The Value of Prevention: A Complex Puzzle

For experts in health economics and outcomes research (HEOR), finding out which interventions are worth pursuing can be extremely complex. That’s especially true when the topic involves preventive medicine.

By Beth Fand Incollingo

While tracking the incidence of a cancer or its mortality rate may be fairly straightforward, measuring the success of preventive measures in healthcare tends to be complicated because there are so many factors to consider.

“If you smoke, you know that your chance of getting lung cancer is very high,” said Jeremy Farrar, MD, PhD, assistant director-general for health promotion, disease prevention, and control at the World Health Organization (WHO). “The impact of living in a polluted area is harder to predict. Evaluating how effectively a measure prevented a disease would require the integration of databases not only from a country’s health agency, but from its environmental, education, and transport agencies and even its food industry.”

Yet, it’s vitally important that the HEOR community pursue those kinds of assessments now, Farrar said, as the healthcare system needs interventions designed to stem a growing incidence of conditions that affect the world’s aging population, including cancer, diabetes, cardiovascular disease, stroke, cognitive impairment, and chronic obstructive pulmonary disease.¹ Clinicians and payers everywhere could also benefit from measures aimed at preventing other health problems that have reached global significance—such as dengue fever, COVID-19, and drug-resistant infection, he said.

Fortunately, HEOR experts are uniquely positioned to take on these types of challenging assessments. Trained to look beyond diagnosis and treatment to consider a host of puzzle pieces, including patient behaviors, access to care, and productivity lost due to disability, these professionals are prepared to help healthcare stakeholders identify and pursue the most cost-effective interventions.

“For us at the WHO and for all countries around the world, a shift toward health promotion and disease prevention is needed; otherwise, our health systems are going to collapse out of the sheer economic costs of operating in a world whose demographics are changing dramatically,” Farrar said. “In 2024, healthcare represented, on average, 9% of national gross domestic product in countries around the world, with some nations, led by the United States, reaching double digits.² No country will be able to dedicate 20% to 30% to those expenditures.”

But what exactly does prevention entail? A broad term, it can describe many types of initiatives across 3 categories:

• Primary prevention, which has the potential to save the most healthcare dollars by stopping illnesses before they start—via measures such as vaccines, diet, health education, and sometimes medications.

• Secondary prevention, which encompasses services such as screenings, mammograms, and blood pressure checks that can identify existing disease or risk factors and facilitate intervention for those most likely to benefit.

• Tertiary prevention, which can be the most expensive—but also most cost-effective—because it involves the management of existing diagnosed conditions—for instance, through medications that control blood pressure or cholesterol or cancer treatments such as chemotherapy or immunotherapy.
  

At the heart of such evaluations are questions about how to define and measure prevention’s value. While governments and private insurers may be focused on reducing healthcare expenditures, patients, physicians, and public health leaders are often satisfied to know that an intervention improves and lengthens lives.

Evaluators also must consider whether it’s sufficient for interventions like breast cancer screening or hypertension drugs to reduce lifetime healthcare spending for some patients and their families, even though the measures don’t save dollars at a population level. In fact, it’s rare for an intervention to do both; examples of those rare exceptions include the world's decades-long effort to increase vaccination rates and reduce tobacco use.

Finally, an HEOR assessment isn’t complete unless researchers and decision makers consider indirect economic effects. For instance, even when preventive measures don’t reduce overall healthcare expenditures, they may improve national economies by keeping patients healthy enough that they and their caregivers can hold jobs. A good example is the US President’s Emergency Plan for AIDS Relief (PEPFAR), which has saved millions of lives in more than 50 countries.³

“Populations that are not healthy are not productive,” Farrar said. “If we can prevent heart disease, kidney disease, and brain disease from happening through behavior change, smoking cessation, taxes on unhealthy products, and a cleaner environment, we can help people live into their senior years and remain in the workplace, which has a huge impact on a country’s economic growth. Prevention is not only a health, moral, and ethical issue, but also, critically, an economic one.”

Even when preventive measures don’t reduce overall healthcare expenditures, they may improve national economies by keeping patients healthy enough that they and their caregivers can hold jobs.

