There’s growing global interest in investing in disease prevention—not just to improve health but to cut health care costs. The idea seems simple: if people eat better, exercise more, and make healthier lifestyle choices, then their medical expenses should decrease.
But there’s a problem with this well- intentioned thinking. If prevention is expected both to improve health and to save money, while traditional treatments are only expected to improve health (at a price), then prevention is being held to a much tougher standard—one it may not be able to meet.
When a new treatment is introduced, the key question is whether it improves health by being safe and effective. The next question is whether the treatment is worth the cost. Does the health benefit justify the price? It’s an uncomfortable calculation, but in a world of limited resources, it’s necessary.
Rather than wrestling with this un- comfortable calculation of whether a health intervention is worth the cost, one might hope to avoid the need for expensive treatments by investing in disease prevention. But that introduces a different test for success: Does prevention save money? Should a lifestyle program that encourages better sleep, diet, or exercise be judged by whether it lowers health care costs in the future? In other words, should preventive treatments only be considered successful if they come with a negative price tag? That’s the wrong way to measure their value. What if a prevention program improves health but raises health care spending slightly—should it be discontinued? What if it improves health a great deal but increases spending significantly—would it still be worth the price?
Preventive health care interventions, like other treatments, should be assessed based on whether the improvement in health is sufficiently large to warrant the cost. And counter to popular narratives, prevention programs (such as many smoking prevention and cessation initiatives)1 often cost money rather than save money, even when downstream health improvements are considered. Prevention, including various forms of public health, can be cost effective, but that is different from being cost saving. This does not mean that prevention doesn’t work as much as it means prevention isn’t free.
Are there policies that can both improve health and reduce health care spending in the long run? Is it possible to improve health for free? The answer is occasionally yes, but only in a very limited set of interventions, such as colonoscopy for 60- to 64-year-old men or childhood vaccinations, where the downstream reduction in health care spending more than pays for the intervention itself.1
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Three things must be assessed to evaluate whether prevention efforts will both improve health and lower costs. First, the cost of the intervention needs to be sufficiently low. Second, the downstream health care it averts must be sufficiently expensive, such as costs for an emergency department visit (about $1000 for Medicare beneficiaries in 2021) or for treatment for heart failure (almost $22 000 in 2018 to treat in the first 90 days).2,3 Third, and perhaps most often overlooked: How many people need to receive a prevention intervention to avoid that emergency department visit or hospitalization for heart failure? The prevention intervention must avert sufficiently expensive downstream care for a sufficiently large number of people receiving the intervention; the number needed to treat (NNT) must be sufficiently low.
As an example, consider a hypothetical 2-year wellness program that costs $400 per month per person (say, $13 per day for healthy food) and reduces the risk of heart failure by 1 percentage point, from 5% to 4%. For the first 90 days alone, heart failure treatment is much more expensive at $22 000 than the wellness program, but that doesn’t mean that the wellness program saves money. In this case, 100 people must participate in the 2-year program to reduce the incidence of heart failure by 1, from 5 people to 4 people. In other words, the number of people who must be treated with the prevention program to avoid 1 heart failure is 100 (NNT = 100). You can’t enroll just that 1 person whose heart failure would be averted in the prevention program, because you don’t know which person that will be ex ante; you must include all 100 people in the prevention program to avoid that single incident of heart failure. If the program costs $400 per person per month, the total prevention cost would be $960 000 (100 people × $400 × 24 months). Meanwhile, treating heart failure in 1 patient costs $22 000. At least in this example, prevention improves health but increases total spending substantially.
With this ratio of the number of participants for each instance of heart failure averted, to save money overall, the wellness program would have to cost less than $9 per person per month (100 people × $9 × 24 months = $21 600, which is less than the cost of treating 1 patient with heart failure). Better targeting of the program—meaning a lower number of program participants needed to avert each instance of heart failure—would increase the cost-effectiveness, though the targeting might have to be implausibly effective to bring the net cost below 0. In this case, the program would have to reduce the risk of heart failure by 50 percentage points, with 1 case of heart failure averted for each 2 people who participate in the wellness program, or NNT = 2 (2 people × $400 × 24 months = <$22 000), to save money. That level of effectiveness is conceptually possible, but no wellness program we’ve seen has come close.
Programs that produce little or no health benefit at a high cost are simply a waste of money in terms of improving health outcomes. There are many examples of behavioral and lifestyle wellness programs initially believed to have great promise, but subsequent rigorous evaluation demonstrated little health benefit. One randomized clinical trial (RCT) co-led by one of us tested the effects of a workplace wellness program that offered employees modules on nutrition, physical activity, stress reduction, and related topics over 18 months.4 The study measured clinical health outcomes, such as weight and blood pressure, as well as health care spending, utilization, absenteeism, and job performance. The results showed no significant impact on clinical health, health care costs, or employment outcomes within the study period, which are similar to others’ findings.5 A recent RCT of a nutrition intervention program that offered healthy groceries for 10 meals per week for an entire household, plus dietitian consultations, nurse evaluations, health coaching, and diabetes education, did not improve glycemic control measures such as HbA1c levels.6 One response to such null findings is to design programs to be more intensive or run for longer periods—both of which could increase health improvements but would also increase costs.
It is not our view that prevention cannot improve health and decrease health care costs. After all, the more expensive health care becomes, the easier it becomes to save money with a slightly less costly alternative. But presently, there is little evidence for lifestyle and behavioral health promotion programs that reduce future health care costs by enough for a large enough share of participants to save money overall—and many may not even improve health outcomes. Ignoring this reality in favor of wishful thinking is, unfortunately, too common. Governments and capitated groups such as accountable care organizations have poured funds into prevention programs to cut costs; ironically, those elevated expectations and higher spending might be exactly why the programs haven’t proved successful in lowering total costs. As additional evidence is developed on the effects of new preventive programs, these programs should be assessed not on the basis of whether they save money but whether they improve health sufficiently based on their cost. That cost need not be negative for programs to be worthwhile.
Article Information
Published: April 3, 2025. doi:10.1001/jamahealthforum.2025.1464
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2025 Baicker K et al. JAMA Health Forum.
Corresponding Author: Katherine Baicker, PhD, The University of Chicago, 5801 S. Ellis Avenue, Chicago, IL 60637 (kbaicker@uchicago.edu).
Conflict of Interest Disclosures: Dr Baicker reported being on the board of directors for Eli Lilly, being on the advisory board for the National Institute for Health Care Management Foundation, and being a trustee for the Mayo Clinic outside the submitted work. Dr Chandra reported being on the Congressional Budget Office’s panel of health advisors, being an academic affiliate of Analysis Group, and being an advisor with equity positions in Kyruus, HealthEngine, and SmithRx.
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Source: https://jamanetwork.com/journals/jama-health-forum/fullarticle/2832497