12
Community-Based and Transitional Care

INTRODUCTION

Given the significant dependence of health status on the dynamics of physical, behavioral, and social determinants (WHO, 2009), community-based and transitional care initiatives represent opportunities to improve health through investments in population and public health. Yet, only approximately 6.4 percent of national health expenditures is spent on public and population health (CMS, 2009). Speakers participating in this session identify the critical role prevention and population health as well as quality and consistency in treatment, with a focus on the medically complex, could play in lowering the burden of chronic illness and improving productivity and quality of life.

Kenneth E. Thorpe of Emory University explains the growing need and proliferation of chronic disease management programs as well as greater opportunities for prevention, better care, and long-run cost savings. Whereas the medical home concept has addressed these needs for larger practices, Thorpe offers community health teams (CHTs) as a more viable approach for smaller practices. CHTs include care coordinators, nutritionists, behavioral and mental health specialists, nurses and nurse practitioners, and social, public health, and community health workers. Whereas these trained resources already exist in many communities, working with home health agencies, hospitals, health plans, and community-based health organizations, he suggests that a CHT’s added benefit lays in coordination of these resources in the interest of addressing transitional care, palliative care, and prevention services.



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12 Community-Based and Transitional Care INTRODUCTION Given the significant dependence of health status on the dynamics of physical, behavioral, and social determinants (WHO, 2009), community- based and transitional care initiatives represent opportunities to improve health through investments in population and public health. Yet, only ap- proximately 6.4 percent of national health expenditures is spent on public and population health (CMS, 2009). Speakers participating in this session identify the critical role prevention and population health as well as quality and consistency in treatment, with a focus on the medically complex, could play in lowering the burden of chronic illness and improving productivity and quality of life. Kenneth E. Thorpe of Emory University explains the growing need and proliferation of chronic disease management programs as well as greater op- portunities for prevention, better care, and long-run cost savings. Whereas the medical home concept has addressed these needs for larger practices, Thorpe offers community health teams (CHTs) as a more viable approach for smaller practices. CHTs include care coordinators, nutritionists, be- havioral and mental health specialists, nurses and nurse practitioners, and social, public health, and community health workers. Whereas these trained resources already exist in many communities, working with home health agencies, hospitals, health plans, and community-based health organiza- tions, he suggests that a CHT’s added benefit lays in coordination of these resources in the interest of addressing transitional care, palliative care, and prevention services. 0

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0 THE HEALTHCARE IMPERATIVE Diane E. Meier of Mt. Sinai Medical Center builds on the idea of patient-centered care, describing the growing need for more robust pallia- tive care programs. Reviewing the evidence, she relates that palliative care has been demonstrated to relieve physical and emotional distress; improve patient–family–professional communication and informed, patient-centered decision making; and coordinate and sustain care across the many transi- tions experienced by patients with complex chronic and serious illness. Meier posits that palliative care not only responds to the needs of this grow- ing population of patients, but translates into better quality care and cost savings. Taken to a national scale, she suggests that palliative care could save $6 billion annually. In his paper, Jeffrey Levi of Trust for America’s Health presents the organization’s collaboration with the Urban Institute, which focuses on developing an economic model that demonstrates the impact of cer- tain community-based prevention programs targeting chronic diseases on healthcare costs. Based on their analysis, he reports that an investment of $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other to- bacco use could save the country more than $16 billion annually within 5 years—a return of $5.60 for every $1 invested. Levi acknowledges that these estimates do not reflect the costs of implementation. He additionally notes a paradigm shift in the commitment to prevention efforts, reflected by the American Recovery and Reinvestment Act of 2009 investment of $650 million to introduce community-based prevention programs and study their impacts. COMMUNITY HEALTH TEAMS: OUTCOMES AND COSTS Kenneth E. Thorpe, Ph.D., and Lydia L. Ogden, M.A., M.P.P. Emory University The rising rate of diagnosed and treated chronic diseases, many as- sociated with obesity, is a key factor in rising U.S. healthcare spending (Table 12-1) (Thorpe and Howard, 2006). Patients with chronic disease are estimated to account for 75 percent of overall health spending (CDC, 2008) and 99 percent of Medicare spending (Partnership for Solutions National Program Office, 2004). Multiple morbidities are common: more than half of Medicare beneficiaries are treated for five or more chronic conditions yearly (Thorpe and Howard, 2006). Six chronic ailments account for 40 percent of the recent rise in Medicare spending (Thorpe and Howard, 2006). Despite significant healthcare outlays, chronically ill patients receive just 55 percent of clinically recommended services (McGlynn et al., 2003), and that gap in care may explain a nontrivial portion of morbidity and mortality.

