Can Too Much Preventive Care Be Hazardous to Your Health?

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.

22 replies »

  1. One of the things to like about ObamaCare and the push to ACOs is that those will create many experiments, and much data, about the cost-effectiveness of prevention and detection approaches that we have adopted in the past as “best practice” based on little actual empirical evidence.

  2. This is the main point isn’t it? In anesthesia, my specialty, one of our quality indicators is timely administration of antibiotics pre-operatively, a measure that has nothing to do with anesthesia and hasn’t been shown to prevent infections. But it’s how we get paid, so we do it. As long as a person is being evaluated and paid based on things they DO, that person will keep DOING

  3. The problem with public education when it comes to health care is that there is the science and then there’s the person. People have visceral emotional responses to things despite what the science says. I’m told this is human nature. Physicians are as suceptible to this as patients are. Why do you think there has been so much resistance to the very well researched recommendations from the USPSTF on mammograms?

  4. There is a “middle-ground” outcome to prevent, and it’s one I have experienced a number of times: the serious attack that is controlled without ER treatment. Once I start seriously wheezing, it usually takes at least a burst-and-taper round of prednisone and an unpleasant attachment to my nebulizer. I am uncomfortable and physically restricted for days or weeks. My very competent pulmonary specialist has worked with me to know when to use my inhaled corticosteroids (fall and spring allergy seasons, for example), but though I have never been to the ED, I know I am better off for preventing those exacerbations.

  5. Al, thanks and very true, a friend of mine is being hounded by his health plan to join a pre diabetes program. He visited his MD who ran an A1c and told him “no you don’t need it, not sure how they came up with that but your numbers are normal, listen to me, not your health plan, they haven’t a clue.”

  6. Call it like it is: It’s those damn HEDIS scores and STARS ratings. The NCQA hammers the HMOS, and the HMOs hammer us and we hammer the patients. They hold all the cards. You cant just say no.

  7. Can preventive care ever be hazardous? Well, it does often dig an unsolicited pit in your pocket, besides serving a few long term health risks. Here’s the study. Post your comments, discuss, disagree, dissent, or simply dwell over it at Social Number. Like always, it’s publicly anonymous http://bit.ly/SdsthC

  8. Can preventive care ever be hazardous? Well, it does often dig an unsolicited pit in your pocket, besides serving a few long term health risks. Here’s the study. Post your comments, discuss, disagree, dissent, or simply dwell over it at Social Number. Like always, it’s publicly anonymous!

  9. Mighty,
    I’m a big fan (I comment on most of his postings too and his Amazon book page). You’ll love it. I don’t think a funnier book has ever been written about health care

  10. That’s saying a lot — many of the TCHB postings are excellent. I read yours quite often even though our politics don’t always agree. (My politics are “severely moderate.”)

    My favorite and the one I commented on — curiously, roughly the same concept as this one in that it used simple math to make an important overlooked point — was the comparative EU vs US health economics column you wrote last year.

  11. This is one of the best posts I have seen at this blog. I am going to do something on it at my blog.

  12. If there’s any doubt that the balance of power in healthcare is skewed, this post should clear that doubt right up.

    Preventive approaches *should* start with simple observation: monitor, and record events if/as they occur. In low-risk asthmatics, that should most certainly include NOT medicating, that tack that Al took. Is it CYA medical practice that’s created this behavior, or is it the health insurers “active management” protocols, or is it “ask your doctor about”-itis?

    Al, I gotta get your book. I have a feeling I’ll swallow it whole.

  13. Fred, good question.

    Here’s the rub. The doctor was over-preventing because he was getting his “report card” from the health plan and it said this was one area that should be of focus. (I know that just about for a fact because I had seen the report cards from that health plan. Not his, but others.)

    So when I say “between the patient and the doctor”, I don’t mean that the health plan is prescribing, but rather than the health plan is pressuring the docs to over-prescribe prevention.

  14. Al,

    Nice column pointing out an interesting effect of treating low risk asthmatics. But I would place the blame on your MD and others and their unwillingness to reduce meds. In fact if anecdotes a study make, I have 2 children with asthma, Severe enough at a younger age to cause ER visits, oral steroids, nebulizers for weeks, missed school days etc. They have an excellent specialist, thankfully, but the primary care doc was not aggressive enough. While they were on a boatload of meds at certain times, the specialist has always sought to taper them off as they show improvement, and we review them based upon longer term (6 month or more) changes. They are currently not on any daily meds, but one son takes albuterol pre exercise and has not had a problem in years. We also know their triggers and made certain modifications. I would also point out I know a lot of local children who have asthma, their pediatrician under treats them and they cough and cough, miss school etc. Perhaps no ER visits, but there is more to costs to an individual, family or employer than just the healthcare costs. How about those missed work days when the parent has to get the child from school, take them home or watch them?

    I like your recommendations at the end, seeking optimums, but why would you recommend letting Doctors and patients figure it out when you clearly went against your doctors advice? Or were they okay with that?

  15. The major advantage of a national health database is the ability to analyze and evaluate the cost effectiveness of certain treatments and protocols. Emotion and other subjective measures, in addition to financial considerations, has been the driver of many preventative procedures.

    We are beginning to see more questioning of preventative value for mammography and prostate cancer but the recommendations to reduce the use of these procedures is met with an emotional response. Many still think that medicine is the prevention rather than the response to ALL health issues. I hope that we can apply this same rigor to other disease states and find a way to change perceptions but I’m afraid few let facts get in the way of their feels.

  16. “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.”

    That doesn’t seem to be looking at the entire picture. A trip to the emergency department may cost a health plan $2000, but it is distruptive to the patient, potentially leading to missed days of school/work, unnecessary follow-up visits and, simply stated, suffering. Although one of the issues with emergency department care is cost, sometimes the bigger issue to consider is simply that emergency department care is care that was not planned and that unplanned care is a sign that we aren’t doing our job.

    Thanks for letting me comment.

  17. Every one is going to die. The life expectancy is influenced mostly by baby deaths and those of the indigent.

    The concept of prevention, unless broad based like vaccines for polio, are a total waste of money.

    Medicines are diseases. Just think how many MRI tests have been done to evaluate back pain in patients on the prevention statin therapies.

    The CDS of CPOE devices is another sham that has no proof of benefit, yet provokes the additional therapies that has side affects.

    For instance, every CDS device instigates prophylaxis for deep blood clots, even in patients on placid, aspirin and axelto, but no one is counting the bleeding deaths from helping on the CDS prescribed prevention.