Preventive Medicine: A Ready Solution for a Health Care System in Crisis

Abstract

Population Health ManagementVol. 13, No. S2 ProceedingsFree AccessPreventive Medicine: A Ready Solution for a Health Care System in CrisisJanice L. ClarkeJanice L. ClarkeSearch for more papers by this authorPublished Online:29 Sep 2010https://doi.org/10.1089/pop.2010.1382AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Preventive Health in the United StatesA half-century journeyPrevention was a prominent feature of the health care reforms that took place in the late 1960s through the early 1970s. During that time, strategies such as universal vaccination, promotion of lifestyle changes, population screenings, and safety regulations were introduced and became widely accepted as means to improve public health while reducing health care expenditures.Enthusiasm for prevention strategies waned in the mid-1980s when some unanticipated outcomes became apparent. Serious, often permanent, injuries were attributed to some vaccines used for immunizations.Private health insurers had begun to use lifestyle factors as the basis for raising rates and/or denying consumer eligibility for disability benefits.Preventive screenings had come under scrutiny as potential tools for activities ranging from denying employment to selective abortion.Litigation increased with suits asserting that occupational safety standards were being used to exclude people from certain jobs.1Under the auspices of the Agency for Healthcare Research and Quality, the US Preventive Services Task Force (USPSTF) introduced the first edition of its Guide to Clinical Preventive Services in the late 1980s.2 The recommendations contained in the guide substantiated the vital importance of preventive care by including prevention in primary health care, ensuring health plan coverage for effective preventive services, and holding health care providers and systems accountable for delivering preventive care. Updated periodically thereafter, these guidelines continue to form the basis of clinical standards for professional societies, health care organizations, and medical quality review groups. Current (2009) USPSTF recommendations for preventive services are listed in Table 1.Table 1. U.S. Preventive Services Task Force (USPSTF) recommended preventive services (2009) AdultsSpecial PopulationsRecommendationMenWomenPregnant WomenChildrenAbdominal Aortic Aneurysm, Screening1X Alcohol Misuse Screening and Behavioral Counseling InterventionsXXX Aspirin for the Prevention of Cardiovascular Disease2XX Asymptomatic Bacteriuria in Adults, Screening3 X Breast Cancer, Screening4 X Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing5 X Breastfeeding, Behavioral Interventions to Promote6 XX Cervical Cancer, Screening7 X Chlamydial Infection, Screening8 XX Colorectal Cancer, Screening9XX Congenital Hypothyroidism, Screening10 XDental Caries in Preschool Children, Prevention11 XDepression (Adults), Screening12XX Diet, Behavioral Counseling in Primary Care to Promote a Healthy13XX Gonorrhea, Screening14 XX Gonorrhea, Prophylactic Medication15 XHearing Loss in Newborns, Screening16 XHepatitis B Virus Infection, Screening17 X High Blood Pressure, ScreeningXX HIV, Screening18XXXXIron Deficiency Anemia, Prevention19 XIron Deficiency Anemia, Screening20 X Lipid Disorders in Adults, Screening21XX Major Depressive Disorder in Children and Adolescents, Screening22 XObesity in Adults, Screening23XX Osteoporosis in Postmenopausal Women, Screening24 X Phenylketonuria, Screening25 XRh (D) Incompatibility, Screening26 X Sexually Transmitted Infections, Counseling27XX XSickle Cell Disease, Screening28 XSyphilis Infection, Screening29XXX Tobacco Use and Tobacco-Caused Disease, Counseling30XXX Type 2 Diabetes Mellitus in Adults, Screening31XX Visual Impairment in Children Younger than Age 5 Years, Screening32 XFrom Guide to Clinical Preventive Services, 2009. Available at: http://www.ahrq.gov/clinic/pocketgd09/gcp09s1.htm. USPSTF recommends that clinicians discuss these preventive services with eligible patients and offer them as a priority. All these services have received an “A” or a “B” (recommended) grade from the Task Force.1One-time screening by ultrasonography in men aged 65 to 75 who have ever smoked.2When the potential harm of an increase in gastrointestinal hemorrhage is outweighed by a potential benefit of a reduction in myocardial infarctions (men aged 45–79 years) or in ischemic strokes (women aged 55–79 years).3Pregnant women at 12–16 weeks gestation or at first prenatal visit, if later.4Mammography every 1–2 years for women 40 and older.5Refer women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes for genetic counseling and evaluation for BRCA testing.6Interventions during pregnancy and after birth to promote and support breastfeeding.7Women aged 21–65 who have been sexually active and have a cervix.8Sexually