Prevention in Health Care Reform

8/8/2019 Prevention in Health Care Reform

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REALHEALTH REFORMSTARTS WITHPREVENTION


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Partnership or Prevention is a memership

organization o usinesses, nonproft organizations,

and government agencies. Partnerships mission

is to advance policies and practices that promote

health and prevent disease.

December 2008


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www.prevent.org

Genetic

predisposition30%

Behavioral

patterns

40%

Health

care10%

Environmental exposure 5%

Social

circumstances

15%

In this report, Partnershipor Prevention oers aseries o recommendations

to the 111th Congress toincrease our health systemsemphasis on health promotionand disease prevention. Therecommendations representa cost-conscious approach tomaximize value in the health careand public health systems.

The crisis acing our health caresystem has disturbing parallels

with the one that has recentlybeallen the nations nancialsystem. Timely actions to addressundamental problems on WallStreet might have averted adevastating day o reckoning inthe nancial sector. We must notail to apply that lesson to the

health sector while we still can.According to the CongressionalBudget Oce, rising health carespending is the main long-termthreat to the ederal budget and

threatens our nations nancialwell-being. CBO projects that,without any changes, totalspending on health care willrise rom 16.5 percent o thegross domestic product (GDP)

The challenge to improve our nations high cost, under-

perorming health system is both daunting and exciting.

Legislators are becoming increasingly aware that in

order to x our ailing systemone that leads the

world in cost but lags behind most industrialized

countries in health perormancewe need to

address the causes o poor health. Giving all

Americans access to quality, aordable medical care

will not by itsel rein in the ballooning health carecosts that threaten to overwhelm our government and

our economy. We must address the drivers o those

costs and do more to keep people healthy.

Real health reorm must start with prevention.

Without a much stronger emphasis on prevention than

now exists, we have little hope o controlling costs

without sacricing health.

The Congressional

Budget Ofce

projects that,

without any changes,

total spending on

health care will rise

rom 16.5 percent o

the gross domestic

product (GDP) in

2007 to 25 percent

in 2025 and to 49

percent in 2082.

CORINNE G. HUSTEN, MD, MPH, INTERIM PRESIDENT, PARTNERSHIP FOR PREVENTION

>>

SOURCE: Schroeder SA. We can do better: improving the health o the American people.

NEJM 2007; 357(12): 1221-1228.

A HEALTH SYSTEM THAT COSTS TOO

MUCH AND DELIVERS TOO LITTLE

DETERMINANTS OF HEALTH AND THEIR

CONTRIbUTIONS TO PREMATURE DEATH


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Partnership for Prevention

in 2007 to 25 percent in 2025and to 49 percent in 2082. Netederal spending on Medicare

and Medicaid will rise rom 4percent o GDP to almost 20percent over the same period.1

In addition, skyrocketinghealth care costs incurredby businesses are making it

increasingly dicult orAmerica to compete in the

global marketplace. Whatsurprises many people,though, is that productivitylosses due to pooremployee health dwarbusinesses direct health

care costs, urther underminingcompetitiveness.

And even though one in sixdollars in the U.S. economycurrently goes to health care 50% more than any othercountry our health system

is ranked 37th in the world,according to the World HealthOrganization.2 On such

important indicators as inantmortality and lie expectancy,the United States ranks 29thand 38th, respectively.3,4

Clearly, the path we are on isunsustainable. We need to getbetter value or our investment inhealth. One way to do this is to

invest in the policies, programs,and services that have beenproven to promote health andprevent disease.

We must ensure our approachesaddress the underlyingcauses o poor health, healthdisparities, and high healthcare costs. These include theeconomic, social, and physicalenvironments that can hinderhealthy behavior and thatcan contribute to stress, poor

...our health

system is ranked

37th in the world,

according to the

World Health

Organization.

