Sonoma State UniversityPrevention & the Healthcare Crisis 2004

Reducing Health Care Costs by Reducing the Need and Demand

For Medical Services

• Overall costs were $838 billion in 1992, or more than $3,000 per person.

• More than 30 million Americans are uninsured, partly because of rising premium costs.

• The approach largely ignored focuses on reducing the need and demand for medical services.

Preventive Health and Cost Savings

• treatment of hypertension• reducing the rate of low-birth-weight infants• smoking cessation• nutrition education and weight reduction• exercise and stress management• appraisal of health risk

The main reason to invest in prevention is to promote health and extend life, improve functioning and prevent suffering.

» "The Role of Prevention in Health Reform", Russell, Louise B., Ph.D., The New England Journal of Medicine, July 29, 1993;329 (5):352-354.

Cardiovascular disease

The estimated cost for cardiovascular disease in 1994 by the American Heart Association is 128 billion dollars.

1 of 2 women in the US dies of heart disease or stroke

• less than 33% identified heart disease as the leading cause of death.

• More women identified breast cancer as the leading cause of death.

• Although 90% of the women reported that they would like to discuss heart disease or risk reduction with their physicians, more than 70% reported that they had not.

Walter C. Willet MD MPHProfessor of MedicineChairman of the Department of NutritionHarvard

• Moderately easily achieved lifestyle intervention* results in 82% reduction risk of coronary artery disease…. This is much more important than Statins

*No cigarette smoking, moderate physical activity and easy diet changes

Nutrition is the Keystone of Prevention

The prevention of disease could result in enormous cost savings to physicians and hospitals.

» Kretchmer, Norman, The American Journal of Clinical Nutrition, 1994;60:1.

The Lyon heart trial

o Adjusted risk ratios ranged from 0.28 to 0.53

o The protective effect of the Mediterranean dietary pattern was maintained up to 4 years after the first infarction

» Circulation 1999 Feb 16;99(6):779-85

Mediterranean dietary pattern in a randomized trial: prolonged survival and possible reduced cancer rate

During a follow-up of 4 years. reduction of risk in experimental subjects compared with control subjects was:

• 56% (P=.03) for total deaths• 61% (P=.05) for cancers• 56% (P=.01) for the combination of deaths

and cancers. » Arch Intern Med 1998 Jun 8;158(11):1181-7

To Supplement or Not To Supplement: Is it a Question?

• improved intakes of certain micronutrients in particular vitamins C, E and beta-carotene would reduce health care costs by 25% for cardiovascular disease, 16% to 30% for a variety of major cancers and 50% for cataracts.

» Lachance, Paul A., Ph.D., DSc, Rutgers, The State University of New York, New Brunswick, NJ 08903-0231, U.S.A.)

Exercise

Americans would pay almost any price for a pill that contained all the benefits associated with exercise: increased life expectancy, improved mental health, and decreased disability. Scientific research has shown repeatedly that exercise can benefit both the body and mind.

• Statement of Dr. Terrie WetleDeputy Director,

National Institute on AgingSenate Special Committee on Aging

Hearing on Healthy Aging September 14, 1999

Physical Activity and Prevention

• Self-directed, moderate-level physical activities which include gardening, yard work and walking with a goal of 30 minutes of activity per day at least 5 days per week.

» "Public Health Focus: Physical Activity and the

Prevention of Coronary Heart Disease", Morbidity and Mortality Weekly Report, September 10, 1993;42(35):669-672

Physical Activity and Prevention

• Coronary artery disease cost $47 billion. • Cost of physical inactivity was $5.7 billion. • Elevated serum cholesterol (>than 200

ug/dL) cost of $7 billion. • For each quality-adjusted life-year gained

the direct cost was $1,395

Physical Activity and Prevention

• Physical activity classes 2 to 3 times per week, for 30 to 45 minutes per session

• For each worker, the intervention program saved $679 in medical claims per year, a return of $6.85 on each dollar invested.

• Other examples of work-site programs have been estimated to cost employers about $100 to $400 per employee, per year. The estimated rate of return is about $513 per employee per year, including reduced health care cost and reduced loss of productivity.

Emotion, Cancer and Heart Disease

• Specific emotional factors are 6 times more predictive of those who will develop cancer or coronary heart disease than cholesterol, blood pressure or smoking in following over 2,000 subjects in Germany over a 13 year period.

– "Emotional Health, Cancer and Heart Disease", Crawford, Robert J.M., The New Zealand Medical Journal, March 1993;10:87

Psychosocial Components

• psychosocial treatment can improve survival.• Those who had a mild or moderate depression had

a risk-adjusted 6.5-fold higher likelihood of death compared to MI patients who were not depressed.

• Those who had psychological stress upon entry into the program had a 3.5-fold increase in the risk of a subsequent cardiac event in the next 2 years.

Job Stress and the Risk of Coronary Heart Disease

• 6895 men & 3,413 women between 35 and 55 followed for 5.3 years

• imbalances between personal efforts and rewards were associated with a 2.15-fold higher risk of new coronary heart disease.

• Job strain and high job demands were not related to coronary heart disease.

• Low job control was strongly associated with new disease.

– "Two Alternative Job Stress Models and the Risk of Coronary Heart Disease," Bosma PH, et al, Am J Public Health, January 1998; 88(1):68-74

"hostility" is cardio-toxic

• Large National Institute of Health studies ultimately demonstrated that it is this "hostility" component of Type-A behavior which is cardio-toxic and coronary-prone

» Mark Goodman, Ph.D., M.A. "Pilot Findings of a Percutaneous Transluminal Coronary Angioplasty Restenosis Prone Prevention Program," Mayo Clinic Proceedings, May, 1997;172:487

Putting it all together…

Walter C. Willet MD MPHProfessor of MedicineChairman of the Department of NutritionHarvard

• Moderately easily achieved lifestyle intervention* results in 82% reduction risk of coronary artery disease…. This is much more important than Statins

*No cigarette smoking, moderate physical activity and easy diet changes

Ornish’s Lifestyle Demonstration Project

• Angiographically documented CAD severe enough to warrant revascularization.

• The cost of the 1-year program averaged $7,000 per person.

• Reduction in angina comparable to that achieved with revascularization

• The average cost for PTCA (with cardiac catheterization) was $31,000, and for CABG was $46,000.

• The average cost savings per patient was $29,529

Survival curves

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Reducing Health Care Costs by Reducing the Need and Demand

For Medical Services• Widespread implementation of preventive

strategies requires a collaboration among business, labor, the insurance industry, government and universities.

• Reducing the need and demand for medical services is a positive solution bringing better health for the individual and ultimately lowering health care costs.

» Fries, James F., et al, The New England Journal of Medicine, July 29, 1993;329(5):321-325.