Preventing what, exactly?
Sex-terrified Theocratic CEOs aren't the Problem with Preventive Health Care
Three weeks ago, lawyers for the parties in a lawsuit to overturn the Affordable Care Act’s requirement that insurers cover some preventive health care agreed to keep the mandates in place while the case plays out. The plaintiffs are employers who don’t want to pay to cover care that offends their religious beliefs, especially drugs that prevent HIV.
The homophobic, sex-terrified religious beliefs of a handful of employers shouldn’t determine U.S. health care policy, but they’re not the main obstacle to preventive health care in the U.S. Prevention doesn’t generate profits for insurers and the non-zealot employers responsible for paying for health care for most Americans. Since they pay the bills we don’t get very much of it. In 2020, less than 6 percent of adults in the U.S. had received all of the preventive clinical services recommended for them.
The ACA required nearly all private health insurance plans to pay 100% of the cost of an annual check-up along with a list of preventive interventions recommended by experts — no copays or deductibles allowed. Insurers must pay for the entire cost of immunizations recommended by the U.S. Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (“ACIP”, recommendations here), preventive services graded “A” or “B” by the U.S. Preventive Services Task Force (“USPSTF”), and guidelines for children, adolescents and women from the Health Care Resources Administration.
The policy was supposed to keep us healthier and save money. In then-First Lady Michelle Obama’s words, “the best way to keep our families healthy and cut health care costs is to keep people from getting sick in the first place.” But long before the ACA, the U.S. private health insurance system was constructed to ignore most preventive health care. By investing in the idea that competition among insurance companies would hold costs down, the ACA doubled down on the incentives.
American policymakers are convinced of the value of price competition among health insurers to control costs. For that to work in theory “consumers,” both individuals and employers who purchase insurance for employees, have to “choose” their health plans often enough to pressure insurers to hold premium prices down. This cornerstone of U.S. policy pulls much harder against prevention than any regulatory insurance “mandates” that encourage preventive care.
Preventive health measures generally don’t pay off quickly and often yield measurable “return on investment” only on the scale of large populations. Organizations typically avoid investing in things that yield benefits for their competition, yet that’s exactly what we ask insurers and employers to do in the case of clinical preventive measures that can be implemented through health care providers and paid for by insurance (as opposed to broader public health prevention).
Many aspects of “normal” U.S. health insurance and labor markets create powerful incentives for extreme short-term health care decisionmaking - and thus against prevention - by the people with the power of the health care purse:
Eligibility I - Job Change: Millions of people lose access to their job-based insurance every year by quitting, taking a new job or getting laid off. According to the Bureau of Labor Statistics, in January 2022, the median length of time that wage and salary workers had been in their jobs was 4.1 years, 3.7 years for private sector workers generally and just 2.8 years for service sector workers. 24% of U.S. workers had been in their jobs for less than 12 months.
Eligibility II - Means Testing: Medicaid is two things at once - a vital protection against illness and death for tens of millions of Americans and the worst public health insurance program in the richer countries considered peers by U.S. politicians. At least once a year, states purge their rolls of people who don’t meet the eligibility criteria. And if a Medicaid participant’s job changes or they get a raise, they have to report it to the government and in many states can lose their insurance altogether or be forced onto another plan by the end of the month.
Consumer Choice I - Employers: Every year, employers decide which health plans to offer employees. Some employers will offer the same plans every year because it costs employers time, effort and money to terminate old health insurance contracts and contract for new plans to offer to workers. Yet a yearly threat of losing the chance to sell plans to any given group of workers hangs over insurers’ heads.
Consumer Choice II - Individuals: People who don’t lose their coverage have the right to choose a new health plan at least once a year during open enrollment, not only for job-based coverage, but privatized Medicaid/CHIP and the exchanges. Nearly half of seniors now get Medicare benefits through private Medicare Advantage plans. Seventeen percent of Medicare enrollees voluntarily quit their Medicare Advantage plan in 2021 according to a Commonwealth Fund study, and many more left involuntarily because they moved or their insurer left their local market.
Networks: Most health plans either require patients to go to doctors and hospitals that are in an approved network or create financial incentives to do so. Insurers, doctors, hospitals and other providers create those networks through high-stakes negotiations, and they change frequently - in 2015 15% of Americans said they lost access to a provider over network issues in the previous year.