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TABLE 12-1 Treated Chronic Disease Prevalence by Body Mass Index (BMI) for Top 10 Health Conditions, Medicare Beneficiaries, 1987, 1997, and 2006 1987 1997 2006 Normal Overweight Obese Normal Overweight Obese Normal Overweight Obese 45.0% 36.9% 13.8% 40.9% 36.3% 19.9% 32.4% 37.0% 28.4% BMI distribution (%) (%) (%) (%) (%) (%) (%) (%) (%) Treated condition (ranked by spending) Heart disease 28.6 27.1 27.3 28.9 28.8 33.2 24.7 26.3 30.5 Cancer 11.0 10.7 12.0 14.2 17.5 14.9 13.6 14.0 13.5 Trauma 17.8 15.0 17.9 22.2 19.7 20.2 13.8 14.3 18.1 Hypertension 31.4 42.4 51.7 32.7 44.0 57.0 45.2 56.2 63.0 Arthritis 17.4 23.9 31.8 25.9 30.1 41.7 19.9 23.6 33.5 Diabetes 8.6 14.5 23.3 8.8 15.6 29.2 11.2 19.8 35.9 Mental disorders 9.7 6.0 8.4 19.1 15.1 20.9 20.6 20.7 28.7 Pulmonary conditions 15.9 14.4 14.4 24.5 26.6 25.8 21.0 21.4 27.4 Kidney disease 2.4 1.7 4.0 1.9 2.7 4.1 3.1 2.9 5.3 Hyperlipidemia 3.3 3.2 2.6 9.6 15.6 13.0 28.0 40.0 42.5 NOTE: Authors’ tabulations using 1987 National Medical Expenditure Survey and the 1997 and 2006 Household Component to the Medical Expen - diture Panel Survey (MEPS-HC), restricted to adults with 6 or more months of Medicare coverage in the survey year, a population overwhelmingly 65 years of age and older, but also including smaller numbers of disabled adults younger than 65 in each year. The MEPS datasets provide nationally representative estimates of healthcare spending, insurance status, use of medical services, sources of payment, and disease prevalence along with a broad set of socioeconomic characteristics for the noninstitutionalized civilian population in the United States. 09

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0 THE HEALTHCARE IMPERATIVE In response, chronic disease management programs have proliferated over the past decade in the private sector and are common in Medicaid and Medicare Advantage programs. But they are notably absent in traditional fee-for-service Medicare—a crucial gap, given that 81 percent of Medicare beneficiaries are enrolled in traditional fee-for-service Medicare and account for about 79 percent of the program’s overall healthcare spending (Orszag, 2007). The Medicare program’s fragmented benefit design and reimburse- ment policies discourage care coordination and disease management. At the same time, these conditions present opportunities for prevention, better care, and long-run cost savings (CBO, 2005). The medical home concept developed by the National Committee on Quality Assurance has attracted attention and interest as a potential solution, but it has limited scalability among the 83 percent of U.S. medical practices that comprise just one or two physicians (GAO, 2008; Sokol et al., 2005). An alternative (and complementary) approach is required to scale coordinated care nationwide. CHTs working with primary care practices, patients, and their families ap- ply key functions and processes used by larger successful physician group practices and integrated plans and replicate them in less resourced and orga- nized settings (Figure 12-1). CHTs include care coordinators, nutritionists, behavioral and mental health specialists, nurses and nurse practitioners, and social, public health, and community health workers. These trained re- sources already exist in many communities, working for home health agen- cies, hospitals, health plans, and community-based health organizations. Evidence of Effectiveness and Cost Savings Research supports the clinical and economic benefits of comprehen- sive, multidisciplinary, individualized interventions targeted to medically complex patients. Evidence-based components of CHT practice elements are listed in Table 12-2. CHTs should include a number of critical foci in order to better address current healthcare needs and control financial costs. Four are discussed below. Prevention services Taking lessons from the large-scale, randomized dia- betes prevention program (DPP) (Department of Health and Human Ser- vices, 2001; Knowler et al., 2002; Wing et al., 2004)1 trials, group-based DPP protocols have been administered in community settings and have produced impressive outcomes, reducing disease incidence at a fraction of 1 At the time of the Department of Health and Human Services press release, the cost of the DPP was reported to be $174.3 million for 3,234 participants, and average cost of $53,896.10.

