Prof Rajendra Pratap Gupta, public policy expert & Author, and Dr Rahul K Garg, a physician turned management consultant examine new frontiers to preserve the value of human life
World over and across healthcare systems, both private and public sectors are focussing on prevention. Public sector (Government) wishes to invest more in prevention programmes, and the private sector aims to build a profitable business around prevention. But both have failed to achieve their goal and yet, continue to struggle for success. Two areas which will be helpful to steer the debate further and give a definite direction, would be; one, what is the benefit for investing in prevention and can it be quantified for Return on Investment (RoI)?; Secondly, is the current model of invasive diagnostic tests and doctor centric preventive model, the right way to go or do we need to change our approach. This article looks at preventive care from these perspectives and makes recommendations whether preventive care makes sense and if yes, what is the net present value of prevention and what is the way forward for prevention to succeed.
Cost factor
We cannot assign any value on the cost of prevention unless we define the cost of maintaining a handicapped human body or assess the contribution of a healthy human being. What is it that we are trying to prevent from being lost? This is a tricky question, but there are various methods or ways in which we can calculate the cost of human life or cost of a healthy human being versus a lost monetary value when someone falls sick or is handicapped to perform routine duties.
Cost (Value) of human life
In 1976, Dr Harold J Morowitz, a biophysicist of Yale University, calculated that a human body is worth anywhere between 97 cents to $6 trillion depending on the methodology of costing (Morowitz 1976). The human body is 70 per cent water, the most precious substance responsible for life on earth. The rest 30 per cent of it is carbon, nitrogen, hydrogen, oxygen, and some 100 other elements in minute quantities. The by-weight biochemical value of these substances in elemental form is around $ 150. That sounds very frugal valuation of a human body. An average American or European college graduate earns up to $3 million in their lifetime (Social Security 2015). Would this mean that human life is worth a few million dollars in direct earning potential or worth the taxes or the GDP contributions to the country? How to value the cost of continuity to human civilisation? Do we consider this in the notional cost as well? Additionally, a human contributes economically to society and nation in various intangible forms like spreading happiness and providing a support system to fellow humans.
Cost metrics in relation to various parameters
Multiple meta-analyses of 25 year-studies calculated the Value of Statistical Life (VSL) between $4-10 million (Ryan C Bosworth 2017). This is the number used by insurance firms, judiciary, and employers to calculate the monetary pay-out in case of an untimely loss of life. For example, employers pay $2,000 annual insurance premium for each of its 5,000 employees to cover them for $10 million covers. Insurance provider assesses the risk at less than 1 life being lost in a year. But all these numbers rotate around the economic benefit a human can provide. In clinical lingo, all the organs of a human body like bone marrow, kidneys, corneas, heart, lung liver, etc. are worth up to $45 million in a black market for organs (Trace Dominguez 2014). This indicates that we all possess an asset, our body. You can put the maximum insurance cover one can get in India / USA / EU and that could be a fair market value based on income.
Dr Harold J Morowitz demonstrated that if he were to incubate a human from elemental substances, it would cost him $6 trillion in terms of efforts and material resources to do so. Harold was a consultant with NASA and advised them on the thermodynamics and economics of sustaining human life on Mars. The takeaway from his research is that the human body is as valuable as you consider it to be. In consideration, one must acknowledge that the value is directly proportional to total expected life in years and the quality of each year of life. The better quality would mean the ability to live life at free-will and without any morbidity. A deduction to his research can be that preventing disease conditions adds monetary value to the most precious asset we all have, ‘Human body’. At this point, we are aligned with the thought that disease prevention is, financially and clinically, an intelligent practice.
Who owns the asset of a human body and who benefits from the deeds of this body? The answer to this question is also the answer to another question: Who should invest money in preventing disease to a human body?
