 Prevention and Health Reform Summary Research Insights Prevention has not played a big part in health reform discussions Health represents one state’s approach to testing interventions that integrate provider and community interventions to improve the to date. Polling suggests that the public is generally supportive care and prevention of chronic disease. of prevention, but concerned about affordability. In addition, there is confusion and vagueness in the public’s understanding of Introduction prevention concepts, in part due to historically modest investments In most discussions of health reform efforts to date, prevention in preventive efforts. Finally, public support suffers because has often been a “footnote in the conversation.” To some investments in prevention have been siloed across a fragmented extent, this is understandable in that much of the conversation funding and delivery system. Proponents argue that prevention takes place around where most current resources are focused: should be a key part of health reform discussions because of its on dealing with sickness and injuries when they happen. The potential to control the growth and costs of chronic illnesses, first challenge to elevating prevention’s role in the debate is to especially obesity. The key policy challenge is to replicate and scale understand public perception of the value of prevention efforts. interventions whose effectiveness have been demonstrated. An Poll statistics suggest that the public is generally supportive of increased focus on prevention may also be effective in reducing prevention efforts, but also concerned about affordability: in health disparities. In order to do so, community-based efforts that a recent survey, one-third supported increasing spending on address environmental and social determinants of health must prevention efforts, but 55 percent favored keeping spending complement an emphasis on clinical preventable services. One at current levels. The public support for prevention falls health plan’s approach to community-based prevention, Kaiser somewhere in between that for Medicaid and protections against Permanente’s Healthy Eating Active Living (HEAL) initiative, bioterrorism; only support for veterans healthcare and the provides an important opportunity to learn which interventions children’s health insurance program (SCHIP) ranked higher.1 work, and to support replication. The Vermont Blueprint for Genesis of This Brief: AcademyHealth’s 2009 National Health Policy Conference At its annual National Health Policy Conference (NHPC) in Washington, D.C. on February 2-3, 2009, AcademyHealth convened a panel of four experts with different perspectives on prevention, particularly primary, community-based prevention efforts, and its role in health reform. Kenneth Thorpe, Ph.D., Emory University, moderated the session and provided some motivation and context for community-based prevention efforts. Ray Baxter, Ph.D., Kaiser Permanente, presented the perspective of a provider, and described the Kaiser Permanente HEAL initiative. Craig Jones, M.D., discussed Vermont’s statewide Blueprint for Health initiative and the early results of pilot sites. Marsha Lillie-Blanton, Dr.P.H., George Wash- ington University, concluded the session with an assessment of the barriers and challenges facing community based prevention efforts, and some suggestions for moving the conversation forward. This issue brief summarizes the presentations and discussion from the NHPC session. Prevention and Health Reform A second challenge is a lack of branding, and resulting public confusion and vagueness about what terms such as disease • The health reform debate should recognize the role of obesity in driving chronic conditions and their resultant costs. Obesity has prevention, health promotion, community-level prevention, doubled since the 1980s, and research suggests that obesity and community-based prevention mean. The policymaker and accounts for 15-25 percent of the growth in healthcare spending. research communities are starting to “unpack the black box” of Obesity is strongly correlated with a number of chronic what those terms mean, but the public’s understanding lags, in part conditions: the growth in obesity accounts for nearly all of the due to the plethora of terms used. The current lack of investment increase in diabetes in recent years. Five medical conditions also inhibits better understanding and support, which in turn could account for much of the cost increases in Medicare: diabetes, engender greater investment. arthritis, hyperlipidemia, hypertension, and back problems—and all are linked to obesity. A third major challenge to increasing the role of prevention is the problem of collaboration across fragmented systems and funding streams. Any broad, community-based initiative raises issues of • The precursors to Medicare’s cost burdens—and opportunities to prevent them—occur long before individuals become eligible who is responsible, who takes leadership, and how the project will for Medicare. Normal-weight 65-year-olds cost 15-40 percent be financed. Silos of funding and service delivery exist, and to less over their remaining life than those entering Medicare move forward, policymakers must devise vehicles and mechanism overweight or obese with one chronic condition. Thus Medicare for cross-collaborations to take place. States and local communities has an incentive to reach out earlier.2 may be ahead of the federal government in this regard, because at the federal level the silos are so institutionalized—not only across federal departments, but even within the Department of Health • Primary and tertiary prevention efforts are target areas for potentially cost-saving intervention. There is considerable buzz and Human Services (HHS). concerning whether prevention works, and whether it is cost- saving. In our current health care system, the vast majority of attention is on secondary prevention: early detection of existing Why Should Prevention Be Part of the Health disease. Cost-savings are not the point of secondary prevention: Reform Debate? the key advantage of secondary prevention is that earlier Proponents argue that prevention should be a key part of the health intervention affords patients with more and better medical reform discussion in part because of its potential role in addressing options. Primary prevention—the prevention of disease before the growth of chronic disease, of which obesity is a major it occurs—can be cost-saving. There is a need to demonstrate, contributor. Assuming that a