INTRODUCTION

“An ounce of prevention is worth a pound of cure.” This saying is reflected in proposed health reform plans and the efforts to increase investments in prevention throughout the U.S. healthcare delivery system. With evidence that nearly 40 percent of all deaths in the United States are due to behavioral causes, attention to prevention has encompassed obesity and tobacco smoking prevention in addition to vaccinations and cancer screening (Mokdad et al., 2004). An aging population, many with multiple chronic conditions (Martini et al., 2007; Meara et al., 2004), has resulted in targeted prevention of additional complications and hospitalizations. In this concluding session of the May workshop, the speakers reframed the discussion by exploring how changing demographic trends in the population’s health status and underinvestment in population health contribute to missed prevention opportunities, and focusing not simply on the potential costs of missed prevention opportunities but on the added value of increasing the delivery of preventive efforts to patients.

Steven H. Woolf of Virginia Commonwealth University opens the session by emphasizing the consequences of an inadequate focus on disease prevention, including greater morbidity and mortality and lower quality of life. While he emphasizes the importance of community- or population-based prevention services, he uses obesity as a case study to demonstrate how lost opportunities in prevention result in measurable health costs and excess resource consumption. Woolf concludes his presentation by asserting that slowing the growth of healthcare spending will ultimately necessitate redistributing current expenditures to high-value services such as prevention.

Thomas J. Flottemesch of HealthPartners Research Foundation suggests that preventive services at the primary and secondary levels yields mixed results in terms of net medical savings to the healthcare system, highlighting the importance of expanding the conversation on prevention beyond costs alone to include value and benefits not captured by pure dollars. Although primary preventive services, such as daily aspirin use and alcohol and tobacco use screenings, could have yielded net savings of nearly $1.5 billion in his analysis, the use of secondary preventive services, such as mammograms and depression screenings, actually results in net costs of almost $2 billion. He also acknowledges that certain costs could have been omitted or double-counted due to insufficient data. Flottemesch concludes that, while different types of evidence-based clinical preventive services have the potential for differential impacts depending upon current delivery rates and target populations, evidence-based preventive services should be embraced, and their use encouraged, because of their positive health impact.

Michael P. Pignone of the University of North Carolina-Chapel Hill focuses on tertiary preventive care, explaining that individuals with one or more chronic conditions account for approximately $1.5 trillion in healthcare spending per year. Focusing on high-risk patients with chronic conditions offers high savings and cost-effectiveness margins because the likelihood of needing high-cost treatments are far greater than the costs incurred by provision of preventive services, he argues. Based on his calculations, widespread use of effective interventions, such as disease management, postdischarge care, and case management for key chronic conditions could produce substantial savings, perhaps as much as $45 billion per year. However, he also explains that translating successful interventions to new populations and settings and realizing savings may be difficult because of the differing organizational and population needs of individual institutions. Despite these limitations, he ultimately suggests that better use of effective tertiary prevention possesses strong potential for improving health and reducing spending.

THE PRICE PAID FOR NOT PREVENTING DISEASES

Steven H. Woolf, M.D., M.P.H.

Virginia Commonwealth University

In considering strategies to control the rising costs of health care, the projected increase in the prevalence of chronic diseases is both cause for concern and an opportunity for intervention. The aging population and advances in medical care that enhance life expectancy are increasing the prevalence of chronic diseases, exerting upward pressure on healthcare spending. Past increases in the prevalence of chronic disease accounted for an estimated $211 billion of the $314 billion increase in healthcare spending in the United States between 1987 and 2000 (Thorpe, 2005). Between 2005 and 2030, the number of individuals with chronic disease is predicted to increase from 133 million to 171 million (Horvath, 2002), with profound implications for public health and the economy.

A large proportion of the chronic diseases of concern are preventable, providing an opportunity to exploit prevention as a strategy to bend the curve and reduce growth in disease burden and its associated costs. Fully 38 percent of all deaths in the United States are attributable to four health behaviors (smoking, unhealthy diet, physical activity, and problem drinking) (Mokdad et al., 2004). But interventions aimed at these behaviors can yield impressive results. Randomized trials have demonstrated that intensive lifestyle change can reduce new cases of diabetes by more than 50 percent (Diabetes Prevention Program, 2002). Early detection of certain cancers and other chronic diseases through screening can reduce mortality from these conditions by 15 to 20 percent (AHRQ, 2008). Taken together, the potential leverage of prevention in calibrating the morbidity and costs associated with chronic disease is substantial, potentially averting 70 percent of such cases (CDC, 2004).