Weighing the Value of Preventive Healthcare

A. Mark Fendrick, MD, has dedicated much of his career to helping patients gain access to high-value preventive clinical services, such as screenings, vaccinations, and medications.

As director of the Center for Value-Based Insurance Design at the University of Michigan, Fendrick worked with colleagues to craft the preventive services provision of the Affordable Care Act (ACA), which requires that more than 90 preventive services must be provided to patients at no cost (eg, without copayments or deductibles) by private insurers in the United States.

“If you have received certain vaccines—including for COVID—and screenings for mental health, unhealthy weight, cardiovascular disease, and cancer with no out of pocket costs,” Fendrick said, “you have that ACA provision to thank for that.”

Now, Fendrick said, it’s time for the HEOR community to stop debating whether those kinds of services will reduce long-term health spending. Instead, he said, they should look for preventive efforts that bring value through cost-effectiveness, meaning that money invested generates intended health gains.^4,5

"We have to change the conversation from how much we spend to how well we spend," he said.

Fendrick cited hepatitis C virus (HCV), which can lead to hepatocellular carcinoma and liver failure in a small percentage of infected patients, as a compelling example of how the economic value of a preventive intervention can change over time—mostly due to changes in drug acquisition price, which can shift the intervention from being cost-effective to cost-saving.

"In previous years, a $100,000 course of direct anti-HCV treatment was both highly cost-effective and associated with a substantial budget impact," he said. "Now that market competition—without federal price negotiations—has led to substantial price reductions, organizations such as the Congressional Budget Office now conclude that 'savings from healthcare costs that would be avoided by increased hepatitis C treatment would more than offset direct spending on that treatment.'⁶”

It is noteworthy, Fendrick said, that despite evidence of cost savings, many patients eligible for HCV treatment still face utilization management strategies (eg, prior authorization) hindering access to these breakthrough drugs.

Much of the work done by HEOR professionals in this area demonstrates that investment in prevention can meaningfully improve longevity or quality of life, goals Fendrick believes are worth pursuing even if preventive interventions don’t reduce spending. He noted, “I did not go to medical school to save people money.” In other words, he’s certain that most of his patients would prefer an intervention that averts an adverse event, (eg, using a statin to prevent a heart attack for those with high cholesterol), than spending the same or more money treating that heart attack with a coronary stent or bypass surgery.

“Very, very few clinical services—including almost all of the services that are considered measures of high quality care—save both lives and dollars—nor should they,” he said. “Similar to our investments in transportation, education, and defense, spending on healthcare should be viewed as worthwhile investment, even if it doesn’t save money.”

Fortunately, Farrar said, in a rare few cases, interventions have been able to accomplish both those goals.

“There are some population-wide prevention measures that bring well-documented, unambiguous benefits in both the health and economic arenas,” he said, such as vaccination against the human papillomavirus (HPV) to prevent the development of cervical and other sexually transmitted cancers.

In a study by the United Kingdom’s National Health Service, researchers used cost-benefit and cost-effectiveness analyses to estimate the economic gains that would be associated with measures aimed at preventing cervical cancer in women living in London between 2025 and 2050. The model projected that, if high vaccination and screening numbers were achieved by 2030, the program would save £113.4 million, assessed in terms of net present value, and prevent 6490 losses in quality-adjusted life years.⁷

“In 2021, Australia made the announcement⁸ that there was no case of cervical cancer in a woman under the age of 21 who had been through its HPV vaccination program,” Farrar said. “That means we now have the capacity with vaccines, diagnostics, and treatment to actually eradicate a cancer and all the costs associated with it, both personal and economic, and that’s an incredible thing to be able to say.”

But perhaps most staggering, Farrar said, are the outcomes of decades of effort to reduce tobacco use across the world. Although he worries that a rise in vaping is eroding health gains, he said that tobacco reduction “has had a massive impact on lung cancer, chronic lung disease, and heart disease, ultimately reducing healthcare costs.⁹ Now, increasingly, evidence-based legislative and public health interventions to reduce consumption of alcohol and sugary drinks are gaining momentum.”^10-12

Economic models also predict that childhood vaccinations will have a clear financial benefit.