active women 24 and younger and other asymptomatic women at increased risk for infection. Asymptomatic pregnant women 24 and younger and others at increased risk.9Adults aged 50–75 using fecal occult blood testing, sigmoidoscopy, or colonoscopy.10Newborns.11Prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months whose primary water source is deficient in fluoride.12In clinical practices with systems to assure accurate diagnoses, effective treatment, and follow-up.13Adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease.14Sexually active women, including pregnant women 25 and younger, or at increased risk for infection.15Prophylactic ocular topical medication for all newborns against gonococcal ophthalmia neonatorum.16Newborns.17Pregnant women at first prenatal visit.18All adolescents and adults at increased risk for HIV infection and all pregnant women.19Routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia.20Routine screening in asymptomatic pregnant women.21Men aged 20–35 and women over age 20 who are at increased risk for coronary heart disease; all men aged 35 and older.22Adolescents (age 12–18) when systems are in place to ensure accurate diagnosis, psychotherapy, and follow-up.23Intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.24Women 65 and older and women 60 and older at increased risk for osteoporotic fractures.25Newborns.26Blood typing and antibody testing at first pregnancy-related visit. Repeated antibody testing for unsensitized Rh (D)-negative women at 24–28 weeks gestation unless biological father is known to be Rh (D) negative.27All sexually active adolescents and adults at increased risk for STIs.28 Newborns.29Persons at increased risk and all pregnant women.30Tobacco cessation interventions for those who use tobacco. Augmented pregnancy-tailored counseling to pregnant women who smoke.31Asymptomatic adults with sustained blood pressure greater than 135/80 mg Hg.32To detect amblyopia, strabismus, and defects in visual acuity.The managed care organizations that flourished in the 1980s and 1990s introduced the concept of insurance coverage for services emphasizing disease prevention and health education. For the first time, primary care providers were encouraged, and often “rewarded,” for attending to appropriate screening and preventive care. Disease state management programs, first appearing in the early 1990s, introduced aggressive interventions aimed at preventing disease onset, progression, and complications as well as providing treatment for patients with chronic conditions.Initiated in 1979 during the Carter administration, the Federal government initiated the Healthy People program to call attention to public health issues and establish 10-year targets for improvement in population health. Over the years, the program has worked collaboratively with public health and other organizations across the country to provide education in the form of prevention programs, information, and resources.Current status of preventive healthAlthough the United States remains one of the world's richest and most technologically advanced nations, our national health continues to fall far short of expectations and the associated costs are alarmingly high. Statistical evidence is abundant: In 2007–2008, the age-adjusted prevalence of obesity in the United States was 33.8% overall, 32.2% among men, and 35.5% among women.3An estimated 23.6 million Americans (7.8% of the population) have diabetes. Of these, 17.9 million have been diagnosed and 5.7 million are undiagnosed.4According to the National Kidney Foundation, more than 26 million Americans have chronic kidney disease and millions of others are at risk.5According to the American Heart Association, 53.7% of American men and 55.8% of American women have developed hypertension by 55–64 years of age. By age 75, the percentages increase to 64.1 for men and 76.4 for women.6At least half of the deaths from cancers (estimated at 292,540 men and 269,800 women in 2009) could be prevented by more systematic efforts to reduce tobacco use, improve diet and physical activity, and expand the use of established screening tests.7As suggested by the foregoing statistics, chronic diseases are the leading causes of death and disability in the United States today. In addition to causing 70% of all US deaths each year, chronic conditions limit activities of daily living for 1 in 10 Americans.8 Most unsettling, for a majority of chronic diseases, onset can be delayed or progression limited by avoiding risky behaviors, increasing physical activity, and obtaining life-saving screening services.The growing price tag associated with chronic conditions looms as a threat to the national economy. A recent Health and Human Services study showed that health care costs increased in 2009 at the fastest rate in more than a half century, with spending rising to an estimated $2.5 trillion. More