by Patrick Appel

A reader writes:

In response to your reader who points out the wisdom in an insurance company spending $20 for the blood pressure medicine, rather than high costs for treating a stroke, you note that it's unclear that preventive care saves money.  But I think you are confusing two very different things:  your reader was talking about routine, low-cost care (which, the reader implies, can nip a condition in the bud and prevent its escalation), but you link to a discussion of whether various measures, including preventive screenings, save money.  I think there is indeed plenty of data to support the idea that routine care that keeps conditions under control is much more cost-effective than getting care only when the condition becomes severe, catastrophic, etc. 
(That's one of the reasons that ER care is so expensive -- people wait until they have the heart attack because they can't afford the cholesterol meds, for example.)  I recall a New York Times series a few years ago about treatment of diabetes, where they discussed how it's much more cost effective to pay for nutrition counseling than to deny payment for this kind of early intervention and instead only pay for the treatment when the diabetes has progressed, requiring insulin, dialysis, surgery to amputate limbs, etc., but that hospitals could not keep their counseling programs open because the insurers wouldn't pay for it.  Similarly, a friend's husband was denied coverage for inpatient alcohol treatment, then ended up falling -- while drunk -- and sustaining a major head injury, costing the insurer far more than the detox would have cost. 
 
Another reader:

I'm a pharmacist (recent graduate - within the past few years - with a Doctor of Pharmacy degree, for whatever that's worth), and I strongly believe that preventative medicine can make a huge difference in terms of saving costs down the road.

Looking at this link, I can see the merits and disadvantages of the different strategies specifically mentioned.

More research - It can be useful to have more information at one's fingertips, certainly!  However, from professional experience, there are a number of different medications that differ, in terms of efficacy and side effects, for each individual patient.  This is perhaps due to their own genetic code, and once we understand more about the field of pharmacogenomics, we may be able to better select a given medication for a given patient.  Comparing different types of drugs may be more useful, in this regard, versus comparing a half-dozen drugs in the same class.  Do beta blockers or calcium channel blockers work better?  Does one have a greater incidence of heart issues down the road, comparatively speaking?  That sort of information would be more useful, I'd think.

More preventive screenings - Definitely something that can be useful, but I'm not sure if a doctor's office is the best location for regular screenings/checkups.  Pharmacists are more than qualified to do basic labwork and screenings, and the Asheville Project is a great example of that. The Asheville Project was a 5-year long study of diabetic patients in North Carolina.  They were monitored frequently by their local pharmacist, who made appropriate referrals to their physician as necessary.  They were put on more medications, yes, which did increase costs in the short term.  However, in the long term:

The total mean direct medical costs per patient per year decreased between $1622 and $3356.

The City of Asheville estimated it gained $18,000 per year in employees’ productivity.

Helping to control serious medical conditions (diabetes is the most notable, but other conditions such as respiratory conditions, for example) could help cut medical costs down the road, of course, but would also have a direct impact on the productivity of the American workforce.  Presuming that employers continue to pay for employee health insurance, it is to their benefit to help control these sorts of conditions to limit their own out of pocket costs.

Of course, this is a change that would likely take at least a few years to see direct results - particular for conditions such as high blood pressure and high cholesterol.  Certainly there will be some short-term benefit, but it may not off-set the costs as much, especially initially.  However, in the long term, I firmly believe that this sort of spending will save money overall, both in terms of costs directly saved and money saved by increased productivity of the American workforce.

Better organized patient data - I'm reading this to be some sort of national patient charting system, which would enable a doctor at Hospital A to see what medications a patient is taking from another physician at Clinic B.  This would help to minimize drug interactions - and drug duplication.  Additionally, if pharmacists had access to patient labs and basic information (height and weight, for example), we could better assess the appropriateness of medication dosages.  This is especially relevant for antibiotic usage in children or in those with kidney or liver dysfunction.

In conclusion, I don't know that Obama's savings proposals are necessarily "the answer."  However, I think they're a good start - and I don't think that refusing to pay for basic medications (blood pressure, cholesterol, diabetes drugs) is any method to saving our health care dollars in the long run.

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