With millions of people leaving their jobs or losing eligibility for public insurance, and nearly everyone in a private plan having the right to switch each year, why would an insurer or employer spend a nickel encouraging people to get preventive health care services that take time to yield financial rewards?
The “mandates” themselves only require insurers and employers to pay for preventive services, not to do anything to make sure that patients actually get care that supposedly keeps them healthy and saves insurers and employers money. Here’s what it takes under the federal insurance mandate to get your free “mandated” colonoscopy, mammogram or vaccine:
IF you have health insurance.
AND IF you’re not one of the 15-20 million people in a health plan that’s technically not covered by the ACA mandates (a “grandfathered” plan).
AND IF you know that you’re entitled to a free annual check-up so you don’t avoid the doctor because you’re afraid of the cost.
AND IF your doctor knows you’re due for a covered treatment or test. The billions of dollars invested in electronic medical records hasn’t produced the promised seamless “interoperable” system where all your doctors can see your medical history. A 2019 Healthline report on the low rate of adults getting vaccinated against shingles cited cost as an obstacle, which theoretically has been removed because the US Preventive Services Task Force recently added the vaccine Shingrix to the list of mandated free preventive services. However, as Ohio State Internal Medicine specialist Dr. Navjot Jain told Healthline, adults’ vaccine records are often incomplete or inaccurate and, of course, not seamlessly available to doctors. “‘[I]t becomes quite challenging, especially when they switch providers, because often times you have to track down records to find out if they’ve been vaccinated,’ said Dr. Jain.”
AND IF you get your preventive care through an in-network provider. Federal “mandates” allow insurers to charge people if they get screenings, vaccines or other preventive care through out-of-network providers. Even that might not matter, since the Kaiser Family Foundation reports that for Obamacare exchange insurers who submitted complete data to healthcare.gov, “nearly 17% of in-network claims were denied in 2021.”
AND IF your insurer agrees that the service is “preventive”. The KFF data are for all claims, without preventive services broken out, but in 2019 Consumer Reports warned that insurers were denying claims for mandated preventive services.* One colonoscopy patient was billed $4,000 because her doctor removed a polyp during the test - a standard feature of colonoscopy for which the insurer nevertheless denied payment because there had been no “medical necessity” for removal. Another was charged a copay because his doctor “did a biopsy on some tissue that he thought was problematic but turned out to be nothing.” Finding “nothing” transformed the procedure from “preventive” to “diagnostic.”
AND IF your preventive service is the only thing you get. Insurers are allowed to charge copays and deductibles if a visit includes something other than the “mandated” preventive service.
THEN you can get free high blood pressure screening, colonoscopy, mammogram, vaccination or smoking cessation counseling.
The heavily hyped and litigated free preventive care mandate has yet to produce a measurable dent in the delivery of preventive services. According to the federal government’s Healthy People 2030 program, which sets national goals for population-wide health improvements, the proportion of American adults age 35 and older who received “all of the recommended high priority appropriate clinical preventive services” actually declined from 8.5% in 2015 to 6.9% in 2018 and 5.3% in 2020, although the pandemic may have skewed the 2020 outcome. Healthy People has a modest goal of having 11.5% of American adults receive all their high priority preventive care by 2030.
To understand how the real-world health care economy works, consider two proven effective preventive services: screening for high blood pressure then treating it with medication and counseling on diet and exercise, and screening for colorectal cancer. Each makes public health and economic sense when viewed from a national perspective on a long timeline. But when the U.S. population is chopped up into tiny slices for short time periods, the economics are far less compelling.
Chronic high blood pressure, known as hypertension, is a primary cause of heart disease and stroke. Controlling hypertension increases your chances of living longer and healthier. Of course, you and your doctor can’t and shouldn’t try to control your blood pressure if you don’t know what it is. So insurers covered by the ACA mandate are required to pay 100% of the cost of hypertension screening for all adults.
“Screening” isn’t just squeezing your arm with an inflatable cuff. A single blood pressure reading often produces false negatives or positives, so the recommendation for hypertension screening includes second readings for people whose first check is too high, to confirm a diagnosis before treatment. Research shows that checking blood pressure outside of the doctor’s office is more accurate, so the Task Force recommended that second readings be done off-site. For someone paying the bills, that might mean paying for jobsite occupational medicine or home care nurses.
