Monday, February 16, 2009

Comment on “A Closer Look at the Economics of Disease Prevention”

In the February 4, 2009 issue of JAMA, Steven Woolf, MD, MPH, writes about an argument for disease prevention (pages 536-538). He stated that, “The question of whether prevention saves money is incorrectly framed. Health care, like other goods, is not purchased to save money. The dollar can be stretched further—more goods can be acquired—by optimizing economic value. The proper question for a preventive (or therapeutic) intervention is how much health the investment purchases.” On this point, I do not fundamentally agree with Dr. Woolf. In general the question is whether we are getting a good value for the money we are spending.

I do take issue with several things, or at least think that economics actually has a lot more to offer to the discussion than what Dr. Woolf suggests. Today, I will address two of these items.

First, Dr. Woolf seems to work from the assertion that employers, private insurers, and individuals should do things that are good for society even if the economic decision might be dubious for the individual decision maker. Now, those are not his words. Those are my words. They are, however, a summary of the argument that over a long time prevention saves money in most cases. That may be true from a societal perspective in which we take all costs and all benefits into consideration. Most decisions are not made from the societal perspective. Most decisions are made with a much more narrow set of costs and benefits in mind. The decision maker who must fund the preventive activity may not, in fact, end up seeing an economic return on investment from prevention. Arguing for prevention without a arguing for finding ways to adjust incentives is not likely to get us very far. This doesn’t contradict Dr. Woolf’s assertion that we should focus on value. It just reminds us that we have to be concerned about value to whom.

Second, Dr. Woolf makes the following statement: “Even if prevention and treatment cost the same per QALY, patients prefer the former to avoid the ordeal of illness.” If you want to read an entire book arguing about why people don’t always choose to avoid the ordeal of illness, pick up The Fattening of America by Eric Finkelstein. Dr.Finkelstein makes a coherent argument that people make tradeoffs in everything in life—even when the tradeoffs might be associated with being overweight. If I work longer hours, don’t exercise, eat less than an optimal diet, make more money to spend on my kids, and put on a few extra pounds, that is my choice. I could prevent the few extra pounds but I choose to get ahead in my career and earn some extra money. Or I stay up very late and then that also shows up in my health. So, presuming that all people prefer prevention to treatment is just not an argument I can accept. I would buy that “all else being equal not one would rather be sick”. However, that is not the question in the end as all else is rarely equal. There are always tradeoffs that come with prevention. Some people, understanding the risks, will still choose not to undertake prevention and take their chances on the disease.

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