than 60% of the nation's medical care costs are attributable to chronic conditions.In 2006, a comparison study concluded that the US population in late middle age is less healthy than the equivalent British population with respect to self-reported chronic conditions and biological markers of disease, despite considerably greater per capita spending on health care by the United States ($5274 vs. $2164 [adjusted]).9 The differences reportedly existed at all points of the socioeconomic status distribution.Recent comparisons reveal that despite better access to diagnostic equipment and surgical procedures, American life expectancy is shorter than for all peer countries around the world.10 Experts believe that this may be due in part to the United States' lag in basic preventive care (eg, annual checkups) and its heavy reliance on expensive specialists.10Our national shortcomings with respect to prevention can be explained in many ways. Some point to commercial insurance carriers rationing coverage by adhering to conservative standards and recommendations. Others look to the public sector. Historically, the Medicare program has not covered preventive services for senior citizens and many Medicaid carriers restrict preventive care to minimal standards and recommendations.Although many system issues exist, the problem is more pervasive. A national survey of 153,000 adults revealed that only 3% of US citizens adhere to the 4 key healthy lifestyle characteristics (ie, not smoking, maintaining healthy weight, eating adequate amounts of fruits and vegetables, exercising regularly).11 Other surveys revealed that 20% of US high school students were cigarette smokers in 200712 and that more than 43 million American adults (approximately 1 in 5) continued to smoke tobacco in 2009.13Despite these disheartening statistics, current conditions are ideal for a major transition in health care delivery. First, the aging population might exert a powerful positive effect. The 80 million “baby boomers” attaining senior status will have an unprecedented passion for enjoying longer, healthier, more active lives. Already, they are beginning to have an impact on markets, businesses, and society in general. While the costs of traditional “sick care” have continued to rise, improved medical and information technologies have enabled higher levels of personalized care to keep this population well.Next, purchaser and consumer markets have begun to challenge traditional health care systems. Faced with increasing personal financial contributions to their health care, consumers have begun to play a larger role in managing their health. They are beginning to demand wellness and prevention services that will help them maintain or improve their quality of life as they age. Although some employers continue to provide coverage that includes preventive services, in most cases consumers are the purchasers of preventive care. The challenge for consumers is to identify how and where to purchase prevention.Employers are increasingly embracing the value of a healthy, productive workforce. Traditionally, the effectiveness of wellness and prevention initiatives has been gauged by assessing changes in utilization and medical care costs. More recently, employers have recognized the impact of other outcomes such as health-related productivity losses due to absenteeism and presenteeism (ie, present at work but not performing at optimal levels due to a health condition or risk) as well as costs of disability benefits. The evidence favors a $1.50–$3.00 return on dollars invested (ROI) on medical and pharmacy costs in well-designed, integrated health promotion programs in industry.14 Furthermore, a recent meta-analysis of 22 separate published studies regarding the impact of workplace wellness programs revealed that on average, for every $1 invested in comprehensive wellness programs there was a savings of $3.27 in medical/pharmacy costs and $2.73 in absenteeism costs—a 6:1 ROI, without taking into account the significant savings from improved performance at work due to better health (reduced presenteeism).15, 16Increasingly, proactive preventive care is viewed as both a logical and a necessary alternative to traditional health care approaches. Screenings, risk assessments, early diagnosis, and aggressive intervention in advance of symptoms come at lower costs with greater potential for positive outcomes at the presymptomatic stage. A study assessing the potential health and economic benefits of reducing common risk factors in older Americans concluded that effective prevention could substantially improve the health of older Americans and, despite increases in longevity, such benefits could be achieved without additional lifetime medical spending.17A challenge to the traditional modelTraditionally, the focus of care has been reactive, with services delivered only when a patient's illness