It seems a reasonable investment since heart disease is a big expense for health care payers. Accounting for both the cost of hospitalization and follow-up care, the average heart attack patient costs nearly $35,000 per year, according to an analysis in the Journal of the American Heart Association ($26,968 in 2013 dollars).
The only randomized clinical trial on how blood pressure screening prevents heart disease was done in Ontario, Canada in 2006. The study found that screening for high blood pressure through a community-based program and following up with additional preventive care for people who had high readings saved 3.02 hospitalizations per 1,000 people in a year (full text is behind a paywall - boo! - but researchers for the Preventive Services Task Force described the results here).
That may sound like a lot of money, pain and lives to save, but from the perspective of employers and insurers, there are two problems with cashing in on the benefits.
Age: The Ontario study only tracked people aged 65 and over. CDC surveys show that people who are 65 and up are 18 times more likely to suffer from heart disease than adults aged 18-44, and nearly three times more likely than people 45-64 years old.
Population Size: In the U.S., millions of employers and insurers are each responsible for tiny pieces of the population. Most adults between 18 and 64 years old have job-based health insurance. According to the census, there were 6.1 million businesses with at least one employee in 2019. The average firm overall had 28 employees. The average “large” firm (500+ employees) had 3,416 employees, but those big companies often don’t buy health care for all of their workers in one place. The 20,686 large U.S. firms operate 1.37 million business sites (“establishments”), with just 52 employees at each. Since health care is bought and sold in local markets, many “large” companies buy health insurance for groups of people much smaller than their overall employment numbers.
A little back-of-the-envelope math** shows how weak the financial incentives for employers and insurers can be in real life.
Let’s assume big means big. Say you’re an employer with 500 employees, half between 45 and 64 years old and the other half younger than 45. Relying on the data from Ontario and the differences in heart disease by age, for the older employees, you would expect annual hypertension screening to prevent a quarter of a hospitalization every year, and less than 5% of one hospitalization among the younger employees. Across your whole workforce blood pressure screening would be expected to yield less than a third (31%) of one hospitalization a year, saving around $10,700. On average you’d expect to prevent a little more than a single hospitalization over the median 3.7-year job tenure for U.S. private sector employees.
That’s for an employer who buys health insurance for a big group of workers. An employer with the large firm establishment average of 52 employees (still much larger than the 28 employee average for all firms!) would expect to save less than a quarter of a single hospitalization over the time a median private sector employee works for the company, and since human beings can’t be chopped up into fractions easily, the odds are against preventing any heart attacks or saving any money at all.
Although the level of follow up is unknown, plenty of employers and insurers do offer opportunities to get a blood pressure reading. Yet delivering an effective blood pressure screening program in the U.S. that meets federal recommendations and prevents hospitalizations faces obstacles beyond economics. The Canadian study included reports to, and follow up with patients’ primary care providers, so people with high initial blood pressure readings could confirm their diagnoses and start preventive treatment.
In the U.S. workers first would need to have regular primary care physicians. Roughly 75 million American adults don’t, according to a report from the National Association of Community Health Centers. Then there’s privacy. For any off-site blood pressure check to include meaningful follow-up, employers would have to get permission from each individual employee to have a health professional collect the data and share it with the provider, and vice versa. Between the administrative work, arranging the screening or directing workers to a partner community clinic, perhaps with leave time to encourage participation, can add up to a $10,000 investment quickly.
Beyond the employer, why would an insurer covering those workers lift a finger to make sure they get screened? There’s no guarantee that the employees will even be enrolled in the insurer’s plan in a year. There may be a sales advantage for a health plan to be visible caring for the workforce of a corporate customer, but overall, it’s a better bet to profit through claims denials and other nickel-and-dime administrative tactics. If the workers get heart attacks later, the odds are that the costs will wind up on someone else’s financial statement.
Hypertension screening is less expensive and easier to implement than some other mandated preventive measures, and heart disease is only one dangerous and expensive condition caused by hypertension, so these numbers are just an illustration of the dynamic between health care costs, prevention and employer and insurer financial interests.
Media outlets have reported on the insurance industry fudging on full payment for a more expensive preventive service that happens to be close to Healing and Stealing’s own, um, heart: screening for colon and rectal cancer. A close look at the numbers makes the troublesome economics of preventive health care much clearer.
