Prevention for a Healthier America: Return on Investment for Disease Prevention at the Community Level

1. Prevention for a Healthier America: Return on Investment for Disease Prevention at the Community Level Jeffrey Levi, PhD Beyond Health Care Coverage The Commonwealth Club San Francisco, CA February 23, 2009

2. Prevention for a Healthier America

3. Prevention for a Healthier America: Financial Return on Investment? With a Strategic Investment in Proven Community-Based Prevention Programs to Increase Physical Activity and Good Nutrition and Prevent Smoking and Other Tobacco Use

4. Key premises • Coverage is important, but what surrounds (or precedes) coverage is also important • Achieving good health outcomes requires healthy communities, not just healthy individuals • Drivers of health care costs (chronic disease) can often be effectively prevented in the community as opposed to managed in the health care setting • Reducing costs as a critical policy outcome • Disparities in chronic diseases related to disparities in the “health” of communities • Poverty, race/ethnicity and obesity • Poor communities provide less support for healthy lifestyles (food, physical activity)

5. Health Care Spending: $2.2 Trillion in 2007 Prevention 4% Health Behaviors 50% Medical Services 96% Environment 20% Genetics 20% Access to Care 10% Factors InfluencingHealth National Health Expenditures SOURCE:CDC, Blue Sky Initiative, University of California at San Francisco, Institute of the Future, 2000

6. Focus on Community-Level Prevention Reduces Health Care Costs Universal agreement that prevention is a good thing; increases length and quality of life Growing evidence that some clinical prevention interventions show savings in health care costs Clinical interventions – one person at a time Community interventions – an entire population (those ill, those at risk, those well) Evidence of savings from some population level interventions (tobacco control, helmet laws, sanitation)

7. What is Community-Level Prevention? Interventions that promote healthy environments and behaviors – making it easier for people to make healthy choices, such as: Changing community norms and empowering communities Coalition and social network building Social marketing campaigns Changing the physical and social environments Organizational practices and governmental policies Facilities and programs Walkability – lighting, sidewalks, signs; Access to healthy foods Increasing individual knowledge and skills

8. How does community prevention differ from workplace efforts? • Non-clinical • Creates a supportive environment that reinforces efforts at the workplace • Reaches families, not just employees

9. Examples of community programs • Shape Up Somerville • School food, school activities, parent and community outreach, restaurants, safe routes to school • Healthy Eating Active Communities (HEAC) • Schools, after school, neighborhoods, healthcare sector, marketing changes • YMCA Pioneering Healthier Communities • Community coalitions, policy changes, leverage other funding • Healthier Communities, Steps, REACH

10. Key Findings 1. Are there community-level interventions that could reduce chronic disease levels – and thus affect the biggest driver of increased disease, disability, and cost? • Yes. Regardless of chronic condition targeted, most interventions fell into 4 categories: physical activity, nutrition, obesity, and smoking cessation. • Reduced or delayed incidence of disease; mitigation of disease

11. Key Findings (2) 2. If we increased funding for community-level interventions, we could see a return on investment and more than break even in terms of ROI. 3. Savings can be shown by payer – with private payers and Medicare the biggest “winners.”

12. Or Are We Just Delaying High End-of-Life Costs? Compression of morbidity: extending healthy life expectancy more than total life expectancy – literally compressing chronic disease and disability into a smaller proportion of life Primary prevention delays or prevents disability vs. management of disability (current focus of health care system) Preventing obesity – delaying or avoiding a knee replacement Managing disability – providing a knee replacement Obesity results in more chronic conditions, but not shorter life

13. Focus of the Model Interventions Type of intervention Effect on disease Associated costs Diseases • Expensive • Chronic • Amenable to community-based prevention

14. Most Expensive Conditions Arthritis Pneumonia Kidney disease Endocrine disorders Skin disorders Back problems Infectious diseases • Heart disease • Cancer • Trauma • Mental disorders • Pulmonary conditions • Diabetes • Hypertension • Cerebrovascular disease

