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Returns on Investments in Health

Returns on Investments in Health. J. Michael McGinnis, MD The Robert Wood Johnson Foundation. 12 questions. What kills? What cripples? How much does it cost? What counts? What’s the big picture? How do we invest? What’s effective? How effective? What’s cost effective?

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Returns on Investments in Health

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  1. Returns on Investments in Health J. Michael McGinnis, MD The Robert Wood Johnson Foundation

  2. 12 questions • What kills? • What cripples? • How much does it cost? • What counts? • What’s the big picture? • How do we invest? • What’s effective? • How effective? • What’s cost effective? • How do Rx and Px compare? • What are our prevention priorities? • What else matters?

  3. What kills? Leading Causes of Death in U.S., 2000 1) 2) 3) 4) 5) 6) 7) 8) • Heart disease 710,760 • Malignant neoplasms 553,091 • Cerebrovascular diseases 167,661 • Chronic lower respiratory disease 122,009 • Unintentional injury 97,900 • Diabetes mellitus 69,301 • Influenza and Pneumonia 65,313 • Alzheimer’s disease 49,558 • Nephritis 37,251 • Septicemia 31,224

  4. What cripples? Leading Causes of Disability Among U.S. Adults, 1999 Percent of 41.2 million persons with a disability

  5. How much does it cost?

  6. What we spent in 1997 (4,095) (2,611)

  7. Male life expectancy 1996

  8. What counts? Actual Causes Of Death, 1990 • Tobacco 400,000 • Diet/activity patterns 300,000 • Alcohol 100,000 • Microbial agents 90,000 • Toxic agents 60,000 • Firearms 35,000 • Sexual behavior 30,000 • Motor vehicles 25,000 • Illicit Drug use 20,000

  9. What counts? Actual Causes Of Death, 2000 • Diet/inactivity patterns 500,000 • Tobacco 400,000 • Alcohol 80,000 • Microbial agents 60,000 • Toxic agents 60,000 • Sexual behavior 40,000 • Firearms 35,000 • Motor vehicles 25,000 • Illicit Drug use 25,000

  10. What’s the big picture? Health care 10% Genetics 30% Behavior 40% Environment 5% Social 15%

  11. How do we invest? Health Expenditures Premature Mortality Social Population-wide effort Environmental Health Care Behavioral Medical Treatment Genetic

  12. What’s effective? Immunization and chemoprophylaxis • e.g. vaccines (childhood, influenza, pneumococcal), folic acid, aspirin, ocular Screening and early intervention • e.g. newborn, colonoscopy, mammography, blood pressure, cholesterol, chlamydia, vision, hearing Counseling • e.g. tobacco, alcohol, physical activity, diet, infant feeding, child safety, STD risk

  13. How effective?

  14. What’s cost-effective?

  15. Costs of prevention—examples Median $/QALY Immunizations $ 1,500 Chemoprophylaxis $ 13,000 CVD screening $ 3,300 Cancer screening $ 18,500 HIV counseling $ 1,200 CVD counseling $ 74,000 Blood donor screening $ 355,000 Autologous blood donation $ 730,000 Source: Stone, et al, AJPM 2000: 19(1)

  16. Ranking: clinically preventable burden • Score QALYs saved • 5 325,000 to 2,600,000 • 4 65,000 to 185,000 • 3 33,000 to 55,000 • 2 19,000 to 27,000 • 1 100 to 12,000

  17. Ranking: cost effectiveness • Score Cost ($)/QALY saved • 5 Most likely cost saving • 4 May be cost saving to 12,000 • 3 12,000 to 18,000 • 2 19,000 to 35,000 • 1 43,000 to 2,000,000

  18. What are the prevention priorities?

  19. What are the prevention priorities? • Service CPB CE Total • Childhood vaccination 5 5 10 • Adult tobacco cessation 5 4 9 • Vision screen >65 4 5 9 • Cervical cancer screen >18 5 3 8 • Hypertension screen 5 3 8 • Adult cholesterol screen 5 2 7 • Breast cancer screen 4 2 6 • Child safety counsel 0-4 1 4 5 • Folic acid counsel 1 3 4 • Rubella screening 1 1 2 • Source: Coffield et al, AJPM

  20. Costs of treatment—examples Median $/QALY Atrial fib (anticoag with 1 RF) $ 8,000 Atrial fib (anticoag with 0 RF) $ 370,000 Diabetes (intensive glycemic control) $ 41,000 Hepatitis C (pegylated interferon) $ 46,000 Sepsis (Rx APACHE >25) $ 24,000 Sepsis (Rx APACHE <24) $ 575,000 HIV (3 drug antiretroviral) $ 23,000 Emphysema (lung reduction surgery) $ 190,000 Lung cancer (CT screening) $ 48,000

  21. Lessons …….we pay going in… …….we pay coming out… …the returns to prevention:Priceless!!

  22. What else matters? not just clinical assessments… • cost benefit analysis • cost effectiveness analysis • ranking schemes but public policy… • health impact assessments

  23. Sample HIA (local)City of Los Angeles Living Wage • Employees working on city contracts must be • paid at least $7.99/hour • provided health insurance, or an additional $1.25/hour • Covers approximately 10,000 workers • Health insurance coverage more cost-effective in reducing excess mortality than an equivalent amount in the form of wages • Any changes to the ordinance should consider increasing health insurance coverage • Applicability: many living wage ordinances throughout the US • Source: Fielding et al, 2003

  24. Sample HIA (state)After-school program funding • California ballot Proposition 49 to set aside $550 million per year for after-school programs in grades K - 8 • Potentially significant health outcomes through effects on education, crime, substance abuse, etc. • Counterintuitive result: unlikely to yield any significant health benefits. Chiefly due to: • small magnitude of effects on key mediators • Inadequate targeting, recruitment and retention of high-risk youth Source: Fielding et al, 2003

  25. Keep the big picture in mind Health care 10% Genetics 30% Behavior 40% Environment 5% Social 15%

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