Public Health, Wellness, and the Prevention and Public Health Fund: How Health Reform Seeks to Transform Health Care and Reduce Costs

Transcription

1 Public Health, Wellness, and the Prevention and Public Health Fund: How Health Reform Seeks to Transform Health Care and Reduce Costs Cosponsored by Trust for America s Health Michael D. Parkinson, MD, MPH, FACPM Past President, ACPM Distinguished Scholar, Innovative Care Financing & Delivery, Altarum Institute

2 American College of Preventive Medicine National medical specialty society of public health and preventive medicine physicians (1954) 2,300 physicians: primary commitment, training and interest in disease prevention, health promotion and systems-based care improvement Public health & clinical perspective and training Major role in evidence-based prevention and application of prevention principles to clinical care, quality & cost 2

3 $2.6 T Medical Tab 75% Behaviors, 35% Waste 3

4 How Many Americans Can Just Say Yes to All 5? I am within 5 pounds of my ideal body weight I exercise 30 minutes or more most days of week I eat a healthy diet with 5 fruits/vegetables most days I don t use tobacco products I have 2 or fewer alcoholic drinks per day 4

5 The True Determinants of Health and Disease Where & How We Live, Learn, Work and Play Social Environment Physical Environment Genetic Environment Individual Response --Behavior --Biology Health & Function Disease Health Care Well-Being Prosperity Evans, R. G., Barer, M. L., & Marmor, T. R. (1994) Why Are Some People Healthy and Others Not?. New York: Aldine De Gruyter 5

6 US Life Years Saved if Preventive Service Used* % Currently QALYs Saved Service Receiving if Use at 90% Tobacco Cessation Counseling 35% 1.3 million Aspirin chemoprophylaxis 50% 590,000 Colorectal Cancer Screening 25% 310,000 Influenza immunization 36% and 65% 110,000 Breast cancer screening 68% 91,000 Problem drinking screening 50% 71,000 Vision screening (>65) 50% 31,000 Cervical cancer screening 79% 29,000 Chlamydia Screening 40% 19,000 Pneumococcal immunization 56% 16,000 Cholesterol screening 87% 12,000 * American Journal of Preventive Medicine 2006, Volume 31, p

7 Prevention Systems Cascade* COMMUNITY Family, Peers, Schools, Employers. MACRO SYSTEM Health/Hospital. Systems Health Plans. MICRO SYSTEM Office Practices (Multiple Dyads) Delivery & Support Systems *ACPM Aspirin Optimization Project, 2007 Physician- Patient. Dyad Am J Med Qual

8 McLipitor Syndrome * "I call it the McLipitor Syndrome. Patients feel they can eat whatever they want as long as they take a statin drug to lower cholesterol. Because of time constraints, physicians may spend little time counseling lifestyle change, which can work as well as or better than the best drugs for heart disease, obesity, diabetes and high blood pressure." *Mark Goldstein, MD, NY Times Magazine Letter to Editor Feb 11,

9 Emerging MD Consensus? Conservative Prescribing Think beyond drugs Seek nondrug alternatives as first not last resort Treat underlying causes, not symptoms Look for prevention opportunities not just treatment More strategic prescribing Heightened adverse effects vigilance Caution and skepticism regarding new drugs Shared agenda with patients Weigh long-term, broader impacts *Schiff, Galanter, Promoting More Conservative Prescribing, JAMA :

10 MD Behavior Change Competencies: A Blue Ribbon Consensus Panel Growing evidence of effectiveness that lifestyle and behavior change is effective for both prevention and primary treatment of chronic disease Representatives of major primary care (ACP, AAFP, AAP) and related groups convened by ACPM Physician competencies for prescribing lifestyle medicine. Lianov L & Johnson M; JAMA 2010;304(2):

11 Affordable & Sustainable Care* Strategic Innovation Principal Transformation Drivers. Consumer and Patient-Centric Decision-Making New Delivery Approaches And Alignments. Optimal Transformation. Market Organization, Financing and Aligned Incentives Altarum Institute 2009: Innovation, Health, and Equity: Taking a Systems Approach to Health and Economic Vitality 11

12 Prevention DOES Save Employers Real Dollars! Rewarding healthy behaviors Lowest cost, highest productivity, lowest total employer cost, and global competitiveness Improving unhealthy behaviors Worksite wellness programs consistently return 3-4:1 in total costs Design, communication, and incentives are the key! Delivering evidence-based clinical preventive services Cost-effective with some cost-savings compared to medical treatment later 12

13 Public Health, Wellness, and the Prevention and Public Health Fund: How Health Reform Seeks to Transform Health Care and Reduce Costs Cosponsored by Trust for America s Health Michael D. Parkinson, MD, MPH, FACPM Jeffrey Levi, PhD, Trust for America s Health Joshua M. Sharfstein, MD, Maryland Dept Health & Mental Hygiene James S. Marks, MD, MPH, Robert Wood Johnson Foundation

14 Moving to a Society that Values Prevention: Opportunities in Health Reform Jeffrey Levi, PhD Trust for America s Health

