Challenges and opportunities states face
Transforming Data
into Information to
Drive the Agenda
• Hurricanes and pandemics
• Globalization of our economy
• National security threats and responses
Joseph W. Thompson, MD, MPH
• 46 million uninsured U.S. citizens
Surgeon General
State of Arkansas
• Medical and information technology
advances
Director
Arkansas Center for Health Improvement
Academy for Health
Services Research
June 25, 2006
• Aging population and deteriorating health
• Fragmented investment strategies at the
federal, state, local, and personal levels
Arkansas Center for
Health Improvement
MISSION: Improving health through
evidence-based health policy research,
program development, and public issue
advocacy
Core Values:
Initiative, Trust,
Commitment, and Innovation
A Model for Public Health Policy Development
Opportunity
Principals for Decisions
Who is the CEO of the
largest health plan
in your state?
Empirical Assessment
Education
Program Development
Political Discourse
J. Thompson et al, Society for Public Health
Education July 2004;5(3)57-63.
Implementation
1
Arkansas Public School Employees /
State Employees Health Insurance Plan
• Largest state-based insurance plan
(~ 120,000 employees)
• Major state influence in plan design, payment
structure, network development
• Self-insured plan with traditional benefit structure
– no preventive coverage
• Aging work force with chronic illnesses
• Escalating health insurance premiums
• Lack of risk management strategies
($1600/yr for smokers)
• Decisions based on annual actuarial experience –
no long-term strategy
Health risk assessment (2005)
• Three phases undertaken:
1) Awareness – Health risk appraisal (2004)
• Tobacco, obesity, physical activity, seat belt
use, binge drinking
2) Support – New benefit incorporation (2005)
• First dollar coverage of evidence-based clinical
preventive services
• Tobacco cessation – Rx and counseling
3) Engagement – Healthy discounts (2006)
• 15% ($23 million) of the $161 million spent last
year was associated with risk factors
3.4%
4.4%
1.1% 2.4%
11.5%
• Goal: Incorporate long-term management
strategy for disease prevention / health
promotion
Arkansas state health plan: Next steps
Tobacco Use
(11.4%)
Obesity
BMI >30.0
(34.7%)
Improving health of plan members
Physical Activity
< 3 days a week
(53.4%)
26.9%
19.6%
• Healthy discounts on insurance premiums
(January 2006)
–
–
$20 per adult/month for HRA completion
$20 per adult/month for no-tobacco use
• Act 724 (March 2005)
– Allows up to 3 days leave each year for employee
participation and point accumulation in Healthy
Employee Lifestyle Program
Self-report Health Risk Assessment Survey -- Fall 2005, n=46,637
(BMI n=46,599) BMI calculated from self-report height and weight
• Development and incorporation of obesity
reduction strategy into discount (2007)
Incorporation of State Employee Strategy
into Medicaid: New waiver requirements
• Requires implementation of cost-containment
strategy in general Medicaid population
• Proposal to incorporate HRA / risk management
strategy with annual reduction in tobacco use and
obesity
National Obesity Epidemic
• Will require integration of EBD and DHHS
strategies
• Opportunity for full integration of public and
private sector programs for optimal population
health impact
2
Obesity* trends among U.S. adults
(*BMI ≥30, or about 30 lbs overweight for 5’4” person)
Source: BRFSS, CDC, 1991, 1996, 2004
1991
Percentage of obese adults, age 20–64, U.S.
population, by sex, 1987 & 2001
1996
30
1987
2001
24.5
23.4
Percent
20
2004
13.8
13.3
10
0
Male
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Average cost of medical care for adults (55+) by weight
$8,000
Female
Data source: Rhoades JA, Altman BM, Cornelius LJ. Trends in Adult Obesity in the United States, 1987 and 2001:
Estimates for the Noninstitutionalized Population, Age 20 to 64. Statistical Brief #37. 2004. Agency for Healthcare
Research and Quality, Rockville, MD. www.meps.ahrq.gov/papers/st37/stat37.pdf.
Potential savings if Americans had normal
weight (adults, 55+)
7,235
Underweight
6,087
$6,000
5,390
$0.96 Billion
5,478
Additional
medical
care costs
Overweight
$2.04 Billion
Expected cost of
care for those of
normal weight
$4,000
$2,000
Obese
$27.62 Billion
$327.16 Billion
$0
Underweight Normal weight
Overweight
Obese
Data source: Rhoades JA. Overweight and Obese Elderly and Near Elderly in the United States, 2002: Estimates
for the Noninstitutionalized Population Age 55 and Older. Statistical Brief #68. February 2005. Agency for
Healthcare Research and Quality, Rockville, MD. www.meps.ahrq.gov/papers/st68/stat68.pdf.
