“An ounce of prevention is worth a pound of cure” -- Benjamin Franklin¹

Even with the constitutionality of the Patient Protection and Affordable Care Act (ACA) confirmed by the June 28, 2012 U.S. Supreme Court decision, a key premise underlying the ACA has continued to incite discussions on the best way to control healthcare spending.  Preventive care, often touted by policymakers as superior to medical treatment in achieving cost savings, has come under fire in recent years for its contribution to the ongoing rise in healthcare spending and its often negligible effect on improving patients’ health.  The use of tests whose effectiveness is unproven may result in: “false positives;” additional testing or procedures to evaluate initial findings; and heightened patient anxiety, all resulting in increased costs of medical care.² Further, patients may be subjected to unnecessary and potentially hazardous tests and procedures when a preventative test reveals a condition for which the course of treatment would remain unchanged.  As various members of the industry seek to clarify preventive care’s proper role in healthcare, from both the clinical and the economic perspective, patients and providers are left to maintain the status quo, which often means overutilization of these services with minimal improvement in health.³

In the current fee-for-service reimbursement system, providers financially benefit from rendering higher volumes of healthcare services. Insured patients do not bear the full cost of these services, prompting many of them to demand certain tests despite clinical evidence suggesting that the tests are unnecessary or ineffective.  Additionally, many providers offer extra testing or procedures as a form of defensive medicine, responding to perceived threats of malpractice liability.⁴ However, medical literature indicates that many preventive services neither save money nor improve health.  For example, studies have shown that annual screenings for cervical cancer significantly increase medical costs without conveying substantially more benefit than less frequent screenings would. Additionally a number of other screening tests, such as those for HIV, diabetes, and breast cancer, all do more to increase medical spending than they achieve in savings.⁵ In response to the uncertainty surrounding many preventive services’ effectiveness and the country’s rising healthcare costs, the American Board of Medicine partnered with Consumer Reports to publish a list of tests and procedures which rarely confer value, but are, nonetheless, often performed on patients.⁶ The project, called “Choosing Wisely,” already contains dozens of professional societies’ recommendations and is set to expand later this year. It is hoped the provision of this information from doctors, rather than insurance companies, will promote better acceptance by patients and eventually lead to reduced patient demand for these services.⁷

Still, other forms of preventive care have been proven both clinically effective and economically sound. In an effort to promote the adoption of these measures over wasteful ones, the U.S. Preventive Services Task Force evaluates the scientific evidence available on preventive services and makes recommendations to providers as to the services that should be rendered and those that should be abandoned.⁸ Under the ACA, preventive services must be provided without imposing any cost-sharing on patients. It is anticipated that preventive care will be more widely utilized as a result, making the determination of what forms of preventive care are useful all the more important to curbing rising healthcare costs.⁹

Economic perspectives on preventive care widely differ, with some health economists arguing it does little to no good in saving money and others asserting preventive care is “cost-effective” because it improves health outcomes.¹⁰ More recent discussions on the issue suggest the proper inquiry should focus on which particular methods (i.e., prevention, screening, or treatment) provide the greatest value in the context of a specific disease.¹¹ Several other developed countries have already adopted this approach, and as a result, have achieved better outcomes on several health measures and lower healthcare spending than the U.S.¹² 

Despite the varying opinions on the value of preventive care, a consensus on several principles does exist within the healthcare industry. Screenings for high cholesterol, obesity, hypertension, and some cancers, such as breast and colon, are recommended almost universally, as well as the use of aspirin by individuals with high cardiovascular disease risks; counseling for smoking cessation; and, the provision of immunizations to children and adults.¹³ Furthermore, studies on the cost-effectiveness of this set of preventive services have shown that “evidence-based clinical preventive services offer high economic value.” Within those services that offer high economic value exists a subset of services that produce net savings, namely, childhood vaccine administration; smoking cessation; and, aspirin use by high cardiovascular disease risk individuals.¹⁴ Other services, such as the use of helical computerized tomography screening in lung cancer patients, are widely acknowledged as having uncertain or minimal effectiveness and thus presumed to provide little economic value.¹⁵

Community preventive services have also been evaluated for cost-effectiveness. The U.S. Task Force on Community Preventive Services evaluates these measures and has identified several which are effective, including: schools’ immunization requirements for entry; taxes on cigarettes; seat belt requirements; and, indoor smoking bans.  Of these, many are either low in cost or yield net savings, making them viable options for policymakers seeking to broaden their approach to community health beyond the traditional medical care context.¹⁶

Collaboration between the healthcare industry and the community may be the key achieving the greatest benefit from preventive services. For each form of care, policymakers must consider both its effectiveness on improving health outcomes; the value per dollar spent; and, the potential of alternative services to deliver better results in care or costs.¹⁷ By thoroughly evaluating each preventive service, the healthcare industry can direct resources towards the best forms of care and begin to curb ever-rising costs.