Why prevention is our best
investment and what we need to
do to make it work
Stephen Bartels, MD MS
Geisel School of Medicine at Dartmouth
October 3, 2012
Dually eligible (Medicare/Medicaid) recipients are the
most expensive publically insured group
Among the dually eligibles, we spend two times the annual
per person cost for SMI compared to others
$50,000
$40,000
$30,000
$20,000
$10,000
$0
Schizophrenia
Medical Diagnoses Only
19 to
34
35 to
44
45 to
54
55 to
64
Depression
65 to
74
75 to
84
85+
Bartels et al., Am J Geriatr Psychiatry, 2003
….Yet the outcomes are worse:
The differential mortality gap for serious mental illness
has increased over recent decades
4
2.98
3.5
3.2
P<.03
3
2.5
1.84
2
1.5
1
0.5
0
1970s
1980s
1990s
Saha, S. et al. Arch Gen Psychiatry 2007;64:1123-1131.
Where should we focus funding and services
to improve health outcomes?
Determinants
Of Health
Lifestyle 5X
Health Care
We spend only
3% of our health care
dollar on preventing
disease, though 75%
of costs are associated
with preventable diseases
We can provide health promotion as an
integrated component of mental health
Example: The In SHAPE Health Mentor Program
Example:
The In SHAPE Health Promotion Intervention
Participants spend time each week
with personal mentors working out,
taking walks, or working on
nutrition plans.
Mentors help participants to track
their progress, set goals, and stay
motivated.
Results of recent study:
Almost ½ of either achieved
clinically significant weight loss or
improved fitness
A Participant’s Story
Pat, who has lifelong mental illness started
a new medication and became dangerously
obese. She withdrew and became more
disabled.
She now plays racquet ball, bikes, walks
the treadmill, and swims 2 times a week
“This program has done more for me than
any medication…It gives me something to
look forward to. I’ve realized, through this
program, that I need structure. Even when I
don’t feel like getting out of bed I know I
have to because my mentor is waiting for
me…..It has been a lifesaver to me.”
Pat has lost weight, discontinued Lipitor due to lowering her cholesterol
and has plans to work with her doctor to discontinue one of here
psychiatric medication to reduce her clinical visits.
Voices of Other In SHAPE Participants with
Serious Mental Illness:
• “I had a friend who was in her late 40’s when she
died. I don’t want that to happen to me.”
• “I am learning to run and climb…even though I
have braces. Physical activity makes me feel so
much better.”
• “It gave me a chance to quit smoking. It seems
like my body wanted the exercise more than the
cigarettes. My mother said that I am a different
person.”
• “I’d rather go to the gym than to the doctor.”
WHAT WE NEED TO DO TO MAKE
PREVENTION WORK?
• Research:
We need to create more effective, more efficient, and more
sustainable interventions.
• Review of the research (24 studies): the most effective programs
combine exercise and nutrition and result in modest risk reduction1
Recommendations:
• Designate research on reversing early mortality among persons with
SMI as an NIH-wide funding priority
• Implement recommendations of the recent September 10-11, 2012
NIMH Meeting “Research to Improve the Health and Longevity of
People with Severe Mental Illness.”
 Need for research on the use of mobile technology, family and peer
support interventions, financial incentives, combined interventions.
 Fund health promotion studies in CMMI, Health Home, and ACO projects
 Establish a national “Learning Collaborative” on how to best disseminate,
implement, and sustain health promotion for persons with SMI.
1Bartels:
SAMHSA Wellness Whitepaper: http://www.integration.samhsa.gov/health-wellness/wellnesswhitepaper
WHAT WE NEED TO DO TO MAKE
PREVENTION WORK?
Policy Recommendations:
• Adults with SMI (3% of the US population) are a high cost,
high risk group and should be designated by CMS, CDC, and
NIH as a public health priority.
• Direct Medicare-Medicaid Coordination Office to ensure
coverage for intensive prevention and lifestyle interventions
among priority high risk, health disparity populations (SMI).
• Mental health and general health care organizations should
be required by CMS to provide evidence-based integrated
health promotion and wellness programs.
• The ACA Prevention and Public Health Fund (including
National Public Health Initiative and Community
Transformation Grants, etc.) should include a focus on
persons with serious mental illness as a special needs group.
Goal: Make the 10 X 10 Campaign a Reality!
“To Increase Life Expectancy by 10 Years in
10 Years for People with Mental Illness”