15. Priority Conditions Arthritis Pneumonia Kidney disease Endocrine disorders Skin disorders Back problems Infectious diseases • Heart disease • Cancer (selected) • Trauma • Mental disorders • Pulmonary conditions (selected) • Diabetes • Hypertension • Cerebrovascular disease

16. Data Analysis Data Medical Expenditures Panel Survey (MEPS), pooled 2003-2005 (adults only, excludes nursing home care) Methods Regression analysis to predict expenditures by disease cluster by disease trajectory by payer

17. Disease Clusters-Intervention Pathways:Short Run Medium Run Long Run diabetes heart disease stroke renal disease diabetes & HBP HBP Physical activity, obesity, nutrition, smoking cessation cancer arthritis heart disease stroke renal disease COPD

18. Effect of Interventions We assume a sustained reduction in the prevalence of diabetes and hypertension Modeled as a one-time permanent change in response to an ongoing community-level intervention We also assume a steady state population In the current iteration of the model, we have not yet taken into account changes in mortality

19. Plausible Intervention Effect Literature review offers a broad range of impact of community interventions Literature supports that interventions can have an impact of 10%, but we modeled a 5% impact to be conservative (2.5% for cancers) Literature does not consistently present data to make comparisons across interventions

20. Cost-Benefit • Data are variable regarding per capita costs of interventions. • Range in the literature is quite wide. • For the purpose of this exercise, we are assuming an average of $10 per capita to be very conservative and to permit a group of interventions to be introduced, including some that might be targeted and higher cost.

21. Net Savings: 5% Impact at $10 Per Capita Cost (in Millions) (in 2004 dollars) Short Run: 1 to 2 Yrs. ● Medium Run: 5 Yrs. ● Long Run: 10 to 20 Yrs.

22. Net Savings By Payer: 5% Impact at $10 Per Capita Cost (in 2004 dollars)

23. Annual Net Savings: California(5% effect, $10 per capita cost, in 2004 dollars) Short Run: 1 to 2 Yrs. ● Medium Run: 5 Yrs. ● Long Run: 10 to 20 Yrs.

24. Net Savings by Payer: California(5% effect, $10 per capita cost, in 2004 dollars) Short Run: 1 to 2 Yrs. ● Medium Run: 5 Yrs. ● Long Run: 10 to 20 Yrs.

25. What’s not captured • Nursing home costs – which would increase MediCal savings • Targeted efforts in high prevalence communities would increase the return on investment • Non-health care costs

26. Multiplier Effect

27. Limitations • Limited data on sustainability and scalability – hence the assumption that only a one-time effect even though intervention sustained over time. (Or new interventions introduced over time.) • Model calculates savings from reductions in prevalence; other models look at stemming the rise. • Savings in 2004 dollars, though costs have risen. • Model incorporates marginal cost of interventions, not the cost of basic infrastructure.

28. Contributors • Trust for America’s Health • Jeff Levi, Chrissie Juliano, and Sherry Kaiman • New York Academy of Medicine • Ruth Finkelstein, Gabriel Cohen, Ana Garcia, and Julie Netherland • Prevention Institute • Larry Cohen, Jeremy Cantor, and Janani Srikantharajah • The Urban Institute • Barbara Ormond, Brenda Spillman, Timothy Waidmann, and Bogdan Tereshchenko

29. Policy Implications (1) • Messages: • Community-level prevention needs to be equal partner with screening and clinical prevention • We cannot do health reform (or afford it) without addressing community and clinical prevention • Workplace wellness programs need community-level prevention to support or reinforce their impact • Business and labor should participate in community-level activities • Certain prevention interventions can save money • Polling shows the public is willing to invest in prevention • Congress and incoming Administration should recognize improving the health of Americans as a national priority

30. Policy implications (2) • Need to identify creative ways to finance community-level prevention • Contributions from those payers who benefit • Health reform – all funding options should be in play • Medicare, Medicaid demonstrations • Economic Recovery Act: Opportunity to invest in communities and make population healthier as we move toward health reform

