Tuesday, August 25, 2009

Secondary Preventive Care Does Not Reduce Health Care Costs

The saying goes, "an ounce of prevention is worth a pound of cure." And that is true when you are talking about primary prevention. Primary prevention is what your mom and dad taught you growing up, such as hygiene, proper diet, exercise, how to handle stress, and spiritual faith so as to not harbor an irrational fear of death. This health knowledge and these life skills can and should be reinforced at school and at church. But they are primarily taught at home to children so that they become habitual and part of a culture of health. Hopefully, these life skills are passed on from one generation to another from parents and grandparents to children and between siblings and neighbors. In case where there are gaps in proper health knowledge and behavior, a pediatrician or other doctor and help remind and reinforce these lessons with parents so that this culture can be perpetuated in the rising generation. However, in a healthy culture, it is the parents that are the primary providers of health skills and disease prevention and not the doctors.

Other than vaccines, which can be given by non-doctors, medicine is not in the business of primary prevention. Doctors really don't have the time needed to transmit information on diet, meal preparation, hygiene, exercise, emotional wellness, end-of-life issues, and substance abuse avoidance. And even when doctors discuss these issues with patients the discussion rarely results in a change of behavior. Furthermore, by the time the topic comes up, the patient probably already has whatever disease the health information would have prevented. And because habits are hard to break, very few people are able to make the changes in their behavior that may slow or even reverse the disease.

There is a myth floating around that more doctor-based prevention will lower health costs. While primary prevention does lower health costs, the truth is, that other than vaccines, doctors do very little primary prevention. Secondary prevention is what physicians do. What is secondary prevention? Secondary prevention involves early detection of disease--period. So, in actual fact, there really is no prevention in secondary prevention. Secondary prevention does nothing to prevent disease onset, it only detects that disease process once it has begun.

Some might think that a doctor's focus only on disease is wrong and doctors should do more disease prevention. However, the reality is, medical doctors are trained and equipped to treat disease. Treating and managing disease is what doctors do. Like Jesus Christ said, "they that are whole have no need of the physician, but they that are sick."

Think about what happens when an adult visits their doctor. Your doctor will likely conduct a series of medical screening tests such as a lipid profile, a fasting glucose challenge, prostate specific antigen, and a colonoscopy. The purpose of these tests are for one purpose only, and that is to detect the presence of disease. None of these tests prevent chronic diseases such as diabetes, hypertension, coronary artery disease, chronic lung disease, dementia, or depression from developing. Only an interplay of genetics, environment, and behavior lead to disease or lead to health. That said, newer genetic testing, and testing for vitamin D deficiency or high cholesterol can inform patients of their risk factors for developing certain diseases, still, the prevention of disease still rests with behavior. That is why real prevention needs to begin at home with parents and children.

But doesn't the early detection of disease like cancer save money? You think it would, but in reality, early detection of disease actually increases health care costs. You don't believe me? We all have been told that 2/3 of health care expenses occurs within the last 6 months of life. With this in mind, it really doesn't matter if you die 6 months from now or 6 years from now, those costs will be the same. What secondary prevention and early disease detection do is make it possible for doctors to slow the progress of disease and therefore extend lifespan. But eventually, one disease or another will progress, become expensive, and kill you. Yes, early detection and management of disease will result in longer life, but that longer lifespan comes at a cost. So, in reality the kind of prevention that doctors do increases health care costs instead of lowering them. This is especially true if you are retired and no longer contributing value to society. And even in the case where a disease can be cured or reversed, the curing of that one disease will only lead to you dying of some other incurable disease.

The cost of disease management and treatment has a name and is assigned a value. Doctors and epidemiologists refer to the cost of disease treatment in exchange for life as the QALY or Quality Adjusted Life Year. A QALY tells doctors, insurance companies, health policy bureaucrats, and patients the cost of a particular disease treatment vs. benefit in terms of quality and quantity of life gained. Every disease treatment and procedure in medicine has a QALY associated with it. The QALY is the cost to manage disease. To give you an idea of what the QALY is and its value, kidney dialysis is the gold standard. Historically, kidney dialysis for those who have suffered complete kidney failure has a QALY of $50,000 per quality-adjusted life year. That means for every good year a dialysis patient gets from being on dialysis, the treatment costs the medical system $50,000. Treatments and procedures less than this mark are considered a good deal, while interventions more expensive than this $50,000 mark are of questionable value.

You can view QALY values by entering the following term into Google: QALY League Tables

If you detect a disease early you may begin by instituting low cost/benefit interventions, but eventually as the disease progresses, the high cost/benefit interventions will follow. Therefore, the only real result of early disease detection is that the low cost/benefit interventions will get implemented before the high cost/benefit interventions. Again, while implementing low cost/benefit interventions will prolong life, it only adds to the bottom line.

Now, please to not misunderstand my intent in writing this post. I am not suggesting that medicine or government or anyone should advocate that disease should not be detected and treated early. My point is that when we talk about reducing medical care costs, we need to be clear about how our health care system is organized, how it operates, and what are its associated costs. Only by a clear understanding of the system can we hope to implement changes to maximize its efficacy and efficiency.

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