The New England Journal of Medicine recently published a paper that I found interesting, and would love to share with you all.
Deployment of Preventive Interventions — Time for a Paradigm Shift
Katherine Pryor, M.D., and Kevin Volpp, M.D., Ph.D.
In 2002, Knowler et al. reported results of a landmark study — a large, randomized, controlled trial comparing a behavioral intervention with medical therapy in the prevention of diabetes.1 Over a mean follow-up period of 2.8 years, the lifestyle-modification program, known as the Diabetes Prevention Program (DPP), reduced the incidence of diabetes by 58% as compared with placebo among people with elevated fasting and post-load plasma glucose concentrations. Metformin reduced the incidence of diabetes by 31% as compared with placebo.
Despite these findings, insurers have been slow to provide coverage for DPP-like interventions. In 2016, the Centers for Medicare and Medicaid Services piloted the program and determined that it improved the quality of patient care and reduced net Medicare spending, prompting a goal of expanding the DPP nationwide by 2018. Although coverage of metformin has been ubiquitous since it was introduced in the United States in 1995, many private insurers started covering the DPP only recently.
Financial incentives for tobacco cessation during pregnancy provide another example of an effective behavioral intervention that hasn’t been translated into practice. Smoking during pregnancy is a leading cause of maternal and neonatal morbidity and mortality, particularly among socially disadvantaged women and their children, and has long been a public health target. In the United States, such smoking rates have decreased only marginally in recent decades. A Cochrane review concluded that financial incentives are the most effective intervention in this population and can lead to quit rates up to four times higher than those achieved with other interventions. But such incentives haven’t been implemented in routine care of pregnant women.
Why are highly effective preventive interventions adopted slowly, if at all? The first issue is that, historically, far more resources have been devoted to treating disease than to preventing it; in 2015, only 3% of health care dollars were spent on preventive services. However, ongoing shifts in health financing are creating incentives for providers to pay more attention to modifiable risks such as antenatal smoking. Hospitals participating in accountable care organizations, for example, save thousands of dollars for each neonatal intensive care unit stay they prevent.
Second, treatments determined by the Food and Drug Administration (FDA) to be safe and effective are usually covered by insurers regardless of their cost, but preventive services have been held to a higher standard: they are often assessed on the basis of whether they generate a positive return on investment and save money in the short term. This disparity leads to overprovision of treatments and underprovision of preventive services, a trend that is exacerbated by high turnover in many health insurance markets. Because insurance contracts tend to be only 1 year long, insurers don’t want to spend money to prevent disease in members who may be covered by a different insurer in the near future.
Even Medicare — which typically covers beneficiaries for life — holds preventive services to a higher standard, applying cost-effectiveness analyses when making coverage decisions about preventive services but not treatments. This double standard has resulted in coverage of cost-ineffective therapies with prices of up to hundreds of thousands of dollars per quality-adjusted life-year, including treatments of questionable benefit (such as Avastin [bevacizumab] for metastatic breast cancer after the FDA withdrew support for this use).2 A recent study showed that reallocating current Medicare expenditures toward “dominant” (cost-saving and health-increasing) interventions would result in efficiency gains and improvement in the aggregate health of Medicare beneficiaries at no additional cost.³
The rest of the article can be found at this link: https://www.nejm.org/doi/full/10.1056/NEJMp1716272?query=TOC&#.WvN4WPHjP-w.twitter