Health Policy Updates: November 11 2017

The USA has a public health problem with gun violence. This is a pretty hot-button issue, with a lot of differing opinions and differing values. One thing that seems very clear from the data, however, is that the notion that privately-owned guns help prevent gun crime is a myth.

One of the most prevalent myths surrounding health care and health policy is the idea that we can reduce health care costs by increasing delivery of primary and preventive care. Intuitively, this is very appealing. Some preventable diseases are so expensive to treat – surely we could have saved money by doing more upstream to prevent the disease in the first place? “Catching it early” actually tends to be much harder in practice than in theory, involving a lot of infrastructure and investment, and usually costing more than it would just to treat disease cases when they occur.

Often lost is the critical distinction between cost effective and cost saving. Preventive efforts, from cancer screening to hypertension treatments, are very often cost-effective; they prevent disease and save lives at a relatively low cost. That is a good thing. But that is different from actually saving money.

On this point, a recent study of high-intensity primary care on a group of high-utilizing veterans failed to show cost savings. There have been many studies of “patient navigation” and primary care that appear to show savings; this study, however, actually randomized patients, eliminating the possibility of simple regression-to-the-mean as the reason that subjects started using less health care. Peter Ubel discusses:

“Primary care sometimes increases healthcare expenses, by identifying patients who need to be hospitalized or need to see subspecialists…If we want to reduce the cost of caring for super-utilizers, we can’t expect intensive primary care to come to our rescue.”

As Aaron Carroll writes in NYTimes’ Upshot, financial incentives to improve patients’ treatment compliance is another strategy that has received great fanfare, but is also generally much more difficult than it is billed:

“There have been successes, after all, with respect to weight loss — although these seemed to disappear over time. We’ve also seen promise with respect to smoking cessation, although these come with caveats as well…Experts caution that the interventions that achieve success are often very intensive. They demand a great deal of attention, and can be quite expensive.”

A new study in JAMA this week examined the different factors contributing to increasing US health care costs over the last two decades. Overall, their results fit with the expert consensus – it is not that Americans are getting sicker than we used to be (and hence need more care); rather, it is that we just pay more for the same care. To some extent, we are older than we used to be, and that is a contributing factor. But the dominant factor in US health care costs is prices. We aren’t getting more care than we used to, we are just paying more for the same amount.


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