Prevention Pros and Cons
Once again, I'd like to thank all of you regular contributors that keep this blog going despite my occasional respite. Of all the health care blogs and even non-health care blogs I've visited, this one has the most ongoing contributions. Kudos to all of you for the great input.
The readership continues to grow and I'll be looking at additional ways of bringing more opinion to us. Welcome to Dazzo and a welcome back to Lurker. We all look forward to hearing more from you as well as from our very informed regulars.
Recently I've been struck by the emotional and divided response to President Obama's call for health care refrom in the US. Various individuals and groups on both sides of the discussion have been vilified from time to time and it just doesn't seem like a very tolerant way to go about debating or advancing improvements in health care.
Can't we just get along and allow individuals who want to spend on their own health care to do so whether through health savings accounts, tax free savings accounts, or transgenerational insurance or other?
Can't we just agree to disagree and then let individuals find what works best for them? We've done this in many areas. Why not in health care?
One of the biggest criticisms of Canadian health care recently is that there isn't enough government money spent on prevention and wellness--we are disease oriented in terms of providing health care. That's a fair criticism but look a bit deeper and it may be surprising to find that prevention won't save health care dollars which is why there are discussions about health care reform in the first place. If there were sufficient funds to cover everything for everybody, there would be no debate or even need for reform.
As much as there are many people devoting much time and energy to the promotion of better health and health outcomes, we need to be honest about the cost of such programs. It seems that the underlying premise is that more prevention will save health care dollars. But such may not be the case.
We should first mention that there is a difference between individuals being in charge of their own prevention and taking responsibility for their actions or inactions versus government funded health prevention programs that take into consideration mass screening, large amounts of pharmaceutical use, and a large scale push toward incentives and pay for performance for providers.
As much as prevention would seem to offer up cost savings, the potential outcome of more government organized screenings and primary care prevention at the provider level (and here I make the distinction that the latter should be seen as separate from public health type policies that allow for clean water, improved sanitary conditions and clean air and environmental awareness) to cost more, not less, is quite real.
I will post the link to the Congressional Budget Office and its information on overall cost savings on prevention in health care and also the link to the letter that is mentioned.
Now some of you reading will think that I am a real dope and that I don't believe in prevention. That is not the case. I do believe in prevention. It's just that I don't believe prevention will save the health care system in Canada any money. It will cost MORE. Let me repeat that. Prevention will cost MORE.
On an individual level, better prevention of all kinds will provide improved quality of life. However, costs of health care prevention measures must be weighed against the need for improved education for Canadians as well as the need for more social programs such as adequate housing for dependent individuals amongst other important and urgently needed public health improvements.
The idea that more prevention will keep down health care costs is just wrong. It certainly deserves its place but preventative health care needs to be seen for what it is...an individual decision requiring individual responsibility.
Thanks for reading and for your most enlightening contributions as always. I am most grateful for your support.
Merrilee Fullerton
208 Comments
Reader Comments (208)
http://cboblog.cbo.gov/?p=345
http://www.cbo.gov/ftpdocs/104xx/doc10492/08-07-Prevention.pdf
http://www.economist.com/businessfinance/displaystory.cfm?story_id=14120903
http://www.healthleadersmedia.com/content/237754/page/1/topic/WS_HLM2_TEC/Docs-Say-Goodbye-to-Bureaucracy-Hello-Health.html
someone who agrees with me...or not
http://online.wsj.com/article/SB10001424052970204005504574235751720822322.html
http://www.economist.com/research/articlesBySubject/displaystory.cfm?subjectid=348945&story_id=14257705
yes, those smart phones are going to change how we do health......only an antiquated, feed at the trough government bureaucracy would be spending $25,000 on speeches and billions on EMR development that is relatively unfruitful. And I see that we are still looking to have 100% EMR by 2015 or sooner...ha ha. Let's make a game out of it and have a pool for who can make the closest guess to how many billion this will take.
Don't forget, the more data created, the more management required, the more action must be taken. A vicious circle don't you think...and the patient is at the vortex not having a pleasant experience.
http://thefirstcanadianhealthcareconference.ca/index.php?/Euro-Canada-Health-Consumer-Index
http://www.fcpp.org/main/publication_detail.php?PubID=2779
My educated guess is that we will be having that discussion within the next decade...our system just isn't sustainable. We may not have the discussion outright. It may just be that new treatments and new pharmaceuticals are just not added to the covered list.
An interesting case is new infertility treatment. I see that a well-educated couple are claiming discrimination for not being eligible for government coverage for their infertility treatments. Two professional people who could afford the treatments can't see past their own sense of entitlement. Quite depressing and cracks open the whole issue of what is "medically necessary".
Where do we go from here?
Makes you wonder, if our health care is increasingly unaffordable, then who will be able to benefit from things like stem cell research? Will it only be for Bill Gates and his ilk?
