The Nation’s Agenda for Prevention
National Health Policy Conference
February 8, 2010
Eduardo Sanchez , MD, MPH
VP and Chief Medical Officer, BlueCross BlueShield of Texas
Former, Texas Commissioner of Health
Health
A state of complete physical, mental,
social, and spiritual well-being.
Not merely the absence of disease.
2
Reform
the improvement or amendment of what
is wrong, corrupt, unsatisfactory, etc.
Primary prevention
… intended to prevent the onset of the disease in the first
place.
• Vaccines
• Health promotion - counseling to encourage
• Eating right
• Being physically active
• Avoiding tobacco
From: Scutchfield and Keck, Principles of Public Health Practice
Secondary prevention
… intended to detect health problems early in their
course so that action can be taken to minimize the risk of
progression of the condition or disease
Screening and early detection
Prediabetes? Diabetes?
Precancer? Cancer?
From: Scutchfield and Keck, Principles of Public Health Practice
Tertiary prevention
...focused on preventing the progression of disease or
rehabilitation after an event
• in the case of chronic diseases such as type 2
•
diabetes, this is called disease management
In the case of a myocardial infarction, this is called
“cardiac rehab”
From: Scutchfield and Keck, Principles of Public Health Practice
A Closer Look at the Economic
Argument for Disease Prevention
1. A core set of preventive services is effective.
2. Many evidence-based clinical preventive services offer high
economic value.
3. Among the core set of preventive services that offer high economic
value, a subset yields net savings.
4. Some preventive services, like many disease treatments, offer
poor economic value.
Woolf, JAMA. 2009;301(5):536-53
The Real Problem:
Medical &
Pharmacy Costs
$3,376 PEPY
25%
The Full Cost of Poor Employee Health
Personal Health Costs
Medical Care
Pharmacy
Productivity Costs
Total Costs =
$13,504 PEPY
75%
Health-Related
Productivity Costs
$10,128 PEPY
Absenteeism
Presenteeism
Short-term Disability
Long-term Disability
Overtime
Turnover
Temporary Staffing
Administrative Costs
Replacement Training
Off-Site Travel for Care
Customer Dissatisfaction
Variable Product Quality
Sources: Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition.
Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152 and Loeppke, R., et al. Health and Productivity as a Business Strategy. Journal of Occupational and
Environmental Medicine. Vol 49, No. 7, July, 2007. Pages 712-721 and the 2006 Mercer Employer Annual Survey;
Causes of Death, United States
2005
26.6%
Diseases of the heart
All cancers
22.8%
5.9%
Stroke
Chronic lower respiratory disease
5.3%
Unintentional injuries
4.8%
Diabetes mellitus
3.1%
Alzheimer’s disease
2.9%
Influenza and pneumonia
1.8%
Septicemia
1.4%
0%
Source: cdc.gov
9%
18%
27%
36%
The Preventable Causes of Death in the United States:
Comparative Risk Assessment of Dietary, Lifestyle, and
Metabolic Risk Factors (Danaei,2009)
Deaths attributable to individual risk (thousands) in both sexes
The role of health plans:
private and public
The value of prevention
• A more productive workforce
• High cost claims avoidance
The National Commission
on Prevention Priorities
• Provides evidence-based information about which
clinical preventive services are most beneficial and
cost effective
• Demonstrates where improving the use of preventive
services and eliminating disparities will save and
improve the most lives
Which Preventive Services Are Most Valuable?
NCPP ranks preventive services based on 2 measures:
1. Health Impact
•
Measured as QALYs Saved
•
Accounts for years of life saved and days lived with
sickness avoided
2. Cost Effectiveness (CE)
•
Measures economic value: what does it cost to produce a
healthy year of life?
•
CE = $s Spent – $s Saved
QALYs Saved
Highest Ranking Preventive Services for U.S. Population
H.I.
C.E.
Total
Discuss daily aspirin use—men 40+, women 50+
5
5
10
Childhood immunizations
5
5
Smoking cessation advice and help to quit—adults
5
5
Alcohol screening and brief counseling—adults
4
5
9
Colorectal cancer screening—adults 50+
4
4
8
Hypertension screening and treatment—adults 18+
5
3
Influenza immunization—adults 50+
4
4
Vision screening—adults 65+
3
5
Cervical cancer screening—women
4
3
Cholesterol screening and treatment—men 35+, women 45+
5
2
Pneumococcal immunization—adults 65+
3
4
Breast cancer screening—women 40+
4
2
Chlamydia screening—sexually active women under 25
2
4
7
6
Not all prevention is equal.
Colorectal Cancer Screening in Adults 50+
HEALTH IMPACT
Population
% Up to Date with
Any Recommended
Screening Method
(2005)
Lives Saved
Annually if % Up to
Date with Screening
Increased to 90%
Lives Saved Annually
Per 100,000 If % Up to
Date with Screening
Increased to 90%
White only
51%
11,100
17
Black only
42%
1,800
26
Hispanic
31%
700
15
Asian only
31%
330
15
Breast Cancer Screening in Women 40+
HEALTH IMPACT
Population
% Screened with
Mammography in
Past 2 Years
(2005)
Lives Saved
Annually If %
Screened in Past 2
Years Increased to
90%
Lives Saved Annually
Per 100,000 If %
Screened in Past 2
Years Increased to
90%
White only
69%
2,950
10
Black only
65%
500
14
Hispanic
59%
190
8
Asian only
55%
90
8
How to increase utilization of Preventive Services
Patient Strategies
•
Lower out-of-pocket costs to increase demand
•
Access to a regular source of health care (a“medical home”)
•
Increase awareness and understanding of the needed preventive
services
•
Increase awareness and understanding of risk of disease
•
Increase awareness and understanding about preventive services’
effectiveness.
How to increase utilization of Preventive Services
Health System Strategies
•
Implement systems proven to increase delivery – high
tech and low tech
•
Increase investment in a prevention-oriented health care
workforce – prevention as a priority
•
Improve cultural and linguistic effectiveness
•
Improve reimbursement
•
Medical home focus on comprehensive primary care
Smoking Cessation Advice and Help to Quit
HEALTH IMPACT
Population
All Adult
Smokers
% of Smokers Who
Were Offered Help to
Quit in Past 12
Months (2005)
28%
Lives Saved
Annually if % of
Smokers Offered
Help to Quit
Increased to 90%
Lives Saved Annually
Per 100,000 Smokers if
% Offered Help to Quit
Increased to 90%
42,000
Hispanics are 55% less likely to have been offered
assistance to quit smoking by a health professional
compared to non-Hispanic whites.
43
Trends in U.S. Smoking—High School
Seniors and Adults (1965–2004)
DSHS