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 COMMUNITY-BASED AND TRANSITIONAL CARE Bundled Payments Specialists Specialists Hospital Worksite Health Specialists Promotion PCP Community PCP CHTs Prevention PCP Physical Tobacco Activity PCP Cessation DPP HEALTH INFORMATION TECHNOLOGY OUTCOME METRICS, VALUATION FIGURE 12-1 Intersectoral collaboration: Community health teams. NOTE: CHT = community health team; DPP = diabetes prevention program; PCP = primary care providers. SOURCE: Thorpe, 2009. Figure 12-1.eps the cost of clinical intervention (Ackermann and Marrero, 2007). A broader new, vector editable investment of $10/person/year in community-based prevention could yield more than $16 billion in medical cost savings within 5 years (Levi et al., 2008). Indirect cost savings derived from preventing just the top seven chronic conditions could be four times higher, adding another $64 billion (DeVol et al., 2007). Transitional care Medicare Payment Advisory Commission (MedPAC) has estimated that 18 percent of all hospital stays result in a readmission within 30 days, costing $15 billion annually. Approximately $12 billion is spent on potentially avoidable readmissions (Miller, 2008). A recent analy- sis by Jencks and colleagues reports that nearly 20 percent of Medicare beneficiaries are readmitted after an index hospital stay within 30 days and 34 percent within 90 days, costing $17.4 billion in 2004 (Jencks et al., 2009). Recent research from the University of Pennsylvania showed a

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2 THE HEALTHCARE IMPERATIVE TABLE 12-2 Evidence-Based Components of CHT Practice Elements Components Sources Targeting the right patients Brown, 2009; Meyer and Smith, 2008; Peikes et al., 2009 Close integration GAO, 2008; Meier, 2009; Morrison et al., 2008; Naylor et al., 2004 Medication and testing adherence McDonald et al., 2002; Osterberg and Blaschke, 2005; Sokol et al., 2005 Transitional care programs Naylor, 2003; Naylor et al., 1994, 1999; Norton et al., 2007 Palliative care programs Elsayem et al., 2004; Meier, 2009; Morrison et al., 2008; Norton et al., 2007 Ability to link with and refer to effective Ackermann and Marrero, 2007; Fielding and community-based interventions Teutsch, 2009; Lurie and Fremont, 2009 Real-time evaluation and information on Fielding and Teutsch, 2009; Lurie and Fremont, clinical markers with feedback 2009; Morrison et al., 2008 Individualized care plans developed with Boyd et al., 2008; Elsayem et al., 2004; Sylvia patients, families, and primary providers et al., 2008 Frequent contact with patients (and CMS, 2003; Elsayem et al., 2004; Esposito et al., families) involving education, reminders, 2009 coaching, and self-management support 56 percent reduction in readmissions and 65 percent fewer hospital days for frail elders in transitional care. At the 12-month mark, average costs were $4,845 lower for these patients (Naylor et al., 2004). If this model were scaled nationally with a 10-year investment of $25 billion, savings could reach $100 billion over the same period. Medication adherence Medication adherence is 50 to 65 percent for com- mon chronic conditions such as hypertension and diabetes (Sherman et al., 2009), and nonadherence is costly, reaching $100 billion/year for hospi- talizations alone (Osterberg and Blaschke, 2005). Primary care providers and CHTs must implement proven strategies to increase adherence: patient education, improved dosing schedules, improved communication between providers and patients, and expanded access through additional clinic hours and/or electronic communication (McDonald et al., 2002; Osterberg and Blaschke, 2005). Studies have shown that increased adherence posts a substantial return on investment; for example: 7:1 for diabetes, 5.1:1 for hyperlipidemia, 3.98:1 for hypertension; and a reduction in overall health- care spending of 15 percent for patients with chronic heart failure (Esposito et al., 2009; Sokol et al., 2005).

