Monday, December 5, 2011

An ounce of prevention is worth a pound of cure....or is it?

Is it possible that Benjamin Franklin could be wrong? I tend to trust in the wisdom of this renowned polymath. He was a statesman, scientists, printer, inventor, author, philosopher, and diplomat. The only person I have ever known who is more knowledgeable in a wider variety of topics than him is the great Jason Kroening-Roche. However, could Franklin be mistaken such that prevention is not cheaper than the costs of cure? Intuitively speaking, preventing something today is less costly and should save a lot of time, energy, and money compared to dealing with the aftermath of full on disease manifestations. Joshua Cohen, however, makes a convincing counter argument against the cost saving effects of prevention, at least on the population level. Maybe an ounce of prevention is actually worth just an ounce of cure.

As an aspiring primary care physician, I often find myself making arguments in support of primary care on the grounds that prevention is cheaper, both financially and generally. Cohen does not reject prevention altogether, but he argues that our preventative efforts are neither as cost-saving nor cost-effective as we are inclined to believe. Smoking cessation, colorectal cancer screening, and flu immunizations are good preventative measures that protect a lot of people at a relatively low cost, but many diseases, which are not as common in the population, do not yield significant benefits from a cost standpoint.

Cohen and his team did a systematic literature review to look at the overall cost-effectiveness ratio (in terms of $ per QALY) of prevention versus treatment for existing conditions. The lower the ratio, the better as that indicates less cost for one quality adjusted life year (QALY) gained. His results are surprising. He found that the cost-effectiveness ratios for prevention and treatment were relatively the same (see graph above). He makes the argument that cost of treatment of disease is nearly as prudent as investing financially in prevention. He does state that preventative interventions, particularly those aimed at high risk populations, do in fact save money, but broadly generalizing that prevention is cost-effective or cost saving is not always the case.

I am intrigued by this article and found it surprising, but I have a couple criticisms. First, what is cost-effective and what is not is a value judgment. He may not think that spending $29,000 for one QALY on combination anti-retroviral therapy is a sensible investment, but I do. Next, he includes secondary prevention efforts as treatment. It seems that a lot of secondary prevention efforts would in fact prevent many diseases from coming to full fruition. He uses the example of an intracardiac defibrillator which cost $52,000 per QALY. However, there are many secondary prevention efforts, like statins for patients after they have a heart attack to prevent a recurring event, which yield good results at a low cost. I would be interested in seeing his analysis if he included secondary prevention and primary prevention together and compared it to tertiary measures. Lastly, Cohen does not tell us how he discounts the future costs of treatment or the future benefits of prevention. This could have a large effect on the cost effectiveness ratio depending on what discount rate he used.

I am not quite ready to discount Franklin’s wisdom on prevention as of yet, but Cohen has at least made me stop and reconsider my argument.


Cohen, J., Does Preventative Care Save Money? Health Economics and the Presidential Candidate, New England Journal of Medicine, 2008; 661-663