A Transforming Health System: Opportunities for Conquering Cancer Jeffrey Levi, PhD 9 th Annual WI Comprehensive Cancer Control Summit March 29, 2012.

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unlikely to be repealed Key elements of ACA taking effect in 2014 are

unlikely to change even if individual mandate is repealed or found unconstitutional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]