Sonoma State University
Prevention & the Healthcare Crisis
2004
Reducing Health Care Costs by
Reducing the Need and Demand
For Medical Services
• Overall costs were $838 billion in 1992, or more
than $3,000 per person.
• More than 30 million Americans are uninsured,
partly because of rising premium costs.
• The approach largely ignored focuses on
reducing the need and demand for medical
services.
Preventive Health and Cost Savings
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treatment of hypertension
reducing the rate of low-birth-weight infants
smoking cessation
nutrition education and weight reduction
exercise and stress management
appraisal of health risk
The main reason to invest in prevention
is to promote health and extend life,
improve functioning and prevent
suffering.
» "The Role of Prevention in Health Reform", Russell,
Louise B., Ph.D., The New England Journal of Medicine,
July 29, 1993;329 (5):352-354.
Cardiovascular disease
The estimated cost for cardiovascular
disease in 1994 by the American Heart
Association is 128 billion dollars.
1 of 2 women in the US dies of
heart disease or stroke
• less than 33% identified heart disease as the
leading cause of death.
• More women identified breast cancer as the
leading cause of death.
• Although 90% of the women reported that they
would like to discuss heart disease or risk
reduction with their physicians, more than 70%
reported that they had not.
Walter C. Willet MD MPH
Professor of Medicine
Chairman of the Department of Nutrition
Harvard
• Moderately easily achieved lifestyle
intervention* results in 82%
reduction risk of coronary artery
disease…. This is much more
important than Statins
*No cigarette smoking, moderate physical activity
and easy diet changes
Nutrition is the Keystone of
Prevention
The prevention of disease could result in
enormous cost savings to physicians and
hospitals.
» Kretchmer, Norman, The American Journal of
Clinical Nutrition, 1994;60:1.
The Lyon heart trial
o Adjusted risk ratios ranged from 0.28 to
0.53
o The protective effect of the Mediterranean
dietary pattern was maintained up to 4 years
after the first infarction
» Circulation 1999 Feb 16;99(6):779-85
Mediterranean dietary pattern in a
randomized trial: prolonged survival and
possible reduced cancer rate
During a follow-up of 4 years. reduction of risk in
experimental subjects compared with control subjects was:
• 56% (P=.03) for total deaths
• 61% (P=.05) for cancers
• 56% (P=.01) for the combination of deaths
and cancers.
» Arch Intern Med 1998 Jun 8;158(11):1181-7
To Supplement or Not To
Supplement: Is it a Question?
• improved intakes of certain micronutrients in
particular vitamins C, E and beta-carotene would
reduce health care costs by 25% for cardiovascular
disease, 16% to 30% for a variety of major cancers
and 50% for cataracts.
» Lachance, Paul A., Ph.D., DSc, Rutgers, The State
University of New York, New Brunswick, NJ 089030231, U.S.A.)
Exercise
Americans would pay almost any price for a pill
that contained all the benefits associated with
exercise: increased life expectancy, improved
mental health, and decreased disability. Scientific
research has shown repeatedly that exercise can
benefit both the body and mind.
• Statement of Dr. Terrie Wetle
Deputy Director,
National Institute on Aging
Senate Special Committee on Aging
Hearing on Healthy Aging
September 14, 1999
Physical Activity and Prevention
• Self-directed, moderate-level physical
activities which include gardening, yard
work and walking with a goal of 30 minutes
of activity per day at least 5 days per week.
» "Public Health Focus: Physical Activity and the
Prevention of Coronary Heart Disease", Morbidity
and Mortality Weekly Report, September 10,
1993;42(35):669-672
Physical Activity and Prevention
• Coronary artery disease cost $47 billion.
• Cost of physical inactivity was $5.7 billion.
• Elevated serum cholesterol (>than 200
ug/dL) cost of $7 billion.
• For each quality-adjusted life-year gained
the direct cost was $1,395
Physical Activity and Prevention
• Physical activity classes 2 to 3 times per week, for
30 to 45 minutes per session
• For each worker, the intervention program saved
$679 in medical claims per year, a return of $6.85
on each dollar invested.
• Other examples of work-site programs have been
estimated to cost employers about $100 to $400
per employee, per year. The estimated rate of
return is about $513 per employee per year,
including reduced health care cost and reduced
loss of productivity.
Emotion, Cancer and Heart
Disease
• Specific emotional factors are 6 times more
predictive of those who will develop cancer or
coronary heart disease than cholesterol, blood
pressure or smoking in following over 2,000
subjects in Germany over a 13 year period.
– "Emotional Health, Cancer and Heart Disease", Crawford,
Robert J.M., The New Zealand Medical Journal, March
1993;10:87
Psychosocial Components
• psychosocial treatment can improve survival.
• Those who had a mild or moderate depression had
a risk-adjusted 6.5-fold higher likelihood of death
compared to MI patients who were not depressed.
• Those who had psychological stress upon entry
into the program had a 3.5-fold increase in the risk
of a subsequent cardiac event in the next 2 years.
Job Stress and the Risk of
Coronary Heart Disease
• 6895 men & 3,413 women between 35 and 55
followed for 5.3 years
• imbalances between personal efforts and rewards
were associated with a 2.15-fold higher risk of
new coronary heart disease.
• Job strain and high job demands were not related
to coronary heart disease.
• Low job control was strongly associated with new
disease.
– "Two Alternative Job Stress Models and the Risk of Coronary
Heart Disease," Bosma PH, et al, Am J Public Health, January
1998; 88(1):68-74
"hostility" is cardio-toxic
• Large National Institute of Health studies
ultimately demonstrated that it is this
"hostility" component of Type-A behavior
which is cardio-toxic and coronary-prone
» Mark Goodman, Ph.D., M.A. "Pilot Findings of a
Percutaneous Transluminal Coronary Angioplasty
Restenosis Prone Prevention Program," Mayo Clinic
Proceedings, May, 1997;172:487
Putting it all together…
Walter C. Willet MD MPH
Professor of Medicine
Chairman of the Department of Nutrition
Harvard
• Moderately easily achieved lifestyle
intervention* results in 82%
reduction risk of coronary artery
disease…. This is much more
important than Statins
*No cigarette smoking, moderate physical activity
and easy diet changes
Ornish’s Lifestyle Demonstration
Project
• Angiographically documented CAD severe
enough to warrant revascularization.
• The cost of the 1-year program averaged $7,000
per person.
• Reduction in angina comparable to that achieved
with revascularization
• The average cost for PTCA (with cardiac
catheterization) was $31,000, and for CABG was
$46,000.
• The average cost savings per patient was $29,529
Survival curves
% survival
100
80
60
survival a
40
survival b
20
0
1
2
3
4
5
6
7
decades
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9 10 11
Reducing Health Care Costs by
Reducing the Need and Demand
For Medical Services
• Widespread implementation of preventive
strategies requires a collaboration among business,
labor, the insurance industry, government and
universities.
• Reducing the need and demand for medical
services is a positive solution bringing better
health for the individual and ultimately lowering
health care costs.
» Fries, James F., et al, The New England Journal of
Medicine, July 29, 1993;329(5):321-325.