Prevention:Medicine for the Health Economy

Peter WolffMarch 27, 2013

IHL 6049 – Integrative Wellness Management

State of the NationLifestyle choices, including poor nutrition, lack of

exercise, tobacco use, and excessive alcohol consumption, are the primary causes of chronic health conditions, leading to 70% of all deaths nationally.

75% of health care dollars are spent on preventable, chronic conditions.

More than two-thirds of surveyed Americans believe more attention needs to be placed on preventing chronic disease.

(CDC, 2009)

Research Question

How do we bend the cost curve on health?

I intentionally limited the scope of the research herein by applying a health economics lens, with the intention of discovering promising models of health care that fit into existing financial structures.

MotivationsUnderstand how integrative health and health

promotion fit into the landscape of our health economy.

Be prepared for business and policy negotiations in corporate, government and non-profit organizations.

Construct a vision for a sustainable future of integrative health and wellness.

The Data

We’re #1!In 2009, the United States spent more on health

as a percentage of GDP than any other nationUSA – 17.4% Japan – 8.5%, while providing comprehensive health

coverage to all if its citizens

(Squires, 2012)

The United States ranks 22nd among industrialized nations in life expectancy27th internationally in infant mortality

(CDC, 2012)

More on SpendingUnited States spent more than $2.6 trillion on

medical care in 2010, or $8,458 per person.

Why the Inflated Costs?Pharma accounts for 10% of spending, with a

114% surge in spending between 2000 and 2010 (Kaiser, 2012)

Medical technology accounts for about 50% of the growth in health care spending. (Smith, Newhouse, & Freeland, 2009)

Employee / patient ratio increased from 2.8 to 8.4 between 1970 and 2010 (Getzen, 2010, p.10)

Three Big Reasons

Higher prices

Medical technology

Obesity(Commonwealth Fund: Squires, 2012)

Poll

How many of you have health insurance?

IHL survey 201228% had no health insurance38% are managing a chronic health condition

Insurance – Who Has It?

Who Doesn’t

Bright SpotsChildren’s Health Insurance Program (CHIP)

Access to care for children has improved, with the rate of uninsured children declining to an all time low of 8% in 2010 (CDC, 2012)

Patient Protection and Affordable Care Act (ACA)Provisions of the law will extend health insurance

coverage to uninsured citizens at the beginning of 2014

How Did This Happen?

Health in the Free MarketIn all other industrialized countries, access to

affordable care is centrally governed and financed through universal insurance-based or single-payer systems (Squires, 2012).

In the United States, market efficiency is purported to provide an “optimal” balance of health services for all who need them (Reinhardt, 2001).

Since the 1970s, we have seen greater degrees of social inequity and unprecedented price inflation for health services.

Insurance

Players

US Health Care SystemMix of private insurance and single-payer

systems

Who pays?48% - US government 34% - Private insurance companies 11% - Personal wages or savings7% - Charities

(Getzen, 2010)

Characteristics of Insurance

Uncertainty of an expected medical loss motivates people to purchase insurance.

Moral hazard is the observed change in human behavior, to engage in more high-risk activities, due to the presence of insurance.

Adverse selection is a behavioral condition in which people with the highest need for health care are also the most likely to seek out insurance.

(Getzen, 2010)

Health Care Reform?Bill Moyers interview

http://www.youtube.com/watch?v=7QwX_soZ1GI

Affordable Care Act

Extend coverage to the uninsured

Control costs

Improve quality of care

More CoverageApproximately 32 million uninsured Americans

will gain health benefits

About 50/50 split between increased Medicaid enrollment and mandatory insurance obtained from private plans via state-run insurance exchanges

(Washington Post, 2010)

Prevention

Chronic DiseaseThe rising tide of health care costs are running

parallel to the rise in obesity.Obesity was responsible for 27 percent of the rise

in inflation-adjusted health spending between 1987 and 2001 (Thorpe, Florence, Howard & Joski, 2004).

Across all payers, obese people had per capita medical spending that was 42 percent greater than spending for normal-weight people in 2006 (Finkelstein, Trogdon, Cohen & Dietz, 2009)

Obesity Trends* Among U.S. Adults, BRFSS 1990 (1)

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults, BRFSS 1991(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults, BRFSS 1992(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults, BRFSS 1993(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults, BRFSS 1994(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults, BRFSS 1995(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults, BRFSS 1996(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults, BRFSS 1997(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults, BRFSS 1998(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults, BRFSS 1999(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults, BRFSS 2000(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults, BRFSS 2001(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. Adults, BRFSS 2002(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. Adults, BRFSS 2003(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. Adults, BRFSS 2004(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. Adults, BRFSS 2005(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults, BRFSS 2006(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults, BRFSS 2007(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults, BRFSS 2008(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults, BRFSS 2009(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Quality of Preventive Care

“When lawmakers discuss providing access to and funding for prevention, they usually mean reimbursing clinical screenings performed in a doctors office” (Goetzel, 2009).

“Statistically, nationwide, anywhere from 50%, and in some places 80%, of patients have chronic conditions and preventive health needs that are not being met” (Brown, 2012).

Prevention in the ACAAlthough the ACA catalyzed the National

Prevention Strategy effort with a call to shift the focus from sickness and disease to prevention and wellness, no explicit funding for health promotion initiatives like behavior change, lifestyle choices, and self-care practices is included, only recommendations.

Sequestration is impacting the relatively small budget allocated for preventive screenings.

Prevention in the ACAEmployers have the ability to encourage

participation in wellness programs by using discounts or incentives valued at up to 30 percent of insurance premiums costs.

Possible SolutionsAccountable Care Organization (ACO)

Employer-based Prevention Clinics

Integrative Primary CarePatient Centered Medical Home (PCMH)

More time with patients is shared between doctors, advanced-practice nurses, physician assistants, health educators, social workers and pharmacists

Cost and QualityIn the Colorado pilot, acute inpatient admissions

declined 18 percent and emergency department visits dropped by a 15 percent. The control groups in the study saw increased utilization.

High satisfaction - 97 percent of participants in the Colorado study said they would recommend the medical home to family and friends.

The New York medical home pilot demonstrated per patient per month cost reductions of 14.5 percent for adults and 8.6 percent for children compared to the control group

Integrative Primary CareEmployer-based Prevention Clinic

The short-term objective is reducing utilization of expensive emergency room visits and hospital care, but the long-term justification is creating a healthier workforce by preventing and managing chronic disease.

Cost and QualityGiven their business orientation, most

employers are seeking a financial return on the cost of implementing a program.

Worker focused programming is not encumbered with institutional limitations.

Employers free to adopt complementary and alternative modalities of healing, such as meditation, yoga, or Traditional Chinese medicine.

Trends