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A Transforming Health System: Opportunities for Conquering CancerJeffrey Levi, PhD
9th Annual WI Comprehensive Cancer Control Summit
March 29, 2012
Assumptions Health reform/transformation is happening
regardless of the political storm Quality movement pre-dates ACA Electronic health records are separate from ACA Key elements of ACA already in place and
unlikely to be repealed Key elements of ACA taking effect in 2014 are
unlikely to change even if individual mandate is repealed or found unconstitutional
Overview: The opportunities in health reform A new vision for access (coverage)
Close to universal coverage An expanded vision for quality
Restructuring delivery systems to improve quality Performance measurement EHRs Comparative Effectiveness
Prevention moves beyond the clinic Levers for change from a cancer perspective
Access Underwriting reforms
Pre-existing conditions, rate setting Medicaid expansion
What will the benefits package look like Exchanges as just a marketplace or also a
force for change (quality, prevention, workplace) Essential health benefits; provider networks
Quality National Quality Strategy Commitment to performance measurement
Meaningful use of HIT New opportunities for defining public health
surveillance – what we ask, how we use it Delivery systems – ACOs, medical homes Comparative effectiveness research
Prevention: It’s not just for clinicians anymore ACA incorporates broad definition of prevention:
where we live, work, learn, and play Comprehensive clinical preventive services removing
financial barriers Investment in community prevention through the
Community Transformation Grants Prevention Fund drives other changes in this direction
Center for Medicare and Medicaid Innovation Population level changes that save money and improve
outcomes
Real money for prevention Prevention and Public Health Fund
$12.5 billion over the next 10 years Mandatory funding stream
Cut as part of “doc fix” Danger of supplantation vs. emphasis on
modernization and transformation FY 13 budget request – major cuts at CDC
but leveraging of consolidated chronic disase grants – what does that mean for cancer?
PPHF FY 2012 Cancer-related $ REACH--$40 million Community Transformation Grants -- $226
million Tobacco activities -- $83 million
True community-based prevention
Community Transformation Grants Requires detailed plan for policy, environmental,
programmatic and infrastructure changes to promote healthy living and reduce disparities
Replicate the National Prevention Council approach (across silos) Targeted areas (active living and healthy eating, tobacco,
clinical preventive services – hypertension and cholesterol) Community approaches Improve access to clinical preventive services
A real investment: $900 million over 5 years
What might CTGs look like? Examples of policy and structural change
High impact efforts to make healthy choices easier Sustainable over time
Smoke free air laws; seat belt laws; child car seats “Health in all policies” at state and local levels Improved nutrition choices in schools, supermarkets, corner
stores Zoning policies
Supports implementation or capacity development Expectations:
Demonstrated ability to bring together a coalition Inclusion of state/local public health agencies in
coalitions
National Prevention Strategy: Setting a Bigger Table for Health Vision
Working together to improve the health and quality of life for individuals, families, and communities by moving the nation from a focus on sickness and disease to one based on prevention and wellness.
Overarching goal: Increase the number of Americans who are healthy at every stage
of life. Partnerships:
17 federal agencies addressing determinants of health Co-benefits of addressing health – mutual self interest
Public sector at all levels; private sector at all levels
The National Prevention Council
Bureau of Indian Affairs Department of Labor
Corporation for National and Community Service Department of Transportation
Department of Agriculture Department of Veterans Affairs
Department of Defense Environmental Protection Agency
Department of Education Federal Trade Commission
Department of Health and Human Services
Office of Management and Budget
Department of Homeland Security
Office of National Drug Control Policy
Department of Housing and Urban Development
White House Domestic Policy Council
Department of Justice
Strategic Directions: Healthy and Safe Community Environments
Clean air and water
Affordable and secure housing
Sustainable and economically vital neighborhoods
Make healthy choices easy and affordable
Clinical and Community Preventive Services
Evidence-based preventive services are effective
Preventive services can be delivered in communities
Preventive services can be reinforced by community-based prevention, policies, and programs
Community programs can promote the use of clinical preventive service (e.g., transportation, child care, patient navigation issues)
Empowered People
Even when healthy options are available and affordable, people still must make the healthy choice
People are empowered when they have the knowledge, resources ability, and motivation to identify and make healthy choices
When people are empowered, they are able to take an active role in improving their health, supporting their families and friends in making healthy choices, and leading community change
Elimination of Health Disparities
Health outcomes vary widely based on race, ethnicity, socio-economic status, and other social factors
Disparities are often linked to social, economic or environmental disadvantage
Health disparities are not intractable and can be reduced or eliminated with focused commitment and effort
Priorities
Tobacco Free Living
Preventing Drug Abuse and Excessive Alcohol Use
Healthy Eating
Active Living
Mental and Emotional Well-being
Reproductive and Sexual Health
Injury and Violence Free Living
27%
23%
6%5%
5%
34% other causes
Five Causes Account For 66% of All Deaths
Heart Disease
Cancer
Chronic Lower Res-piratory Disease
Stroke
Unintentional Injuries
Source: National Vital Statistics Report, CDC, 2008
Recommendations (Example)
Active Living • Encourage community design and
development that supports physical activity.
