Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, November 11, 2008

Prevention Myths

Preventive care saves money.
Wrong; wrong and...wrong!

This has been pointed out over and over in the blogosphere and other places in the media. It is not true. Prevention can be damned expensive, as the latest addition to the medical literature demonstrates. The Jupiter study, paid for by the makers of Crestor, the most expensive statin on the market, is pretty darn convincing from a statistical point of view. Dr. Wes and others point out, though, that the impressive risk reductions seen come at rather a significant monetary cost; to whit, $213,000 to prevent one cardiovascular event, by Dr. Wes' (corrected) calculations. Happy the Hospitalist then goes off on a tear about "Should America pay $1,400 a year per person per year to prevent an event that lifestyle changes can do far better, for free?" A straw man argument if ever there were one, because of course other lifestyle changes are free, but presumably what the Jupiter study showed was that Crestor reduced cardiovascular risk even further.

Although "Prevention" does not save money -- in fact, it can be quite expensive -- the question remains "Is it worth it?" Because we live in the United States, each individual gets to make that decision for him or herself. Because guess what, Happy, you aren't paying for anyone's Crestor but your own. Whether or not an insurance company chooses to cover the drug for low-risk patients is also an individual decision. Hell, I'd probably offer my patients cheap generic statins, because so far just about every benefit turns out to be a class effect. $40 a year ($10 for a 90-day supply) for simvastatin at Target? To halve the risk of a cardiovascular event? I bet Happy (and most other active people) pay more than that for shoes in one year.

Just to make it even more convincing, though, I looked at Dr. Wes' numbers and found them a little unrealistic:
  • $250 for LFTs? Quest charges me $12; I charge the patient $20.
  • $150 for lipids? My charge is $35.
  • Knock the statin cost down to $40 a year
Here's how it adds up now:
  • Lipid level evaluation ($35 per test x 5 years) = $175
  • C-reactive protein level ($20 per year x 5 years) = $100
  • Annual liver function tests: ($20 per test per year x 5 years) = $100
  • Annual statin costs ($40 per year x 5 years) = $200
  • Number of people needing to be treated over 5 years to prevent one cardiovascular event: 25
More than an order of magnitude less, and it actually comes down to less than $100 per person per year. Add in a good pair of running shoes for that exercise regimen, and you're still talking less than $20 per month; way less than what most smokers spend on cigarettes.

Look, I agree wholeheartedly with HH and others that people need to take more responsibility for their health. But you have to admit that the ones eating those McBypass burgers from the drive-through on their way to buy cigarettes to go sit on the couch watching TV are NOT the ones beating down our doors looking for the latest and greatest ways to cut their cardiovascular risk. But for those conscientious patients paying their own bills who are looking to optimize their health, you have to admit this is an exciting study.

Preventive care does not save money. Never did; never will. Just because lots of people make the claim doesn't make it true. Preventive medicine needs to be looked at for its own sake instead of strictly from a financial point of view. The whole concept of risk is an individual one: you may not mind going out in a thunderstorm knowing that the risk of being struck by lightning is remote; your little sister may cower inside in terror. Preventive medicine is, at its heart, the exercise of reducing risk. Just don't go about it thinking you're going to save money.


At Tue Nov 11, 04:43:00 PM, Anonymous Anonymous said...

1. I believe you left out the costs of physician visits, both for ordering or reviewing the normal labs and prescribing the statins, as well as the inevitable visits to discuss the incidental elevated transaminases or mild to moderate myalgias that many patients get from statins. Generalist docs don't get paid much but most of us won't be managing CRP based statin programs for free.

2. In the coming age of mandated private or single payer "insurance", you will be paying for everyone else's Crestor (and CRP and liver tests, etc.).

At Tue Nov 11, 06:42:00 PM, Blogger DrWes said...

You forgot the five additional patients that would have to be "screened" for C reactive protein to identify an "appropriate" cohort to treat. Also, can we be so sure that simvastatin will offer the same effect when the drug is applied to such a large population? What about the diabetes that you might induce with the prescribed therapy? Worse, what about all those "healthy" people that you've now classified as "sick?" What will happen to their insurance premiums?

This prevention issue is not so cut and dried as we might like to think. The use of CRP to screen patient remains controvertial due to its VERY HIGH false positive rate (note that all patients with arthritis, renal disease, etc were excluded).

Finally, when we apply your stated costs (that exceed the average annual TOTAL insurance premium for the average person in America, by the way) to the population as a whole for ONE sole prevention measure, will anyone want to pay for their colonoscopies, mammograms, and other "prevention" measures?

I doubt it.

I must say, though, that I'm impressed with your blood test costs and your minimal markup.

Thanks for offering your take on this - it's refreshing as always.

Now, if you'll forgive me, I have to get back to screening patients with my CT to assess their calcium scores...

At Wed Nov 12, 11:36:00 AM, Anonymous Anonymous said...

Most doctors do not give such good rates on tests as you do or do not test in the office at all. So, your figures are valid only for your practice and can not be extrapolated to the whole profession/population.

There are other problems with this study if you read more about it rather than just the hype. They used relative risk rather than absolute in determining the benefits and didn't give enough attention to the increase of diabetes in the Crestor segment.
Stopping the study early (imho) was only done to be able to use the "good" results to sell more statins.

The fact that Jupiter was paid for by AZ also should give one pause to consider the possible machinations...

At Wed Nov 12, 08:57:00 PM, Blogger The Happy Hospitalist said...

I Have A Solution

At Wed Nov 12, 10:02:00 PM, Anonymous Anonymous said...

will all these people be retired or not-working?

Heaven forbid that you should count in time off of work to appear for these visits and lab work.

Plus, as a writer on another blog pointed out, once you start taking these pills insurance companies consider you a risk and any hope of being underwritten is dashed.

I still want to know what effect visiting your dentist regularly and reducing gum disease would have. Then at least you end up with teeth, which are preferable to just a bunch of empty pill bottles.

At Thu Nov 13, 12:43:00 AM, Anonymous Anonymous said...

For what it's worth: Merrill Goozner at noted

"...the first thing you need to know about this trial is that its lead investigator, Paul Ridker of Brigham and Women's Hospital in Boston, owns a patent on the $20 test that measures CRP, and the trial was funded by AstraZeneca, whose $3.45-per-day or $1,250-per-year statin (rosuvastatin or Crestor), was used in the trial. If they can get two million more "apparently healthy men and women" on rosuvastatin, it's an additional $2 billion-plus in sales for AstraZeneca. If they can test 10 million people to find the estimated two million with elevated CRP levels (they had to screen nearly 90,000 people to find the 17,800 eligible for the trial), it's $200 million in test sales, which, if the royalty is only 1 percent, amounts to a hefty $2 million a year in extra income for Dr. Ridker."


At Thu Nov 13, 11:37:00 AM, Anonymous Anonymous said...

Not disagreeing with your main point, but the study singled out crestor, NOT statins. My plan charges me $10 copay for most statins, but $40/mo for crestor.

At Thu Nov 13, 07:15:00 PM, Blogger Pem said...

Another take on the Jupiter study is here:

No written by me--I just like Jenny's work.


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