Tobacco

435,000

112,000

85,000

75,000

55,00043,000

29,00020,000 17,000

Poor diet

and physical

inactivity

Alchohol

consumption

Microbial

agents

Toxic

agents

Motor

vehicle

Firearms Sexual

behavior

Illicit

drug use

SOURCE: Mokdad AH, Marks JS, Stroup DF, et al. Actual causes o death in the United States, 2000. JAMA 2004;291(10):1238-1245. Correction

published in JAMA 2005;293:298. SOURCE: Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight,

and obesity. JAMA. 2005;293:1861-1867.

ESTIMATED ACTUAL CAUSES OF DEATH, 2000


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www.prevent.org

educational outcomes, andmedical illiteracy. Withoutaddressing these underlyingdrivers, we will never be ableto do more than providetemporary solutions to the

dicult problems acing ourhealth system.

When the ocus is on thenancing issues that threatenour health care system, criticalhealth issues oten get lost innational health policy debates.We need to nd ways, such as

orming a high-level commissiono important stakeholders, tokeep Congress inormed aboutthe important opportunities tostrengthen the nations public

health system and make theUnited States the healthiestnation in the world.

Partnership or Preventionbelieves that keepingpeople healthy andpreventing disease mustbe an important part othe solution in xing ourhigh cost, low yield healthsystem. In this report, wewill explain why that isso, and we will present aseries o recommendations

to increase the nationscommitment to diseaseprevention andhealth promotion.

...i utilization

rates o just fveo these services

could be increased

to 90% o the target

population, more

than 100,000 lives

would be saved

each year.

SOURCE: Source: National Commission on Prevention Priorities. Preventive Care: A National Prole on Use, Disparities, and Health Benets.

Partnership or Prevention, August 2007.

Daily aspirin use in men over 40 and women over 50

Percentage receiving

services in 2005:

Lives saved per year ifutilization increased to 90%:

Smokers offered assistance to quit


services in 2005:

Lives saved per year if

utilization increased to 90%:

Colorectal cancer screening of adults 50 and older


services in 2005:



Adult influenza immunization


services in 2005:

Lives saved per year ifutilization increased to 90%:

Breast Cancer Screening


services in 2005:



45,000

40%

42,000

28%

14,000

48%

12,000

37%

3,700

67%

COST-EFFECTIVE PREVENTIVE SERVICES CAN SAVE LIVES


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RANkINGS OF PREVENTIVE SERVICES FOR

THE U.S. POPULATION

Clinical Preventive Services CPb CE Total

Discuss daily aspirin use, men 40+, women 50+ 5 5 10

Childhood immunizations 5 5

Smoking cessation advise and help to quit, adults 5 5

Alcohol screening and brie counseling, adults 4 5 9

Colorectal cancer screening, adults 50+ 4 4 8

Hypertension screening and treatment, adults 18+ 5 3

Infuenza immunization, adults 50+ 4 4

Vision screening, adults 65+ 3 5

Cervical cancer screening, women 4 3 7

Cholesterol screening and treatment, men 35+, women 45+ 5 2

Pneumococcal immunizations, adults 65+ 3 4

Breast cancer screening, women 40+ 4 2 6

Chlamydia screening, sexually active women under 25 2 4

Discuss calcium supplementation, women 3 3

Vision screening, preschool children 2 4

Discuss olic acid use, women o childbearing age 2 3 5

Obesity screening, adults 3 2

Depression screening, adults 3 1 4

Hearing screening adults 65+ 2 2

Injury prevention counseling, parents o children ages 0-4 1 3

Osteoporosis screening, women 65+ 2 2

Cholesterol screening, men < 35, women


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www.prevent.org

PREVENTION

WORkS

Nearly all o the leading causeso death in the United Statesare chronic diseases heartdisease, cancer, stroke, chroniclower respiratory diseases, anddiabetes. Yet these statisticsdo not tell the ull story. Theprimary drivers o poor healthand high health care costs arebehaviors tobacco use, poordiet, physical inactivity, and

alcohol consumption that arepotentially preventable. Whatsmore, there are many policies,programs and services that havebeen proven to be eective inaddressing these underlyingdrivers. These interventionsinclude programs and policiesthat oster environments that

support healthy behaviorsand healthy choices. Theyalso include services that aredelivered within the clinicalhealth care system.