My father died when he was 60 years old of colon cancer that spread to his liver, lungs and brain. To reduce the risk that others will meet the same fate, the Preventive Services Task Force recommends regular colorectal cancer screening for all adults 45 and older.
ACA rules require full reimbursement for one of several mix-and-match screenings: one of three different tests on samples of your stool; using a short, flexible scope to examine the last part of your lower intestine (sigmoidoscopy), and; examining the whole length of your lower intestine with a longer scope (colonoscopy). Fecal sample testing is required to be paid in full once a year, although a newer DNA-based stool test is recommended every 1-3 years. Sigmoidoscopy is recommended every 5 years and colonoscopy once a decade. Colonoscopy is also used for follow up diagnosis when the results of fecal screening raise concerns.
Colorectal cancer screening prevents cancer and saves lives. In 2016, the Preventive Services Task Force recommended that adults between 50 and 75 years old get screened, then in May 2021 lowered the recommended starting age to 45. The Task Force’s full recommendation includes a thorough review of available data. Based on dozens of studies, the Task Force found that regular screening could prevent an average of between 42 and 61 cases of cancer and between 24 and 28 deaths per 1,000 people screened, depending on the methods and the type of screening program.
So, for every hundred adults around 40 years old that you come across in your life, 5 of them won’t get colorectal cancer and 2 or 3 of them won’t die from it if the U.S. runs an effective screening program with available technology. That’s a lot of cancer and death prevented and a lot of people walking around alive who might not otherwise.
But only if you take the long view.
The numbers are for cancers and deaths averted over decades. For example, the Task Force reviewed two large studies of colonoscopy. One surveyed and examined medical records for 88,902 nurses and doctors over 22 years, while the other looked at Medicare patients for a period of 11 to 17 years. The Task Force’s consensus estimates are for preventing cancer and death over the lifetimes of people who get preventive screening.
When you view colorectal cancer screening through the eyes of an employer or a company selling insurance to that employer, the questions become very different.
How many cancer cases can an employer or insurer prevent? Although randomized clinical trials are still in process to establish precisely how much prevention colonoscopy delivers when used for screening, the American Cancer Society concluded “observational studies suggest that colonoscopy can help reduce [colorectal cancer] incidence by about 40% and mortality by about 60%.” Sigmoidoscopy and the fecal tests tend to be a little less effective, but let’s assume that any recommended screening achieves the colonoscopy “gold standard” results: 40% fewer cases and 60% fewer deaths.
According to an analysis of data from the National Association of Central Cancer Registries by the American Cancer Society, there were 63 new cases of colorectal cancer for every 100,000 U.S. adults aged 45-64 in 2019. Assuming there would be the same rate of new cancers every year (there won’t be, of course), effective universal screening could prevent around 25 cases of cancer per 100,000 people per year in this age group.
For our hypothetical employer with 500 workers, half of whom are aged 45-64, screening every eligible worker on the recommended timetable would prevent 6.3% of one cancer case every year (.063). Our smaller 52-person company? Seven-tenths of one percent of one cancer a year (.0065). Over the 3.7-year median time workers spend in a private sector job, the larger employer would prevent less than a quarter of a case and the smaller one less than 2 1/2 percent of a single case of colorectal cancer.
Older workers tend to stay in the workforce longer than other workers - the median time 45-64 year old employees had been in their jobs in January 2022 was 8.2 years. With the longer time frame, the larger employer would prevent slightly more than half of a single cancer (51.5%) and the smaller employer just 5% of one case.
How much does screening an entire workforce cost? In 2009, the CDC funded 29 community programs designed to increase the number of low-income people who are screened for colon cancer and tracked the full cost of each program closely over five years. The programs offered patients different choices from the colorectal cancer screening menu - some tested fecal samples, others performed colonoscopy, still others both. There were significant differences in the cost of the various tests, but CDC found that it cost an average of $2,378 per patient per year ($2,060 in 2017 dollars) to screen patients.
Returning to the back of our envelope***, an employer or insurer covering 500 workers split evenly between ages 19-44 and 45-64 would only be required to fully pay to screen the older half of the workforce. That means an investment of $594,310 per year to prevent 6% of a case of cancer or $4.8 million to avert 52% of just one case over the 8.2-year time the median employee in the age group works for the company. The smaller business and its insurers would lay out $61,808 to prevent 7/10 of a percent of a case per year, or $506,828 over 8.2 years to prevent 5.4% of a single incidence of cancer.
