Supporters say prevention will save the nation billions in averted long-term healthcare costs, and recent studies show that Americans support investing in prevention. But questions persist—most notably from the Congressional Budget Office.
Prevention has been mentioned as an important piece of healthcare reform. In its health reform draft proposal, The House Committees on Ways and Means, Energy and Commerce, and Education and Labor shed some light on where the prevention dollars would flow:
- Expand community health centers
- Waive cost-sharing for preventive services in benefit packages
- Create community-based programs to deliver prevention and wellness services
- Target community-based programs and new data collection efforts to better identify and address racial, ethnic, and other health disparities
- Strengthen state, local, tribal, and territorial public health department programs
This proposed package of prevention programs in the healthcare reform debate would go beyond provider-based healthcare with supporters hoping to create a better wellness culture in the country. But will the government be more successful than doctors, employers, health plans, and population health companies who have struggled to get people more active and eat right? Then, there's the question whether prevention programs actually save money.
Employers and the population health industry have been discussing the issue of prevention and ROI for years. Groups, such as the Trust for America's Health, suggest the U.S. could save $16 billion annually within five years and experience a 5.6:1 ROI by simply investing $10 per person annually in community-based programs to increase physical activity.
Another study, funded by Pittsburgh-based health insurer Highmark Inc., found a modest 1:64:1 ROI in a four-year review of the insurer's employee wellness program, which includes employer health risk assessments, online programs in nutrition, weight, and stress management, tobacco-cessation programs, on-site nutrition and stress classes, biometric screening, and health coaching.
Anna Silberman, vice president of preventive health services for Highmark, says the company's prevention program stops non-healthcare users from becoming "huge users of the system." Prevention not only reduces direct medical costs, but also saves companies and the nation on work-related costs in the areas of absenteeism, work production, and presenteeism, she says.
Silberman says the healthcare system should reward physicians for educating their patients about prevention and reminding patients of recommended tests, such as mammograms and diabetes screenings. "There are so many things that we can do that often get put on the backburner because we're dealing with the acute thing that's happened as a result of not addressing them earlier in our lives," she says.
However, there are others who say prevention doesn't save much—if anything. The issue is that preventive programs are open to a wide population rather than those who could be at risk of chronic diseases, such as diabetes, heart failure, or kidney disease. So, in fact, the companies are using a wide net to help people who may never have a chronic disease or are destined for a chronic disease regardless of activation level or food choices.
One group to question the cost-effectiveness is the CBO, which suggested in December that more prevention would bring modest cost reductions over 10 years, and could actually increase costs.
Mary Jane Osmick, MD, vice president and medical director at LifeMasters, a health management company in Irvine, CA, supports wellness programs, but acknowledges there are still questions about whether wellness programs can save money.
"My guess is that there is a [positive] ROI, but I don't know that we have the methodology to say this is what it is and this is when you'll see it. I think the jury's still out on that. But I sure believe it from a physician stand point, that prevention is the absolute way to go," says Osmick.
Judith H. Hibbard, PhD, professor of health policy in the University of Oregon's Department of Planning, Public Policy and Management in Eugene, OR, who created the Patient Activation Measure, which is a questionnaire that gauges an individual's activation level in health, says whether prevention is cost-effective depends on the program. "If you mean by clinical prevention, I don't think it's going to get us that far. If you mean to really help people to avert illness or avert future declines in health, then yes, I think it could [save money]."
Hibbard says prevention programs can't merely happen in physicians' offices. Ninety percent of what determines an individual's health state is outside of the healthcare system. For prevention to be successful, the country will have to need a more encompassing wellness program.
"I think we have to take a more holistic view and get outside the system too. People live inside the community and not just look for the medical system to make that happen. They need to be part of the solution too—not divorced from it," says Hibbard about empowering the individual.
With that thought in mind, Sen. Tom Harkin, D-IA, filed legislation that would provide tax credits for employers that spark employers to participate in programs, such as health education and behavior change.
Health management company Alere also recently presented its National Health Improvement Strategy that it claims could save American businesses and health insurers "tens of billions of dollars" by focusing on preventing health risks and chronic illness. Alere CEO Ron Geraty, MD, promotes more collaboration between providers, employers, and health plans in the areas of health information technology, home monitoring services, rapid diagnostic tools, clinical outreach, and health coaching. He says these program could avoid episodic visits, procedures, and treatments. In addition to national nutrition programs, Geraty says the government needs to kick off a national healthy pregnancy campaign because healthy babies lead to healthy adults.
"We think a concerted strategy for the country is needed to say ‘we care about health, we promote health, and then when there is disease, we are actively managing the longitudinal impacts of those illnesses.' That will really change the way healthcare is delivered in the country," says Geraty.
What would need to happen?
In order to change the healthcare system to focus on prevention, industry experts pointed to a number of needed changes:
- Paying healthcare providers for keeping patients well, such as reimbursing for patient education, prevention, and early detection. "I think it's important for physicians and other healthcare professionals that there be a mechanism introduced where immunizations are adequately reimbursed for," says Silberman.
- Physicians need to be trained on nutrition and exercise so they can provide guidance to patients.
- Incentive programs for people who are active in physical or nutrition programs, which employers have found can improve the wellness culture
- Technology to make health a more compelling choice, such as portable interactive Web sites that integrate a person's personal health record and patient history. "Most people when they think of personal health records think of a place to store medical information, which I think is critically a part of it, but we think the PHR ought to be a personal healthcare planner," says Geraty.
Silberman says the good news is that much of healthcare costs is preventable. But to benefit from prevention, the nation will need to make major investments inside and outside of healthcare.
"There's so much potential when you think about the fact that 75% of what we cope with as a country is preventable," says Silberman.