Clinical Preventive Services

Some preventive services areclinical delivered in thedoctors oce or other clinicalsettings. These services whichinclude immunizations, diseasescreenings, and behavioralcounseling are designed toprevent diseases rom occurringin the rst place or to enable

early detection and earlytreatment o disease.

Partnership or PreventionsNational Commission onPrevention Priorities hasidentied the highest valueclinical preventive services byranking them according to (1)

the burden o disease eachservice can prevent and (2) theextent to which the servicesare cost-eective or cost-saving.5 Policy makers, health

care providers, and health carepurchasers use Partnershipsanalyses to allocateresources to the highestvalue preventive services.

Many preventive services,however, are under-utilized.In addition, signicantdisparities exist in the useo preventive services byracial and ethnic minoritiescompared to the generalU.S. population. TheCommission ound that

i utilization rates o justve o these services could beincreased to 90% o the targetpopulation, more than 100,000lives would be saved each year.(See Chart on pg. 3)

There are several reasons peopledo not receive the clinical

preventive services that wouldhelp keep them healthy. Ourhealth care system reimbursesspecialty care and acute caretreatment at a much higherrate than the delivery opreventive services. Uninsuredconsumers ace high out-o-pocket charges or preventive

services, while even those withinsurance are hampered bypoor coverage o these servicesand high deductibles or co-pays. Many consumers are notaware o preventive servicesrecommended or people otheir age, gender, and riskactors, while many health careproviders either lack or ail to usesystems to identiy and ollow upwith patients who need them.Additionally, many Americans,particularly disadvantagedminorities, have no connectionto a regular source o health careto help ensure they are getting

all the preventive services theyneed. And nally, the nation hasmade only a limited investmentin developing a prevention-oriented health care workorce

Our progress in

reducing tobacco

use among adults

rom 42% to 21%

over the last 40

years serves as

an example o how

policy and program

interventions can

produce enormous

health benefts.

>>


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and providing ocused trainingor doctors and other healthcare providers in deliveringpreventive care.

Community Preventive

Services

Community preventive servicesare policies, programs, andservices that aim to improve thehealth o the entire populationor specic sub-populations.The Task Force on CommunityPreventive Services, anindependent panel o expertssponsored by the Centers orDisease Control and Prevention,has identied more than sixtypolicies and programs thataddress the nations most seriouspreventable health problems.

Investing in these evidence-

based programs and policiesis essential i we are torestore a better balancebetween investing in healthrather than just sick care.

Examples o provencommunity preventiveservices include: designingstreets and neighborhoodsso that they are moreconducive to walking,

jogging, and biking; enactingpolicies that discourage the useo harmul products, such asincreasing the price o tobaccoproducts; providing diabetessel-management education in

community gathering places;and even enacting policies toimprove the social and economicenvironment, such as earlychildhood development programsor low-income children.

Our progress in reducing tobaccouse among adults rom 42%

to 21% over the last 40 yearsserves as an example o howpolicy and program interventionscan produce enormous healthbenets. Successul tobacco

prevention policies and programshave included media campaigns,higher tobacco taxes, smokereepolicies, and ree telephonecounseling services or tobaccousers. But progress has plateaued

in recent years making itimperative that we strengthenour eorts on tobacco.

Meanwhile, an epidemic oobesity threatens the healtho millions o adults and,increasingly, the uture healtho todays young people. While

obesity has serious medicalconsequences, the medicalcommunity alone cannot reversethe epidemic. Only a multi-pronged, community-orientedapproach will help create thehealthy environments thatacilitate good nutrition choicesand opportunities to engage in

physical activity. The problem oobesity also illustrates the needto assess both prospectivelyand retrospectively theimpact on health o policies ina wide range o areas, such astransportation, city planning,and agriculture. Legislators

are already using these healthimpact assessments inCaliornia and elsewhere.

