necessitate redistributing current expenditures to high-value services such as prevention.

Thomas J. Flottemesch of HealthPartners Research Foundation suggests that preventive services at the primary and secondary levels yields mixed results in terms of net medical savings to the healthcare system, highlighting the importance of expanding the conversation on prevention beyond costs alone to include value and benefits not captured by pure dollars. Although primary preventive services, such as daily aspirin use and alcohol and tobacco use screenings, could have yielded net savings of nearly $1.5 billion in his analysis, the use of secondary preventive services, such as mammograms and depression screenings, actually results in net costs of almost $2 billion. He also acknowledges that certain costs could have been omitted or double-counted due to insufficient data. Flottemesch concludes that, while different types of evidence-based clinical preventive services have the potential for differential impacts depending upon current delivery rates and target populations, evidence-based preventive services should be embraced, and their use encouraged, because of their positive health impact.

Michael P. Pignone of the University of North Carolina-Chapel Hill focuses on tertiary preventive care, explaining that individuals with one or more chronic conditions account for approximately $1.5 trillion in healthcare spending per year. Focusing on high-risk patients with chronic conditions offers high savings and cost-effectiveness margins because the likelihood of needing high-cost treatments are far greater than the costs incurred by provision of preventive services, he argues. Based on his calculations, widespread use of effective interventions, such as disease management, postdischarge care, and case management for key chronic conditions could produce substantial savings, perhaps as much as $45 billion per year. However, he also explains that translating successful interventions to new populations and settings and realizing savings may be difficult because of the differing organizational and population needs of individual institutions. Despite these limitations, he ultimately suggests that better use of effective tertiary prevention possesses strong potential for improving health and reducing spending.


Steven H. Woolf, M.D., M.P.H.

Virginia Commonwealth University

In considering strategies to control the rising costs of health care, the projected increase in the prevalence of chronic diseases is both cause for concern and an opportunity for intervention. The aging population and advances in medical care that enhance life expectancy are increasing the

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