National data sources on
child and adolescent obesity
BMI normalized percentile histograms from NHANES
1976–1980
1971–1974
• National Health and Nutrition Examination
Survey (1970–2001)
– Source of federal estimates for childhood
obesity
– Actual measurements of <15,000 kids
00
0
20 0
20
40 0
40
60 0
60
80 0
80
100 0
100
0
20
40
60
80
100
60
80
100
1999–2001
1988–1994
• Youth Risk Behavior Survey
– CDC/State survey of adolescents
– Self-reported data on height and weight
0
20
40
60
80
100
0
20
40
3
84th General Assembly Act 1220 of 2003
An act to create a Child Health Advisory Committee; to
coordinate statewide efforts to combat childhood
obesity and related illnesses; to improve the health of the
next generation of Arkansans; and for other purposes.
Arkansas’s Response to the
Obesity Epidemic
Goals:
• Change the environment within which children go to
school and learn health habits everyday
• Engage the community to support parents and build a
system that encourages health
• Enhance awareness of child and adolescent obesity to
mobilize resources and establish support structures
BMI normalized percentile histograms from NHANES
Act 1220 Requirements
1. Elimination of all vending machines in public
elementary schools statewide
1976–1980
1971–1974
2. Requirement of professional education for
all cafeteria workers
3. Public disclosure of “pouring contracts”
4. Establishment of local parent advisory
committees for all schools
00
0
20 0
20
40 0
40
60 0
60
80 0
100 0
80
100
0
20
40
60
80
100
60
80
100
1999–2001
1988–1994
5. Establishment of an Arkansas Child Health
Advisory Committee
6. Confidential child health report delivered
annually to parents with body mass index
(BMI) assessment
Arkansas BMI standardized percentiles
0
20
40
60
80
100
0
20
40
2005 overall statewide results:
BMI classifications for all students
2003–2004
Underweight
6,946
2%
Overweight
77,351
21%
60%
Healthy
Weight
223,127
0
10
20
30
40
50
60
70
80
90
17%
At Risk for
Overweight
63,943
100
Source: ACHI. The 2005 Arkansas Assessment of Childhood and Adolescent Obesity: Online State Report.
Little Rock, AR: Arkansas Center for Health Improvement, September 2005. Available at
www.achi.net/current_initiatives/bmi/default.asp
4
Percent at risk for overweight & overweight
by grade
41.7%
41.7%
41.4%
41.3%
40.7%
40.5%
39.4%
39.1%
38.7%
37.8%
1|2
1|2
1|2
1|2
1|2
1|2
1|2
1|2
1|2
1|2
1|2
1|2
1|2
K
1
2
3
4
5
6
7
8
9
10
11
12
36.2%
36.1%
38.0%
38.6%
40.9%
40.7%
At risk for overweight
34.2%
34.1%
40%
39.7%
40.1%
50%
35.3%
34.7%
Overweight
32.6%
33.0%
2004-2005
37.1%
36.0%
Arkansas BMI standardized percentiles
30%
Normal weight
20%
10%
Underweight
0%
Year
0
10
20
30
40
50
60
70
80
90
Grade
100
Overweight
Year 1 N = 347,103; Year 2 N = 367,879
At risk for overweight
Percent at risk for overweight & overweight
by gender and ethnicity
Percent at risk for overweight & overweight
by grade and ethnicity
43.1%
42.6%
38.6%
38.5%
44.2%
38.7%
38.3%
34.6%
40%
34.3%
Overweight
At risk for overweight
50%
43.9%
60%
50.7%
Source: Arkansas Center for Health Improvement, Little Rock, AR. Unpublished data, 2004, 2005.
49.7%
Source: Arkansas Center for Health Improvement, Little Rock, AR. Unpublished data, 2005.
60%
50%
40%
30%
30%
20%
20%
10%
White (Yr 1)
Black (Yr 1)
Hispanic (Yr 1)
10%
0%
Year
1
2
1
2
Females
Males
Caucasians
1
2
1
2
Females
Males
African Americans
1
2
1
2
Females
Males
Hispanics
White (Yr 2)
Black (Yr 2)
Hispanic (Yr 2)
0%
K
1
2
3
4
5
6
7
8
9
10
11
12
Source: Thompson et al, Morbidity and Mortality Weekly Reports January 2006; 55(1):5-8.
