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The Cost Savings and Cost-Effectiveness of Preventive Care

The Cost Savings and Cost-Effectiveness of Preventive Care. Peter J. Neumann, Sc.D. Joshua T. Cohen, Ph.D. The Center for the Evaluation of Value and Risk Institute for Clinical Research and Health Policy Studies Tufts Medical Center The Robert Wood Johnson Foundation Synthesis Project

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The Cost Savings and Cost-Effectiveness of Preventive Care

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  1. The Cost Savings and Cost-Effectiveness of Preventive Care Peter J. Neumann, Sc.D. Joshua T. Cohen, Ph.D. The Center for the Evaluation of Value and Risk Institute for Clinical Research and Health Policy Studies Tufts Medical Center The Robert Wood Johnson Foundation Synthesis Project September 16, 2009

  2. Project Purpose • Investigate economic evidence for prevention • Did not evaluate • Merits of clinical evidence • Ethical advantage of preventing (vs. treating) disease

  3. Evaluation Limited to Clinical Preventive Services • Clinical services – those primarily offered in a health care facility • Community preventive service examples: • Mass media campaigns to discourage smoking • Taxes on high calorie foods • Child automobile safety seat requirements

  4. Focus on Primary and Secondary Prevention • Primary prevention – combats disease onset • Vaccination • Smoking cessation counseling • Weight loss programs • Secondary prevention – mitigate disease progression beyond early stages • Mammogram screening to detect early cancer • Tertiary prevention – manage established disease • Control of blood sugar in diabetes patients to prevent kidney damage

  5. Cost-Effectiveness Criterion • Cost-effectiveness is the incremental cost per quality adjusted life year (QALY) gained • Good Value: Less than $50,000 to $100,000 per QALY • “Cost effective” not the same as “saves money”

  6. Data • Synthesis of three reviews • National Commission on Prevention Priorities (NCPP) • National Business Group on Health (NBGH) • Louise Russell report

  7. FindingsMany Preventive Measures Deliver Good Value • Coronary heart disease • Hypertension screening • Targeted cholesterol management • Targeted diabetes screening • Cancer screening • Colorectal cancer • Breast cancer • Cervical cancer

  8. Many Preventive Measures Deliver Good Value (Continued) • Other • Counseling women to use calcium supplements • Hepatitis B screening in pregnant women • Counseling parents about motor vehicle injury prevention

  9. FindingsSavings Difficult to Achieve • Two interventions identified as cost-saving by all three reviews: • Childhood immunizations • Counseling on the use of aspirin to reduce cardiovascular disease risk

  10. Population receiving drug Individuals who would develop heart disease without prevention Individuals for whom cholesterol is a major risk factor Individuals benefiting from medication Savings (1) Averted Disease Savings Spread Over Many Patients Hypothetical Example – Cholesterol lowering medications

  11. (2) Status Quo Includes Prevention for Part of Population • Population not yet receiving intervention may be more costly to enroll or accrue fewer benefits

  12. Status Quo Includes Less Intensive Prevention Based on Table 2 in Frazier et al. JAMA; 284(15):1954-1961

  13. Everyone is dead Lower cost of smoking and obesity-related illnesses Higher costs associated with longer life-expectancy (3) Competing Risks:Example: Obesity Prevention and Smoking Prevention Obesity Prevention Smoking Prevention Van Baal et al. (2008) PLoS Medicine; 5(2):e29-e36.

  14. Can Savings from Decreased Disability Outweigh Competing Risk Costs? (a) • Does not account for cost of prevention • $9,000 savings reduces care costs by 6% (a) Lubitz et al. (2003) NEJM; 349(11):1048-55.

  15. Data Limitations • Internal validity • Intervention described ≠ Intervention analyzed • Study does not isolate impact of intervention • External validity • Study population representative?

  16. Would a Focus on Community Interventions Have Produced More Favorable Findings? • Analysis of community prevention is desirable, but evidence base is limited • Community prevention subject to many factors affecting clinical prevention

  17. Would “Smart Prevention” Save Money? • Many “smart prevention” initiatives already utilized • E.g., childhood vaccination • Initiatives often regarded as “smart prevention” often do not save money • Obesity programs (a) • Diabetes prevention (b) (a) Van Baal et al. (2008) PLoS Medicine; 5(2):e29-e36. (b) Jacobs-van der Bruggen et al. (2007) Diabetes Care; 30(1):128-134.

  18. Conclusions • Preventive measures can contribute good value to health care • Savings are possible, but total savings limited in magnitude

  19. Conclusions • Evidence base can be improved • Federal role could ensure relevance and transparency • Systematic reviews could help identify best opportunities to invest health care resources • Clinical guideline developers should incorporate economic information in reviews

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