proceed only cautiously.

COPYRIGHT 1994 A Thomson Healthcare Company
COPYRIGHT 2004 Gale Group