Let’s continue our conversation about health reform. Issues about coverage and the uninsured have dominated recent campaign debates, especially among the Democrats. But candidates are also putting forward lots of proposals to improve performance and hold down costs. One popular idea across the political spectrum from Clinton, Edwards and Obama to McCain is wellness and preventive services. It’s understandable. They are seemingly a double whammy, improving health and saving money at the same time. The problem is that wellness and prevention aren’t exactly the twofer they seem. Candidate proposals are pretty terse and it’s not always easy to parse out exactly what they have in mind. It is nice to see prevention and wellness getting some limelight. But I worry if they get linked to cost containment in the implementation process, there could be a lot of foregone opportunities with bad consequences for your health and mine. Let me explain.
There is no question inexpensive prevention and wellness services offer extraordinary opportunities for enabling us to live longer, healthier lives. If we adopted a system of zero based budgeting, many of these services would come out at the top of the list for allocating health care dollars, far ahead of things like open heart surgery and expensive diagnostic tests. But linking incremental decisions about adding these services to cost savings is another story.
It might seem that at the margin wellness and prevention would still be no brainers for saving money. But it isn’t necessarily so even for seemingly obvious cases like flu shots. The rub is the problem of future costs. A shot may prevent me from getting the flu and dying of pneumonia may save money up front. But if I end up dying instead from a series of strokes, total expenditures may end up greater.
From a cost containment perspective the response is predictable. Recent comments in the Times by Helen Darling, president of the National Business Group on Health, about the willingness of her members, 200 large employers, to pay for enhanced primary care services sum it up well. Adding such services is ok. But ‘‘It has to be budget neutral.’’ That is, it’s a no go unless these services reduce or leave unchanged total costs. Similarly, budget neutrality is being held up by CMS as a criteria for evaluating new demonstration projects such as the Medicare Stop Smoking Program.
I don’t know about you, but I would rather not see wellness and prevention placed on the Procrustean bed of budget neutrality. A lot of potentially very beneficial innovations could lose out. A much better approach seems to me to ask the following question: “If we have X dollars from new funding or savings from elsewhere, where should we put it to maximize the impact on population health?” I’m betting wellness and prevention services will win hands down.
You thoughts bring to mind a bigger question that all the candidates are ignoring—what is so bad about spending money on health care? Cost containment per se is a worthy goal only if we are get nothing in return for our dollars. (This is not to say that we should ignore inefficiencies.) But Harvard’s David Cutler and his colleagues have made a very compelling case that we get a huge bang for our buck from health care spending, in the form of longer, healthier, and more productive lives.
Holding any new health spending to a strict budget neutrality standard would be downright dangerous to our health. Not only would we fail to make proper investments in prevention. Think of all the ongoing scientific advances that promise to greatly improve our health. Advances in biotechnology and pharmacogenomics will revolutionize the diagnosis and treatment of disease. Nanomedicine will enable doctors to use microrobots to monitor and repair organ systems. Device manufacturers are miniaturizing pacemakers, defibrillators and brain stimulators to permit non-invasive procedures. The FDA recently approved the first temporary implantable artificial heart for patients awaiting heart transplants. It will not be long before patients receive permanent implantable artificial hearts. And thanks to the lessons learned in the development of artificial skin for burn patients, it is only a matter of time before it is possible to grow entire organs. We will soon enjoy the benefits of many of these admittedly costly technologies. And just as with today’s well-accepted technologies like CT scans, joint replacement, neonatology, heart surgery—the list goes on and on—we will wonder how we managed without them. That is unless the Luddites have their way and, by imposing budget neutrality, halt technological change in its tracks.