The obesity epidemic enhances the leverage of disease prevention because of its prominent role as a risk factor for cardiovascular disease, diabetes, and other major contributors to mortality and costs. Some economists predict that the obesity epidemic, if unchecked, will increase Medicare spending by 34 percent (Lakdawalla et al., 2005), a forecast not lost on policy makers. Testifying in Congress in 2008 as director of the Congressional Budget Office (CBO), Peter R. Orszag (now director of the White House Office of Management and Budget) noted that per capita health spending in 2001 was $2,783 for persons of normal weight but $3,737 and $4,725 for obese and morbidly obese persons, respectively (U.S. Senate, 2008). State governments, payers, and employers have made similar calculations (Texas Comptroller of Public Accountants, 2007). They recognize the need to address obesity or face adverse economic and workforce consequences.

Defining Prevention

The classic categories of prevention include primary prevention, controlling modifiable risk factors to avert the occurrence of disease; secondary prevention, the early detection of disease before it manifests clinical symptoms; and tertiary prevention, the control of existing diseases to prevent more serious complications. These distinctions are important, but a source of confusion is failing to differentiate between clinical and community- or population-based settings for prevention. Primary, secondary, and tertiary prevention can take the form of clinical preventive services, as when clinicians offer nutritional counseling or perform periodic examinations, blood tests, or imaging studies to screen for diseases. Prevention can also occur in the community, often with greater effectiveness, to help the general public adopt healthier lifestyles and reduce harmful exposures that precipitate diseases and injuries. Worksite wellness programs, school policies, information technology and other resources for self-care at home, nutrient labeling at restaurants and supermarkets, media and advertising countermarketing messages, changes to the built environment to facilitate exercise, legislation (e.g., indoor smoking bans), and counseling services in the community to help modify health behaviors can together accomplish far more than a physician’s intervention. The health benefits, science base, and economic merits can vary for each cell in the matrix (Table 6-1), and therefore the specific context of the intervention should be specified when characterizing the benefits and cost-effectiveness of “prevention.”

TABLE 6-1

Matrix for Classifying Categories of Prevention.

Defining the Price Paid

Loss of Human Life or Quality of Life

The consequences of inadequate emphasis on disease prevention are first measured in human terms: the price paid in terms of greater illness (e.g., morbidity, incidence and prevalence of disease, impaired functional status/quality of life) and premature mortality (e.g., deaths before age 65, diminished life expectancy, healthy years of life lost). According to the National Commission on Prevention Priorities, fully 100,000 deaths would be averted each year by improving the delivery of just five preventive services (National Commission on Prevention Priorities, 2007).

Lost Productivity and Other Economic Losses

Health effects carry obvious economic implications. The price paid for inadequate emphasis on prevention includes the costs of excess medical care for avertable diseases and complications, as well as the deleterious economic effects of illness on a healthy workforce, corporate competitiveness, children’s education, mental health, and community well-being. The Milken Institute estimates that chronic illnesses cost the economy $4 in lost productivity for every $1 spent on health care (DeVol et al., 2007). Some of these intangibles are difficult for economic studies to measure, and some require longer time horizons to capture, but they make up the broader benefits of preventing disease.

Underusing High-Value Prevention

By making too little use of the forms of prevention that offer high economic value—greater health benefits per dollar—the opportunity to do more with the same resources, and to save more lives in the process, is also forfeited. This opportunity cost, albeit subtle, may be the more important economic price paid for inadequate emphasis on prevention. The majority of the $2 trillion that society spends annually on health care goes toward interventions of low-economic value (e.g., services costing $50,000 to $1 million per quality-adjusted life year [QALY]) gained. Services of high-economic value (e.g., costing less than $50,000 per QALY) represent the minority of healthcare services, of which only a small fraction are known to produce net savings (economic benefits that exceed the costs of delivery). Examples of the latter include childhood immunizations and counseling smokers to quit (Maciosek et al., 2006). Many companies report cost savings by promoting policies that improve the health of their workforce (Goetzel and Ozminkowski, 2008). PriceWaterhouseCoopers estimates that the nation could save almost $500 billion per year by addressing obesity, smoking, and other modifiable risk factors (PriceWaterhouseCoopers, 2008). The Trust for America’s Health estimates that community-based interventions could save $5 for every $1 invested (Levi et al., 2008).

Shifting the Focus from Cost Savings to High Value

However, the first priority in bending the curve to slow growth in spending is less about searching for the handful of services that produce net savings and more about shifting spending from low-value to high-value services. This redistribution of spending can achieve greater health gains for the same resource investment while also reducing outlays for costly services that offer modest or no benefits. Channeling resources toward health services that optimize economic value can save more lives for the same dollar, and failing to do so has measurable human and monetary consequences.