Imagine being able to regenerate heart tissue using stem cell innovation or grow new kidney tissue. It means that society is going to have to make some very difficult decisions as people are able to live longer and longer.
Perhaps a situation where one covers more primary health care out of pocket and then uses additional insurance for the "organ regeneration" situations.
Just look at cord blood banks. People pay to store their children's stem cells. Is there a government bank? Not sure, but I"ll check.
One other thing that is of interest: If suddenly everyone signed their donor cards and organs were suddenly available to all who needed them, we couldn't afford the cost of all the procedures. No surprise that in Ontario, the MOHLTC didn't field the concept of funding private clinics to do hip and knee replacements with public money for very long. I doubt that it could afford the cost of the increased access.
Perhaps there will be a lawsuit soon requiring government to fund this kind of "care" as well.
http://www.cordbloodbankofcanada.com/sign.html
I take this to mean that there isn't a public cord bank currently.
http://www.cbo.gov/ftpdocs/104xx/doc10453/08-13-VHA.pdf
presence of such a system does not ensure those outcomes.
One team of researchers used two national surveys to examine ambulatory care visits to providers who used electronic health records and those who did not.82 The
researchers considered 17 ambulatory quality-of-careindicators. They found no correlation between the use of electronic health records and the quality of ambulatory care for 14 of those indicators, better performance on 2
measures for practices using EHRs, and worse performance on 1 measure for practices using EHRs. Some practices may be using EHRs that do not incorporate clinical decision support and quality reporting features.
The authors conclude that the diffusion of electronic health records may not be associated with overall improvements in quality unless policymakers encourage
the adoption of EHRs specifically designed to improve health care quality.
In addition, developers and users of electronic health records systems must remain vigilant for possible software errors and other problems that could have negative effects on the accuracy of the information presented to providers or patients through the various health IT components.
Proper design and testing of health information technology is crucial—a poorly designed or inadequately tested
electronic health record can lead to inappropriate drug treatment or even worse outcomes. For example, VHA
rolled out an update to its VistA software in August 2008 that sometimes displayed medical information for a patient under another patient’s name and sometimes failed to clearly display a doctor’s order to stop administering a drug or other treatment. As a result, some patients were given incorrect doses of medications or were treated for longer periods than physicians had
ordered. VHA instituted new safety measures until the errors were fixed. Although the potential for serious injury existed, there is no evidence that any patients were harmed."
those pharmacists are going to be busy!! syringe in one hand, Tamiflu in the other....
It seems that the government line is that pharmacists will be the solution.
http://nhsblogdoc.blogspot.com/
The longer patients live, the greater the cost to the state in particular after retirement....prevent one disease, postpone death, and the patient develops other disorders and eventually succumbs to something else over time...noone will leave this planet alive unless they join the space programme.
The state is aware of the fact....and happily take their cut from the sin taxes.
Preventive care is politically sexy however and provides lucrative jobs for the health care bureaucracy as well as the whole preventive care/wellness industry.
My own vocation is in disease detection and its treatment....the well bore me.
It would appear this effort will run $2,000,000,000.00 or so to run out. The anticipated savings to health care operations are unknown.
Hoefully, at the end we will get a evidence based measurement of cost effectiveness of this strategy. Or will we get platitudes of "we did well but can't effectively measure how well we did in this complex field"
mfO, are you suggesting that the H1N1 "prevention" will cost approximately 2 billion dollars?
Strange, as much of what I have seen to date is lack of leadership on this front. Gosh, even the local high school won't let the kids have hand sanitizer...apparently it is highly flammable and they fear fire more than influenza. Teachers tell me that they have received no direction or information from anyone in public health. If this is true, it is very unsettling. Essentially, groups such as schools are simply to make up their plan with no guidance.
What is costing 2 billion?
These programs are not cheap.
The number of doses is enough for all Canadians who want and need to be vaccinated against the H1N1 pandemic virus, said Dr. David Butler-Jones, chief public health officer of Canada.
The total cost will be more than $400 million, Butler-Jones told reporters."
How cost effective will be a vaccine that arrives "after" the second wave goes through Canada's largest city.
As for who should administer the vaccine where are the creative thinkers in government? Argentina used the final year med students and I'm sure final year nursing students would be glad to help as well. I had a retired public health nurse who said she would gladly come out of retirement for a couple of weeks to help administer vaccine. If the government can't even figure out how to administer the vaccine promptly then we are in big trouble.
Are you suggesting that the H1N1 vaccination program may be a preventive shell game to show the well meaning political attention of health care managers but with no liklihood of "value" to the public from a cost effective point of view. How cynical!
At want point do the risks of vaccination that is not rigorously tested and perhaps being provided too late outweigh the benefit?