Likewise, many other actors such as substance abuse, sexualactivity, and occupational healthrisks are best addressedthrough coordinated clinical andcommunity approaches.

The Healthy People 2010national health objectives, alongwith the soon-to-be-releasedHealthy People 2020 objectives,tell us what a healthy nationlooks like. Our nation needs tonow turn its attention to bringingtogether the many agencies

and stakeholders needed todevelop and implement plans orachieving the objectives and ahealthier population.

Partnership or

Prevention has

estimated that $4

billion would have

been saved in 2006 i

the utilization o 20

recommended clinical

preventive services

was increased romcurrent levels to 90%.


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www.prevent.org

PREVENTION IS

COST-EFFECTIVE

Todays economic realitiesunderscore the need to build

a more cost-eective healthsystem. Underuse o eectivepreventive care is a wastedopportunity in this regardbecause most recommendedclinical preventive servicesprovide substantial healthbenets at a very reasonablecost. Seventy-ve percent o

the nations health spending ison chronic disease, and thevast majority o these diseasesare preventable.

Some clinical preventive serviceswill save the health care systemmoney; others are highlycost-eective. Partnership or

Prevention has estimated that$4 billion would have been savedin 2006 i the utilization o 20recommended clinical preventiveservices was increased rom

current levels to 90% (the costo increasing the use o theseservices would have been $18billion while the savings wouldhave been $22 billion).And the potential impact

o these services wouldhave been substantial:more than 2 million lieyears would have beensaved in 2006 i these 20clinical preventive serviceshad been delivered asrecommended to 90%o each services target

population in previous years.While the costs and savingso these services is a smallraction o total health careexpenditures (the $4 billion insavings represents 0.2% o healthcare expenditures in 2006),the ndings make clear that

investing in prevention yieldshigh value.

keeping

people healthy

and preventing

disease must be

an important part

o the solution in

fxing our high-

cost, low-yield

health system.

>>


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Clinical preventive services thatsave money include:

advising at-risk adults aboutregular aspirin use to prevent

heart disease,

counseling smokers to helpthem quit,

immunizing children,

screening adults or andcounseling them aboutalcohol misuse,

screening older adults orpoor vision, and

immunizing older adults orpneumococcal disease.

Many other preventive servicesare highly cost-eective.Eighteen o the 25 preventive

services evaluated by Partnershipin 2006 cost $50,000 or less perquality-adjusted lie year, and 10

o these cost less than $15,000per QALY, all well within therange o what is considereda avorable cost-eectivenessratio. (A QALY is a measure thataccounts or both years o lie

gained and disease and injuryavoided.)

Policies and programs aimed atthe entire population or specicsub-populations are oten themost eective way to infuencethe social- and built-environmentactors that so directly aect

health. Many o these programsand policies have been provento be cost-eective. In thetobacco control arena, orexample, tobacco quitlines andincreasing tobacco taxes arecost-saving interventions.

While research on the

cost-eectiveness o manycommunity prevention programsand policies is not as extensiveas we would like, common sensetells us that interventions thatreach thousands or millionso people at once are otenar more cost-eective thanclinical preventive services that

must be delivered one patientat a time. Other examplesinclude education campaignsencouraging seat belt use, laws toprohibit sale o alcohol to minors,school-based sealant programsto prevent cavities, and olic acidortication o ood products toreduce the number o inantsaected by neural tube deects.

In addition, the benets omany o these interventions gobeyond health. Policies thatmake neighborhoods morehospitable to walking and bikingcan lead to more pleasant

communities, increased realestate values, and an increasedsense o community.


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Clinical preventive services

should e a asic eneft o

proposed health fnancing

reorm.

1. Makerecommendedclinicalpreventiveservicesaccessibletoall.

Ensure that ederally-sponsored health insuranceprograms (e.g., Medicare,Medicaid, DoD, VA) andthe private-sector healthinsurance oerings includedin the Federal EmployeesHealth Benets Programprovide coverage orclinical preventive servicesrecommended by the U.S.Preventive Services TaskForce and the AdvisoryCommittee on Immunization

Practices. Considerwithdrawing coverage orpreventive services notrecommended by thesegroups, helping to payor added services andhigher utilization orecommended services.