considerable portion of chronic replicate, and scale projects that establish the cost-saving disease is preventable, the cost-savings potential of prevention is potential of primary prevention. Tertiary prevention—efforts to considerable: mitigate the impact of established disease—is also an important area for intervention, because that is where the money is—75 • Prevention is fundamental to affordability. Three-quarters of percent of healthcare dollars are linked to chronic conditions. health-care expenditures are linked to chronic conditions. Thus tertiary prevention can be cost-saving if it lowers the A great deal of discussion in health policy is dedicated to expense of caring for the most expensive group of patients. preventing unnecessary use, and the proper design of health insurance in the form of higher co-pays or deductibles to minimize it. But, a different set of policy instruments is needed • The key policy challenge is to replicate and scale the interventions whose effectiveness has been demonstrated by current projects. The to refocus priorities toward prevention of chronic disease, and evidence base is building from current and established projects those instruments need to focus on driving supply-side changes. that primary prevention, including community-based efforts, can be effective and cost-effective at preventing chronic disease. • Many cost-driving conditions are preventable. The World Health The next step is to build on those efforts by scaling up the Organization data suggest that 80 percent of new cases of interventions that have demonstrated success. stroke, coronary heart disease, and other chronic conditions are potentially preventable. Failure to prevent such conditions imposes considerable suffering on individuals and a large and growing cost burden on payers. 2 Could a Larger Role for Prevention Reduce Health One Health Plan’s Approach to Community-Based Disparities? Promise and Challenges Prevention An increased focus on prevention may also be effective in Kaiser Permanente’s community-based prevention efforts are reducing health disparities. Even though health outcomes are driven by the conviction that access to quality health care is improving over time, there are still significant gaps in health critical but it is not enough, because providers don’t shape health. disparities. Outcomes may be increasing across all groups, but “As a delivery system, we may see you for an hour or two a year. not increasing fast enough among disadvantaged subgroups to We don’t shape your health: where you live, where you play, what erase the disparity. And, while an increased focus on increasing you eat shapes your health” says Ray Baxter, Senior Vice President the use of clinical preventive services (CPS) will help, it may for Community Benefit at Kaiser Permanente. He adds that not be sufficient to eliminate disparities. Current measures of health choices are not simply a matter of personal responsibility: CPS use document similar use across races, and in some cases, the environment shapes people’s choices for healthy living. higher utilization by minorities, yet the gaps in health outcomes People cannot be healthy in toxic environments even with remain. These findings suggest that clinical preventive service universal coverage. use is part of the answer, but not sufficient, because of the multiple, overlapping social factors behind health disparities. The Healthy Eating Active Living (HEAL) initiative provides Community-based efforts must complement the emphasis on an important opportunity to learn which community-level CPS by addressing environmental and social determinants of interventions work, and to support replication. The Healthy health. The social and physical environments in low-income Eating Active Living Convergence Partnership is a collaboration populations and communities of color generally present greater that includes the Centers for Disease Control and Prevention, risk in terms of toxic exposure, quality of housing stock, and Kaiser Permanente, the Nemours Foundation, the Robert Wood stressors. As much as 20 percent of differential mortality seen in Johnson Foundation, the Kellogg Foundation, and the California disadvantaged groups is associated with social and environmental Endowment. With the support of other partners, Kaiser factors, and social environments have the added effect of Permanente has 39 HEAL sites nationwide to advance policies influencing personal behaviors.3 For these reasons, finding a way that improve the food and exercise environments in communities. to integrate community level prevention into the framework of Such efforts include giving youth the tools to document and health reform will be necessary to make progress in reducing mitigate barriers to walking to school, and promoting workplace- disparities, and funding and financing these efforts may be as based farmers markets. important as increasing awareness of these connections. Marsha Lillie-Blanton of George Washington University believes that the If health reform efforts are to include a greater emphasis on biggest challenge going forward is not generating new knowledge, prevention, they need to build on and incorporate the lessons but is coordinating the resources to implement what is already from community-based prevention efforts such as HEAL. This known to shape health disparities. includes addressing the social determinants of health. Reform efforts need to converge across sectors, with a goal of “health in all Blanton shares a quotation from her former colleague Jeanne policies” by including a public health perspective in other sectors Lambrew, now deputy director of the HHS Office of Health that have important health implications, such as transportation, Reform: “the change we need is to put wellness ahead of land use, and agriculture. Funding for community-based sickness in allocating healthcare resources and priorities, and prevention and public health should reflect the value of these success, like in Homeland Security, is measured by the absence strategies in reducing healthcare costs and lowering the burden of tragedy.” Blanton adds that our goal should be to reduce the of disease. Currently, prevention only commands a small need for healthcare, not just insure access when it is needed. If percentage of health care dollars and research budgets. To community-level prevention efforts can achieve the goal of support community efforts, funding for those efforts needs to reducing the need for healthcare, then that will help sustain be consistent over time, sustained, and dedicated. According whatever health reform strategy is passed. to Baxter, state and local entities should be able to consolidate funding streams in order to rationalize service delivery and increase flexibility and innovation. 