Will Prevention Save Money? (Text Version)

Slide Presentation from the AHRQ 2009 Annual Conferenc

Slide Presentation from the AHRQ 2009 Annual Conference

On September 15, 2009, Steven Woolf made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (5 MB) (Plugin Software Help).

Slide 1

Will Prevention Save Money?

Reforming Disease Prevention and Health Promotion

AHRQ 2009 Annual Conference
Bethesda, Maryland
September 15, 2009
 

Steven H. Woolf, MD, MPH
Director, VCU Center on Human Needs
Professor, Department of Family Medicine
Virginia Commonwealth University

Slide 2

A Closer Look at the Economic Argument for Disease Prevention

Image: The first page of a journal articles titles "A Closer Look at the Economic Argument for Disease Prevention."

Slide 3

Projected Spending on Health Care as a Percentage of Gross Domestic Product.

Image: Line graph shows projection of Medicare costs rising from 3% of Gross Domestic Product in 2007 to over 10% by 2082; Medicaid rises from 4% to 15% during the same period. All other health care rises from 15% to nearly 50% by 2082.

Source: Congressional Budget Office, The Long-Term Outlook for Health Care Spending, 2007

Slide 4

Figure 1. Percentage of the Population with Chronic Diseases, 1995-2030

Image: Bar graph shows projection of persons with two or more chronic illnesses rising from 21.3% in 1995 to 25.9% by 2030. The percentage of chronically ill persons is projected to rise from 44.7% to 49.2% during that same period.

Source: O'Grady MJ, Capretta JC. Health-Care Cost Projections for Diabetes and other Chronic Diseases: The Current Context and Potential Enhancements. Washington, DC: Partnership to Fight Chronic Disease, 2009.

Slide 5

Two-thirds of the increase in health care spending is due to increased prevalence of treated chronic disease

Image shows the following data:
~$211 billion increase in level of health spending among the noninstitutionalized U.S. population, 1987-2000, from $313.5 billion to $627.9 billion.
This increase attributable to rise in prevalence of treated chronic disease (in billions of nominal dollars)

Slide 6

The doubling of obesity between 1987 and today accounts for nearly 30% of the rise in health care spending

The percent of children and youth who are overweight has tripled since 1980.

If the prevalence of obesity was the same today as 1987, health care spending in the U.S. would be 10 percent lower per person—about $200 billion less.

Image: Map of the United States showing percent of adults who are obese by state according to 1995 data.

Slide 7

The Logic of Prevention

• 38% of all U.S. deaths attributable to 4 behaviors*:
  • Tobacco use
  • Diet
  • Physical inactivity
  • Alcohol misuse
• For some, health argument is reason enough to invest in prevention

*Mokdad et al., 2001

Slide 8

The Price Paid for Not Preventing Diseases

• Health outcomes
  • Illness: Morbidity, frequency/severity of illness, functional status, quality of life
  • Lives lost: Mortality, life expectancy, healthy years of life lost

Slide 9

The Full Price of Not Preventing Diseases

• Health outcomes
  • Illness: Morbidity, frequency/severity of illness, functional status, quality of life
  • Lives lost: Mortality, life expectancy, healthy years of life lost
• Resource consumption
  • Costs of avertable disease
    • Excess medical care
    • Stresses on broader economy, societal costs
  • Getting less for the dollar

Slide 10

"In 2001... spending for health care per person of normal weight was $2,783, compared with $3,737 per obese person and $4,725 per morbidly obese person.A rise in the prevalence of obesity is therefore a likely contributor to the growth of health care spending."
 

Statement of Peter R. Orszag, Director, CBO, Growth in Health Care Costs, before the Committee on the Budget, United States Senate, January 31, 2008

Slide 11

Tobacco: Results

Image: Line graph shows the "Prevalence of Smoking among National, Minnesota, and Blue Cross Member Populations." The prevelance of smoking has decreases in all populations.

Slide 12

Blue Cross savings

• The decrease in smoking rates among our members results in:
  • At least $25 million less in health care costs each year
  • Average annual savings per additional nonsmoker = $1,067

Slide 13

The Politics of Prevention

Cancer screening and other measures for heading off disease don't always reduce health-care costs.

Slide 14

The Importance of Value

• Health is a good
• Goods are not purchased to save money; there is no free lunch

Slide 15

Image: Picture of grocery store, restaurant, car wrapped in bow, gas station.

