By Franco Sassi and Jeremy Hurst
Organisation for Economic Co-operation and Development
OECD Health Working Paper No. 32
March 25, 2008
Abstract:
This paper provides an economic perspective on the prevention of chronic diseases, focusing in particular on diseases linked to lifestyle choices. The proposed economic framework is centred on the hypothesis that the prevention of chronic diseases may provide the means for increasing social welfare, enhancing health equity, or both, relative to a situation in which chronic diseases are simply treated once they emerge. Testing this hypothesis requires the completion of several conceptual and methodological steps. The pathways through which chronic diseases are generated must be identified as well as the levers that could modify those pathways. Justification for action must be sought by examining whether the determinants of chronic diseases are simply the outcome of efficient market dynamics, or the effect of market and rationality failures preventing individuals from achieving the best possible outcomes. Where failures exist, possible preventive interventions must be conceived, whose expected impact on individual choices should be commensurate to the extent of those failures and to the severity of the outcomes arising from them. A positive impact of such interventions on social welfare and health equity should be assessed empirically through a comprehensive evaluation before interventions are implemented.
Paragraph 171 (page 61):
Tackling major risk factors for health, or chronic diseases linked to behaviours that are highly prevalent in a population, requires more than a single preventive intervention, however effective and broadly based it may be. Turning the tide of diseases that have assumed epidemic proportions during the course of the 20th century requires fundamental changes in the social norms that regulate individual and collective behaviours. Such changes can only be triggered by wide ranging prevention strategies addressing multiple determinants of health, strategies that are likely to develop incrementally, rather than through comprehensive planning. Although the contribution and cooperation of many agents is needed for the success of a prevention strategy, none of the agents potentially involved, at any point in time, is in possession of the information, the tools and the power required for the comprehensive planning of chronic disease prevention, and none of the agents is able to take a sufficiently long time perspective in its action to make such an approach possible. Social norms cannot be engineered. They set the boundaries and the rules for a complex interplay of conflicting interests which we have interpreted here, using the tools of economics, as market dynamics. At the same time, it is precisely that interplay of interests that progressively adapts and changes social norms.
http://www.oecd.org/dataoecd/57/14/40324263.pdf
Comment:
By Don McCanne, MD
“We are not going to control health care costs until we change from a health care system focused on treating disease to a system that focuses on prevention.”
How many times have you heard that statement? It’s everywhere – in questions from audiences at community forums, in letters to the editor, in op-eds, in communications from advocacy organizations, in the ubiquitous blogs throughout the Internet, and everywhere else. It even appears in the health policy literature – often in the form of reducing spending through disease management by preventing the complications of obesity, diabetes, hypertension, and other disorders.
Before addressing this report, let’s acknowledge that everyone agrees that prevention of disease and injury is far better than treating it after it occurs. Efforts to promote prevention are crucial to maintaining and improving the health of the people of the nation.
Accepting the health benefits of prevention as a given, there are two other questions to be addressed as we sort out the proposals to reform the financing of our health care system. First, does the health care delivery system provide the appropriate infrastructure for providing the interventions that would prevent injury and disease? Second, assuming that it does, would these interventions be effective in controlling health care costs, making health care affordable?
So what answers does this OECD health working paper provide to these questions?
It is important to understand what this paper is. It is a highly technical discussion of the economic framework of the prevention of lifestyle-related chronic diseases. The issues are very complex. If you really want to understand the economics of prevention, I would recommend reading the entire paper (78 pages). At a minimum, you should read the conclusions, pages 57-63.
What will become evident is that the statement that we must change the emphasis from treatment of disease to prevention really does not have much applicability to the topic of reforming the financing of health care, when one of our most important goals is to ensure that health care will be affordable for present and future generations.
In answering the first question posed, the paper demonstrates that prevention is complex function involving the interaction of government and private sectors of our society. Although the health care delivery system plays a role in prevention, it is comparatively minor. Most interventions would occur outside of the health care delivery system.
For the second question, interventions within the health care delivery system can have only a very minor impact on total health care spending. Further, it is not at all clear as to whether that would reduce or increase our total national health expenditures.
It is important that both government and the private sector invest in prevention, simply to improve the health of our nation. But we must not allow ourselves to divert the national dialogue from the other important goals of financing reform to a non-productive debate over the theoretical cost savings from prevention.
This paper is important to policy advocates since it will arm you with the confidence to reply to questions about and proposals for prevention. It is also a paper that you can recommend to individuals who are locked into the concept that health care reform is all about prevention. You can show that that prevention is crucial, but that it alone does not adequately address the very important issue of making access to the health care delivery system affordable for everyone.