becomes symptomatic. As our health care system has evolved, the focus has shifted steadily from reactive to proactive, preventive care in which consumers are treated on a presymptomatic basis. Not coincidentally, this concept is one that dovetails with the population health management philosophy.Converging trends are already driving these changes. A combination of factors (ie, the increasing financial transfer of the cost of care to consumers, the compelling evidence of the effect of personal health behaviors on health outcomes, the growing societal interest in health and well-being) have been gradually shifting the responsibility for health to the individual. In addition to an increase in deductibles and co-payments, Health Savings Accounts, in which health spending and associated benefits are at the discretion of the consumer, are on the rise. This has triggered consumers' interest in their personal health and increased their involvement in health care purchasing and decision making.By far the greatest challenge—and the greatest opportunity—regarding the traditional model came in the form of the recent health care reform legislation that solidified the vital role of prevention in lowering the total costs of poor health to our society, our business community, and our economy.Health Care Reform and PreventionThere can be no doubt that the US Congress recognized the importance of addressing wellness and prevention when crafting the Patient Protection and Affordable Care Act (PL 111–148). A broad range of entitlements, programs, and interventions are evident in the synopses of related sections that follow.Wellness Incentives (Sec. 1201) codifies an amended version of the Health Insurance Portability and Accountability Act wellness program regulations. Wellness programs, with conditions for obtaining a reward based on an individual meeting a certain standard relating to a health factor, would have to meet additional requirements. Among these requirements, the reward must be capped at 30% of the cost of the employee-only coverage under the plan (under current regulations, the cap is 20%), but the Secretaries of Health and Human Services (HHS), Labor, and the Treasury would have the discretion to increase the reward up to 50%.Wellness and Health Promotion (Sec. 1201) requires the Secretary of HHS to develop reporting requirements for group health plans and insurers. Under this section, wellness and health promotion activities could include personalized wellness and prevention services “that are coordinated, maintained or delivered by a health care provider, a wellness and prevention plan manager, or a health, wellness, or prevention services organization that conducts health risk assessments or offers ongoing face-to-face, telephonic, or Web-based intervention efforts for each of the program's participants …”Coverage of Preventive Health Services (Sec. 2713) stipulates that a group health plan and/or a health insurance issuer that offers group or individual health insurance coverage must provide coverage without imposing cost-sharing requirements for: Evidence-based items or services that, in effect, have a rating of “A” or “B” in the current recommendations of the USPSTFImmunizations recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) with respect to the individual involvedNational Prevention, Health Promotion, and Public Health Council (Sec. 4001) creates a Council with HHS to provide coordination and leadership at the Federal level, and among Federal departments and agencies, with respect to prevention, wellness, and health promotion practices; the public health system; and integrative health care in the United States. Composed of departmental secretaries from across the Federal government with the Surgeon General serving as chair, the Council is charged with developing the National Prevention Strategy.Advisory Group of Prevention, Health Promotion, and Integrative and Public Health (Sec. 4001): The President is to appoint an Advisory Group to the National Prevention, Health Promotion, and Public Health Council. The Advisory Group is to include a diverse group of licensed health professionals, including integrated health practitioners who have expertise in specific areas including worksite health promotion and preventive medicine.Prevention and Public Health Fund (Sec. 4002) establishes a fund to provide for expanded and sustained national investment in prevention and public health programs. Administered by the Office of the Secretary of HHS, the fund will support programs authorized by the Public Health Service Act for prevention, wellness, and public health activities including prevention research and health screenings and initiatives.Employer-based Wellness Programs (Sec. 4303) directs the CDC to provide employers with technical assistance, consultation, and tools to evaluate wellness programs and to build evaluation capacity