Slide 16

Picture of jet landing on aircraft carrier.

Slide 17

Picture of airport security screening.

Slide 18

Picture of space shuttle.

Slide 19

The Importance of Value

• Health is a good
• Goods are not purchased to save money; there is no free lunch
• The priority is optimizing value: making the dollar go farther
• Money is saved relative to competing options
• Return on investment is what matters; whether a service is preventive or otherwise is not the point

Slide 20

Will it Save Money?

The Wrong Question

Slide 21

Controlling Costs by Optimizing Value

Slide 22

Return on Investment

Images: A pot of gold, and a number of graphic figures representing people.

Slide 23

Return on Investment

• Cost-benefit
• Cost-effectiveness
• Cost-utility

Cost-effectiveness ratio:

Cost ($) civided by Health Benefit

Slide 24

Health Care Expenditures

Cost Saving
(CE ratio ≤0)

High value care
(<$50,000/LY)

Low value care
($50,000-$1,000,000/LY)

Slide 25

Health Care Expenditures

Cost Saving
(CE ratio ≤0)

High value care
(&$50,000/LY)

Low value care
($50,000-$1,000,000/LY)

An arrow points up to "Cost Saving" and another arrow points from "Low value care " to "High value care."

Slide 26

Health Care Expenditures

Cost Saving
(CE ratio ≤0)

High value care
(<$50,000/LY)

Low value care
($50,000-$1,000,000/LY)

Arrows point back and forth between the three components.

Slide 27

Health Care Expenditures

Cost Saving
(CE ratio ≤0)

High value care
(<$50,000/LY)

Low value care
($50,000-$1,000,000/LY)

Arrows point back and forth between the three components.

Slide 28

Return on Investment

Images: A pot of gold, and a number of graphic figures representing people.

Slide 29

Return on Investment

Images: A pot of gold, and a number of graphic figures representing people—twice the number of figures seen in previous slide.

Slide 30

Areas of Consensus

• 1. A core set of preventive services is effective
• 2. Evidence-based preventive services offer high economic value
• 3. A subset of core preventive services yields net savings
• 4. Some preventive services, like many disease treatments, offer poor economic value

Slide 31

1. A Core Set of Preventive Services is Effective

Images: Covers of three preventive services publications.

Slide 32

2. Evidence-Based Preventive Services Offer High Economic Value

• Screening
  • Breast cancer
  • Cervical cancer
  • Chlamydia infection
  • Colorectal cancer
  • Hypertension
  • Problem drinking*
  • Poor vision*
• Health behavior counseling
  • Smoking cessation*
  • Calcium supplementation
  • Folic acid use
  • Injury prevention among children
• Immunizations (vaccines)*
• Chemoprophylaxis—Aspirin use (high-risk adults)*

* Net cost savings in certain groups.
Source: Am J Prev Med 2006;31(1):52-61

Slide 33

Most Cost Effective Preventive Services

$0 to $13,999/QALY:

• Chlamydia screening (sexually active adolescents and young women)
• Colorectal cancer screening (adults 50+)
• Influenza immunization (adults 50+)
• Pneumococcal immunization (adults 65+)
• Vision screening in preschool age children

Slide 34

Most Cost Effective Preventive Services

$14,000 to $34,999/QALY:

• Cervical cancer screening (all women)
• Counseling women of childbearing age to take folic acid supplements
• Counseling women to use calcium supplements
• Injury prevention counseling for parents of young children
• Hypertension screening (all adults)

Slide 35

3. A Subset of Core Preventive Services Yields Net Savings

• Aspirin prophylaxis among persons at risk for cardiovascular disease
• Childhood immunizations
• Smoking cessation & smoking cessation counseling
• Screening for problem drinking
• Vision screening among seniors

Source: Am J Prev Med 2006;31(1):52-61

Slide 36

4. Some Preventive Services
(Like Many Disease Treatments)
Offer Poor Economic Value

• When effectiveness or safety is uncertain
• When the absolute probability of benefit is low
  • Low-risk patients
  • Frequent rescreening
  • Aggressive treatment targets

Slide 37

The Importance of Context

Who is doing the preventive intervention?

• Individuals
• Health care system
• Community-based programs

Slide 38

What is Prevention?

