6
Missed Prevention Opportunities

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



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6 Missed Prevention Opportunities 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 invest- ments 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 popula- tion’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 increas- ing the delivery of preventive efforts to patients. Steven H. Woolf of Virginia Commonwealth University opens the ses- sion 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 29

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220 THE HEALTHCARE IMPERATIVE necessitate redistributing current expenditures to high-value services such as prevention. Thomas J. Flottemesch of HealthPartners Research Foundation sug- gests 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 calcu- lations, widespread use of effective interventions, such as disease manage- ment, 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

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22 MISSED PREVENTION OPPORTUNITIES 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 spend- ing 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 pro- found 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 drink- ing) (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 per- cent of such cases (CDC, 2004). The obesity epidemic enhances the leverage of disease prevention be- cause of its prominent role as a risk factor for cardiovascular disease, diabe- tes, 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 Congressio- nal 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 ad- dress obesity or face adverse economic and workforce consequences. Defining Prevention The classic categories of prevention include primary prevention, con- trolling modifiable risk factors to avert the occurrence of disease; secondary prevention, the early detection of disease before it manifests clinical symp- toms; 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

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222 THE HEALTHCARE IMPERATIVE TABLE 6-1 Matrix for Classifying Categories of Prevention Primary Prevention Secondary Prevention Tertiary Prevention Clinical Behavioral counseling Testing by clinicians Chronic illness care and prevention by clinicians; for early detection of disease management immunizations cancer, heart disease, administered by and other conditions clinicians Community- Altering the Screening fairs and Self-care; disease or population- community and other community management at home, based environment to venues for disease work, school prevention promote healthy testing lifestyles and reduce risks for disease and injuries NOTE: primary prevention = controlling modifiable risk factors to avert the occurrence of disease; secondary prevention = the early detection of disease before it manifests clinical symptoms; tertiary prevention = the control of existing diseases to prevent more serious complications. prevention can take the form of clinical preventive services, as when clini- cians 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, informa- tion 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, legisla- tion (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.” 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 Na- tional Commission on Prevention Priorities, fully 100,000 deaths would be

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22 MISSED PREVENTION OPPORTUNITIES 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 competitive- ness, 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 inter- ventions 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 pro- moting 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

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22 THE HEALTHCARE IMPERATIVE TABLE 6-2 Cost-Effectiveness of 15 Out of 25 Clinical Preventive Services Reviewed by the National Commission on Prevention Priorities Cost-Effectiveness Preventive Service CE ratio < 0 Advising at-risk adults to take aspirin (cost saving) Childhood immunization Smoking cessation advice and help to quit Screening adults for alcohol misuse and brief counseling Vision screening (for adults age 65 and older) CE ratio = Chlamydia screening (sexually active adolescents and young women) $0-13,999/QALY Colorectal cancer screening (adults age 50 and older) Influenza immunization (adults age 50 and older) Pneumococcal immunization (adults age 65 and older) Vision screening in preschool age children CE ratio = Cervical cancer screening (all women) $14,000-34,999/ Counseling women of childbearing age to take folic acid supplements QALY Counseling women to use calcium supplements Injury prevention counseling for parents of young children Hypertension screening (all adults) NOTE: CE = cost-effectiveness; QALY = quality-adjusted life year. the same resource investment while also reducing outlays for costly services that offer modest or no benefits. Channeling resources toward health ser- vices 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 ef- fectiveness. 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. Conclusion The Wrong Question: How Much Can We Save? Current policy discussions about prevention are preoccupied with the question of whether it will “save money,” and in some cases it can, but whether health spending (preventive or otherwise) produces savings is ulti- mately the wrong question. Health is a good, and goods are not purchased to reduce spending. Expenditures by individuals (e.g., grocery shopping) and by society (e.g., national defense) are made to purchase goods of value,