The preventive services that offer high value are clearly identified. Reputable review panels, such as the U.S. Preventive Services Task Force, have identified a core set of clinical preventive services of established effectiveness. Of 25 such services reviewed by the National Commission on Prevention Priorities, 15 cost less than $35,000 per QALY (Table 6-2). The Community Task Force on Preventive Services has identified a similar cadre of effective population-based interventions (Zaza et al., 2005). Investment in such high-value, effective preventive services is one element of a larger transformation to value-based priorities in health spending.

TABLE 6-2

Cost-Effectiveness of 15 Out of 25 Clinical Preventive Services Reviewed by the National Commission on Prevention Priorities.

COST SAVINGS FROM PRIMARY AND SECONDARY PREVENTION

Thomas J. Flottemesch, Ph.D., Michael V. Maciosek, Ph.D., Nichol M. Edwards, M.S., and Leif I. Solberg, M.D., Health Partners Research Foundation and Ashley B. Coffield, M.P.A.

Partnership for Prevention

The current economic realities confronting the U.S. medical system require a focus upon value. In this context, there has been increased attention paid to the use, and current underuse, of preventive services. Some view preventive services—such as immunizations, screening, and counseling—as a potential windfall. Others question that premise and instead emphasize value. They state that prevention must be viewed alongside other medical services, and payers must balance benefits and costs in determining value (Brown, 2008; Cohen et al., 2008; Frieden and Mostashari, 2008; Woolf, 2008). In this view, costs minimization and improved efficiency will only be realized by emphasizing the use of high-value services, be they prevention or treatment.

One undisputed fact is that clinical preventive services are currently underused (CDC, 2008b; National Commission on Prevention Priorities, 2007). According to data from the Centers for Disease Control and Prevention’s (CDC’s) National Health Interview Survey and Behavioral Risk Factor Surveillance System, only 37 percent of adults are routinely immunized for influenza, and 28 percent of adults are routinely screened for tobacco use and provided assistance to quit. In addition, obesity, alcohol, and depression are not routinely screened for during clinical visits. Clearly, these missed opportunities for improving health and increasing quality have financial ramifications. Here, we discuss these ramifications in terms of the costs and potential savings of improving the delivery of baskets of evidence-based primary and secondary preventive services.

Generating National Estimates

This inquiry estimates the direct costs and potential savings in 2006 of increasing the delivery rate of the select clinical preventive services as listed in Table 6-3. We segment these evidence-based services into two baskets: primary and secondary preventive clinical services. We classify primary preventive clinical services as those services delivered by primary care providers with the intent of preventing the occurrence of one or more medical conditions or events (e.g., vaccinations, sexually transmitted disease [STD] screenings, tobacco counseling, and obesity counseling). We classify secondary clinical preventive services as those clinical services delivered by primary care providers with the intent of identifying medical conditions in an asymptomatic state (e.g., depression and cancer screening). Some of the services we include in this analysis, such as childhood vision screening, are cross-classified as they have both a primary (preventing amblyopia) and secondary (correcting visual acuity) purpose.

TABLE 6-3

Evidence-Based Package of 20 Clinical Preventive Services.

The estimates are calculated using models developed in support of the work of the National Commission on Prevention Priorities (NCPP) (Maciosek et al., 2006). NCPP models are carefully designed so as to allow consistent comparison among and between clinical preventive services. The data underlying the models are obtained from structured literature reviews (Maciosek et al., 2006). The scope of the NCPP’s work is preventative services recommended for the general population by the U.S. Preventive Services Task Force (USPSTF) or Advisory Committee on Immunization Practices (ACIP). The USPSTF recommends primary and secondary preventive services offered by primary care clinicians to asymptomatic people in clinical settings where sufficient evidence of effectiveness is found. For example, obesity screening is recommended only for adults and only when follow-up is the form of intensive behavioral therapy for adults with a BMI ≥ 30. The USPSTF found insufficient evidence of effectiveness for less intensive interventions, screening children, or primary obesity prevention through dietary or activity counseling. Thus, the estimates provided here must be interpreted in the context of USPSTF or ACIP recommendations that strictly define each intervention and its target population as noted in Table 6-3.

We use the NCPP models to estimate the per person medical costs and savings per year of intervention with the goal of determining the net impact upon 2006 healthcare expenditures of increasing delivery rates of our selected clinical preventative services to 90 percent from current levels. In following this cross-sectional perspective, future costs and savings are expressed in terms of their present value and not discounted. For those services that are currently uncommon (obesity, alcohol, depression screening) we assumed conservative current delivery rates of 25 percent.