Slide 39

Questions About the Economics of Prevention

• How much time do interventions and outcomes require?
• Are the absolute benefits on the population level too modest?
• Does prevention delay but not avert spending?
• Does it cost more if people live longer?

Slide 40

Economic Advantages of Preventive Interventions

• Single risk factors influence multiple diseases
• Long time horizon is an opportunity for "compounding" of benefits (e.g., childhood obesity)
• Intangible benefits of good health (longer, healthier life; workforce productivity; competitiveness; broader societal effects)

Slide 41

Avertable Costs

Image: Figure 4: The Budget Window and Disease Progression. Type 2 Diabetes and Glucose Control Efforts. Average Annual Costs Averted from Complications—2007$. Line graph shows that while Conventional Protocol rises from $300 to $500 during the 10 Year "Budget Window," Intensive Protocol rises from $300 to $900; further, while Conventional Protocol will rise to $1,000 in the next 10 years, Intensive Protocol will rise to $2,250.

Source: O'Grady MJ, Capretta JC. Health-Care Cost Projections for Diabetes and other Chronic Diseases: The Current Context and Potential Enhancements. Washington, DC: Partnership to Fight Chronic Disease, 2009.

Slide 42

Community-Based Prevention

• Many community-based preventive measures are (a) effective, and (b) offer high economic value, and (c) some produce net savings
• Some community or public health measures outperform clinical interventions
• Collaborations between clinical and community interventions offer high yield

Slide 43

Tobacco: Major activities

• Tobacco tax increases
• Passage and defense of smoke-free laws
• Mass media campaigns
• Cessation support for Blue Cross members
• Outreach to high priority populations

Slide 44

Physical activity: Current activities

• Do campaign
• Active Living Minnesota
• Complete Streets
• Active Workplaces

Slide 45

The do campaign—workplace signs

Images: Signs encourage workers to use the stairs.

Slide 46

Sample ads—in stores, billboards, etc.

Image: Poster encourages people to buy fruits and vegetables to help prevent cancer.

Slide 47

Physical environment influences behavior

Images: Poster featuring a bulldozer, and photograph of people walking and riding bicycles beside a freeway.

Slide 48

A comprehensive approach integrated across all initiatives.

Image: chart presents the following points arrayed in a circle around a central circle that reads, "All foods are not created equal. Some are life-saving."

Interventions
Demonstration projects with food industry customers: Schwan, SUPERVALU, Hormel; National produce partnership

Interventions
6-8 communities and networks increase access to healthier foods
Multi-media campaign targets moms to prioritize FV

Interventions
Dietician and MD reimbursement, Coverage for treatment of obesity, weight mgmt, nutrition counseling, BMI mgmt incentives

Interventions
Consulting services, On-line resources, e-advising, worksite interventions with small employers, Weight management, Incentive based benefits

Interventions
Statewide surveillance, project evaluation, cost analysis

Interventions
Peer-to-peer networks and youth advocate development

Interventions
Local zoning
Menu labeling
School food policies
State food policy council
Community & High Priority Populations
Media Campaign
Food Industry
Employers
Providers
Research & Measurement
Policy
Youth
 

Slide 49

The Double Standard

$2 Trillion Health Care Budget, United States

Figure: Pie chart depicts the U.S. Health Care Budget; 2% is spent on prevention, 98% on other costs.

Slide 50

Leveling the Playing Field

1. Does the intervention improve health outcomes, and how strong is the evidence?
2. If the intervention is effective, is it cost-effective (a good value)?
3. Can other options achieve better results, or the same results at lower cost?

Prevention (Images: fruits and vegetables; a jogger)
Diagnostic Tests Treatments (Images: pills, a person undergoing an MRI scan)

Slide 51

Conclusion

• The spending crisis requires a comprehensive search for ways to shift spending from services of low economic value to those with high cost-effectiveness or net savings.
• Whether they are preventive or otherwise is not the point.
• What matters is getting good value on the dollar.
• It makes sense to invest in a core package of preventive services that are effective and offer good economic value.
• Services that yield net savings are obvious priorities, but shifting spending to high-value services offers the greatest gains.
• We can't afford to apply this test to prevention only and not to the rest of medical care.

Slide 52

Contact details
Steven H. Woolf, MD, MPH
Department of Family Medicine
Virginia Commonwealth University
1200 East Broad Street
P.O. Box 980251
Richmond, VA 23298-0251
804-828-9625
swoolf@vcu.edu