among workplace staff. It directs the CDC to study and evaluate employer-based wellness practices. It also clarifies that the recommendations, data, or assessments will not be used to mandate requirements for workplace wellness programs.Grants for Small Businesses to Provide Comprehensive Workplace Wellness Programs (Sec.10408) directs the Secretary of HHS to award grants to small businesses to provide employees with access to comprehensive workplace wellness programs. A total of $200 million in funding is available for 5-year grants to companies with fewer than 100 employees and no current wellness program.Effectiveness of Federal Health and Wellness Initiatives (Sec. 4402) requires an HHS evaluation of all existing Federal health and wellness initiatives and a report to Congress concerning the reasons for program successes or failures including the factors contributing to these conclusions.Medicare Coverage of Annual Wellness Visit (Sec. 4103) calls for the creation of a personalized/individual prevention plan that includes the following: health risk appraisalup-to-date medical and family historylist of current health care providers and suppliersmeasures of height, weight, body mass index (BMI [or waist circumference]), blood pressure, and other routine measuresdetection of cognitive impairmenta 5- to 10-year screening schedule based on USPSTF and ACIP recommendationslist of risk factors and conditions for which primary, secondary, and tertiary prevention services are recommended or are under wayfurnishing of personal health advice and referral, as appropriate, to health education or prevention counseling services aimed at reducing risk factors and improving self-management … including weight loss, physical activity, smoking cessation, fall prevention, and nutritionservice delivered by physician, registered nurse, health educator, registered dietitian, or nutrition professionalservice may be furnished through an interactive telephonic or Web-based programDemonstration Project Concerning Individualized Wellness Plan (Sec. 4206) calls for the HHS Secretary to establish up to 10 pilot programs to test the impact of providing an individualized wellness plan to at-risk populations who utilize community health centers. Programs must include 1 or more of the following: nutritional counseling, physical activity plan, alcohol and smoking cessation counseling and services, and stress management.Incentives for Prevention of Chronic Disease in Medicaid (Sec. 4108) provides $100 million to establish grants to states (beginning in 2011) for minimum 3-year Medicaid beneficiary incentive programs. States that receive grants must provide programs to individuals for cessation of tobacco use, weight reduction/control, lower cholesterol and/or blood pressure, diabetes avoidance or control, and outcome measurement.Healthy Aging, Living Well: Evaluation of Community-Based Prevention and Wellness Programs for Medicare Beneficiaries (Sec. 4202) provides $50 million to the CDC to fund pilot programs operated by state and local health departments or Native American groups. Individual screening and interventions must focus on improving nutrition, increasing physical activity, reducing tobacco use and substance abuse, improving mental health, and promoting healthy lifestyles among a target population of persons 55–64 years of age.The Preventive Medicine and Public Health Training Grant Program enables the HHS Secretary to award grants to, or enter into contracts with, eligible entities to provide training to graduate medical residents in preventive medicine specialties.Sense of Senate concerning Congressional Budget Office scoring (Sec. 4401): The Senate found that the costs associated with prevention programs are difficult to estimate, initiatives are difficult to measure, and outcomes may not be apparent within the 5- to 10-year budget window. Given these issues, the Congress senses a need to work with the Congressional Budget Office to develop better methodologies to evaluate and score the progress made by prevention and wellness programs.The prevention and wellness measures contained in the health care reform law help pave the way for a necessary fundamental change from cost shifting to cost reduction. Reducing the burden of health risks and illness will lead to a healthier population and measurable cost decreases.U.S. Preventive Medicine: An Innovative Model RevisitedUSPM envisions a “culture of prevention” in which the definition of “prevention” is expanded to include each individual understanding what goes on inside his or her body (eg, lifestyle factors, biometric tests, blood tests). The company's goal is to facilitate the health care system transformation necessary for this transition (Figure 1).FIG. 1. Transformation of the health care system.In the 4 years since the publication of “Preventive Medicine: A ‘Cure’ for the Healthcare Crisis,” USPM has