• Promote and strengthen school and early learning policies and programs that increase physical activity.
• Facilitate access to safe, accessible, and affordable places for physical activity.
• Support workplace policies and programs that increase physical activity.
• Assess physical activity levels and provide education, counseling, and referrals.
NPS Implementation Resources: Indicators/Key Documents
Indicator Current 10-Year Target
Proportion of adults who meet physical activity guidelines for aerobic physical activity
43.5% 47.9%
Proportion of adolescents who meet physical activity guidelines for aerobic physical activity
18.4% 20.2%
Proportion of the nation’s public and private schools that provide access to their physical activity spaces and facilities for all persons outside of normal school hours
28.8% 31.7%
Proportion of commuters who use active transportation (i.e., walk, bicycle, and public transit) to travel to work
8.7% 20.0%
Key Documents- Physical Activity Guidelines for Americans- The White House Task Force on Childhood Obesity Report to the
President
Goal ∙ Strategic Directions ∙ Priorities
Recommended Actions For Partners
States, tribal, local, and territorial governments
Health care systems, insurers, and clinicians
Businesses and employers
Early learning centers, schools, colleges, and universities
Community, non-profit, and faith-based organizations
Individuals and families
NPS Implementation Resources: Evidence-Based Recommendations
The Guide to Community Preventive
Services
The US Preventive Services Task Force
Healthy People 2020
The Institute of Medicine
Cochrane Reviews
Doing away with stovepipes Thinking about interventions and populations
rather than diseases Interventions are cross-cutting Social determinants of risk and poor outcomes are
not going to be addressed on a disease-by-disease basis
Small changes matter
BC Study of Physical Activity Costs Evidence indicates that in British Columbia, 15% of heart disease, 19% of
stroke, 10% of hypertension, 14% of colon cancer, 11% of breast cancer, 16% of Type 2 Diabetes, and 18% of osteoporosis cases are attributable to physical inactivity.
If just 10% fewer British Columbians were physically inactive – that is, if the rate of physical inactivity were 34.2% instead of 38% - the province could save an estimated $18.3 million every year in avoided hospital, drug, physician and other direct costs. Added to an estimated $31.1 million in productivity gains, total economic savings to British Columbia from a 10 % reduction in physical inactivity amount to $49.4 million.
http://www.gpiatlantic.org/pdf/health/inactivity-bc.pdf
Small changes matter (2) 1% reduction in adult BMI at population
level: nearly 16,000 fewer cases of diabetes, heart disease and stroke, and cancer (73K)
Incidence of cancer per 100,000 population related to obesity in 2020: Current trend: 1820 1% reduction in BMI: 1805 5% reduction in BMI: 1750
Small changes bend the cost curve
Where to make a difference? Exchanges – structure, consumer rep, oversight,
workplace wellness Essential Health Benefits Essential Health Providers
Community Benefit Surveillance Bring the National Prevention Strategy home Community Transformation Grants and other policy
efforts
For more information Keep up with developments:
www.healthyamericans.org/health-reform [email protected]