4
Wrap-Up Session
Dr. Tim Byers: I’m going to hit the high points of the discussion of the tobacco and obesity group and then ask a couple of specific questions for some final discussion. The group felt that we’re not serious about public health education in either tobacco or nutrition, given the size of the budgets for the efforts that we need. It’s said that nutrition education doesn’t work. Well, we have never really tried it, so maybe it works, maybe it doesn’t. To adequately fund marketing of a new product, we spend tens and tens of millions of dollars. To adequately fund nutrition, or tobacco education for that matter, it is going to be at least that much. So, that was an important point. Along those lines, we were urged, even during an economic downturn for public support for things like this, to continue to be very assertive and not apologetic about advocating for resources in these areas.
Another comment was that there is really not a single entity or organization empowered or resourced to do the job of primary prevention for tobacco and obesity and improved nutrition. There are scattered resources across disease specific centers and Institutes in the government. Different agencies have missions, either overlapping or not, leaving gaps between them. That is a problem that we allude to in the report, and that is a problem that I’d like to ask a pointed question about. Those of you who are at NCI and those of you who are at CDC, is there a hole between these two agencies when it comes to getting the job done on tobacco control and nutrition?
Dr. Peter Greenwald: I don’t think there is a hole between the agencies. Some people say NCI does research, and CDC does applications, but I don’t feel that way. I feel that if NCI doesn’t do some applications for NIH, we don’t keep our eye on the ball, and if CDC doesn’t do some research, they are behind the times, so we both have to do both. But one does more of one than the other. The problem in nutrition is what you pointed out first; there is
not a serious intensive effort where the resource allocation is anywhere near the level needed to address the obesity and physical activity problem. There is individual variability, there is a lot of interest in bioactive food compounds, and there are a lot of other things besides obesity and fitness that fall under nutrition. So, it is a matter of the scope of the effort that is not up to the scope of the problem.
Dr. William Dietz: I wouldn’t say there is a gap. There is a lack of a coordinated approach. Nutrition is scattered across several different Institutes. So, internally at NIH there is not coherency, and that interferes with coherency between what we try to do and what NIH tries to do. Physical activity is even weaker, because there is no home for physical activity at NIH. It has been a neglected area for research investment. As a result, we have ended up funding some of these programs, but because we are so resource limited, we don’t have the data that we need to effectively translate into state programs.
Dr. Tim Byers: To move on another highlight was that the paradigm for dealing with the tobacco problem falls apart a little bit in dealing with the obesity problem. There was a lot of discussion about lack of analogies, the risk of demonization of the food industry versus cooperation, stigmatization of the obese, and so forth, so that the solution for tobacco probably will not work well for obesity.
The final big point was that there was a continuing need for a clear national strategy, not only for the obesity problem as we pointed out in the report, but even still for tobacco. There is a national plan for tobacco which has been held up in departmental review within our government, but some feel such a plan cannot be considered a consensus strategy. So, lack of a clear strategic plan for these two is an ongoing problem.
Dr. Bob Vollinger, NCI: I came to NCI in 1996 to work on the ASSIST project. I would say at that time there was as much competition with CDC and OSH (Office on Smoking and Health, CDC) as there was cooperation. We were funding 17 states that were competitively awarded, and CDC was funding the other states, and we had much more money to do it than they did, so there was tension around the way that was happening.
But that was a long time ago. Since then, a lot of people have changed, and our respective organizations have gotten a lot more proactively collaborative. It started happening around the transition when ASSIST was ending and CDC was beginning the national tobacco control program. We worked very collaboratively with them to make sure that the lessons from ASSIST were going to be put into practice with this new national RFA that was funding all the states.
Since that time, we have done different things. We have a monthly meeting on video conference, where our group and OSH get together and
strategize about things. We make sure that there is pretty good cooperation there. I sat on an external advisory board on those that were putting out their new RFAs to fund the states. So I think things have come a long way over the last few years.
Dr. Susan Curry: I’ll quickly summarize the two groups that I sat in on, and then you can have the last word, Tim. I want to talk about the payer-provider managed care issues, and just summarize some of the key points. In terms of the payers, the point was made that they know they are paying for a lot of care that isn’t effective. There are opportunities for reallocation of resources. But in order to do that, they need to be guided by very short, crisp messages about what works and how, and those messages need to be very specific. There is a general tuning out of people in the payer groups at the generic use of the term prevention, so I think we need to be very strategic about it. A couple of people have expressed some good ideas about what are the low-hanging fruit that we can pick to move prevention forward.
