Proposals for reforming our country’s dysfunctional healthcare system often emphasize that prevention can save us money, but the Washington Post’s David Brown cautions that it doesn’t always work out that way. He notes that some interventions, like uniform childhood immunization and colonoscopies for men ages 60-64, are clear financial winners, either because they don’t cost a whole lot or because they prevent diseases that are expensive to treat. But when it comes to reducing smoking and obesity, two of the big risk factors for the U.S. population, the answers aren’t as clear-cut.

Smoking may be “the most unhealthful thing a person can do,” but Brown points out that many smokers still make it to 70, and a 50-year-old male smoker with high cholesterol with untreated moderate hypertension has only a 25% chance of having a heart attack over the next decade. In other words, a lot of people in high-risk categories will survive without interventions, so the number of lives saved through prevention efforts is smaller than a lot of people expect.

The type of intervention and the target population matter, too. Brown gives two examples of interventions with very different cost-effectiveness figures:

Prevention can be expensive even when it doesn’t involve taking drugs or undergoing procedures. Even giving information can be uneconomical. That’s because giving information takes time, and the yield in terms of behavior change that leads to less disease is very low — as anyone who has been told to eat less and exercise more knows.

For example, Australian researchers tried out a program in which general practitioners watched a video and read a booklet about how to help their patients lower their heart attack risk. The patients were then given a series of videos and a self-help booklet on the same topic.

How cost-effective is this instruction? When it is provided for women at low risk of heart disease, $9.8 million has to be spent for every year of life saved in the prevention of premature heart attack deaths.

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In just one example of dozens of cost-effectiveness studies examining strategies to reduce smoking deaths, a team of British researchers in 2002 calculated that providing brief counseling, nicotine replacement and the anti-craving drug buproprion to smokers would save one year of life for every $1,300 spent — an incredible bargain.

I wonder how the Australian numbers would change if the intervention were offered only to women at high risk of heart disease – the expense per years of life saved would probably be a lot lower. And if the British researchers had only offered counseling, their expense would probably have been higher.

Then, of course, Brown points out that preventing obesity and smoking might contribute to our population’s overall health, but it might not save money in the long run. He cites the PLoS One study published in February about lifetime healthcare expenditures. When researchers studies three groups – obese people, smokers, and “healthy-living persons” (non-obese nonsmokers) – they found that, due to differences in longevity, the healthy-living cohort actually had the highest lifetime health expenditure, and smokers the lowest. Smokers may require expensive treatments for emphysema and lung cancer, but many of them don’t live long enough to get the other expensive diseases that often develop in old age.

Brown concludes, “Prevention can be a great investment, but it’s still an investment.” This is an important point for healthcare reformers to keep in mind. When we argue for more investment in healthcare, we have to be clear about what the costs and benefits will be. The costs will still be substantial, and in many cases, the benefits come in terms of quality of life rather than years of life. Making our population healthier is still a worthwhile goal, and a good use of money.

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