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22 MISSED PREVENTION OPPORTUNITIES not to save money. Discussions about “saving money,” whether for grocer- ies or battleships, are about getting more for the dollar (i.e., improved ef- ficiency), not about acquiring goods at no cost (cost neutrality). Health is no different; spending on diagnostic tests and treatments is not conditioned on cost savings. Society is willing to spend money for good health; the nation now spends 17 percent of its gross domestic product on health. The challenge of our time is how to purchase health more efficiently to restore sustainable growth rates. Scrutiny must be applied across the board—in reviewing the full portfolio of health expenditures—to find more effective ways to enhance value and produce better health outcomes for the same dollar. This question is not just for prevention but for all classes of health-related spending. The Right Question: How Do We Maximize Value? This question has always been germane, but the current economic crisis adds urgency. With government budgets and corporate survival imperiled by healthcare costs, the search for “savings” in prevention, which accounts for an estimated 3 percent of spending, not only misses the point but risks overlooking the major cost drivers responsible for spending. The crisis calls for a shift in attitude that places prevention on the same playing field as all of health care and poses the same questions of any service, whether its purpose is prevention, diagnostic testing, or treatment: (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)? and (3) Can other options achieve better results, or the same results at lower cost? The evidence identifies a cadre of effective preventive services, in the clinical and community setting, that can help optimize value and reduce the burden of chronic diseases for the current population and the generation to come. The long-term human and economic consequences of diseases that need not occur constitute the ultimate price paid for inadequate emphasis on prevention. 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 re- quire 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

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22 THE HEALTHCARE IMPERATIVE 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 preven- tion 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 Pre- vention’s (CDC’s) National Health Interview Survey and Behavioral Risk Factor Surveillance System, only 37 percent of adults are routinely im- munized 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 pro- viders 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 sec- ondary 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. The estimates are calculated using models developed in support of the work of the National Commission on Prevention Priorities (NCPP) (Ma- ciosek 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

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22 MISSED PREVENTION OPPORTUNITIES TABLE 6-3 Evidence-Based Package of 20 Clinical Preventive Services Clinical Preventive Type of Service Prevention Description and Target Population Tetanus- Primary Immunize adults every 10 years diphtheria booster Folic acid use Primary Counsel women of childbearing age routinely on the use of folic acid supplements to prevent birth defects Chlamydia Primary Screen sexually active women under age 25 routinely screening Pneumococcal Primary Immunize adults age 65 and older against pneumococcal immunization disease with one dose Osteoporosis Primary Screen routinely women age 65 and older and age 60 and screening older at increased risk for osteoporosis and discuss the benefits and harms of treatment options Influenza Primary Immunize adults age 50 and older against influenza once immunization annually Obesity Primary Screen adults age 18 and older routinely for obesity and offer screening high-intensity counseling about diet, exercise, or both together with behavioral interventions for at least 1 year Cholesterol Primary Screen routinely for lipid disorders among men age 35 and screening older and women age 45 and older and treat with lipid- lowering drugs to prevent cardiovascular disease Alcohol Primary Screen adults age 18 and older routinely to identify those screening whose alcohol use places them at increased risk and provide brief counseling with follow-up Tobacco Primary Screen adults age 18 and older for tobacco use, provide brief counseling, offer medication, and make referrals for more intensive counseling Hypertension Primary Measure blood pressure routinely in all adults age 18 and screening older and treat with antihypertensive medication to prevent cardiovascular disease Childhood Primary Immunize children under age 5 against diphtheria, tetanus, immunizations pertussis, measles, mumps, rubella, polio, Haemophilus influenza type b, varicella, pneumococcal, and influenza Daily aspirin Primary Discuss daily aspirin use with men age 40 and older, women use age 50 and older, and others at increased risk to prevent heart disease Depression Secondary Screen adults age 18 and older for depression in clinical screening practices with systems in place to assure accurate diagnosis, treatment and follow-up continued