We also talked a lot about Medicare and the idea that right now it is a defined benefit. It is a defined benefit for services that are reasonable and necessary for the diagnosis and treatment of illness and injury. There is consensus that that language is outdated. It was crafted in 1964. It focuses on acute and episodic care, but it is statutory language, and that means that you literally need an act of Congress to change it. Why not set that as a goal, and keep our eyes open for opportunities to get there?
The biggest bang for the buck lies in being concise in picking an issue that we can move, and that appears to be the smoking cessation benefit. There was talk about the fact that medical nutrition therapy has been added in recent years to Medicare. The process that was used in order to move that through this messy legal process might serve as a model for what we could do with smoking cessation. There was also talk about the idea of adding to Medicare flexible spending accounts for preventive services.
In terms of private insurance, we touched on two possible leverage points. One was expanding options for pretax medical spending plans; people participate in them, but they don’t know that they could spend them for help with smoking cessation, with dietary change, and so forth. Consumer directed health care benefits were also discussed—where you actually get an allocation of dollars for health care and spend it; there was some interest in knowing exactly what people do with these. So, that was the payer-managed care-insurer piece.
In the applied research meeting, there were lots of interesting ideas, including some concrete suggestions about more funding for dissemination research, and some very specific ideas on what that might mean. For one thing, maybe we should be investing some resources in funding replications of successful interventions in new populations and new settings. Sometimes
those kinds of studies have been pejoratively referred to as turning the screw one little notch; we’re going to take this thing that worked there, and we’re going to apply it over here. However, there is some value in doing that, and also in funding research that looks at different methods for implementing successful interventions.
We discussed better use of the task forces, the U.S. Preventive Services Task Force and the U.S. Task Force for Community Preventive Services. Using those task forces, their deliberation processes, the information that they glean from really drilling down in the extant literature, in research and funding announcements, so that they can provide some direction on where we want to go.
There was also talk about publication and dissemination. There is a CONSORT statement which provides guidelines for the reporting of the methods and results from randomized clinical trials. Certainly we could come up with, and I think we would need, a parallel set of guidelines for reporting community intervention research. The methods are not often randomized clinical trials, but that doesn’t mean that you can’t have rigor and consistency in how the results and methods are reported. A common theme is if we are going to be doing more dissemination research, we need to identify leaders and owners of that. We have talked about the American Cancer Society, about CDC. I think the person who was saying this was from NCI, but there are other agencies that would be involved.
Then a final suggestion was the importance of involving science-based agencies in new dissemination initiatives that come out of other departments, like DHHS, or others. There have been some recent investments on the part of DHHS in these national programs to get people more active and more healthy. They are going to be funding state and community level initiatives, but it would be important to have the science-based agencies that have provided the evidence base for this at the table when these initiatives are developed, and even more so, when the proposals for these new initiatives come in and are evaluated.
Dr. Tim Byers: The education and primary care group discussion was largely on primary care itself, not so much on public education, although some of the discussion was about the age-old problem of how you get doctors to do something. There was also a recognition that doctors are really heavily burdened, and that a lot of prevention is going to have to be borne by systems in addition to physicians.
A couple of ideas emerged. If you fund it, they will do it, and if you measure it, it will get done. So carrot and the stick, obviously. We didn’t explore too much new options in those areas, but there were some examples of things happening with accreditation bodies and HEDIS that have had beneficial influences on provider behavior. The realization of the difficulty
of adding clinical preventive services in small practices, as opposed to large groups, was new to me.
The Partnership for Prevention has recently come up with three or four priority clinical preventive services that were suggested as areas of emphasis, smoking cessation, obesity/nutrition, for example. So, in the spirit of summary, I flagged a couple of things that stuck in my mind as interesting ideas. It was suggested that Medicare might be extended to provide clinical preventive services for the age group 50 to 64. This national or federalized clinical preventive services program would allow private insurers to offload these, and give the Medicare program, that would benefit most from healthier beneficiaries at entry, the responsibility of providing those services that would make for a healthier population.
Another interesting thought was raised on a sticking point between individual choice in behaviors and policy options. This is seen by many as being either/or, the big hand of government telling us what to eat or what to smoke, versus individual freedom, individual choice. So as we think about policy changes as a way to advance prevention, we need to be aware that there is a view of policy as heavy handed, in contradiction to individual liberty and individual choice.
Dr. Len Lichtenfeld: In closing we’d like to thank Sue Curry, Tim Byers, and the IOM for sponsoring the report and for the use of their facilities, the invited speakers and all the participants for their wonderful contributions, and to thank the NCI and the ACS for their support of this symposium.