That is a tough call but I hope that political optics are not driving the vaccination bus.
Having a vaccination ready by Sept. or Oct. does not seem to be in the cards. If many people including well young people have already been exposed to a mild case, then it would be very helpful to know before they are unnecessarily vaccinated with something that could pose them greater risk than the illness.
Does make me wonder who is driving the bus and why some sharp biotech company hasn't come up with a process to provide quick testing. Maybe that is in the works. Seems Ottawa could be a hub for that development.
From a different perspective, an influenza pandemic would mean, I think, that provision of care would not be as usual. ie In the midst of a pandemic is it not reasonable to expect an atmosphere other than business as usual? Patients with follow-up appointments for their BP or who need a PAP test may just wait until the pandemic passes. This in itself would free up some human resources to assist with vaccination.
During the SARS crisis in TO, people stayed away from doctors' offices and from hospitals in droves.
It is expected that hospitals will see approximately 20% more cases overall. However, if the public sees the pandemic as serious and life-threatening, the usual pattern of ER visit and office visits could change significantly.
Tough to predict but I would hope that it wouldn't be business as usual either in the ER, in the various clinics or in doctors' offices.
Smart companies have figured this out years ago and have not waited until know to form a "plan".
And word as to whether the powers that be will cover our our medical colleagues insurance and disability wise if they succumb to the H1N1 or any other viral condition as they toil in the trenches this autumn?
The declaration in the recent nurse/SARS court case that the government owed no duty of care towards those of us in the trenches is troubling...the fact that the CPSO believes that we in the trenches have a duty of care towards the state and that the state hasn't any duty of care towards those it orders about don't, doesn't bode well for morale in the trenches.
Does the CPSO itself not have a duty of care towards the medical profession...or are we all to be ordered to behave as sacrificial lambs, hurling ourselves onto the flames for the "common good"?
I gather it is we,in our office trenches who will have to supply our own masks at our own expense...and for patients as well.
Don't we in our FP offices have a duty of care towards our own staff... isn't it our responsibility to tell them to stay in their homes...in particular if they have school children to care for, if the schools themselves close down?
https://h1n1study.oahpp.ca/Pages/home.aspx
Efforts are in place to try to understand this potential issue on the Canandian and Ontario population. Best guess splits, of course, into two extreme camps - its' bad and thousands will suffer - versus no effect stop scaring the public. Likely, it falls in the middle.
The good things (maybe) - lots of "tracking" going on, lots of communication at least among the "trackers", some discussion involving getting a vaccine out (and money has flowed).
Most interesting, this is a further example of why health care costs won't ever come down - this is a substantial investment for a problem that may never exist. In the old days, this stuff came and went as part of "life"; now we prepare and "pretreat" for an illness that isn't here, and we can't reliablity predict how many will be "adversely" affected. The cost per QALY can't be measured - as we continue to add these costs to "health care", our systematic costs will rise, and will become more politically driven. We continue to add "predisease" programs that we really can't measure, and we know likely are not cost-effective, but certainly are "feel good".
Appears we will hit 60% of Ontario's budget into health care by 2018.
Frustrating to see how much breast beaating this is engendering. The cost estimates are enough to build 2 new hospitals or fund 8 of them for a year.
and more of these decisons about allocation of resources are to come, H1N1 is a good learning experience of the new future resource draw decisons that will have to be made off the limited public purse. Treat "disease" that could occur and we might prevent; or deal with waiting lists and current "need".
http://theburningplatform.com/groups/quinns-daily-dose-of-reality/discussions/how-to-get-banned-from-wal-mart
Before having satellite technology we also did not have the capability to track an incoming hurricane for a week prior to it hitting out east coast. We saw hurricane Bill with its large eye bob and weave in direction meanwhile intensity rose to catagory 4 yet when it finally hit land it was down to a category 1. The impact was minimal. People accept and understand that you still must make preparations for a category 4 storm even though in the end Bill was a bust, however the population still remembers Juan in 2003 which caused great damage.
Flu preparations and the resulting costs are nothing more than purchasing an insurance plan. One hopes not to have to use it. We prepare for the cat 4 scenario and spend the cash but hope for a tropical storm and breath a sigh of relief when that is all that arrives.
It may be more accurate to compare to West Nile which threatened to emerge and then went west literally and south figuratively.
In this case H1N1 money is being spent for a vaccine that is going to arrive too late and may cause more direct harm than benefit.
I would agree with your vaccine assessment however I suspect the problem is not with the vaccine per se, but the fact we did not read the fine print or understand the implications of using a new adjuvant when drawing up a contract with GSK.
