Does Preventive Care Save Money?

OK, the perspectives piece "Does Preventive Care Save Money? Health Economics and the Presidential Candidates" does raise an interesting question. 

In this case, the authors have raised the question based on the hypothesis that the statements and claims being made presidential candidates are perhaps a bit too broad.

Maybe.  I actually think this was a pretty crappy article overall...I get the point.  But it really trashes prevention in the areas where there are huge savings (brushing over the economic impact of some high-impact USPTF recommendations).  I also think it doesn't go far enough in telling the hard truth for docs and the public:

• Not all "screening tests" currently in use meet the criteria for ideal screening tests.  
• Screening tests should be use appropriately.  The authors say that "...screening costs will exceed the savings from avoided treatment in cases in which only a very small fraction of the population would have become ill in the absence of preventive measures."  Well, then, this doesn't quite meet the criteria for the ideal screening test.  The 80-year-old man doesn't need a PSA, and his wife doesn't need a pap smear.  Similarly, people shouldn't be ordering CA-125 tests for women to screen for ovarian cancer.  Strap on some balls, and tell your patient they don't need the tests.
• The public tends to think we have the ability to detect anything early and cheat death if it's caught early.  As a society, we need to get a grip on our mortality, and on what is and is not possible.
  
• The concierge physical market isn't doing any favors here.  Lots of high-cost tests without proven outcomes set the expectations for all patients that they need these things when, in fact, they may actually cause harm
  
• People need to be clear on the definitions of primary care and prevention.  Yes, prevention is part of what we do.  But it's not just prevention of heart disease, it's also prevention of the avoidable ER visit or hospitalization.  Access to primary care is clearly tied to reductions in these areas.
  
• Everyone is dancing around the fact that we'll have to ration resources more.  No, Mr. Johnson, you can't get a fucking MRI for your back given your symptoms.  And no, you can't fucking sue me for saying so.  (OK, so the candidates are just trying to get into office right now...but someone's got to be saying it!)

The authors actually provide some misleading information.  Although they didn't list the 279 preventive measures that they refer to, the authors do present some of the measures used in their tables.  The quality of some of the studies used for the analysis is really shoddy.  Take the "high" versus "low" intensity smoking relapse-prevention programs, for example.  The high intensity program sent 7 mailings to patients, while the low intensity approach sent one single booklet.  First of all, neither approach works that well!  If it were to be compared to a more effective approach (regular access with a primary care physician, support groups, etc.), I wonder if the results would be different.

And screening for medium chain acyl-coenzyme A dehydrogenase deficiency in newborns?  Since when is that a useful screening test worthy (in terms of ideal screening test criteria) of application to all patients?  I think the real issue here is that when it comes to babies, people have a real hard time rationing care (not to mention the medico-legal pressures).

It's not a horrible article.  It raises a point.  But don't fucking dance around the issues.  This is a perspectives piece, and some leeway is allowed.  We're not doing the public any service by sugar-coating the real issues.