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22 THE HEALTHCARE IMPERATIVE TABLE 6-3 Continued Clinical Preventive Type of Service Prevention Description and Target Population Hearing Secondary Screen for hearing impairments in adults age 65 and older and screening make referrals to specialists for treatment Breast cancer Secondary Screen women age 50 and older routinely with mammography screening alone or with clinical breast examination and discuss screening with women 40-49 to choose an age to initiate screening Vision Cross- Screen children under age 5 routinely to detect amblyopia, screening classified strabismus, and defects in visual acuity Vision Cross- Screen adults age 65 and older routinely for diminished vision screening classified with the Snellen visual acuity chart and make referrals Cervical Cross- Screen women who have been sexually active and have a cancer classified cervix within 3 years of onset of sexual activity or age 21 screening routinely with cervical cytology (Pap smears) Colorectal Cross- Screen adults age 50 and older routinely with fecal occult cancer classified blood test, sigmoidoscopy, or colonoscopy screening Services Task Force (USPSTF) or Advisory Committee on Immunization Practices (ACIP). The USPSTF recommends primary and secondary pre- ventive 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 ser- vices 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

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229 MISSED PREVENTION OPPORTUNITIES selected a 90 percent target rate to reflect limitations to even the most ef- fective 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 ca- pacity). 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. 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 reduc- tion, 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 pri- mary and secondary preventive services (i.e., the costs and savings of de- livering 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 bil- lion (3.1 percent of 2006 personal healthcare expenditures [PHCE]) at a

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20 THE HEALTHCARE IMPERATIVE TABLE 6-4 Impact of Preventive Services Target Net Cost Impact Population Current Delivery of a 90% Delivery Clinical Preventive Service Size* Rate (%) Rate ($ billions) Tetanus-diphtheria booster 217,319,378 50 0.3 Folic acid chemoprophylaxis 48,446,619 25 0.2 Chlamydia screening 9,703,067 30 0.034 Pneumococcal immunization 2,248,747 54 –0.054 Osteoporosis screening 37,260,352 50 1.1 Influenza immunization 89,327,640 37 0.74 Obesity screening 225,662,922 20 –0.48 Cholesterol screening 133,975,491 79 1.5 Alcohol screening 225,662,922 25 –1.7 Tobacco screening 225,662,922 28 –5.6 Hypertension screening 225,662,922 87 0.23 >90 Childhood immunizations 20,417,636 — Discuss daily aspirin use 138,172,243 33 –3.3 Total for primary prevention –7.0 Depression screening 11,283,146 25 0.31 Hearing screening 37,260,352 50 0.34 Breast cancer screening 71,235,621 67 1.0 Total for secondary prevention 1.6 Vision screening—children 4,021,602 75 0.008 Vision screening—adults 37,260,352 50 0.3 Cervical cancer screening 115,885,477 80 0.47 Colorectal cancer screening 225,662,922 48 1.4 Total for cross-classified services 2.2 *Based on U.S. population in 2006. 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). The remaining columns show the marginal impact of increasing current delivery rates to 90 percent from their current level. Primary clinical pre- ventive 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 bil- lion for cross-classified services. Limitations and Caveats As with any analysis, ours is subject to certain limitations and requires the proper context. When arriving at the broad population-level results pre-

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2 MISSED PREVENTION OPPORTUNITIES TABLE 6-5 Impact of Preventive Service Type on 2006 Personal Healthcare Expenditures Total Marginal Delivery Total Delivery Marginal Costs to Savings Costs to Savings Marginal Reach with Net Health Reach with Net Health 90% use 90% use Expenditures 90% use 90% use Expenditures ($ billions) ($ billions) ($ billions) ($ billions) ($ billions) ($ billions) Primary $52.1 $53.9 –$1.8 $11.6 $18.6 –$7.0 prevention As 3.0% 3.1% –0.1% 0.7% 1.1% –0.4% percent of PCHE Secondary $5.3 $0.2 $5.1 $1.7 $.047 $1.6 prevention As 0.3% 0.0% 0.3% 0.1% 0.0% 0.1% percent of PCHE NOTE: PCHE = personal healthcare expenditures. sented here, it is possible that certain costs were omitted or double-counted. For example, available data did not allow us to estimate the marginal benefit of tobacco cessation counseling on heart disease after cholesterol screening reaches 90 percent. Further, depending on whether multiple risk factors act additively or multiplicatively on health events, our estimates may overstate, or understate, potential savings. In addition, the cost of delivery and treatment were abstracted from different sources and adjusted to 2006 dollars. Variation across sources and inherent inaccuracies of price indices reduces the validity of strict comparisons of the service-by-service estimates in Table 6-4. Instead, one should view our results in terms of the magnitude of differences across services in terms of their target populations, current delivery rates, and potential impact and the cost impact of primary and secondary preventive services as baskets of services. Context and Discussion Prevention is often lumped into one large undifferentiated group (Woolf, 2008). Our analyses indicate that different types of evidence-based clinical preventive services have the potential for differential impacts de- pending upon current delivery rates and target populations. Further, there are certainly questionable preventive services for which there is not yet a

