Steven Teutsch, MD, MPH

Disclosures

July 13, 2006

Healthcare costs continue to skyrocket[1] and the solution appears to be simple: prevention. But how cost-effective is prevention? Does it really save money?

First, let's be clear about what cost-effectiveness means. In the simplest terms, it is the value of a preventive service -- the costs incurred as a result of that service divided by the health outcomes achieved.[2] The costs incurred include patient costs for travel, the healthcare costs, as well as any follow-up and treatment costs. The outcomes are best expressed as those that patients care most about -- such as years of life saved -- but more and more analyses also include quality of life. There are other kinds of economic evaluations, such as cost benefit analysis and cost analyses, but these won't be considered here.

We often hear that something is cost-effective. Something that is cost-effective, however, is not necessarily cost-saving. After all the consequences are accounted for, very few services of any kind save more money than the cost incurred. Childhood vaccines are among the rare examples that actually are cost-saving.[3]

Many other preventive services are cost-effective -- that is, they provide reasonable value. Though there are no firm cut-offs, generally a service that costs less than $50,000 per life-year saved is considered a good value, and those over $100,000 per life-year are generally not considered cost-effective.

So why are preventive services rarely cost-saving? The main reason is that while everyone incurs the cost of the preventive service and follow-up, the health and financial benefits generally only accrue to the individuals who would eventually have the disease or injury. In addition, most preventive services are only partly effective. Even a well-established test such as mammography screening reduces breast cancer deaths by less than 20%. In some cases, the rate of false-positive tests can be high. As many as 85% of positive mammograms are fortunately false-positives, but each positive mammogram requires a woman to have careful additional examination(s) and many need biopsy.[4]

Although it is unrealistic to expect clinical preventive services to save money, many do provide excellent value. A recent analysis by the National Commission on Prevention Priorities[3] identified the most effective and the most cost-effective clinical preventive services. Among the services at the top of list are aspirin to prevent heart disease; childhood immunization; screening and counseling for tobacco use and problem drinking; screening for colorectal cancer, cervical cancer, vision impairment, blood pressure, and cholesterol; and pneumococcal and influenza immunization.

Cost-effectiveness analyses themselves can also help shape the delivery of these services by providing information on the value of services for people in different risk groups or how often services should be delivered. Many of these services are inadequately provided to the American people and provide a great opportunity for improvement. To accomplish this requires the commitment of payers and physicians, as well as knowledgeable patients.

Even though I have focused on clinical preventive services, ie, services provided from a clinician to an individual patient, many of the most effective interventions occur at the population level. These include things such as systems to assure access to healthcare, laws and regulations to limit access to tobacco and assure clean air, programs to reduce toxic exposures, interventions to reduce risky behaviors, health education programs and messages, and creation of healthy environments and the availability of healthy foods. In addition, there are major opportunities to address some of the leading causes of disease and injury, such as income disparities, and long-term threats like global warming and ecosystem destruction. Studies of the cost-effectiveness for many of these interventions are badly needed.

Cost-effectiveness analysis is a very useful tool for assessing value, but it is only a tool, not a formula, for decision making. Though a topic of considerable debate, there are methodologic standards for cost-effectiveness analyses;[5] careful review of individual studies is required to assure the relevance and the appropriateness of the methods actually used. This process can be greatly facilitated by better reporting of studies.

Decision processes should be built upon a firm foundation of evidence of safety, effectiveness, and value (cost-effectiveness),[6] but this core information needs to be integrated with other considerations, including cost and budgetary constraints, feasibility and stakeholder interests, equity, patient preferences, and availability of necessary infrastructure. If properly used, cost-effectiveness analyses should allow us to secure greater health benefit from the resources that are available.

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