3 Prevention and Health Reform Baxter believes that reform should support the role of health management. The teams include nurse practitioners, registered care delivery systems in promoting community health. This nurses, social workers, dieticians, behavior specialists, community may include incorporating and sufficiently funding community health workers, and a Vermont Department of Health public health centers and public hospitals that support public health. health specialist. This combination of patient providers and a Other delivery-system initiatives should support the development prevention specialist reconnects healthcare delivery with public of health information technology and reward the provision of health prevention. The CCTs are a shared resource that interacts preventive services across all payers. Solutions should be designed with primary care providers, patients, and the community to with a view to simultaneously address equity, the economy, both support patients with chronic conditions and facilitate and environmental sustainability. These priorities needn’t be community health planning. in conflict, and can work together, as in the case of investing in public transit and parks. Health information technology plays a key role in providing patient care, calibrating provider payment, assessing community Integrating Community-Based Prevention with needs, and evaluating the pilot programs. Components include a Improved Chronic Care: One State’s Approach to web-based clinical tracking system, visit planners and population Systematic Reform reports, electronic prescribing, updated electronic medical The Vermont Blueprint for Health is a state-wide initiative to records to match clinical measures with program goals, and a improve the functioning of the healthcare system for Vermonters. health information exchange network. Jones acknowledges the According to Director Craig Jones, the Blueprint began as the challenges of integrating information exchange without getting state’s vision for health reform, and has grown and evolved in the way of clinical care, but reports that it can be done using over the past few years. The Blueprint Communities Act of existing patient health data in unique ways to provide individual 2006 focused on community activation and community-based patient care and support, to manage and plan for the health of the prevention efforts which have been primarily state-funded. The community, and to effect quality improvement. Blueprint Integrated Pilots Act of 2007 and 2008 broadened the funding base to include insurer as well as state funding, and focuses on integrating provider and community efforts to improve the care and prevention of chronic disease. Links and Resources HEAL Initiative at Kaiser Permanente The Integrated Pilot Programs are currently up and running in info.kp.org/communitybenefit/html/ two sites—Burlington and St. Johnsbury—and in the planning our_work/global/our_work_3.html stages in Bennington. A key aspect of the Integrated Pilot is the integration of two sets of key players: a patient-centered HEAL Initiative Convergance medical home (PCMH) and the community care team (CCT). Partnership Jones argues that to be sustainable, delivery system reform www.convergancepartnership.org must be tied to financial reform. To this end, the pilots include all payers: Medicaid, commercial insurers, and Medicare (the Vermont Blueprint for Health Blueprint program subsidizes the cost of Medicare beneficiaries’ healthvermont.gov/blueprint.aspx participation). Payment to primary care providers is based on the degree to which they meet the National Committee for Partnership to Fight Chronic Disease Quality Assurance’s standards for a patient-centered medical www.fightchronicdisease.org home. A key feature of the payment scheme is that provider payment is based on incremental changes in the NCQA score of Prevention Institute five points, not just large payment changes in response to a large www.preventioninstitute.org/healthdis.html change in level. A second key financing feature is that all payers share the cost of the CCTs. The CCTs are multidisciplinary care support teams that provide local care support and population 4 The integrated pilots emphasize community prevention and Pilot program will be used to refine and target Blueprint wellness efforts as well as interventions designed to improve Community grants, and build capacity and readiness for more chronic disease care. To that end, prevention specialists are complete healthcare reform. members of the CCTs, and the teams conduct community profiles and risk assessments. About the author Adele Kirk, Ph.D. is an assistant professor of public policy at the The infrastructure for evaluation is built into the integrated University of Maryland, Baltimore County and a consultant to pilot model. Key evaluation tools include NCQA PCMH scores AcademyHealth. and score changes to evaluate process quality, clinical process measures, health status measures, and the multi-payer claims data Endnotes base. These tools provide valuable insights into the results of 1 Kaiser Family Foundation and Harvard School of Public Health. The wording of the health policy priority is “Public health programs to prevent the spread the pilot efforts to improve the health of individual patients and of disease and improve health”; 34 percent of respondents favored increasing communities, and to evaluate the sustainability of the program. funding for this health policy option. Toplines: The Public’s Health Care Agenda for the New President and Congress. January, 2009. Available at www. kff.org/kaiserpolls/upload/7853.pdf. Accessed on June 4, 2009. The eventual plan for the Blueprint model is to expand the 2 Finkelstein, Eric, Ian Fiebelkorn, and Guijing Wang, 2003. National Medical programs statewide. Jones notes that the Blueprint is designed to Spending Attributable to Overweight and Obesity: How much, and Who’s Paying? Health Affairs Web Exclusives W3-219-26. work in different settings. The model anticipates that as Blueprint 3 McGinnis, J. Michael, Pamela Williams-Russo, and James Knickman, 2002. The communities mature, they will add components, or expand Case for More Active Policy Attention to Health Promotion. Health Affairs, Vol. existing ones. At the same time, experience from the Integrated 21, No. 2, pp. 78-93.