Source: Thompson et al, Morbidity and Mortality Weekly Reports January 2006; 55(1):5-8.
Child Health Report (2004)
Spanish Child Health Report (2005)
EXAMPLE SCHOOL DISTRICT
EXAMPLE SCHOOL NAME
Address
City, AR, #####
May 16, 2005
Parent Name
«MailingAddress1»
«MailingCity», «MailingState» «Zip»
Estimados Padres:
Esta carta importante se refiere a la salud de Example Student. Por favor léala toda.
Muchos niños en Arkansas tienen problemas de salud debido a su peso. Recientemente, en la escuela de su niña, la
estatura y su peso fueron medidos. Las medidas de peso y estatura, así como la edad y el sexo se usaron para calcular
el percentil del índice de masa corporal (IMC). El IMC es una prueba inicial que sugiere si una persona tiene sobrepeso,
está al riesgo de sobrepeso, tiene peso apropiado o está baja de peso.
¿Por qué se midió el IMC en la escuela?
Las leyes del estado de Arkansas requieren que la escuela de su niña mida el IMC cada año y que se le envíe a usted un
reporte sobre los resultados. En las escuelas de Arkansas también se practican pruebas iniciales para buscar problemas
con la vista y la audición de los niños. Medir el IMC de su niña es otra manera de ayudarle a cuidar su salud. Acciones
que se tomen ahora pueden ayudar a disminuir el riesgo de desarrollar enfermedades serias cuando crezca su niña. Así
Raramente, la IMC de un niño puede estar alta (sobrepeso o al riesgo de sobrepeso) debido a que el niño sea muy
que, es importante medir el IMC cada año para ver si su niña está creciendo y desarrollando de una manera saludable.
muscular. Al ser muy muscular no aumentan los problemas de la salud en el niño. Solamente puede decir un doctor si la
Si un niña está pasada de peso, usualmente se debe a que tiene un exceso de grasa corporal. Las niñas que tienen
exceso de grasa corporal tienen más riesgo de tener problemas de salud que las niñas con un peso apropiado. Las niñas
que están pasados de peso o en riesgo de estar pasados de peso son mas propensos a ser adultos obesos o con
sobrepeso. La obesidad puede causar enfermedades tales como diabetes, alta presión, problemas del corazón así como
otros problemas de salud. Las niñas bajas de peso también pueden tener problemas de salud.
IMC está alta a causa de mucha grasa corporal. Según la información en esta carta, seria bueno que hablara con el
doctor de su niña.
¿Es el peso de su niña un problema de salud?
El pasado 3/1/05, su niña fue medida y pesada en
la escuela. EXAMPLE midió 4 pies con 8 pulgadas
y pesó 137.4 libras, lo que le da un IMC que
sugiere que ella pueda estar sobrepeso.
El IMC de su Niña
¿Por qué se midió el IMC en la escuela?
Las leyes del estado de Arkansas requieren que la escuela de su niña mida el IMC cada año y que se le envíe a usted un
reporte sobre los resultados. En las escuelas de Arkansas también se practican pruebas iniciales para buscar problemas
con la vista y la audición de los niños. Medir el IMC de su niña es otra manera de ayudarle a cuidar su salud. Acciones
que se tomen ahora pueden ayudar a disminuir el riesgo de desarrollar enfermedades serias cuando crezca su niña. Así
que, es importante medir el IMC cada año para ver si su niña está creciendo y desarrollando de una manera saludable.
¿Es el peso de su niña un problema de salud?
El pasado 3/1/05, su niña fue medida y pesada en
la escuela. EXAMPLE midió 4 pies con 8 pulgadas
y pesó 137.4 libras, lo que le da un IMC que
sugiere que ella pueda estar sobrepeso.
Bajo de peso
El IMC de su Niña
¿Qué debe hacer usted?
Bajo de peso
Peso apropiado
En riesgo de
estar sobrepeso
Sobrepeso
Peso apropiado
En riesgo de
estar sobrepeso
Sobrepeso
La línea demuestra como el IMC de su niña se compara con el de otros niños en
las escuelas de Arkansas.
La línea demuestra como el IMC de su niña se compara con el de otros niños en
las escuelas de Arkansas.
¿Qué debe hacer usted?
