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Tuesday, November 3, 2009

Obama Health Care Plan-An Ounce of Prevention?

One of the critical questions that remains to be answered in the current healthcare debate is that of preventive services. Preventive services are those that are designed to maintain wellness, and to screen people for conditions that-if caught early-are more likely to be cured than if caught when they are more advanced. It is a commonly held belief that preventive health services can lead to better health outcomes, and can save money along the way. While this statement would seem self-evident, it is not quite as simplistic as it may seem. For example, an editorial in the New England Journal of Medicine from February 14,2008 calls into question whether preventive medicine truly results in economic savings, and the conclusion of the authors is that it does not necessarily. The authors included the director of the Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts–New England Medical Center, as well as a professor of health policy and management at the Harvard School of Public Health, -not exactly academic lightweights.

While one measure of success for preventive health programs is cost savings, surely another is a better health outcome. Even if there is a net increase in overall cost for implementing preventive health programs, such as cancer screening, there may be enough of a societal justification to implement them.

Not all preventive services were created equal.It turns out that some preventive services give a “better bang for the buck” than others. Some of these “high value” services include smoking cessation, counseling for use of aspirin, colorectal cancer screening, and appropriate vaccination for influenza. These services are currently underutilized. It is estimated that 90% utilization of such measures would result in 100,000 lives saved each year.

Where does President Obama stand on the matter? Is the current climate in Congress one which will expand preventive services regardless of the cost and the cost effectiveness involved? Or will Congress give only lip service to preventive services (as seems to be the case with malpractice reform)? While we may never know the inner thinking of some of the key politicians involved, including President Obama(a sad commentary on transparency in government!), at least we can try to read the tea leaves based on some of their public comments.
President Obama, in his speech to the joint session of Congress in September of this year certainly talked a good game regarding prevention. The President argued that "there's no reason we shouldn't be catching diseases like breast cancer and colon cancer before they get worse. That makes sense." This endorsement of colorectal cancer screening was welcomed by the American College of Gastroenterology. "We know screening for colorectal cancer is good health policy, and makes good economic sense," commented ACG President Dr. Eamonn Quigley. Studies have shown that for every dollar spent by Medicare for this life-saving test cuts about $3 in long-term medical costs. The New England Journal of Medicine says that a colonoscopy colorectal cancer screening is one of the few preventive services shown to reduce future health care costs. "That's a good return on investment in any business - especially when you're saving lives. When screening procedures detect colon cancer early, nine of ten patients beat the disease. In the absence of screening, colon cancer is usually found too late and many patients die. Those are starkly different outcomes that we have the power to change," added Dr. Quigley. Will Congress exercise good judgment regarding preventive health services? Let us hope that they expand those preventive services that have proven benefit, and shun those that do not. This is a tall order-when even the medical community is divided about which services are worthwhile. However, there is little question that colonoscopy for colorectal cancer screening is effective in saving both lives and money. Let us hope that our political leaders put the appropriate resources into this type of preventive services. Now would be a great time to contact your Senator and Congressman to urge them to include colon and rectal cancer screening as a priority in any health care bill that emerges.

Fielding J. Does Preventive Care Save Money. N Engl J Med 2008;358: 2847-2848

Cohen J, Neumann P, Weinstein M. Does Preventive Care Save Money? Health Economics and the Presidential Candidates. N Engl J Med 2008; 358:661-663
Preventive care: a national profile on use, disparities, and health benefits. Washington, DC: Partnership for Prevention, 2007.