They say an ounce of prevention is worth a pound of cure, but is that still true in today’s money? Recently I had an illuminating conversation with a patient that got me thinking about how I may try to answer this question. This is the first in a short series on the price of preventive health care.
Mr. GR, as I will call him, had recently turned 60 years young. Though he had been in good health, the notion that he was “getting old” was beginning to settle in, and so Mr. GR came to me interested in finding out what more he could do to stay healthy. In discussing various preventive health measures, I pointed out that he would benefit from getting vaccinated against shingles. Shingles, I explained, is a painful skin condition that in 1 in every 3 people can expect to develop in their lifetime. For most people an episode of shingles lasts a few weeks, but in 1 in every 5 affected individuals the condition becomes permanent and debilitating (called post-herpetic neuralgia). The shingles vaccine can reduce the risk of shingles by half and of post-herpetic neuralgia by two-thirds, which is why the Centers for Disease Control and Prevention (CDC) recommends vaccination for everyone ages 60 and older.
After our discussion, Mr. GR was convinced the merits of the shingle vaccine were worth the discomfort and small risks of vaccination. But then he found out his insurance company didn’t cover the vaccine. Mr. GR immediately changed his mind: “If it’s not covered by insurance, I don’t want it.”
This is an all too common scenario. Patients don’t want health care that isn’t paid for by insurers. It is a sentiment shared by many of my patients and one I am empathetic toward. If not CDC recommended preventive health measures, what exactly is health insurance coverage for? At the same time, another part of me believes that while we should be indignant towards our health insurance companies for the decisions they make, this alone should not preclude us from doing the right thing for our health. As individuals we spend money on many things, not all of which is essential, so why the reluctance to spend money for better health?
In this case, the shingles vaccine costed a whopping $844. No small change, to be sure, for somebody to pay for in one setting. But what if we thought about it another way? What if instead of considering the vaccine as a one-time cost we thought of it as a daily expense — the cost per day of reducing my risk of a painful, potentially disabling medical condition? After all, the benefits of vaccination accrue daily so why not consider the costs daily. If we assume that Mr. GR lives until age 76 (the life-expectancy for men in the United States) the cost of the shingles vaccine amounts to $52.75/year or 14 cents per day. (For those of you are into finance, a more appropriate method of estimation would be to use discounting. After all, a dollar today is worth more than a dollar tomorrow. Assuming a 5 percent discount rate, $844 today is equivalent to spending 21 cents per day for 16 years.*)
Explained this way Mr. GR had a real choice on his hands – were the health benefits of vaccination worth more than 14 cents per day? To my delight, Mr. GR changed his mind. He still wasn’t happy about dishing out over $800 for something that he felt his health insurance company should cover but the simple back-of-the-envelope math we did helped him better understand the decision he faced.
In the end, whether or not we like to consider it this way, health care decisions are also financial decisions. We make plenty of financial decisions that pertain to our health: whether we buy organic food, get membership at a gym, or drive a car with more safety features. I certainly won’t argue against health insurance companies’ providing better coverage for preventive health care or against the government increasing programs to support prevention. But while we wait for change to come, we cannot afford to put our health on hold.
At less than a quarter a day the shingles vaccine is a downright bargain. And having done similar calculations for other areas of prevention so are many other established preventive health services. So go on, treat yourself to better health.
- Shantanu Nundy, M.D.
* Calculation courtesy of my dad, Rajiv Nundy, an actuary for the Asian Development Bank.
I'm an internal medicine doctor passionate about keeping people healthy and out of the hospital. For a brief bio 
Problem is – we won’t be paying out the cost at 21¢ per day for 16 years. $844 is a lot of money to many people. It’s my food budget for 8.44 months. It’s the gas I need to get to work for a year ($70/month X 12). It’s the difference between paying my mortgage or not.