31. Policy implications (3) • Healthy communities perspective requires eliminating stovepipes – and thinking how all funding streams come together to improve health • How can primary care and community prevention work together? • How can we fund more creatively? • Appropriated funds, new streams (e.g., soda tax, premium tax)

32. A Wellness Trust at state/local level?

33. A natural experiment • $650 million in stimulus bill to “carry out evidence-based clinical and community-based prevention and wellness strategies…that deliver specific, measurable health outcomes that address chronic disease rates.” • “a historic commitment to wellness initiatives will keep millions of Americans from setting foot in the doctor's office in the first place -- because these are preventable diseases and we're going to invest in prevention.” – President Barack Obama, Feb. 17, 2009

34. Questions • To access the national edition of Prevention for a Healthier America: www.healthyamericans.org

35. The American Recovery and Reinvestment Act of 2009: Social Disparities and Health Improvement Jeffrey Levi, PhD Beyond Health Care Coverage The Commonwealth Club San Francisco, CA February 23, 2009

36. Stimulus address multiple aspects of social determinants of health • Poverty, education, and employment • Making Work Pay tax credit • Food stamp benefit increase • Unemployment insurance increases/expansions • Education funding • Workforce training and employment services • Emergency shelter • General support for states • Access to coverage and care • Access to prevention and support for a healthier environment

37. Health specific aspects of stimulus • Medicaid support for states ($87.1 billion) • Extending health insurance for the unemployed (COBRA) ($25 billion) • (9 months, 65% of premium with income <$125K/$250K) • Health center investments ($1.5 billion) • Health workforce ($500 million) • Steps toward reform: Health IT ($19.2 billion) and comparative effectiveness ($1.1 billion) • Public health investments ($1 billion)

38. Public health investments • $300 million for immunizations, including adult immunizations • $650 million for community prevention programs such as Healthier Communities

39. Rationale for stimulus • Overall objective: Meeting immediate economic needs of states and those most affected by the recession • Health IT, comparative effectiveness and prevention funding: down payment on systemic reform

40. California’s share 2009-11 (estimates from Center on Budget and Policy Priorities) • Administration estimates creates or saves 396,000 jobs in CA over 2 years • Making Work Pay Tax credit: 12,570,000 people • Medicaid: $11.23 billion • Increase in federal match by 6.2%; additional increase based on unemployment level • State Fiscal Stabilization Fund • Education: $4.9 billion • Flexible: $1.084 billion

41. California’s share 2009-11 (2) • Education • Title I: $1.591 billion • IDEA: $1.28 billion • Unemployment Insurance • 2.4 million recipients will receive $25 increase • 506,000 new beneficiaries • Supplemental Nutrition Assistance Program • $1.466 billion = 13.6 % increase in benefits • 2,432,000 beneficiaries affected

42. California’s share 2009-11(3) • Workforce Training and Employment Services • Youth Services: $185 million • Dislocated Workers: $225 million • Adult Activities: $80.9 million • Emergency Shelter Grant Program • $190.7 million • Assist 25,200 households in CA

43. OMB Guidance: Transparency and Accountability • Funds are awarded and distributed in a prompt, fair, and reasonable manner; • The recipients and uses of all funds are transparent to the public, and the public benefits of these funds are reported clearly, accurately, and in a timely manner; • Funds are used for authorized purposes and instances of fraud, waste, error, and abuse are mitigated; • Projects funded under this Act avoid unnecessary delays and cost overruns; and • Program goals are achieved, including specific program outcomes and improved results on broader economic indicators.

44. Keeping the focus • Assuring that discretionary dollars are used in targeted ways that address social determinants of health • Research agenda: • Measuring impact on social determinants and on health – regardless of motivation for funding • Showing a return on investment

45. For further information • Center for Budget and Policy Priorities • www.cbpp.org • GWU analysis of health provisions • www.gwhealthpolicy.org • TFAH efforts on stimulus • www.healthyamericans.org/stimulusdocs • Federal site • www.recovery.gov