Paying—and Playing—for Prevention: Is it Worth a Pound of Cure?
February 3, 2011
by Holly Korda
The focus on wellness and prevention is part of the Patient Protection and Affordable Care Act (PPACA, or P.L.111-148) with an emphasis on value-based health care: improving access and quality of care while slowing health care cost growth. This wellness and prevention focus includes certain clinical prevention services, and expands the continuum of care to include community-based programs. It also reflects the PPACA’s emphasis on population health. The PPACA is investing $15 billion over 10 years on health care providers and programs that promote prevention, including $500 million in fiscal year 2010 for improving community and clinical prevention efforts, improving research and data collection, and increasing the number of primary care professionals (1).
What is covered?
Private health insurance plans are now required to cover 45 preventive care services for adults recommended by the United States Preventive Services Task Force (USPSTF), an independent panel of non-federal experts in prevention and evidence-based medicine. These services include those the task force has rated as “A” or “B,” and were selected because research shows they have a high or moderate certainty of showing a moderate or substantial net benefit. Private health plans must also cover an annual wellness visit and physical examination, a health risk assessment, preventive services recommended by the USPSTF, and vaccines for flu, pneumonia, and hepatitis B without cost (2).
The same provisions apply to the Medicaid and Medicare programs. Both programs are required to eliminate patient cost sharing for the same recommended preventive services and vaccines. State Medicaid programs are allowed greater flexibility under the new health care reform legislation, and can provide a broad range of home- and community-based services, including targeting benefits to populations with specific conditions.
While most of these benefits are clinical services, Medicare will expand coverage to include community-based prevention and wellness programs. It is not yet clear which programs will be included, but the PPACA calls out several categories for special focus under Medicare: physical activity, nutrition, obesity, falls, chronic disease self management, and mental health.
How will these services be provided?
Preventive care will be provided in a variety of settings, including primary care practices, health clinics—and for some services—pharmacies. Increasingly, these services will be provided through integrated delivery systems like accountable care organizations and patient-centered medical homes. Federally-qualified health centers can expect to serve a growing number of patients as PPACA provisions expand coverage to an estimated 32 million uninsured individuals (3). Preventive services will also be provided by community-based service providers, from YMCAs to social services organizations and other community-based organizations.
What do we know about what works?
1. Prevention and wellness services are a diverse lot, of different types and levels.
Prevention and wellness services are a diverse lot, with different types and levels. There’s not always clear agreement about which programs and services to include as “prevention and wellness,” and this poses a huge challenge to policymakers and health professionals. Preventive medical care includes services such as screening tests, counseling, chronic disease management, and immunizations. Community-based preventive services and programs include interventions that encourage the provision of services such as health education, screening, and outreach to groups of people in community settings. Wellness services encourage people to engage in healthy behaviors and lifestyles, such as eating a healthy diet, exercising, and discouraging tobacco use.
Adding to this confusion are classifications of preventive activities as primary, secondary, and tertiary strategies. Primary prevention approaches seek to avoid development of disease and include population-based health promotion. Secondary prevention addresses diagnosis and treatment of existing disease in its early stages, while tertiary prevention aims to reduce the impact of existing disease and its complications.
2. Most preventive care services do not save money, and most add to costs.
Another issue to consider is that most preventive care services do not save money, and most add to costs. Research shows that preventive care may improve health, but it comes at a cost. One widely cited study in the New England Journal of Medicine, based on 599 studies published between 2000 and 2005, reports that fewer than 20 percent of preventive services save money (4). More than 80 percent of the time, spending more on prevention increased medical spending, leading the authors to conclude that “opportunities for efficient investment in health care programs are roughly equal for prevention and treatment.”(5)
It has also been argued that the costs of large-scale screening—for example, annual screenings for cervical cancer, a slow growing disease—can substantially increase medical costs with little additional health benefit compared with screening less often (6). In spite of their often hefty price tags, many preventive interventions actually do improve health. Diabetes prevention counseling is said to be effective, but adds to medical costs: a whopping $192,000 for each healthy year gained, in 2007 dollars (7).
3. Some preventive services do save money, while reducing morbidity and mortality.
Of course, we do know that some preventive services save money, while reducing morbidity and mortality. Increasing utilization of low cost, high net benefit services reduces morbidity and mortality, and saves money. A recent study in Health Affairs identified several clinical services that produce net medical savings: the childhood immunization series, pneumococcal immunization for adults, discussion of daily aspirin use, smoking cessation advice and assistance, vision screening in older adults, alcohol screening and brief advice, and obesity screening (8). Three of these services contributed more than $1 billion each to the net additional medical savings: tobacco cessation screening and assistance, discussing daily aspirin use, and alcohol screening with brief counseling. Adding colorectal cancer screening to the mix, each service would have contributed more than 100,000 life years in 2006 if screening had been increased to 90 percent of the population (9).
Some types of community-based prevention can offer a high return on investment (10). In September 2008, Trust for America's Health reported an investment of $10 per person in community-based prevention programs could yield health care cost savings of $16 billion annually within 5 years and a return on investment of more than $6 for every $1 invested within 10-20 years (11).
There is also strong evidence that wellness programs more than pay their way. Wellness programs can reduce health care costs and strengthen workforce productivity. In his often cited review of the financial impact of work site programs, Aldana reports several studies with medical cost savings averaging $3.48 per program dollar and reductions in absenteeism averaging savings of $5.82 per dollar invested (12).