Oh, and I don’t have cable or other paid TV service, in-home internet – (need a cell phone for work) – I don’t drink soda, eat junk food – have expensive coffee drinks (I make tea at home). I bring my lunch to work. I drink tap water. I cut out the fat from my budget when I was out of work for two years (there wasn’t much to begin with). I’m working again – freelance – pay a lot for insurance in the high-risk pool I had to join (Cancer X 3, thyroid disease, depression – go figure) – but the work’s not secure and any money above expenses has to be set aside for the unknowable future. (I say this, because the usual retort to “I can’t afford it,” is to assume the individual is spending money on all kinds of unnecessary things that he/she is unwilling to give up for something that effects his/her health).
For the record – I’m as healthy as I can be given my medical history. Low BP, varied, mostly plant-based diet (one good thing about austerity measures – can’t afford meat), BMI of 19. No added sugar, minimal processed foods, low sodium intake.
That’s reality. I suggest you have your actuarial dad do a few budget scenarios for individuals and families at different income levels. You’ll find that $844 is a luxury many of us simply cannot afford. And, if we could – would the $844 be better spent on some other item(s) to further a healthy lifestyle? Maybe organic produce? – maybe a vacation to reduce the stress of such a meagre life? – some other screening test? Is the shingles vaccine the very best health-investment for that sum? I don’t know the answer to these questions. Maybe you do.
I truly respect your wisdom, and your vision – but there is a tendency among those who do not need to concern themselves about money for the necessities – secure position – future income assured – to fail to see how much money $844 is. You’re awfully quick to condemn us for failing to spend such a sum for this particular purpose.
Also – my car is 13 years old. A lot of the doctor bloggers like to use the car that their patients drive, the fact that they may have a cell phone – as ways to condemn those patients for being reluctant to fork over their hard-to-come-by dollars to the doctors themselves (who, generally speaking, aren’t worried if they’ll be able to stay in their home or have enough to eat this week).
You don’t come off this way – your writing is very measured and generally shows great empathy – but I think you missed something with this post.
Hi, thanks for your comments and I’m sorry if the post came across harshly or indifferently. I just re-read the piece. I definitely want to see proven preventive health care covered by insurance. That’s the best thing, period. What I was trying to do in this piece was frame the financial decision of whether to buy preventive health care not covered by insurance in the same terms we frame other everyday decisions. This way of thinking was helpful for this one patient but certainly is not for everyone. I take care of a predominantly African American (>80%), urban, poor community on the South Side of Chicago. I know for them this way of thinking would not be helpful and would not change their decision to not get the shingles vaccine. I don’t blame them or fault them for that. But there are others, this particular patient for one, who have the means to afford uncovered preventive health care but for whom the standard way of viewing the expense makes it difficult for them to appreciate the decision in terms of cost-benefit.
Question – I read in two different articles recently that the shingles vaccine is $200. Why do you quote a price of $844?
Great question. That is the “list price” at my institution, which includes the vaccine and its administration. Hardly anyone (if anyone) pays that price. Prices in health care, as you probably know, are rarely transparent. If you want into a clinic and ask how much they charge for a cholesterol test or even a routine office visit, many cannot tell you. This is in part because insurers contract with clinics and hospitals to get a discounted rate. But even these rates are not easy to obtain. It took me 4 months to get a list of charges for all the preventive health care measures at my institution, including the shingles vaccine. But even these prices do not always translate to actual prices in the real world, as you’ve learned.
Thank you so much for responding. I understand it is quite a challenge to know how much medical services and procedures cost. With a vaccine or other drug it seems slightly easier. One can know the cost of the vaccine itself – I understand that there are storage, administration, other costs that are less clear.
It seems, however that a mark-up of over 400% is outrageous, even given these other factors. Did Mr. GR have to pay the full amount? These sorts of things contribute to our mistrust of medical providers – however little they may actually be at fault.
Why not send Mr. GR to a pharmacist for the vaccine? It would have been less the 1/4 the cost of having it administered in your clinic.