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Dispute widens on merits of health tests

Peter Neumann, director of the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center, is one of the authors of the study on health care cost effectiveness. Peter Neumann, director of the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center, is one of the authors of the study on health care cost effectiveness. (Jonathan Wiggs/ Globe Staff)
By Michael Kranish
Globe Staff / August 17, 2009

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WASHINGTON - One of President Obama’s favorite arguments for his health care overhaul plan is that he would require insurance companies to pay for tests and other preventive care that can determine whether a person has a life-threatening disease. “It saves lives, it also saves money,’’ he said at his town hall meeting last week in New Hampshire.

But things are not that simple. While cholesterol tests, cancer screenings, and other preventive measures can save lives, there is strong disagreement about whether they really reduce health care spending, because the tests themselves are costly and often lead to more doctor’s visits and procedures. And now, that longstanding medical debate has become a big political sticking point.

The Congressional Budget Office, a nonpartisan agency that estimates the cost of legislation, said this month that expanding the use of preventive measures and screening tests would actually lead to “higher, not lower, medical spending overall’’ - a finding that gives Republicans ammunition to oppose the president’s proposal.

Moreover, the CBO suggested that if the tests do save lives, that could also cost the government more in other areas, by extending lives and increasing the time elderly Americans rely on Social Security and federal Medicare insurance.

This is not an abstract debate. Obama has demanded that his health care bill not add to the national deficit, and lawmakers struggling to find ways to pay for the program - which some estimates have pegged at $1 trillion over 10 years - had hoped strong prevention and testing programs contained in legislation would produce savings.

Now lawmakers and advocates are scrambling to justify those claims. One advocacy group, which represents companies that make MRI machines, CT scanners, and ultrasound units, says that the CBO’s action could lead to a decline in the availability of medical testing.

“We just think it is wrong-headed,’’ Eric Hoffman, a spokesman for the Access to Medical Imaging Coalition, said of the CBO report. He said members of the coalition are concerned that payments for tests will be reduced, which in turn will lead to fewer available tests.

Challenging the CBO’s conclusion, Hoffman said widespread testing would save money overall by catching diseases early and reducing serious hospitalizations, although he said no specific valuation is available. “It is clearly less expensive to treat a disease when it is caught in stage one, when it is preventable, rather than stage four,’’ he said.

The CBO relied heavily on an article written by three Boston-area analysts that was published last year in the New England Journal of Medicine. In that report, the authors said the presidential candidates, including Obama, were “overreaching’’ and potentially misleading when they made sweeping statements about the savings from various tests. After analyzing data collected at Tufts Medical Center’s Center for the Evaluation of Value and Risk in Health, the authors concluded that about 80 percent of preventive measures did not save a net amount of money.

“They might be good things to do in the sense that they improve health,’’ said Peter J. Neumann, a coauthor of the study and the director of the Tufts-based center. “They might even be good value for money in the sense that the health gains are worth the investment. But that is a different statement than saying they save money.’’

A CBO spokesman said the agency would not provide an official to discuss its analysis on the record.

The White House stood by Obama’s assertion that the tests would save money, providing a statement of support from Assistant Secretary for Health Howard Koh. He said a number of measures, such as colorectal cancer screening, do save money. Koh’s statement, however, did not address the broader question of whether widespread screening for many diseases would produce a net savings. The White House declined to make an official available for an interview.

Some specialists interviewed this week said the CBO analysis is misleading. They said the agency looked only at the cost of certain disease screenings, many of which are designed to improve quality of life and were not expected to save money, but not at the full financial benefit of disease-prevention programs that do save large sums of money.

For example, programs aimed at curtailing obesity and diabetes can be cost-effective, according to Kenneth E. Thorpe, a professor of health policy at Emory University. He cited a study in which people who were screened and counseled for obesity lost a modest amount of weight and significantly cut their chances of having diabetes, thus saving many dollars in treatment that might have otherwise been necessary.

“When properly designed, they do indeed save money,’’ Thorpe said of such programs.

Legislators, meanwhile, are trying to balance the costs of mandating payment for widespread screening with ethical questions, such as whether the government should be in a position of denying payments for some tests that are considered less effective.

The House bill includes a proposal to establish a federal panel, to be called the Comparative Effectiveness Research Center, that will examine the effectiveness and “appropriateness’’ of various medical services. The legislation does not directly call for the center to analyze the return on investment of the tests and procedures, but analysts said it seems inevitable that would be the result.

The proposal is one of several measures that have helped stoke some of the confrontations at meetings members of Congress held with their constituents, some of whom said they fear that the government would be in a position of determining who lives or dies.

One leading opponent of the Obama proposal said the administration is using the discussion about the screenings in an effort to divert attention away from the possibility that the government will ration care. Phil Kerpen, policy director of Americans for Prosperity, a privately funded group, said the analysis that screenings will cost more money bolsters a Republican contention that Obama’s plan will have to deny care to save money.

The biggest potential health savings, according to some analysts, could come from a rigorous campaign against obesity. By some measures, the country spends $200 billion annually on obesity-related expenses, accounting for one-tenth of all spending in Medicare and Medicaid.

But the CBO, which usually sticks to questions of dollars and cents, expressed skepticism about whether Americans can keep off the weight. The agency said that while many diets succeed in the short run, “relatively few’’ people are able to maintain the lower weight. Implementing a more effective dietary program would add still more costs to the federal budget, with no guarantee of net savings, the CBO said.

Still, preventive measures shouldn’t be forsaken if the country decides they are worthwhile, as long as the cost is recognized, in the view of the CBO director, Douglas W. Elmendorf.

“Just because a preventive service adds to total spending does not mean that it is a bad investment,’’ Elmendorf wrote.

Michael Kranish can be reached at kranish@globe.com.

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