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22 THE HEALTHCARE IMPERATIVE good evidence base. Payers, policy makers, and consumers should focus on evidence-based recommendations from reputable sources such as those of the USPSTF. This analysis suggests that investing in an evidence-based package of primary preventive services could produce net cost savings. Our estimates show the potential cost savings of clinical preventive services after the cost of their delivery and necessary follow-up are taken into account. However, these savings were small relative to overall healthcare expenditures. Further, we did not include costs of reminders to patients, media campaigns, patient incentives, or changes to delivery systems needed to achieve increased use and these costs likely rise as one attempts to realize higher and higher levels of use. Thus, while the package of evidence-based clinical primary preven- tive services appears cost savings, it is best viewed as cost neutral. Similarly, the package of secondary preventive services has a net cost that is virtually cost-neutral when viewed as a percent of PCHE. That is not to say evidence-based preventive services, such as those considered here, should not be promoted. Instead, support for prevention should be given for the right reasons and with reasonable expectations. The true question confronting patients, payers, and policy makers is one of value. As with any medical expenditure, dollars spent on prevention should be gauged in terms of the benefit they provide, be it improved quality of life, productivity, or both. All of the services considered here are recom- mended by the USPSTF and/or ACIP because a significant evidence base of their effectiveness exists. A preventive service should not be written off simply because it does not appear to save money following a modeling exercise. Evidence-based preventive services should be embraced, and their use encouraged, because of their health impact. These services preserve health and well-being and, thereby, provide a significant return on invest- ment. As noted in our introduction, the choice of whether or not to invest in prevention is one of spending toward the avoidance of disease in the hope of improving overall quality of life or spending in reaction to and in treatment of disease whose deleterious physical and mental effects may have already been incurred. 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 in- creasing burden of chronic illness in the United States compel policy mak- ers to identify better means of improving the value of health care in the

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2 MISSED PREVENTION OPPORTUNITIES 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 ser- vices for tertiary prevention. Tertiary prevention focuses on patients with es- tablished 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 re- habilitative services; care coordination by multidisciplinary teams; self-care training; adherence support; and measurement and attention to quality im- provement. 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. Opportunities for Tertiary Prevention Effective and cost-saving interventions have been developed for several individual chronic conditions, including diabetes, heart failure, and depres- sion, as well as for patients in certain care situations, such as having been recently discharged from the hospital or living with terminal illnesses. Disease Management For example, Rubin examined diabetes disease management for a ret- rospective cohort of 7,000 patients enrolled in several health maintenance organizations (HMOs) and found that the annual admission rate decreased from 239 to 196 per 1,000 and costs decreased by $44 per member per month (Rubin et al., 1999). For heart failure, McAlister and colleagues conducted a systematic review of intervention trials and found that 15 of 18 that examined costs found cost savings, mainly through reduced hospital admissions. Effective interventions included use of multidisciplinary teams, telephone-based follow-up to prevent or treat exacerbations, and self- management training (McAlister et al., 2004). For depression, several trials of collaborative care have demonstrated effectiveness in improving depres- sive symptoms (Goetzel et al., 2005). While they have not generally reduced

