Politicians and pundits everywhere call for more disease prevention as a way to reduce healthcare costs. Certainly you cannot argue with the logic that “an ounce of prevention is worth a pound of cure.”
Or can you? It turns out that you can not only argue against that so-called logic, but – just as with cancer detection, which may have been done to excess in some protocols — you can mathematically prove that, at least for asthma, it takes a pound of prevention to avoid an ounce of cure.
The database of the Disease Management Purchasing Consortium Inc. (www.dismgmt.com) tracks both asthma drugs and visits to the emergency room (ER) and hospital stays associated with asthma. The average cost of an attack requiring an ER visit or inpatient stay is about $2000. The average cost to fill a prescription to prevent or recover from an asthma attack is about $100. It turns out that asthma attacks serious enough to send someone to the ER or hospital are rare indeed. In the commercially insured population, these attacks happen only about 3-4 times a year for every thousand people. (The rate is much greater for children insured by Medicaid; additional resources spent on prevention could very well be cost-effective for them.)
For a million-member health plan, that might be 3000 or 4000 attacks Yet that same million-member health plan is paying for hundreds of thousands of prescriptions designed to prevent or recover from asthma attacks. Depending on the health plan, the ratio of drugs prescribed to asthma events serious enough to generate an ER or hospital claim ranges from 60-to-1 to 133-to-1. Using those statistics of $2000 per event and $100 per prescription, a health plan would pay, on average, anywhere from $6000 to $13,300 to prescribe enough incremental drugs to enough incremental people to prevent a $2000 attack.
Averages lump together people at all risk levels. Surely some of those people really are at high enough risk of an attack that they are already inhaling their drugs regularly to prevent one, and have a “rescue inhaler” nearby. By definition their risk of attack is much greater than for low-risk people. Assume, very conservatively, that low-risk patients have a risk of attack which is half that of the average patient. This means that putting most low-risk patients on drugs costs $12,000 to $26,600 for every $2000 attack prevented.
A staggering number to begin with, but one which is probably still understated for two reasons:
Because the low-risk patients are far more likely to be treated in the ER and sent home, that $2000 weight-average of inpatient and ER costs is also overstated, making the ratio of prevention cost to attack cost even greater.
The true difference in risk between the low-risk asthma cohort and others probably far exceeds two times, making the incremental cost per prevented attack far greater in the low-risk population. We are just using this conservative arithmetic for illustration.
It’s not just that this is a wasteful negative return on investment. This is where the catchy title comes in: It’s also that there are known short-term side effects to these drugs. Additionally, no one knows what the long-term effect is of inhaling these substances regularly. Yet low-risk asthma patients are told to take them regularly as though there are no long-term effects. So it may very well be that, even ignoring the cost-benefit ratio itself and focusing solely on health, ongoing use of these drugs creates more long-term health risks than it prevents in low-risk asthmatics.
Notably, during the depths of the recession when it was believed that people were “economizing” on drugs, there was no offsetting increase in the ER visit rate for asthma. (That rate has been declining slowly but steadily for years.) That suggests that the people who economized were making a rational choice, preferring to accept what was apparently a very low risk of a serious attack by foregoing their daily inhaler.
Sometimes an anecdote is worth a thousand statistics. My very own son has asthma, and was on medication when he was thought to be at high risk. Since he stopped getting frequent attacks (none of which was severe enough for an ER visit) he eventually, against his doctor’s advice, also stopped using his daily inhaler.
He hasn’t had a serious attack since then, but for years the health plan sent him reminders and once even called us to implore him to take his daily preventive drugs, but he didn’t. That last call from them was about four years ago. Clearly, though he has asthma, the right solution for him is to do nothing except have a rescue inhaler nearby, and take the apparently very low risk of ending up in the ER.
Why are we apparently over-prescribing so many asthma drugs and why is the imbalance between drug use and attacks likely to get worse? It appears that, without regard to costs and benefits, prophylactic asthma drugs designed to be used every day are considered “good” and attacks are considered “bad” while the “rescue” inhalers – the ones people use when they feel an attack coming on, are considered closer to bad than good due to their potential for overuse. Doctors and health plans, like everyone else, maximize what is measured and incentivized, which in this case is “good” asthma medication.
Like many situations where the “market” seems to be producing the wrong answer, there are many sources of the breakdown causing the “good” drugs to be favored without regard to either cost-effectiveness or marginal therapeutic benefit on low-risk asthmatics. First, doctors expect, with justification, that patients want them to “do something,” when they go for an office visit. (That is also why you see patients getting antibiotics prescribed for viral infections.)
Second, health plans are increasingly evaluating and even paying doctors based on their prescribing of these “good” asthma medications. This is partly because various regulatory scoring mechanisms encourage health plans to “manage” their asthma populations.
Third, there is a large constituency – pharmaceutical companies – which financially benefits from high drug use, and advertises to both prescribers and end-users.
Finally, insured members don’t pay much of the bill for prevention, so they tend to go along with the convenient and reassuring inhaler program. Like anything else where the full cost isn’t reflected in the price, people will use more of it than if they were paying the full cost.
Bottom line: it would appear that Mae West’s observation that “too much of a good thing can be wonderful” does not apply to health care. As with cancer screening tests, perhaps it is time for policymakers to start thinking in terms of optimums rather than maximums when designing a prevention strategy, starting with asthma. Or better yet, leave doctors and patients alone for a year or two to find their own solutions, and see if national asthma attack rates increase.
Al Lewis, president of the Disease Management Purchasing Consortium, is author of thecritically acclaimed 2012 humorous look at the innumeracy of health plans, consultants and vendors, Why Nobody Believes the Numbers.