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CBO Brings Obama Back To Earth on Preventive Care

It's an article of faith in the Obama Administration that better preventive care will reduce health costs. But Congressional Budget Office Director Douglas W. Elmendorf brought everyone back to earth when he pointed out, in a recent letter to the House Energy and Commerce Committee, that many preventive services cost more than they save.

This should not come as a shock to anyone who has studied health care. In fact, Elmendorf cited a 2008 review article in The New England Journal of Medicine that found that "slightly fewer than 20 percent of [preventive] services that were examined save money, while the rest add to costs." Another study sponsored by the American Diabetes Association, the American Heart Association, and the American Cancer Society concluded that savings from preventive services like checking diabetic patients' blood pressure and measuring the cholesterol of people at high risk for heart disease would offset only about 10 percent of their cost.

Of course, the researchers weren't saying that we shouldn't provide those services. They noted that regular preventive care of this kind would substantially reduce the expected number of heart attacks and strokes. But many clinical guidelines call for far broader use of screening tests, regardless of the likelihood that the patients screened will ever get the disease they're being tested for. As the authors of the NEJM article note, "screening costs will exceed the savings from avoided treatment in cases in which only a very small fraction of the population would have become ill in the absence of preventive measures."

An eye-opening conclusion of that study is that, for most of the preventive services studied, the cost of treating the illness was only slightly higher or even less than the cost of providing the care that might have prevented it. Again, it might still be good medical practice to furnish these services to people at risk of getting the disease; and in some cases, such as smoking cessation advice, flu shots, and prenatal care, that will also save a lot of money. But the vast majority of preventive services will not reduce spending unless they're carefully targeted. For example, it makes neither economic nor medical sense to screen younger adults for high cholesterol unless they have a family history of heart disease. Few men under 35 and few women under 45 will get coronary-artery disease, and even if treatment isn't commenced until later in life, two years of drug therapy can reduce cholesterol enough to eliminate most of the cardiac risk. The only parties that benefit from screening younger people are pharmaceutical companies.

The CBO's stance, of course, runs directly counter to that of the Administration, which is desperately seeking to forge a consensus on how to finance health reform. But I fail to see how it makes sense to continue insisting that preventive care will save elephant bucks when the facts clearly indicate otherwise. Instead, the health policy experts who are advising Congress and the President on reform should look elsewhere for savings--perhaps by changing how providers are paid. As the New York Times suggested in an editorial, perhaps Congress should keep an eye on Massachusetts' proposed plan to make hospitals and physicians financially responsible for the care they provide.