The asset is in principle owned by the individual human being living inside the body. The individual utilises the capabilities of this asset to perform tasks, make a living, and experience life. In addition to this individual, his/her family is benefitted from the activities like cooking food, physical safety provided, companionship, and in some cases, money provided through the skilled use of the asset in the discussion. If the individual is working for an organisation, the employer is benefitted from the activities of perfectly health human body. Our social ecosystem, including society, governments, cultures, and environment are directly or indirectly benefitted from the deeds of an individual over his/her lifetime. All these parties, including the individual, family, employer, government, and society hold direct interest in the physical, mental, social, and spiritual wellbeing of the asset, human body. To be fair and square, every beneficiary should be responsible for the health and well-being of the asset. It is in the interest of every stakeholder to keep every human being as healthy as possible and invest efforts to extend the longevity of life.
It might be difficult to distribute the $6 trillion equity amongst various stakeholders. But what is possible is to identify the role each stakeholder plays in the prevention of depreciation of the asset. In the case of a human body, getting a chronic disease impacting lifestyle and productivity is essentially the depreciation of the asset. Spending time in a hospital for a surgery or for any acute reason is downtime that erodes the productivity of the asset. The comparison of a sacred human body, which is considered a temple in many cultures, to an accounting jargon appears very blunt and cold. However, being more rational about the asset might put the point across the table effectively. The point is, if the human body is not taken care of, it depreciates to a level where chronic diseases dent the experience of living.
Depreciation with time or appreciation with experience? Cost of humans may vary with their age, more age means more valuable unlike durables or white goods! A human being is an appreciable asset, as an adult human with learnt skills is increasingly valuable to society. The value commensurate with the amplitude of the experience and inherent wisdom.
How much should be spent on prevention of diseases on a daily basis and over a lifetime? We must keep in mind that eventually, the human body will perish someday. The aim of prevention is to keep the body disease-free until it dies off just the old age. The answer to how much begins with who should spend time, money, and efforts to keep the body fit. The individual who lives within it has the highest level of control and authority on the asset. An individual holds the majority shares of this asset. While other parties are minor shareholders (stakeholders) to a varying degree. Each stakeholder is an influencer and beneficiary in keeping the asset healthy. Family educates the individual about good habits of hygiene and benefits of exercise. Family provides the basis of balanced diets and spiritual well-being. The society and the government provide the broader infrastructure entailing health education, community wellness programmes, and prevention of epidemics. The employers are interested in keeping up productivity through mental wellbeing, provide some sort of insurance to get treated appropriately and return to work. To keep employees healthy, employers provide gym and yoga memberships, extended health covers, positive working environment, and counselling support. Insurance companies are evolving their role in keeping their clients healthy. Insurance companies have begun rewarding the individuals and employers for good behaviour leading to a healthy outcome. All of the above-mentioned efforts are constructed on the individual’s instinct of leading a healthy and healthy life.
Cost of living vs cost of untimely death? DALYS & Absenteeism
The final quest is how much is enough to invest in the asset of interest? Economists have concluded that if somebody lives a year in disability, there are cost implications on the individual and stakeholders. Not only the individual loses the earning potential, but there is also an extra expenditure incurred on medical treatment. According to the World Health Organization (WHO) one Disability-Adjusted Life Year (DALY) is one lost year of a healthy life. If a prevention strategy can postpone a stroke by 10 years, 10 DALYs are saved. In addition to the money value of DALYs saved, 10 years provide the time to develop the better medical management of stroke. Based on the method of calculation and socio-economic conditions, 1 DALY for an individual could be worth $5,000 or $1 million or any other number. According to WHO’s Global Burden of Disease study, respiratory infections cause a loss of 95 million DALYs per year, depression takes 65 million DALYs, cardiac disease is 63 million DALYs, and HIV is 59 million DALYs (WHO 2004). Adding and multiplying these numbers with the economic value of 1 DALY suggest that we are losing more money to preventable causes of disability than the collective GDP of the whole world.
The Center for Disease Control and Prevention suggest that preventing diseases through vaccination returns $10 to the society for every dollar spent (Cynthia G. Whitney 2014). A meta-analysis of 22 studies demonstrates that employers gain $3.27 in employee productivity for every dollar spent on workplace wellness programs (Katherine Baicker 2010). IBM is saving $130 million (with an RoI of 200 per cent) in insurance premiums and other costs through its flagship health and wellness programs (Carroll 2008). According to the American Diabetes Association, it takes $700 investment per year on lifestyle to prevent diabetes by 10 Quality Adjusted Life Years (QALYs)Â (Jeffrey A. Tice 2016). This saves $12,878 per QALY in terms of medical treatment and complications prevented (Samantha Roberts 2017). An increase in physical activity by 2.5 hours per week reduces the lifetime risk of diabetes by 58 per cent(Sheri R. Colberg 2010). Every individual can save $100 per year in medical costs by keeping a check on weight and blood pressure. Milken Institute suggests that society can save $1 trillion annually through a modest focus on prevention (Bedroussian 2007). All these studies and data conclude that there is an economic benefit in preventing diseases.
