Wednesday, October 28, 2009

The Value of Prevention

I got The Nation's Health in the mail yesterday.  This is APHA's newspaper that I think has been mentioned in my blog before.  I read with interest the cover page article titled "Value of prevention debated as part of the U.S. health reform"  (This is in the November issue which may not be online yet.)  The entire article is basically an argument for communicating about the value of spending on prevention rather than trying to promote prevention as cost-saving.  I have no problem whatsoever with that argument.  It is a reasonable argument to make.  There is plenty of evidence suggesting that prevention saves money at a population level in a limited number of cases--the prevention certainly saves money for the person for whom a disease or its progression is prevented but the prevention is applied to many people who will never get the disease or suffer from its progression.  However, many preventions are still cost-effective in some sense.  So why the fuss in the article and why might I find the presentation in this article to be of concern?

The first sentence of this article is "Prevention, a touchstone of public health, has landed in the crosshairs of the national health reform debate, with cost-effectiveness pitted against the sometimes incalculable value of a healthy life."  That is an interesting sentence.  I don't see the science of cost-effectiveness as being pitted against the value of  human life.  And, the value of human life (from a policy perspective) is not incalculable.  While we may not be able to express a value, we ultimately decide that there are some things we are not willing to do to protect our lives.  That implies that the value may be difficult to calculate but is certainly finite.  And understanding that incalculable is not synonymous with infinite is the first step in sorting out this discussion.

One difficulty in this debate is that some people interpret cost-effective as meaning cost-saving.  That is not what people who "practice" the science of cost-effectiveness ever mean.  This is an important distinction between the casual use of terminology and the academic (or jargon-based) use of terminology.  It is why part of the argument on which we must focus is the communication issue so that we are all talking about the same thing.

And, if we switch the conversation to "value", I can't figure out why that is any different from cost-effectiveness--or at least one interpretation of the cost-effectiveness science called cost-consequence analysis.  Cost-effectiveness ultimately asks "how much more health are we getting for more spending".  And, just as we would in a grocery store, hardware store, shoe store, or book store, we then ask "is that too much to pay for that amount of health."  How is assessing "value" any different?  Maybe we don't come up with a measure like quality adjusted life years and put the outcomes of care for all conditions on the same scale.  Maybe we just describe the extra costs and the health benefits.

Even if we don't want to place a value directly on human life, we still place an implicit value on human life.  We still will choose to implement some activities related to prevention and not implement others.  Even if everything seems like a relatively good buy there is a limit to our resources.  What I ask is whether we want to talk about value in terms of numerous outcomes and leave the decision about whether it is worthwhile to spend the money to decision makers who don't have to explain the choices in a systematic way or whether we want to try to achieve some measure that helps us to compare the efforts aimed at different programs to use as the basis of comparison, while acknowledging that there may still be things that are difficult to capture.

Value is a good concept.  But even if we agree to look at value we will ultimately have to decide how to measure that value.  And we can spend as much time debating the appropriate measure of value as we are now spending debating whether cost savings or being a good value should be the right criterion.  The key is that we have to realize that not everyone comes at this from the same perspective and respect those differences in the debate.


  1. I agree that we must value our differences. As a nurse, every human life has value but I am aware in economics, especially with health disparities every human life is not equally valued. for example, in your blog recently you spoke of prostate screening. I do not believe we put the same value in prevention in a 90 year old life as a 40 year old life. Moreover, prevention programs are values when we prevent heart attacks in the middle aged lawyer but not so valued when we prevent diabetic retinopathy (blindness) in the middle aged diabetic with social security disability. we like prevention ( teen pregnancy, illiteracy) when it improves social ills. I am not so sure we value each life the same and that becomes a problem when discussing the opportunity cost or cost effectiveness of prevention programs. renee DNP

  2. Good points. Key question--should every life be giving the same value? Is age a reasonable criterion for differing value? No definite answers. I'm sure many different opinions.