Pre­ven­tive meds at heart of health-spend­ing slow­down

The Columbus Dispatch - - Opinion - Cather­ine Ram­pell Cather­ine Ram­pell writes for the Wash­ing­ton Post Writ­ers Group. Email her at cram­[email protected]­post.com.

Thanks to pre­ven­tive medicine, older Amer­i­cans have health­ier hearts. Which means, in­ci­den­tally, that fed­eral bud­gets are health­ier, too.

At the turn of the mil­len­nium, health-spend­ing growth was spi­ral­ing out of con­trol. Econ­o­mists pro­jected that the al­ready gi­nor­mous health-care sec­tor would soon gob­ble up mon­ster por­tions of the fed­eral bud­get and the en­tire econ­omy. But some­thing strange hap­pened in the past decade and a half.

Rather than rock­et­ing up­ward at lu­di­crous speed, health-spend­ing growth slowed — dra­mat­i­cally so.

That's true whether we're talk­ing about pub­lic- or pri­vate-sec­tor health spend­ing; for Medi­care, Med­i­caid, pri­vate in­sur­ance and outof-pocket spend­ing, an­nual out­lays have been way lower than the dooms­day fore­cast­ers an­tic­i­pated. Cu­ri­ously, too, the sharpest slow­down has oc­curred with Medi­care.

In fact, about three-quar­ters of the health-spend­ing slow­down na­tion­wide was due to slow-as-an-(al­most)trickle growth in spend­ing on the el­derly. From 1992 to 2004, per-capita spend­ing among Medi­care ben­e­fi­cia­ries grew by 3.8 per­cent each year, ad­justed for econ­omy-wide in­fla­tion; since 2005, the rate has been a mere 1.1 per­cent, ac­cord­ing to a new Health Af­fairs study.

So who gets credit? Some have at­trib­uted the spend­ing slow­down to lousy eco­nomic con­di­tions, but the de­cel­er­a­tion ap­pears to have be­gun be­fore the Great Re­ces­sion, and it con­tin­ued long af­ter it ended.

Some have cred­ited struc­tural changes to the health-care sys­tem, in­clud­ing some of Oba­macare's cost-con­trol mea­sures. Maybe bun­dled pay­ments and ac­count­able-care or­ga­ni­za­tions are re­spon­si­ble — though stud­ies so far sug­gest their ef­fects have been mod­est com­pared with the mag­ni­tude of the over­all changes in health-spend­ing trends. What's more, the slow­down pre­dates Oba­macare.

That new study sug­gests a dif­fer­ent cause: Amer­i­cans tak­ing bet­ter care of their hearts.

The study, from a team of re­searchers led by Har­vard eco­nom­ics pro­fes­sor David M. Cut­ler, fo­cuses specif­i­cally on med­i­cal spend­ing for the el­derly. The au­thors be­gan by dis­ag­gre­gat­ing spend­ing into cat­e­gories, based on the con­di­tion a pa­tient was be­ing treated for — cancer, de­men­tia and so on.

The cat­e­gories with far and away the big­gest slow­down in spend­ing were re­lated to heart health. Spend­ing on car­dio­vas­cu­lar and cere­brovas­cu­lar dis­eases (heart at­tack, car­diac ar­rest, stroke, etc.) de­clined by $827 per per­son rel­a­tive to ear­lier trends. Spend­ing on a re­lated cat­e­gory called car­dio­vas­cu­lar risk fac­tors (high blood pres­sure, high choles­terol, di­a­betes) also fell $802 per per­son below the trend line.

Al­to­gether, the re­searchers cal­cu­lated that more than half of the el­derly-spend­ing slow­down was be­cause of slower spend­ing on car­dio­vas­cu­lar dis­eases and con­di­tions. In dol­lar terms, this means the slow­down in car­dio­vas­cu­lar spend­ing growth ef­fec­tively saved the Medi­care pro­gram about $34 bil­lion in 2012 (the most re­cent year of data avail­able).

You can see sim­i­lar re­sults in other health stats. El­derly death rates for car­dio­vas­cu­lar dis­eases, for in­stance, have plum­meted, ac­cord­ing to data from the Cen­ters for Dis­ease Con­trol and Pre­ven­tion.

These are sig­nif­i­cant find­ings, with ma­jor pol­icy im­pli­ca­tions.

The con­ven­tional wis­dom among health-pol­icy ex­perts has long been that pre­ven­tive medicine does not save money. It has other virtues — in­clud­ing, well, mak­ing peo­ple health­ier. That's quite a good thing. But study af­ter study has found that in dol­lar terms, at least, in­vest­ing more in pre­ven­tive care doesn't pay off.

This new pa­per sug­gests that at least when it comes to heart health, that's not the case.

Lower-than-ex­pected car­dio­vas­cu­lar spend­ing ap­pears to be pri­mar­ily due to suc­cess­ful use of pre­ven­tive mea­sures, the au­thors find. Greater use of statins, anti-hy­per­ten­sives, di­a­betes med­i­ca­tions and as­pirin has helped pre­vent lots of ex­pen­sive health events and con­trib­uted to out­right de­clines in hos­pi­tal ad­mis­sions for heart dis­ease and stroke.

"We think that half of the re­duc­tion in car­dio­vas­cu­lar cost growth is a re­sult of more peo­ple tak­ing med­i­ca­tions and tak­ing them more reg­u­larly," Cut­ler said.

Why are peo­ple tak­ing their meds more reg­u­larly? There's more aware­ness of the need for treat­ment, and a bunch of ex­ist­ing drugs went off patent and got cheaper. And in 2006, we got Medi­care Part D, which re­duced out-of-pocket pre­scrip­tion costs for many older peo­ple.

Whether pol­i­cy­mak­ers can du­pli­cate these re­sults for other con­di­tions and pre­ven­tive ther­a­pies re­mains to be seen. But as the coun­try de­bates the mer­its of ex­pand­ing health cov­er­age, these lat­est find­ings are use­ful — and heart­en­ing? — dat­a­points.

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