The Dollars and Sense of Prevention: A Primer for Health Policy Makers

The Dollars and Sense of Prevention: A Primer for Health Policy Makers

Conference Transcript | June 8, 2009 | Hosted by the Center for Studying Health System Change

The Center for Studying Health System Change hosted a conference examining the role of disease prevention in health care reform. This event, the third in a four-part series sponsored by the Pharmaceutical Research and Manufacturers of America, the DMAA (The Care Continuum Alliance) and the American College of Preventive Medicine, brought together leading researchers and policy experts to assess the costs, benefits and practical realities of preventive health strategies.

The Growing Burden of Chronic Disease

HSC President Paul Ginsburg opened the conference by noting that the prevalence of chronic conditions among working-age Americans was rising steadily, tracking closely with increasing obesity rates. In 2007, 39 percent of the working-age population -- roughly 72 million people -- reported having at least one chronic condition such as diabetes, asthma or depression. That was a significant increase from 35 percent just four years earlier. Over the same period, the proportion of working Americans classified as obese (body mass index of 30 or higher) grew from 25 to 29 percent.

Yet the U.S. health care system remained oriented around treating acute episodes rather than keeping people healthy, helping them change risky behaviors or managing chronic conditions effectively. This mismatch between the population's health needs and the system's design made the conference's focus on prevention particularly timely as health reform moved forward.

Mixed Messages About Prevention Economics

Keynote speaker Dr. Steven Woolf of Virginia Commonwealth University addressed the confusion surrounding whether prevention saves money. His research, published in the Journal of the American Medical Association, moved beyond the simple question of cost savings to focus on the value that effective preventive services add to the health care system. Woolf argued that the real question was not whether all prevention saves money -- some interventions do, others do not -- but rather how to shift health care spending from low-value to high-value services, both within prevention and within disease treatment.

Prevention 101: Expert Panel Discussion

A panel moderated by Ginsburg featured Jason Spangler of Partnership for Prevention and A. Mark Fendrick of the University of Michigan. The panelists discussed value-based insurance design, which proposed adjusting patient cost sharing based on the clinical value of specific services rather than applying uniform copayments. Fendrick's work on this concept argued for reducing financial barriers to high-value preventive services while maintaining or increasing cost sharing for low-value care -- a strategy he called 'fiscally responsible, clinically sensitive' cost sharing.

Spangler emphasized the importance of distinguishing between primary prevention (keeping healthy people from getting sick), secondary prevention (catching disease early through screening) and tertiary prevention (managing existing conditions to avoid complications). Each category had a different cost profile and evidence base, and treating prevention as a monolithic concept obscured important differences in return on investment.

Policy Implications for Health Reform

The conference highlighted a core tension in the prevention debate. While many individual preventive services deliver excellent health value, relatively few generate net cost savings for the health care system. Policy makers who promised that prevention would pay for health reform risked setting unrealistic expectations. The more defensible argument was that targeted preventive interventions improve health outcomes and deliver good value relative to their cost, even if they do not reduce total spending. As health reform legislation moved through Congress in 2009, these distinctions had direct bearing on how prevention was incorporated into the final bill.

Sources and Further Reading

This conference was organized by the Center for Studying Health System Change, a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation and affiliated with Mathematica Policy Research.