Tuesday, October 6, 2009

Prevention - Is It Worth It?

I've already mentioned my skepticism of the cost-effectiveness of prostate cancer tests as a preventative measure, since they have notoriously high false positive rates and lead to much unnecessary cancer treatment that results in many side-effects and iatrogenic consequences. I have a vague memory of an issue in California a while back in which gonorrhea tests or treatments were mandatory at birth because gonorrhea can lead to blindness, but the processes were very expensive and only found such a tiny incidence that the requirement was not worth while. Remember, we have finite resources, and they have to be used where they do the most good. If we had infinite resources, we could test and treat everyone for everything.

Many preventative measures are easily worth their costs. Vaccines, obviously. How much has the US had to spend on polio over the last few decades? This CBO letter describes a few other good preventions, but points out that about 20% are not worth doing. Again, very obviously, don't smoke and don't be fat. Get even a modest amount of exercise.

There are some issues with how cost-effectiveness is evaluated. Different projective models come up with different results. (The Health Affairs article linked to by that blog costs money)

One of the most controversial issues in determining the cost-effectiveness of preventative measures is that they can result in increasing people's life spans so that they end up using more health care than they would have if they died earlier. There is also the argument that the elderly worked hard to pay into the system during their lives and deserve to be kept alive as long as technologically possible. Well, they're actually sucking out 2-4 times as much money from social security and Medicare as they ever put in, so that argument is junk. They should definitely get what they deserve, but not more than that at everyone else's expense. This is the reason those social services are unsustainable and threatening to bankrupt our country in less than ten years. We spend great amounts of money to keep people alive past the point of function. To state that we should reduce what we spend on that outcome incites revolt from hillbillies who throw around accusations of trying to kill their grandmothers. Remember, we have finite resources. Keeping someone alive in a bed at great cost takes away money that could help children and workers be more productive and contribute to our whole system. It is not heartless of me to deprive an aged person of expensive care. It is selfish to demand that expensive care at everyone else's expense. The utilitarian ethic is the most compassionate. England realizes this. If we stop spending great amounts of resources on end-of-life care, we change the models that calculate the cost-effectiveness of preventative measures, making more preventative measures worth using that will increase the overall health and productivity of the population of the United States. It is good for the whole country.

Health care is an investment. We pay up front so that we have better outcomes for the future. Make sure that we get the best outcomes we can for our investment. Pay to maximize function for us overall. This will help the system grow strong and be sustainable.

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