Every stakeholder has an interest in keeping health intact for every human body on this planet. The highest interest is in investing efforts on the present-day children to imbibe in them the healthy living practices. This would provide the highest return on investments in the coming decades for the whole society. Irrespective of who spends how much on whose health, the positive spillover effect would benefit the stakeholder collectively. The consensus is to define the disease prevention role for every stakeholder. An individual must keep oneself motivated to adopt a healthy lifestyle. Family, society and government provides a proper ecosystem to help individuals and corporations in working towards the common goal of prevention. Municipality planners should emphasise on the access to fitness facilities for all the residents. Insurance companies and employers should reward positive behaviour. Doing so, there is a lot of money to be saved and generated.
Cost-benefit (Economic value) analysis of keeping people health: Absenteeism, economic contribution and productivity
Sickcare is negative dollars, prevention is positive dollars with RoI demonstrated. In any healthcare systems, 5 per cent of the sickest patients consume over half of the healthcare resources (Zimmerman 2017). If people stay healthy and reduce the burden on health systems, the quality of care would go up as well. The lack of right prevention activities is costing the world 2-3 times of the global annual GDP. According to Centres for Disease Control and Prevention, American annual healthcare spend is $3 trillion to manage chronic and mental conditions (CDC 2019). Productivity loss from these conditions costs another $2 trillion annually to the American economy. A joint report by the World Economic Forum and Harvard University estimates the economic burden of preventable non-communicable diseases will be over $47 trillion (globally) in the next two decades (Bloom 2011). If you connect all these dots, the fair amount of prevention based on ‘Return on Investment’ can be arrived close to at least 20 per cent with an upside potential of 200 per cent. This should become the thumb-rule for spending on prevention. Start investing in programmes promoting right eating habits, smoking cessation, getting enough sleep, regular physical activity, annual healthcare screening after 40 years of age, vaccination, and prevention of infectious diseases like AIDS and Tuberculosis. Such practices would generate a positive feedback loop between the economy, individual health, and health systems. Since governments, employers, and insurance companies are more informed institutions as compared to individuals and families, it is the onus of the former to spread the wellness literacy amongst the masses. Though the individual is the ultimate go-getter for better health, the positive right-directed influence of the institutional beneficiaries is the key ingredient. A perfect combination of health and wellness policy framing, workplace incentives, societal enlightenment, and willpower to live and die healthy will be all that it takes.
New frontiers to preserve the value of human life
While the truth has always been shining about the secret of a healthy life, few have the resilience to practice it. Eat healthy, sleep early, sleep enough, exercise adequately, breathe healthy air, and keeping mental wellbeing are some of the examples. Mortal humans need a push in the right direction to follow the habits that maximise the outcome of life. Stakeholders like governments, employers, and communities are always looking for affordable solutions that would promote a healthy lifestyle. Technology is one tool that is affordable and is evolving to exponentially increase its relevance in wellness space. There are mobile apps that guide people to drink water on time, sleep on time, help to wake early, improving compliance with an exercise routine, and help in preparing a balanced diet plan. Some of this intervention might seem over-engineered, but that is the part of the fine-tuning process. Wearable gadgets like smartwatches, vitals’ monitors, activity sensors, etc. are all catalysts aiding individuals to maximise the value of their life. There will always be a financial and common-sense case to invest in technology that helps humans to live healthier, longer, and do more in a lifetime. Right health education, powered by the tools to live well, and supported by the adequate infrastructure to exercise is the key for any nation to unlock their demographic dividend.
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We human beings are more concerned about the Opportunity Cost but completely neglect the Cost of Ignorance towards any subject and specifically Health.