"Prevention saves money" has become a refrain of managed care, repeated in ads and by HMO executives so often that it has taken on the aura of truth.
This wisdom, the industry's version of "a stitch in time saves nine," is backed by a certain logic: if managed care plans detect illness early and offer good preventive care, patients will remain healthier and will be cheaper to care for in the long term.
Presto! Health and profits are in perfect alignment. Patients get benefits like free immunizations and mammograms, even subsidized health-club memberships. HMOs, which care for patients for a fixed yearly fee, will incur fewer bills.
There is only one hitch: While studies have shown that preventive care is generally good for your health, they have also shown that it often does not save money.
The central problem is that the early detection of many diseases, like high cholesterol and HIV infection, is often followed by a lifetime of costly treatments and drugs. Expensive hospitalizations may only be forestalled. So in many cases, total medical costs actually rise.
"An awful lot of preventive care has no payoff economically -- it actually costs money," said Uwe Reinhardt, a health economist at Princeton University. "If the plans are doing it, they're doing it because they think it gives them a good image. A lot of this stuff is overhyped."
To their credit, HMOs cover more "wellness care" than traditional insurance does -- and marketing departments know that even a small package of preventive services is a big draw.
But health experts say consumers should not rest assured that the self-interest of the HMOs will lead them to provide top-notch early detection and prevention programs. As legislators around the country who are increasingly scrutinizing and regulating the HMOs have found, it does not.
What's more, even in situations where good preventive care might save money in the long run, HMOs often have little incentive to act, since patients tend to change health plans every few years.
"If I run a commercial HMO with Wall Street breathing down my neck and there is an intervention that costs me now but will save me money in 10 years, I won't do it," Reinhardt said. "Or I might do it if it wasn't too expensive and I could parlay it into a perception of quality."
For example, studies have shown that diagnosing and treating high cholesterol in adults will ward off heart attacks and strokes as those patients age. But standard drug treatments for high cholesterol cost more than $1,000 a year, and the big benefits do not accrue for well over a decade.
"If you are a company looking at what gives you a return on your investment, immunizations certainly have a payoff, and smoking cessation in pregnant women is probably also a slam dunk," said Dr. David Plocher, a partner at Ernst and Young, the consulting firm. "But beyond that, our conversation is over. That's it."
Many HMO executives insist that the payoff of a well-designed prevention program is higher.
Studies at Group Health of Puget Sound, an HMO in Seattle, found that smoking cessation programs and mammography screening could be cost-effective, particularly when targeted at the groups most likely to benefit.
Dr. Neal Sofian, an expert in preventive medicine who was until recently at Group Health, said great cost savings could be realized if a diabetic smoker could be made to quit, since such patients have astronomical rates of strokes and heart disease.
But even within the managed care companies, many advocates of prevention programs acknowledge that the financial benefits are overrated.
"I've been trying to promote prevention for years," said Dr. Robert G. Harmon, the medical director of prevention plans at United Health Care, which owns 45 HMOs nationwide. "But we really have to be specific that in some cases it costs more that it saves."
Still, Harmon said managed care plans considered these services a "good investment that we should be making" because of the health benefits to patients. He added that the company's market research had shown that prevention programs were very important to subscribers.
Sofian said many valuable preventive services could never be justified on the basis of cost, and he was chagrined that some health care providers think about them in these terms. "You don't hear people asking about the cost benefit of a heart-lung transplant," he said. "You don't do it because it saves money. You do it because it's the right thing to do."
Health economists say managed care plans that regard economics as the driving force behind prevention tend to offer preventive care that is low cost (like rebates on the purchase of bike helmets) or high profile (like mammograms).
Moreover, prevention programs advertised in glossy brochures sometimes have little substance, they say. The stop-smoking program at one large HMO consists of a prescription for a nicotine patch -- the cost of which is not covered by the plan -- and 12 follow-up letters.
"For some companies this has become a marketing strategy as opposed to a medical strategy, and that gives prevention a bad name," Sofian said.
He and others predicted that managed care plans would improve their wellness care not because "prevention pays," but because employers would demand it.
Consider smoking cessation, for example. While patients who quit reduce their risk of heart disease, cancer and respiratory ailments over time, they also live longer and so are more likely to experience the complex medical problems of old age. Their lifetime medical costs actually rise.
But the economics of smoking looks different to the employer, who loses valuable employees to death or disability and bears the costs of sick days and smoking breaks.
In some instances, prevention and early detection are so uneconomical that managed care plans are unlikely to act without significant prodding.
Doctors now urge that people at risk for HIV be screened for the virus since there are now effective drug treatments to delay progression of the disease. But these drugs cost more than $10,000 a year.
Susan M. Dooha, a senior policy analyst at Gay Men's Health Crisis, said doctors in health maintenance organizations were not taught or encouraged to screen members for the virus.
And subscriber booklets rarely mention programs for testing, even in areas with high rates of the disease. "Not all prevention is cheap -- the plans don't treat all preventive services the same way," she said.
"Realistically, the only way a plan is going to screen for HIV is if an employer said, 'We won't offer you as a plan unless you do it,' " Reinhardt said. "From a purely economic standpoint, the smart strategy is not to screen, because a quick death from advanced AIDS is far more profitable than the long drawn-out maintenance of someone with early HIV."
Copyright 1997 The New York Times