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2 THE HEALTHCARE IMPERATIVE healthcare spending, their overall economic impact has been positive due to improvements in absenteeism and productivity (Simon et al., 2007). Reducing Rehospitalizations Prevention of rehospitalizations following discharge is another form of tertiary prevention with substantial opportunity for cost savings. About 20 percent of Medicare beneficiaries are rehospitalized within 30 days and 34 percent within 90 days of an initial hospitalization (Jencks et al., 2009). Almost half of those rehospitalized had no evidence of an outpatient follow- up visit between admissions. In 2004, the costs associated with rehospital- ization were estimated to be $17 billion. Coleman and colleagues found that an intervention based on discharge coaching reduced rehospitalization for adults with 11 selected conditions at 180 days; mean costs were $2,058 for intervention patients versus $2,546 for controls. Recently, Jack and colleagues demonstrated a 30 percent de- crease in rehospitalization after interventions with nurse and pharmacist support. That decrease translated into a $412 reduction in cost per partici- pant (Coleman et al., 2006). Palliative Care Only a few trials of limited quality have examined the effects of spe- cialized palliative care compared with usual care in patients with terminal illnesses. In general, they have found lower costs with specialized palliative care teams, as well as greater patient satisfaction. Larger, higher-quality studies are needed to confirm these findings and ensure their generalizability (Zimmermann et al., 2008). Tertiary Prevention Does Not Universally Produce Savings Despite these successful examples, not all evaluations of disease man- agement or care coordination programs have found them to be effective or to produce cost savings. Peikes and colleagues recently reported on the initial evaluation of the Medicare demonstration trial for care coordination. They examined the effect of 15 different care coordination programs. Most used nurse telephonic support as their main intervention. The investigators found little evidence of improved processes of care or better adherence, and few of the programs had lower costs (Peikes et al., 2009). Translating successful interventions to new populations and settings may also be difficult. Successful interventions are often incompletely de- scribed in publications, making it difficult to replicate programs. The origi- nal programs often have highly experienced and specially trained staff with

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2 MISSED PREVENTION OPPORTUNITIES high levels of enthusiasm who have dedicated themselves to the mission of programmatic success. When applied more broadly, limitations in skills or training and lower degrees of enthusiasm may produce more modest results. Organizations often have other issues that limit their ability to im- plement effective interventions, including administrative structures and budgeting procedures that limit the establishment and maintenance of mul- tidisciplinary, patient-centered teams. External financial and reimbursement structures also limit implementation: cost savings accrue to payers; provid- ers may see no effect or could even have reduced income. Interventions that reduce nonmedical spending, such as better depression care, may not be implemented because their economic benefits accrue mainly to the patients or their employers, rather than to payers or healthcare providers. Within the current fee-for-service environment, many payers have no means of compensating providers for more efficient, nontraditional means of service delivery, such as e-mail or home visits (Siu et al., 2009). Savings from Enhanced Tertiary Prevention With these limitations in mind, we can attempt to estimate how the widespread implementation of effective tertiary preventive services could affect healthcare costs. Current total annual health spending on patients with chronic conditions is $1.5 trillion (CDC, 2008a). If we estimate that 30 percent ($450 billion) of that spending is potentially amenable to inter- ventions (based on the proportion of spending on chronic conditions that is accounted for by pathology that would be amendable to effective tertiary prevention activities), we can then base an estimate of potential savings on a relatively conservative assumption about program efficacy. If, based on the effect sizes of cost reductions achieved in the evaluations of successful interventions, the available interventions can produce 10 percent reductions in spending on average, then widespread adoption of effective programs for key chronic conditions could produce substantial savings, perhaps as much as $45 billion per year. Such an estimate is uncertain for several reasons. First, the propor- tion of real-world spending amenable to tertiary prevention is difficult to estimate. Secondly, as mentioned above, the effectiveness and economic impact of real-world interventions may differ when implemented widely. Thirdly, tertiary prevention overlaps with many other types of cost-saving interventions being considered, making the total dollar savings dependent on the degree of implementation of other effective interventions. Despite these limitations, the available evidence suggests that better use of effective tertiary prevention has strong potential for improving health and reducing spending.

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