Create incentives or statesto cover cost-eectiveclinical preventive servicesin their Medicaid and StateChildrens Health Insurance

Programs (SCHIP). Cost-eective services are thoseservices that cost less than$50,000 per quality-adjustedlie year saved.

Authorize the Secretary oHHS to expand Medicarecoverage under Part B orimmunization servicesrecommended by theAdvisory Committee onImmunization Practices(ACIP). The recently

enacted MedicareImprovements orPatients and ProvidersAct allows theSecretary to coverservices recommendedby the U.S. PreventiveServices Task Forcebut makes no mentiono services recommendedby ACIP.

2. Encouragepatientstousepreventiveservices.

Oer rst-dollar coverage(i.e., no deductibles orcopayments) or cost-

eective clinical preventiveservices in ederally-sponsored health insuranceprograms, in state Medicaidand SCHIP programs, and in

RECOMMENDATIONS TO MAkE PREVENTION

AN IMPORTANT PART OF HEALTH REFORM

In 2007, Partnership or Prevention developed nine Principles orPrevention-Centered Health Reorm to guide eorts to increase the

priority or prevention. Partnership then commissioned some o thenations leading prevention experts to develop issue bries to identiypolicy options or implementing the principles (online at www.prevent.org/HealthReorm). Based on the issue bries, Partnership has developeda series o legislative recommendations to elevate the priority that ourhealth system places on disease prevention and health promotion bothclinical prevention and community prevention. These recommendationsshould be viewed as a starting point or helping the health sector unctionin a more rational and cost-eective manner.

Partnerships recommendations ollow. They are arrayed in accordancewith Partnerships Principles or Prevention-Centered Health Reorm.

>>

Common sense

tells us that

interventions that

reach thousands or

millions o people

at once are oten

cost-eective.


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0 Partnership for Prevention

private sector insurance plansincluded in FEHBP.

3. Oerincentivestohealthcareproviderstodeliverclinicalpreventiveservices.

Increase reimbursementin ederally-sponsoredhealth insurance programsto provide an incentiveto deliver cost-eectiveclinical preventive services.The services should bedelivered on a recommendedschedule with appropriatedocumentation andpatient education.

Reward health plans andinsurers that achievehigh delivery rates orecommended clinicalpreventive services inederally-sponsored health

insurance programs. Metrics,such as those developed bythe National Committeeor Quality Assurance, shouldbe utilized, and such ratingsshould be shared withpatients and employers.

Provide incentive payments

to community healthcenters (CHCs) that meetperormance objectives ordelivering recommendedclinical preventive services.

4. Rewardemployersortheiractiveengagementinemployeehealthpromotion.

Provide time-limited taxincentives to employersinstituting or enhancingevidence-based workplacehealth promotion programsand policies. The programsshould raise awareness aboutimportant health issues,

encourage healthy behaviors,or create environments orincentives to encourageemployee participation inthe programs.

Community preventive services

should e an integral part o

health fnancing reorm and o

community-ased health

promotion and disease

prevention.

1. Createhealthyenvironmentsandpromotehealthyliestyles.

Identiy and establish adiscrete, sustainable revenuesource rom which proceedswould be dedicated to corestate and local public healthprevention activities.

Establish a Public HealthAdvisory Commission torecommend to the Congresshow these core public healthunds should be allocatedto have maximum impacton the health o Americans.

The Commission shouldadvise on strategies to holdederal, state, and local publichealth agencies accountableor achieving the HHS-sponsored Healthy PeopleNational Health Objectives,and it should report on the

state o the nations publichealth system and on thedelivery o evidence-basedclinical and communitypreventive interventions.

Provide incentive paymentsto states that meet statehealth objectives jointlydeveloped by HHS and statehealth departments.