4. It matters how we count savings and measure the costs and benefits of prevention.
We also know that it matters how we count savings and measure the costs and benefits of prevention. Debate over how to measure the costs and benefits of prevention continues as policymakers and program officials address coverage of prevention and wellness by public and private sector health systems. Preventive services that decrease costs are “cost-saving,” like, for example, childhood immunizations. Two preventive interventions have been found to be cost-saving in several reviews: childhood immunization and counseling adults on the use of low dose aspirin (13).
“Cost-effective” services may not decrease costs, but yield benefits in improved health outcomes that outweigh the costs of providing the service. Screening for colorectal cancer, breast, and cervical cancers are typically considered cost-effective. Cost-effectiveness depends on the demographics of the population served and how their quality life years (QALYs) are determined. Good value is a judgment call that depends on the value of a QALY, which in turn reflects how much we are willing to spend on improving health. Cost-effectiveness may also depend on how frequently the service is provided.
5. Prevention works—but disparities in access and utilization are great.
Last, we know that prevention works, saving money, lives, and improving individual, and population health. But disparities in access and utilization are significant. Among the 12 preventive services examined in this report, 7 are being used by about half or less of the people who should be using them (14). Racial and ethnic minorities are getting even less preventive care than the general U.S. population. These same groups participate in prevention and wellness programs at lower rates than national averages, and often have limited access to programs, in many cases as a consequence of lifestyle-related conditions and disabilities (15).
So What’s Next?
The PPACA removes the financial barriers to prevention and wellness. But will employers and purchasers step up as willing sponsors, and consumers as willing participants in prevention and wellness interventions? Will we value an ounce of prevention, or a pound of cure?
Clinical prevention screening and vaccination require little more than visiting a primary care provider or community setting. For many this is challenge enough. Programs that require changes in lifestyle and behavior require more effort. Currently, preventable causes of death, such as tobacco smoking, poor diet and physical inactivity, and misuse of alcohol have been estimated to be responsible for 900,000 deaths annually—nearly 40 percent of total yearly mortality in the United States (16). Prevention and wellness services for these areas require active engagement of patients and consumers—and a willingness to change old habits and patterns of living.
There’s plenty of low hanging fruit. Identifying those wellness and prevention interventions that are low cost and high net benefit is one place to start. Targeting approaches that contribute the most to better health is another. Even seemingly small improvements can yield great benefit. A review conducted by CDC’s Community Preventive Services Task Force examining worksite wellness program impacts on a range of health behaviors, physiologic outcomes, and productivity indicators showed that while many changes in outcomes were small when measured at the individual level, they were substantial when measured at the population level (17).
Ultimately, there is one thing we can say for sure. While the evidence –the case for prevention, for health—is clear, the PPACA puts value, and our public priorities, to the test.
1. HealthCare.gov. Background:The Affordable Care Act’s new rules on preventive care. Retrieved January 7, 2011, from http://healthcare.gov/law/about/provisions/services/background.html.
2. A list of covered services is available at http://healthcare.gov/center/regulations/prevention.html.
3. Collins, S.R. How the Affordable Care Act of 2010 will help low and moderate income families. Retrieved February 2, 2011, from http://www.spotlightonpoverty.org/ExclusiveCommentary.aspx?id=ba21673c-b1ac-44b7-8f76-50e856cdb9b5.
4. Cohen, J., Neumann, P., & Weinstein, M. (2008, February 14, 2010). Does preventive care save money? Health economics and the presidential candidates. New England Journal of Medicine, 358(7), 661–663.
6. Russell, L. (2007, October). Prevention’s potential for slowing the growth of medical spending. Retrieved January 17, 2011, from http://www.ihhcpar.rutgers.edu/downloads/nchc_report.pdf.
8. Maciosek, M. V., Coffield, A. B., Flottemesch, T. J., Edwards, N. M., & Solberg L. I. (2010, September). Greater use of preventive services in U.S. health care could save lives at little or no cost. Health Affairs, 29(9), 1656–1660.
10. Trust for America's Health. Prevention for a healthier America. Retrieved January 13, 2001, fromhttp://healthyamericans.org/reports/prevention08/Prevention08.pdf.
12. Aldana, S. (2001). Financial impact of health promotion programs: A comprehensive review of the literature. American Journal of Health Promotion, 15(5), 296–320.
13. Goodell, S., Cohen, J., & Neumann, P. (2009, September). Cost savings and cost effectiveness of preventive care. Robert Wood Johnson Foundation Policy Brief No. 18. Retrieved January 3, 2011, fromhttp://www.rwjf.org/files/research/092209.policysynthesis.preventivecare.brief.pdf.
14. National Commission on Prevention Priorities. (2007). Preventive care: A national profile on use, disparities, and health benefits. Retrieved January 5, 2011, from http://www.rwjf.org/pr/product.jsp?id=19896.
16. Mokdad, A., Marks, J., Stroup, D., & Gerberding, J. (2004, March 10). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291(10), 1238–1245.
17. Community Prevention Services Task Force. (2007). Proceedings of the task force meeting: Worksite reviews. Atlanta, GA: Centers for Disease Control and Prevention.
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