made considerable progress toward meeting the challenges of creating an appropriate prevention model in a changing US health care landscape. The model has evolved, shifting direction and expanding its focus to meet current needs.USPM continues to view its role as a catalyst, coalescing divergent interests (ie, employers, consumers, providers, government) in a business model focused on creating and sustaining a “culture of prevention.” Its comprehensive, individual-oriented approach is best described as a bundled clinical model of prevention that incorporates (1) primary, secondary, and tertiary prevention; (2) a novel “prevention benefit” solution; and (3) an array of high-tech/high-touch components.The Prevention PlanThe expanded model—The Prevention Plan (TPP) (in development)—is a suite of products that includes a general prevention and wellness plan, a screening/early detection plan, a chronic condition management plan, a prevention plan directed at senior wellness and care management, and a children's prevention plan in addition to its initial product – a concierge and executive health prevention plan.Each of the TPP plans contains 1 or more assessment elements (eg, health risk appraisals, lab tests/biometrics, physician review/recommendations, personalized plan and report, personal Web-based health record) and 1 or more interventions (eg, access to telephonic nurse coaches, how-to videos, prevention score, online education programs, progress tracking, screening/exam schedules, challenges/contests).Fully accredited by both the National Committee for Quality Assurance and the Utilization Review Accreditation Committee, TPP plans are portable, independent of but synergistic with traditional health insurance, and can be integrated with employer and/or public health benefits packages.Using detailed information from a person's medical history along with data from blood tests, biometric screenings, and self-reported risk behaviors, TPP creates a personal risk analysis and customized plan. This “road map” identifies the person's health risks and recommends a personalized program to minimize those risks. In addition to the robust online tools, a health coaching team led by nurse advocates provides support and the individual also has the option of having his or her plan reviewed by a physician. In this way, the participant receives a comprehensive personal plan for health, similar to someone getting financial advice and a plan from a financial planner.The Prevention ScoreA unique feature of TPP is the Prevention Score. This score differs from a health risk score in that it measures a person's proactive behavior by incorporating and offering “points” for key metrics and for completing educational sections, screenings, and other components of TPP.The Prevention Score is an effective tool to engage individuals in their own health on a year-to-year basis. The underlying assumption is that knowing one's score will encourage the person to strive for improvement. The only circumstance under which a person receives “0” points is when he or she does nothing. Merely joining the program earns a point.Key to the scoring system is the tracking of individuals' progress by comparing their baseline metrics at the beginning of each year with their metrics at the beginning of the following year. At the end of each year, individuals receive their Prevention Score based on the sum of points from this comparison and points from their participation level in TPP (eg, completion of educational sections, screenings). Thus, the final Prevention Score is a reflection of each person's efforts in the previous year—improvement on their metrics over baseline and their involvement in recommended activities during that year. Incorporation of key metrics, together with the dynamic nature of the score, encourages each person to learn the reasons for a low score and provides the knowledge, tools, and incentive to improve. The maximum Prevention Score is 1000 points. Participants can see the points they have earned in real time and they are given customized recommendations on how they can accrue additional points.TPP interventions are designed to elevate a person's concern about his/her health, to make wellness and prevention easy to understand and to achieve, and to foster social networking and community. More than 15 customized Action Programs are built into the model. Personal pointers are developed to connect the person to all of the necessary pieces of prevention on an individual basis. Educational information is updated regularly by collecting and/or synthesizing thousands of condition-related articles to make them readily accessible and relevant to participants.In addition to the collection of bundled benefits, TPP offers challenges and contests to engage employers and members alike. For example, TPP offers individual members the opportunity to compete in teams again