15 Nothing less than transformation US life expectancy rates among lowest in developed world US health care costs are highest in the world Current focus is on sick care Prevention has been seen as biomedical Our biggest problems from HIV to obesity haven t had biomedically-based solutions and we shouldn t be waiting for them Need to think about context of choice and risk What are structural solutions rather than biomedical or strictly behavioral ones 15

16 Health reform offers the potential for this transformation What are the prevention elements in the Affordable Care Act? How did prevention become a key part of health reform? What are the particular challenges ahead for prevention in the new political climate? 16

17 Key elements of health reform Coverage expansion does have a prevention effect First dollar coverage of clinical preventive services Government-wide commitment to prevention through the National Prevention, Health Promotion and Public Health Council National Prevention and Health Promotion Strategy Commitment to new programs in community prevention Prevention and Public Health Fund Public health workforce Nutrition labeling 17

18 Coverage of preventive services Requires new health plans to cover without cost-sharing: Evidence-based items or services rated A or B by the USPSTF ACIP recommended immunizations Preventive care for infants, children, and adolescents recommended by HRSA, and additional preventive care and screenings for women recommended by HRSA. Provides 1% FMAP increase for states that offer Medicaid coverage of and remove cost-sharing for A and B USPSTF recommended services and ACIP recommended immunizations. (Effective January 1, 2013) Eliminates cost-sharing for Medicare-covered preventive services that are USPSTF recommended A or B services and authorizes the Secretary to modify Medicare coverage of preventive services based on USPSTF recommendations. 18

19 Real money for prevention Prevention and Public Health Fund $15 billion over 10 years $2 billion a year starting in 2015 Mandatory funding stream 19

20 Purpose of the Fund: Non-clinical prevention Typically prevention and public health initiatives are subject to unpredictable and unstable funding. This means that important interventions often go unfunded from one year to the next.. The prevention and public health fund in this bill will provide an expanded and sustained national investment in programs that promote physical activity, improve nutrition, and reduce tobacco use. We all appreciate that checkups and immunizations and other clinical services are important. But this bill also recognizes that where Americans live and work and go to school also has a profound impact on our health. This is the very first opportunity in a generation one that may never return to invest in modernizing the public health system. (Senator Harkin, December 21, 2009, Congressional Record, pp. S ) 20

21 Fiscal Year 2010 $250 million for public health and prevention $44 million for approved but not funded ARRA grants $16 million for tobacco cessation activities $20 million for primary and behavioral health integration $16 million for obesity prevention and fitness $20 million for Epi and Lab Capacity state grants $50 million for state public health infrastructure $15 million for public health training centers $30 million for HIV/AIDS $8 million for public health workforce $10 million for Community and clinical preventive services task forces $21 million for surveillance 21

22 FY $750 million Community and State Prevention--$222 million $145 million for CTGs Tobacco Prevention -- $60 million Obesity Prevention and Fitness -- $16 million Clinical Prevention -- $182 million Immunizations Behavioral health and primary care integration Public Health Infrastructure -- $137 million Research and Tracking -- $133 million 22

23 FY 2012 (Proposed) -- $1 billion CDC -- $752 million CTGs -- $221 million Chronic Disease Grants -- $158 million Immunizations -- $62 million Unintentional injury -- $20 million Tobacco -- $79 million HRSA -- $20 million (workforce) SAMHSA -- $92 million (integration) OS -- $135 million (tobacco, teen pregnancy) 23

24 National Prevention and Health Promotion Strategy National Prevention, Health Promotion and Public Health Council Chaired by Surgeon General HHS, HUD, USDA, ED, FTC, DOT, DOL, DHS, EPA, ONDCP, DPC, Asst. Secretary for Indian Affairs Others: VA, DOD Health in all policies Due March 23, 2011 Vision: Improve life expectancy in the US, with a focus on disparities External advisory group 24

25 Framework for Prevention Strategy we're putting our focus in the White House on people and places in a way that we believe strengthens neighborhoods and improves health outcomes. We're using a multidisciplinary approach and strategy because, after all, every aspect of life includes health, it includes education, it includes housing and energy and transportation. People don t wake up in the morning and say I'm going to have an education day today and tomorrow I'm going to have a transportation day. For families, all of these pieces are integrated so we have to start thinking about our policies and our approach in that same integrated fashion. So, for us, what we're trying to insure, is that the days of thinking and working and talking in silos is, in fact, over. Melody Barnes, Domestic Policy Advisor, July 13,

26 Draft National Prevention Strategy Achieve significant gains in life expectancy at birth and at age 65 within a generation Healthy Communities where people live, learn, work, and play Preventive Clinical and Community Efforts Empowered Individuals Focus on disparities Mental and emotional wellbeing 26

27 True community-based prevention Community Transformation Grants Requires detailed plan for policy, environmental, programmatic and infrastructure changes to promote healthy living and reduce disparities Create healthier school environments, including healthy food options, physical activity opportunities, promotion of healthy lifestyles Develop and promote programs targeting increased access to nutrition, physical activity, smoking cessation and safety Highlight healthy options at restaurants and food venues NOT limited to chronic diseases or one disease at a time 27