A study published by the US Centers for Disease Control and Prevention included 117 million children born between 1994 and 2023 and used economic models to predict the outcomes of their routine childhood vaccinations. In that cohort, the vaccinations were expected to prevent about 508 million cases of illness, 32 million hospitalizations, and 1.13 million deaths, in addition to generating direct savings of $540 billion and societal savings of $2.7 trillion.¹³

“We now have the capacity to actually eradicate a cancer and all the costs associated with it, and that’s an incredible thing to be able to say.”— Jeremy Farrar, MD, PhD

Establishing Goals in Preventive Care

While countries typically devote less than 10% of their healthcare spending to prevention,¹⁴ it’s not necessarily the amount committed that determines success, said Norrina Bai Allen, PhD, vice chair for research in the Department of Preventive Medicine at Northwestern University.

“The countries that do the best promote healthy behaviors through the public health system and then share the same messages in the clinic with individual patients,” she said.

Among the WHO’s 194 member countries, Farrar praised Singapore for using economic and health incentives at workplaces and schools to promote exercise and nutrition.¹⁵ Meanwhile, he said, Vietnam is pushing safety in traffic accidents by requiring drivers to wear seatbelts in cars and helmets on motorbikes,¹⁶ China is targeting smoking,¹⁷ and the Nordic countries are discouraging alcohol use through health taxes, restricted availability, and state-owned and regulated retail monopolies.¹⁸ In addition, the Philippines has implemented health taxes to discourage smoking, alcohol, and sugary beverages,¹⁹ and Mexico is using the same tactics to target gambling and violent video games.²⁰

Also known as “sin taxes,” health taxes often target sugar-sweetened beverages and alcohol because their excessive consumption has been associated with multiple serious health conditions. Studies support the success of this legislative approach to prevention. A 2023 study reported a tax-driven drop in consumption of sugary drinks in Oakland, CA, and estimated societal gains of more than $100,000 per 10,000 residents over 10 years.²¹ In a 2021 review of studies done in Latin America, 5 studies that focused on health impact estimated that sin tax implementation or increase would avert thousands of deaths, particularly from cardiovascular disease and cancer, as well as lead to hundreds of thousands of life years gained in a relatively short timeframe.²²

But efforts shouldn’t stop there, Farrar said.

He suggested that countries spend an additional $3 per citizen each year to implement the WHO’s 29 preventive “Best Buys,” which include taxing tobacco and alcohol, protecting children from harmful marketing, controlling hypertension, and boosting cervical cancer screening. With full compliance by 2030, the global community could save 12 million lives, prevent 28 million heart attacks and strokes, add 150 million healthy life years, and generate over $1 trillion in economic benefits, he said.²³

Leaders are also calling for healthcare spending to be directed toward the efforts that will generate the most health for the money, something the HEOR community is uniquely positioned to assess and document. GLP-1 drugs, which can stimulate significant weight loss and help manage diabetes, are an example of a good preventive investment, Fendrick said, despite their sometimes hefty price tags.

To pay for such high-cost, high-value interventions, he recommends relying on HEOR assessments to also identify and bring more attention to those services that have no net clinical benefit, those too costly to achieve benefit, and those that cause harm. His research and work from others have identified  hundreds of millions of dollars spent on theses no- and low- value services, such as those identified by the Choosing Wisely initiative (now discontinued) and those preventive services that have a received “D” ratings from the US Preventive Services Task Force (eg, asymptomatic bacteriuria screening²⁴ and vitamin D supplements for fracture prevention²⁵).

Prostate cancer screening also has dubious value, Farrar said. While studies are mixed on whether it reduces prostate cancer mortality, the screening, compared with a watch-and-wait approach, is associated with false-positive findings that can cause anxiety and lead to invasive biopsies that sometimes spark complications.²⁶ The screening is also associated with overdiagnosis that can lead to unnecessary treatment and the potential for life-changing side effects, including urinary incontinence and erectile dysfunction.

But what if some low-value efforts could turn into high-value solutions?

Weight and diet counseling often fails because cities are not set up to promote exercise and underserved neighborhoods lack sources for healthy, affordable food,^27,28 Allen said.