GSK said sure we can produce X number of doses for the country, but why did we not negotiate a production time line including penalties for late production. It has been delayed once now due to bottle necks in filling the vials. The entire adjuvant issue is something we could have easily avoided (as the US has done) if the powers that be understood that with the Internet concerns over squalene oil would disseminate to every corner of the country and result in lower, probably quite substantial, vaccine uptake rates by the population. Then we have the debacle of the planners not taking into account the quantity of manpower needed to administer the vaccine to millions of people over a short time frame.
It sounds like GSK was running the show and the government planners just accepted the company's material data at face value without any real due diligence undertaken. Look what happened when our police forces accepted Taser's technical data sheets are face value without proper testing before using them outside healthy police volunteers.
The USA and Australia are much further ahead with their vaccine development and neither will have to deal with uncertainties over using a new adjuvant on young children and adults in an era where Oprah and her guests inform the masses on issues of vaccine safety.
just the name of the journal is telling about future health costs...
There is also some discussion about using Tamiflu prophylactically....some in the know are saying that it should be used for front line providers before exposure....
Lots and lots of unknowns.
http://emruser.typepad.com/canadianemr/
http://healthmgmtrx.blogspot.com/2009/04/demand-check-supply-nope-42-want.html
hmmmm....how many billion dollars will it take?
where have you heard this before?
Labour input: A drag on potential output growth
For the past 30 years, Canada, like some other nations, has been sailing with a favourable wind at its back. Potential output has increased fairly steadily at about 2.7 per cent per annum, largely because of long-term increases in labour input – that is, the total hours supplied by the labour force. Since 1977, trend labour input – a function of population, the labour force employment rate, and the change in average weekly hours worked - has grown about 1.6 per cent annually. Some key factors here have been the growth of the working-age population as baby boomers reached working age and, to a lesser extent, the increased participation of women in the labour force.
Over the next few years, these trends will begin to lose steam. Those on the leading edge of the baby boom are now in their 60s. Growth in the working-age population is slowing, and participation rates are declining. As these changes work their way through the population, they will have a dampening effect on trend labour input.6 As well, the dependency ratio is likely to double over the next 20 years.7 The demographic challenges that we have been worrying about for years have started to arrive.
Immigration is not likely to diminish this challenge significantly. Even a large increase in immigration would be unlikely to provide a major offset to the projected downward trend of labour input.8
How will these trends be affected by the financial crisis and recession? One potential mitigating factor is the negative wealth effect that households have experienced over the past year. This loss of wealth could lead some older workers to defer retirement or even to re-enter the workforce – and there is anecdotal evidence suggesting that this may be happening. But our estimates suggest that such an effect is likely to be small – perhaps 0.1 or 0.2 percentage points for one to three years into the future. In the larger scheme of things, it is thus unlikely to provide any significant offset to the projected long-term decline in labour input.
Working in the other direction, the recession has resulted in sharply higher unemployment, and some of that unemployment may persist. During recessions, long-term spells of unemployment become more prevalent, and such spells can impair workers' ability to find other jobs. Some workers become discouraged and drop out of the workforce. Scenarios from the OECD suggest that such longer-term unemployment will dampen potential output growth in Canada as well as in other countries over the next few years.
In sum, the recession has not altered the basic situation: The favourable conditions we've had over the past decades are no longer with us – and indeed, we are about to face some headwinds. This sobering outlook for the likely evolution of labour input leaves one other possibility for boosting potential output: improved labour productivity.
Labour productivity: The key to increased living standards
Compared with other countries, the growth of labour productivity in Canada over the past decade has been disappointing. After some promising signs of improvement in the late 1990s, average labour productivity growth from 2000 to 2008 has been only about 1 per cent, well below the 2.6 per cent level achieved in the United States over the same period. Canada's productivity ranking has gone from third out of 20 countries in the OECD in 1960 to 17th out of the current 30 members.
What accounts for this disappointing performance, and is it likely to continue beyond the recession? Three factors help to explain the situation. First, relative to other countries, especially the United States, workers in Canada have lower amounts of capital with which to do their jobs. But particularly striking is the fact in Canada, Information and Communications Technology (ICT) capital is half the amount per worker in the United States. A study by Andrew Sharpe reveals that Canada's ICT investment gap relative to the United States is not primarily related to industrial structure and firm size; in fact, the gap exists in most industries.9 This is important because ICT capital investment has been linked to stronger multifactor productivity growth in many countries, as firms reorganize their workplaces to take advantage of new technology. Bank of Canada research suggests that the contribution of ICT capital to productivity growth over the first half of this decade has been considerable.10
A second, and related, factor is Canada's poor record on innovation. In a recent report, Peter Nicholson concluded that "too many businesses in Canada are technology followers, not leaders" and stressed the need for "innovation-based business strategies."11 Canada stands only 16th within the OECD in the intensity of business research and development. Moreover, this situation exists despite the fact that Canada would appear to have all the ingredients needed for innovation: a highly educated work force, flexible labour markets, and high rates of firm entry and exit.12