28 What might CTGs look like? Examples of policy and structural change High impact efforts to make healthy choices easier Sustainable over time Smoke free air laws Improved nutrition choices in schools, supermarkets, corner stores Taxes (tobacco, alcohol) Zoning laws Syringe exchange, condom availability Eligibility: State and local government, national networks of CBOs, and local CBOs Expectations: Demonstrated ability to bring together a coalition Have or use grants to build policy development capacity Inclusion of state/local public health agencies in coalitions 28

29 How did prevention especially community prevention become so important? Coverage is important, but what surrounds (or precedes) coverage is also important Achieving good health outcomes requires healthy communities, not just healthy individuals Drivers of health care costs (chronic disease) can often be effectively prevented in the community as opposed to managed in the health care setting Reducing costs as a critical policy outcome Disparities in chronic diseases related to disparities in the health of communities Poverty, race/ethnicity and obesity Poor communities provide less support for healthy lifestyles (food, physical activity) 29

30 Key messages about prevention It s about health and prevention not about public health Making healthy choices the easy choices There is a role for personal responsibility Based on sound polling and messaging research 30

31 Prevention is central to ACA implementation government wide [W]e shouldn t be waiting for problems we should be preventing them. And that means tackling the causes of illness where those causes lie in our communities, our habits, our social supports, our choices where we live. America is seriously under-invested in using what we know about preventing illness, and we therefore live with the chronic epidemics of obesity, heart disease, asthma, and depression, for example, that we don t need to live with. I intend to guide CMS toward the Triple Aim as our highest-level goal better care, better health, and lower per capita costs, and I intend to focus our energies, as much as I can, on those three levels of excellence: excellence in care, excellence in integration, and excellence in prevention at the community level. Donald Berwick, CMS Administrator, NASHP Conference, October 2,

32 Opportunities within CMS Center for Medicare and Medicaid Innovation ($10 billion over 10 years) Care Models Group Integrated Care Models Group Community Improvement Care Models Group Exploring steps to improve public health and make communities healthier and stronger by fighting the epidemics of obesity, smoking, and heart disease $100 million Medicaid Incentives for Prevention of Chronic Diseases Public health quality standards and measures within current structure 32

33 The challenges in a changing political climate. Legislative and legal challenges to reform Legislative challenges to the Prevention Fund Making the case for prevention: ROI from community prevention Messaging about healthy choices vs. nanny state Continuing to build the evidence base Valuing prevention Success stories Bottom line: transformation is still essential 33

34 For further information 34

35 Public Health, Wellness, and the Prevention and Public Health Fund: How Health Reform Seeks to Transform Health Care and Reduce Costs Cosponsored by Trust for America s Health

36 Back up slides 36

37 Affordable Care Act and Prevention National Prevention, Health Promotion and Public Health Council created to develop a national strategy Prevention fund: $15 billion over 10 years to expand and sustain the necessary infrastructure to prevent disease, detect it early, and manage conditions before they become severe. Insurers required to cover preventive screenings (USPSTF A and B + future guidelines for women, children, adolescents, to be developed by HRSA) State Medicaid matching funds enhanced for following USPSTF recommendations Medicare coverage of annual wellness visit Medicaid coverage of tobacco cessation pregnant women 37

38 Affordable Care Act and Prevention Increased funding to HHS for: Community transformation grants Expansion of National Health Service Corps Media campaign on health promotion and disease prevention State demonstration program to improve immunization coverage through use of population-based interventions for high-risk populations GAO report on Medicare access to vaccines Advancing research and treatment for pain care management Chronic Disease Care Improvement Pilots 38

39 Prevention and Public Health Fund Mandatory funding stream to expand support for prevention and public health programs FY $500 million FY $750 million FY $1 billion FY $1.25 billion FY $1.5 billion FY 2015 and subsequent - $2 billion per year 39

40 Prevention and Public Health Fund Current Climate Lack of understanding regarding the impacts of public health have caused some to target the fund for other non-public health uses First attack came in Sept when Sen. Mike Johanns (R-NE) sought to use fund to pay for 1099 tax fix Several lawmakers have since attacked the fund on the floor of the House and Senate In current budgetary climate attacks will continue Need to explain public health & goals to win support 40

41 Mediterranean Diet, Nonsmoker, Daily Activity & No or Moderate Alcohol Use Disease Reduction Compared to US Comment Heart Disease 64%* - 83%** 80% due to modifiable risk factors Cancer 60%* Approximates NCI estimates Diabetes 91% ** No Type II Epidemic All-cause Mortality 50%* 25 year Okinawa Program Similar Findings * Knoops et al and **Rimm, Stampfer, JAMA 2004;292:

42 National County Health Rankings Starting Point? National and state ranking of health outcomes and factors Methodology originated in Wisconsin by David Kindig, MD and Center for Population Health RWJF supported national analysis and dissemination Logical place for leading health systems to understand and address determinants of health and drivers of care/costs 42