How much money would screening save an employer or insurer? Screening is important to patients because when caught early and treated, colorectal cancer has a good survival rate. 64% of all people diagnosed with colorectal cancer now survive to five years and 58% at ten. The earlier the cancer is diagnosed, the better a patient’s chances of surviving. Successfully preventing colorectal cancer also saves employers and insurers several years of treatment costs for each case.
Colorectal cancer treatment costs a lot of money. In 2019, researchers analyzed Medicare medical and prescription drug claims for survivors of all types of cancers. They divided medical and drug costs for each person into three phases: the first 12 months (Initial Phase); the last 12 months before death (End of Life), and; all the time in between (Continuing Phase). For colorectal cancer, the first year of treatment averages $89,388 ($81,200 in 2019 dollars), the last year $46,235 and the years in between $151,475 per year.
Private health plans generally pay twice what Medicare does for hospital care, so the costs would be higher for our hypothetical employers. Correcting those prices and making a few other assumptions that likely increase the projected cost savings, an employer with 500 employees, half of them aged 45-64 would save $1,026,368 over the 8.2 years that the median employee in that age group stays with their job. The smaller 52-person company would save $106,742 over the same stretch. According to these admittedly rough calculations, the employers and their insurers earn back only 21 cents for every dollar they spend on colon cancer prevention.
Like many hypotheticals, the math is a little silly. No one actually gets 5% or a quarter or a half of a colorectal cancer. Someone in your workforce gets colorectal cancer or they don’t. However, even comparing the full cost of taking care of someone who survives cancer for 8.2 years, the savings for the larger employer - $2.77 million - would be much smaller than the $4.8 million cost of prevention. The savings for the smaller employer would be around five and a half times larger than the cost of prevention, but the odds of even a single employee developing colorectal cancer in that time frame are 18 to 1 against, so it remains a poor financial risk. (See “A Little Extra for the Data Curious” for assumptions and math).
This economic reality is background for the slow spread of colorectal screening since passage of the Affordable Care Act. According to the American Cancer Society, only two-thirds of U.S. adults age 50 to 75 are up to date for screening. In addition, “screening in accordance with guidelines increased rapidly among adults ages 50 and older from 2000 (38%) to 2010 (59%), but more slowly in the past decade, reaching 66% in 2018.”
If preventive care saves money and lives, insurers might be expected to do everything possible to encourage it, including not denying colonoscopy claims as reported by Consumer Reports. The money-saving logic should also create urgency for employers not just to pay for screenings when their employees’ doctors happen to bill for them, but to ensure their workers actually get screened. As clients of insurers, employers might also be expected to challenge claims denials and other insurance behaviors that discourage people from getting screened.
In real life, employers and insurers focus on tiny fragments of the U.S. population over too short a time for most preventive care to generate a positive return on investment. The CDC’s analysis of the cost of colorectal cancer screening recognized this problem.
Like all U.S. health care, the CDC-funded screening programs had large non-clinical costs. Only 39% of the spending measured by the researchers went to direct clinical costs. On average, the non-clinical costs “were lower for programs with large patient volumes than for programs with small patient volumes. These findings indicate that substantial fixed costs are associated with nonclinical activities. These results are further evidence that economies of scale exist in CRC screening programs.”
Only an organization responsible for very large groups of people over a long period of time would find financial value in encouraging someone who might be looking for another job to get blood pressure or colorectal cancer screening. The stability of a Medicare-for-All system would turn the current incentives upside down. The people paying for health care would have both a financial and a policy incentive to follow up with providers and make sure that they’re hitting preventive care benchmarks with all their patients, especially for recommended services for younger patients whose care at the moment will only affect Medicare’s bottom line years from now.
The theocratic company owners challenging the preventive mandates in court ought not have any say in U.S. health care policy. But the real problem isn’t the ideology of those particular employers.
The problem is that employers and the insurers who work for them have any say over health care at all, and that the American obsession with competition as a cure for any social ill makes it profitable for them to ignore preventive care. When it comes to prevention, neither employers nor insurers are making money from most recommended services. It shouldn’t be a surprise that we don’t get very much of them.