Dado que el IMC de EXAMPLE sugiere que ella
está sobrepeso, seria bueno que hablara con el doctor de su niña. Por favor enséñele esta carta al doctor (EXAMPLE’s
BMI was 30.8 or 97.4 percentile). Su doctor verificara el IMC de su niña y se asegurara que las medidas que se tomaron
en la escuela son las correctas. Además, su doctor puede informarle acerca de una alimentación saludable y actividades
físicas para su niña. Por ejemplo, la Academia Americana de Pediatría es un grupo de médicos que atienden a niños y
sugieren que su familia debe de:
• Ofrecer bocadillos saludables tales como frutas, verduras y otras comidas bajas en azúcar y sal.
• Beber menos sodas y tomar más agua, leche desgrasada o bebidas bajas en calorías.
• Limitar a dos horas diarias el tiempo viendo televisión o jugando videos.
• Hacer ejercicios con sus niños tales como corriendo, caminando o usando la bicicleta.
Los hábitos saludables empiezan a una edad temprana. Por favor, esté conciente que la alimentación y la actividad física
afectarán la salud y vida de su niña.
Gracias,
EXAMPLE SCHOOL NAME
Para mayor información, visite www.achi.net.
Source: Arkansas Center for Health Improvement, Little Rock, AR, 2004.
Source: Arkansas Center for Health Improvement, Little Rock, AR, 2005.
5
Percentage
of students
overweight
or at risk
for
overweight
by
Arkansas
school
districts
(2004–2005)
Arkansas Board of Education actions
• Vending machines restricted until 30
minutes after lunch in all schools
– 12 ounce maximum size
– 50% healthy options required
• No competitive foods in cafeterias
• Cafeteria food service education
• Nutrition and health curriculum changes
• 30 minutes per day physical activity (K-12)
Source: ACHI. The 2005 Arkansas Assessment of Childhood and Adolescent Obesity: Online State Report. Little Rock, AR:
Arkansas Center for Health Improvement, September 2005. Available at www.achi.net/current_initiatives/bmi/default.asp
College of Public Health Evaluation
College of Public Health Evaluation
• Evaluation of schools, parents, and teens
• “Change is beginning to occur”
• Parents and adolescents continue to
believe that contents of vending machines
should be improved
• Parents awareness of heatlh problems
associated with childhood obesity
increased
• Adolescents did not report changes in
either eating or physical activity patterns
• After year one BMI reporting, parents of
overweight children more accurately
identify their weight status
• Substantial increase in proportion of
families eating evening meals together
• Adolescents did report fewer purchases
from vending machines
• BMI assessments did NOT increase weight
based teasing, result in skipped meals, or
increase use of diet pills or supplements
6
Overall results by BMI classification
Category
Year 1
Alliance for a Healthier Generation
• Alliance a joint initiative of the Clinton
Foundation and the American Heart Assn.
Year 2
Overweight
72,636
21.0%
77,351
20.8%
At risk
59,503
17.2%
63,943
17.2%
• Co-Chairs, President Bill Clinton &
Governor Mike Huckabee
Healthy
207,491
60.0%
223,127
60.1%
• June 2006: Corporate agreement
6,262
1.8%
6,946
1.9%
345,892
100%
371,367
100%
Underweight
Total
*χ2=6.3,
df=3, p >.05
–
–
–
–
American Beverage Industry,
Pepsico
Coca-Cola
Cadbury Schweppes
Morbidity and Mortality Weekly Reports, January 2006
Agreement: Corporate self-regulation
•
Elementary School
– Bottled water
– Up to 8 ounce servings of milk and 100% juice
– Low fat and non fat regular and flavored milk with up to 150 calories / 8
ounces
– 100% juice with no added sweeteners and up to 120 calories / 8 ounces
•
Middle School
•
High School
– Same as elementary school, except juice and milk may be sold in 10
ounce servings
– Bottled water
– No or low calorie beverages with up to 10 calories / 8 ounces
– Up to 12 ounce servings of milk, 100% juice, light juice and sports
drinks
– Low fat and non fat regular and flavored milk with up to 150 calories / 8
ounces
– 100% juice with no added sweeteners and up to 120 calories / 8 ounces
– Light juices and sports drinks with no more than 66 calories / 8 ounces
– At least 50% of beverages must be water and no or low calorie options
Arkansas Policy Initiatives:
Next Steps
• State employees assessment of health risks,
medical costs, and lost productivity
• Evaluation of obesity impact on Medicaid
enrolled children
– Linked BMI data to individual claims (n~250,000)
– Evaluation of conditions, service utilization, and
costs underway
– Goal to achieve CMS coverage for obesity in
kids
• Extension of Alliance strategy to food
7