Four key dimensions drive our results: (1) delivery costs, (2) potential medical savings, (3) target populations, and (4) current delivery rate. We selected a 90 percent target rate to reflect limitations to even the most effective delivery strategy due to contraindications for portions of the target population and variation in individual choice (Maciosek et al., 2006). We included only direct medical costs such as the initial cost of the service (screening or counseling) and any necessary follow-up including diagnostic testing, pharmacotherapy, and intensive interventions, and, in the case of cost savings, the direct medical costs of treatments averted. Excluded are indirect costs such as the value of patient time, productivity gains/losses, and any transition costs incurred as a result of increasing delivery rates to 90 percent (e.g., promotion, patient/provider education, and increasing capacity). The medical savings reflect the reduced use that would have been incurred by the 2006 U.S. population had it been consistently receiving the services.

Our cost estimates are also dependent upon the frequency and duration of a screening service. A service recommended every year for 10 years will have a higher annual cost than a screen with a biannual recommendation.

Key Findings

Table 6-4 lists the target population, current delivery rates, and net impact of 90 percent service delivery for 2006. Aside from adult vision screening, which is cross-classified, all of the services with an estimated net cost reduction are primary preventive services. Among these, the service with the greatest net impact is tobacco screening with an estimated cost saving of $5.6 billion dollars for 2006.

TABLE 6-4

Impact of Preventive Services.

Current delivery rates and target population size significantly impact net effects. While seven of the recommended preventive services (childhood immunization, pneumococcal immunization, daily aspirin use, tobacco screening, adult vision screening, alcohol screening, and obesity screening) are cost saving, the service with the greatest per person marginal cost reduction, childhood immunization ($270/person), has no impact upon overall medical costs due to its current high rate of delivery. Conversely, while alcohol screening has relative small individual impact ($11/person/year) its overall financial impact is large due to both a large target population and current low rate of delivery (assumed to be 25 percent).

Table 6-5 presents the costs, savings, and net impact upon personal healthcare expenditures of primary and secondary preventive services. The first three columns calculate total costs of 90 percent delivery of both primary and secondary preventive services (i.e., the costs and savings of delivering the service to 90 percent of the target population). As can be seen, potential delivery costs and savings differ by category. A 90 percent delivery rate of primary preventive services could reduce expenditures by $53.9 billion (3.1 percent of 2006 personal healthcare expenditures [PHCE]) at a cost of $52.1 billion for a net cost reduction of 1.8 billion (.1 percent of 2006 PHCE). Achieving the same delivery rate of secondary services would cost an estimated $5.3 billion with an associated savings of $.2 billion for a net cost increase of $5.1 billion (.3 percent of 2006 PHCE).

TABLE 6-5

Impact of Preventive Service Type on 2006 Personal Healthcare Expenditures.

The remaining columns show the marginal impact of increasing current delivery rates to 90 percent from their current level. Primary clinical preventive services have an estimated net savings of $7 billion (−0.4 percent of 2006 PHCE) compared with costs of 1.6 billion for secondary and 1.7 billion for cross-classified services.

TERTIARY PREVENTION AND TREATMENT COSTS

Michael P. Pignone, M.D., M.P.H.

University of North Carolina-Chapel Hill

Rising healthcare costs, increasing numbers of uninsured, and the increasing burden of chronic illness in the United States compel policy makers to identify better means of improving the value of health care in the United States. Fortunately, interventions have been identified that have the potential to both improve clinical care and reduce healthcare spending. Although such interventions have been examined in research, they have not been widely integrated into usual practice. Better implementation and use of effective cost-saving services could yield significant healthcare savings.

In this paper, we focus on the costs of incomplete use of effective services for tertiary prevention. Tertiary prevention focuses on patients with established health conditions, particularly chronic conditions, with the goals of preventing additional morbidity, improving quality of life, and reducing disability. In doing so, such programs present an excellent opportunity to lower costs because baseline use of expensive health services (particularly hospital care) for patients with chronic conditions is high. The key elements of tertiary preventive services (often called care coordination or disease management services) include the prescription of effective therapies and rehabilitative services; care coordination by multidisciplinary teams; self-care training; adherence support; and measurement and attention to quality improvement. To be cost saving, these programs must achieve effectiveness at a reasonable cost (considering both fixed programmatic costs and variable per patient costs). They must focus on high-risk patients, as the potential costs for such patients are higher, maximizing the potential benefits.

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