That could change, she suggested, with the availability of telehealth appointments, wearable digital health trackers, and “food is medicine” programs, which prescribe and sometimes deliver healthy food to patients, such as those in low-income neighborhoods who are at high risk of repeat heart attacks.²⁹

Starting prevention efforts earlier could also make them more powerful, she said.

Allen has spent years researching how early life behaviors, environments, and health conditions—such as hypertension and diabetes—affect the development of cardiovascular disease, and she’s learned that intervening is most effective when high-risk patients are in their 20s, rather than their 40s or 50s.³⁰

“This creates a compression of morbidity, meaning that the period of life lived with disease and increasing healthcare expenditures is shortened,” she said, “so people not only live longer, but they live healthier and reduce their lifetime healthcare expenditures.”

Leaders are calling for spending to be directed toward efforts that will generate the most health for the money, something HEOR is uniquely positioned to assess and document.

Navigating Unique Concerns in the United States

Unfortunately, countries without universal healthcare are less prepared to pursue early prevention, Allen said.

“In the United States, the challenge is that many adults, particularly young adults, don’t have regular healthcare providers because they don’t have insurance, so they’re not going for preventive screening,” she said. “We’re testing strategies that would increase the screening rate by identifying the patients who could most benefit—for instance, by offering a 5-minute cellphone survey that assesses predisposition to cardiovascular disease and prioritizes high-risk individuals for clinic visits.”

Another promising strategy in the United States and other countries where private health insurance plays a role, Farrar said, is for payers to offer lower premiums to customers who meet healthy lifestyle metrics.^31,32 Allen added that insurers, both public and private, can create incentives through value-based care models that reimburse providers for preventive measures as part of a set of healthcare services via bundled or population-based payments, either through employer or coverage groups.³³

“Compared with fee-for-service reimbursement, pay for performance models may increase the frequency of preventive screening and evaluation^34,35; however, more work is needed to understand the financial multiple drivers needed to promote prevention,” Allen said.

With the constitutionality of free preventive care through the Affordable Care Act having recently been upheld by the United States Supreme Court, Fendrick says healthcare stakeholders in the United States have a second chance to remind patients to use the recommended preventive services covered without cost-sharing and to make sure that they follow up with diagnostic testing/evidence-based treatments when necessary.³⁶

“There’s a substantial minority of people who don’t know these services are available to them at no cost, and others avoid them due to fear or inconvenience,” Fendrick said. This is a problem that exists even in countries with universal healthcare.^37,38 He added that practitioners in the United States should reassure patients who are wary of preventive services because they have previously been hit with surprise bills or misled by false claims that vaccinations aren’t safe.

Along with providing more robust public and individual education and restoring trust in preventive services, Fendrick said, it can be beneficial for all healthcare stakeholders to do what they can to encourage participation by addressing access barriers, including offering transportation to clinics and a wider variety of appointment times.^39,40

“There’s a substantial minority of people who don’t know preventive services are available to them at no cost, and others avoid them due to fear or inconvenience.”— A. Mark Fendrick, MD

Measuring Success

Several initiatives can support HEOR professionals in thoroughly and accurately assessing the cost-effectiveness of preventive measures in healthcare.

For instance, Farrar said, an integration of data across government ministries, from health to environment to transportation, would provide information that would help experts identify patterns in preventive healthcare.

That idea is central to ISPOR’s Whole Health initiative, which emphasizes using nontraditional data points for more accurate, fair, and useful value assessments.

Artificial intelligence can also assist with these calculations, Farrar said, by providing information about anything from the impact of pollution on cancer to how mosquito flight patterns are associated with the spread of communicable diseases.

Allen added that thinking long-term can provide a more accurate understanding of the outcomes of preventive interventions.

“When I’m thinking about prevention, I’m thinking about preventing a disease that’s going to happen in 20 or 30 years, but most prevention forecasting looks ahead just 3 to 5 years, and that’s too short a time span to really be able to see the benefits,” she said.

In all these efforts, Farrar cautioned, success depends on the quality of the information studied, which is why he urges everyone from patients to policy makers to ignore political ideologies and look for answers in evidence-based data, such as the vast collection provided to the public at no cost by the WHO.

“The crucial element in implementing preventive measures is the independent scientific evidence that drives decision making,” Farrar said. “That should be the bedrock of good policy decisions.”

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