A Little Extra for the Data Curious
*Consumer Reports says “Insurers deny claims for 1 in 10 preventive care screenings and medical tests, affecting 7.7 million Americans, according to a recent report by the Doctor-Patient Rights Project, an advocacy group that represents healthcare professionals and patient groups. About 40 percent of patients appeal these denials, but only half are successful, according to the DPRP report.” I can’t find this report and DPRP appears defunct. No Facebook updates since 2019, and the website yields a blank screen with a pop up to sign in, which you can’t do if you’re not already registered. If anyone has a copy of this report, I’d love to see it.
**Critical Assumptions: 1. We assume the distribution of heart attacks is the same as the reported distribution of “heart disease” by age group. 2. We assume that hospitalizations and subsequent follow up care for heart attacks are the only meaningful outcomes of the chain of interventions triggered by blood pressure screenings. As noted in the text, there are other clinical outcomes like stroke and additional “costs” that matter to employers, including the cost of labor to replace workers receiving treatment and the moral and emotional cost of suffering and death for employees. This analysis shouldn’t be taken as an accurate summation of costs and benefits.
***This analysis draws a few different sources together, requiring assumptions at each step.
Cases Prevented over 8.2 years:
Median job tenure for workers age 45-64. See “Employee Tenure in 2022,” BLS 9/22/2022. Workers 45-54 = 6.9 years; 55-64 = 9.8 years. There are more workers in the younger group according to the census. A weighted average yields 8.2 years. This estimate overstates how long employers and insurers would pay the costs and reap the benefits of screening for a median employee because the numbers are for all employees, and public sector workers tend to stay in jobs longer.
Annual Cases (Incidence) per 100,000 population, ages 45-64. The American Cancer Society breaks down the data in five year age groups: 45-49 = 33.1; 50-54 =59.5; 55-59 = 68.3; 60-64 = 90.2. (33.1+59.6+68.3+90.2)/4 = 62.8 cases per year per 100,000 people in the U.S.
Estimated case prevention from full screening:
National: 62.8*40% = 25.2 cases prevented per 100,000 population.
Big Employer: (25.2*(250/100,000))*8.2 = .0628 cases prevented per year. .0628*8.2 = 0.51496 cases prevented per 8.2 years.
Smaller Employer: (25.2*(26/100,000))*8.2 = .0066 cases prevented per year. 0066*8.2 = .05355 cases prevented per 8.2 years
Cost of screening: The study of CDC contractors found wide variations between the use of colonoscopy and fecal testing. Colonoscopy was more expensive, but since it is only recommended every ten years, the authors concluded “The clinical costs over a 10-year period for colonoscopy and FOBT/FIT may not be substantially different.”
Inflation: The study ran from 2009 to 2014, but the authors don’t give a reference date for the dollar amounts. Healing and Stealing assumes constant 2017 dollars since that’s the date the paper was published. Costs have been updated to 2023 with a commercial calculator using BLS’s medical cost inflation index. If the figures in the study are earlier than 2017, inflation-adjusted 2023 costs would be higher.
Annual total cost: $2,060 x 1.1543 = $2,377.78 per year.
Big Employer: Annual: 250 x $2,377.78 = $594,469.65. 8.2 x $594,469.65 = $4,874,651
Smaller Employer: Annual: 26*$2,377.78 = $61,824.84. 8.2 x $61,824,84 = $506,964.
Benefit of Screening (medical costs for colorectal cancer): The numbers measure costs not incurred due to prevented medical treatment, so it’s easy to get a little confused. The more expensive treating an illness is, the more money saved and the better investment prevention would be.
Survival: Colorectal cancer has a 64% five year and a 58% ten year survival rate. Healing and Stealing assumes that survival declines evenly from year 1 to year 5, then from year 6 to year ten. This is likely not accurate, but we are dealing with the back of an envelope, and more precise annual mortality wouldn’t affect the overall analysis significantly.
Cost per year. Healing and Stealing assumes no change in the cost of treating a colorectal cancer patient until they enter the final year year of life. Year 1 medical costs equal the “Initial Phase” cost. Years 2 through 9 equals the “Continuing Phase” annual cost times the expected survival of a single case, plus the annual expected mortality times the cost of the “End of Life Phase”. This maximizes the expected cost of treatment, and therefor the expected financial benefit of prevention to employers and insurers. The analysis also assumes that prevention begins immediately on the first day of the first year of investment in screening. The table below shows the calculations.