2. Oerincentivestoorganizationsthatinuencethehealthopopulationstodelivercommunitypreventiveservices.

Require that state and localrecipients o public healthunding use evidence-basedprograms and policies inall areas where they exist


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as a condition o ullFederal unding.

3. EncourageAmericanstogivegreaterattentiontopreventionintheir

ownlives.Support consumer educationinitiatives to encourageindividuals to adopt healthybehaviors. Mount sustainedcampaigns that build onsuccessul past campaigns,e.g., seat belt use, tobaccoreduction, immunizations,and physical activity.

Health reorms should aim

to increase the impact o

prevention through studies and

fnancing mechanisms.

1. Increasesupportor

researchoncommunity-basedandclinicalprevention.

Support expansion oresearch on eectivecommunity interventionsas well as the work beingdone by the CDC-sponsored

Task Force on CommunityPreventive Services toconduct systematicreviews o what worksto improve health at thepopulation level, withrelated economic analyses.

Support expansion o

research on eective clinicalpreventive services as wellas the work being doneby the AHRQ-sponsoredU.S. Preventive ServicesTask Force to conductsystematic reviews o whichclinical preventive servicesare eective in preventing

disease, with relatedeconomic analyses.

Create a National Center orHealth Impact Assessmentto examine the potentialhealth eects o a widerange o multi-sectoralproposed policies and

programs, especially thosethat are not viewed asprimarily health policiesand programs, such ashousing and urban renewal,land use, and agriculture.

2. Supportdevelopmentandtrackingosystem

perormancestandardsrelatedtoprevention.

Invest in improved datasystems to monitor progresstoward achieving theHHS-sponsored HealthyPeople National HealthObjectives and toward

reducing disparities inaccess to preventive servicesamong racial and ethnicpopulation groups.


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APPENDIX

ADDITIONAL RESOURCES FOR UNDERSTANDING

AND IMPLEMENTING PREVENTION

PartnershiporPrevention. Principles or Prevention-Centered

Health Reorm. 2007. Available at www.prevent.org/HealthReorm/.

NationalCommissiononPreventionPriorities.Preventive Care:A National Profle on Use, Disparities, and Health Benefts. Partnershipor Prevention, August 2007. Available at www.prevent.org/100,000Lives/

MaciosekMV,CofeldAB,EdwardsNM,GoodmanMJ,FlottemeschTJ,SolbergLI.Priorities among eective clinical

preventive services: results o a systematic review and analysis. AmJ Prev Med 2006; 31(1):52-61. Available atwww.prevent.org/PreventionPriorities/.

Partnership or Prevention has commissioned a series o issue bries,authored by some o the nations leading prevention authorities,addressing many o the most important prevention policy issues acingthe nation. The issue bries can be viewed at www.prevent.org/

HealthReorm/.

To view recommendations rom the U.S. Preventive Services TaskForce about eective clinical preventive services, go towww.ahrq.gov/clinic/prevenix.htm.

To view recommendations rom the Task Force on CommunityPreventive Services about eective community preventive services,go to www.thecommunityguide.org/.

Congressional Budget Ofce. The Long-Term Outlook or Health Care Spending.Congressional Budget Ofce, November 2007.

World Health Organization. Health Systems: Improving Perormance. The World HealthReport, 2000. Geneva: World Health Organization, 2000.

MacDorman MF, Mathews TJ. Recent Trends in Inant Mortality in the United States.NCHS data brie, no. 9. Hyattsv ille, MD: National Center or Health Statistics, 2008.

United Nations, Department o Economic and Social Aairs, Population, Division

(2007). World Population Prospects: The 2006 Revision, Highlights, Working PaperNo. ESA/P/WP.202.

Maciosek MV, Cofeld AB, Edwards NM, Goodman MJ, Flottemesch TJ, Solberg LI.Priorities among eective clinical preventive services: results o a systematic review andanalysis. Am J Prev Med 2006; 31(1):52-61.

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Prevention in Health Care Reform