Preventative Care: Does It Save Costs and Improve Health?

This political season I have tried to “sit on my hands” and stay out of the various health care debates until after the presidential election which will finally happen in a few weeks. But, I can’t contain myself. The other day, I read an article in the New York Times entitled “Campaign Myth: Prevention as Cure-All,” written by H. Gilbert Welch, M.D. (NYT, Tuesday, October 7, 2008, page D6). Dr. Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H. His article, which was labeled an “essay,” addressed the question of whether the presidential candidate claims that improving preventative health efforts will save money and improve health care.

What does Dr. Welch think?

Basically, Dr. Welch writes that preventative health these days is mostly overdiagnosis and not worth pursuing. He contends that the issue “boils down to encouraging the well to have themselves tested to be sure they are not sick. And that approach doesn’t save money; it costs money.” Wow, that’s interesting. But is Dr. Welch correct?

A critique of Dr. Welch’s thesis

In my opinion, Dr. Welch is guilty (very guilty) of generalizing to such an extent that his argument is at best misleading, and at worst, very misleading. Let me defend my position with one simple example- screening for diabetes mellitus. First of all, it is important for you to understand that screening IS defined as testing asymptomatic people for the presence of disease. Diabetes mellitus is incredibly common and we SHOULD encourage people to be tested for the disease. Why? We know that many millions of people in the U.S. (to say nothing about the rest of the world) have diabetes and don’t know it. Studies have shown that the average duration of diabetes prior to its discovery is 9 years; patients not infrequently learn that they have had diabetes for years when their eye doctor asks them after a routine eye exam how long they’ve had diabetes? Furthermore, we now know that early detection and proper treatment can prevent all diabetes complications, which account for most of the diabetes care costs. So, at least for diabetes, early detection improves health and saves money, lots of money. If you don’t believe me, ask Kaiser-Permanente why they screen for diabetes and have specialized diabetes management teams for patients enrolled in one of their health care plans.

Maybe I shouldn’t be so hard on Dr. Welch?

I do agree with Dr. Welch that for some disorders, early diagnosis does not improve health outcomes and save money. I also agree that screening for disease needs to be done in a way that few false positives (people who have positive screens but do not really have the disorder) and false negatives (people who really do have the disease but are missed by the screening test) result from the screening. It is also important in making a decision to screen for a disease that an effective treatment for the disease exists. One last thing- it is possible that for some diseases that not making a timely diagnosis saves money by not having to treat the patient with an expensive drug or procedure; but that’s an ethical/moral question that I’m not in a mood to discuss today.

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