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 COMMUNITY-BASED AND TRANSITIONAL CARE Palliative care Spending for beneficiaries in their last year of life is nearly six times more than for those who are not in their last year of life (about a quarter of Medicare outlays). Expenditures rapidly accelerate in the last few months of life, a result of inpatient hospitalizations. In the last month of life, expenditures are 20 times higher than for other beneficiaries (CMS, 2003). Increasing the uptake of palliative care services to just 7.5 percent of hospital discharges (from the current level of 1.5 percent) could save more than $37 billion over 10 years2 and improve quality of life for patients with advanced illness (Zhang et al., 2009). Funding and Financial Incentives Making CHTs available to all beneficiaries enrolled in traditional fee- for-service Medicare would cost $1 billion annually in federal grants.3 Because reimbursement for crucial elements of effective chronic disease management—education, patient counseling, care coordination, and pa- tient monitoring—is limited in fee-for-service Medicare, payment reforms assume a powerful role in incentivizing the adoption of CHTs and the development of accountable health teams that also include hospitals and specialists. At least three potential payment reforms would provide strong incentives to move toward these integrated approaches and reduce some of the well-publicized problems with Medicare’s current fee-for-service pay- ment system. Primary care reimbursements Medicare payment policy must change to reward coordinated care. A straightforward mechanism is a supplemental per person per month (PPPM) payment for physician practices that estab- lish a formal relationship with a CHT. PPPM payments should increase as the practice successfully incorporates evidence-based components of the patient-centered medical home. Additional financial assistance should sup- port the acquisition and implementation of electronic medical records. Bundled payments Coordinated, accountable care can also be encouraged through bundled hospital payments, starting with seven high readmis- sion Medicare Severity-Diagnosis Related Groups (MS-DRGs) identified 2 Authors’ estimates based on (Meier, 2009). 3 This estimate is based on Vermont staffing models of approximately five full-time equiva- lent (FTE) healthcare providers per 20,000 patients. The 34 million enrollees in fee-for-service Medicare would thus require roughly 1,700 teams of five providers each, at a cost of $500,000 each, totaling $850 million. We have added another 20 percent for administrative costs to derive a total cost of approximately $1.02 billion.

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 THE HEALTHCARE IMPERATIVE by MedPAC4 (2007) and, within a 3- to 5-year period, extending to all Medicare admissions. Payments would cover all acute services for the MS- DRG admission, and Medicare covered post-acute (30 days after discharge) spending. Hospitals with above-average readmission rates would receive re- duced payments for patients readmitted within the 30-day period. This ap- proach would create strong incentives for hospitals to contract with CHTs to focus on transitional care. The National Quality Forum is working to develop consensus measures focused on preventable hospital readmissions (National Quality Forum, 2006). Bonus pools Incentives for improving health outcomes and reducing un- necessary care are an essential element of integrated care. Physicians and CHT staff should be eligible for additional payments if key performance measures are met. In addition to preventable readmissions, other quality measures should include improvement in clinically recommended services for common and costly chronic illnesses. To be eligible for bonus pay- ments, health teams would have to meet a three-part test: First, Medicare per capita spending in the hospital service/referral area (as defined by the states in establishing the CHTs) would have to be lower than an established benchmark amount (lower than the average annual per capita growth for the prior 2 to 3 years). Second, readmissions for the seven MedPAC tracer hospital conditions would have to decline. Third, quality measures (starting with the Healthcare Effectiveness Data and Information Set [HEDIS] mea- sures for managing and treating diabetes, hypertension, and other targeted conditions) would have to improve. Next Steps To scale CHTs nationally, they should be implemented in the Medicare program within 3 years, supported by federal funds flowing to state gov- ernments, which would create CHTs tied to hospital referral areas within or between states. Services within and outside the traditional health system should be covered—integrating public health and primary prevention ini- tiatives (e.g., diet, exercise, weight loss, smoking cessation) with secondary and tertiary prevention (screening, treatment, and care). States could (and should) use CHTs to manage dual eligibles, Medicaid, Children’s Health Insurance Program, or other patients. Self-insured firms and private health plans could (and should) contract with CHTs to manage medically complex patients and at-risk clients. Payment reforms that support and promote coordinated care and lower volume of services should encompass changes 4 The seven conditions are heart failure, chronic obstructive pulmonary disease, pneumonia, acute myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, and a general category of “other vascular” conditions.

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 COMMUNITY-BASED AND TRANSITIONAL CARE in physician reimbursements, bundled payments, and bonus pools. In ad- dition, patients actively engaged in following their care plan (per their care coordinator) should receive all clinically indicated preventive services and generic drugs (or discounts for the use of brand-name drugs without a ge- neric alternative) with no cost sharing. Improving chronically ill patients’ care and health outcomes and reducing healthcare cost growth are inter- twined. Each is essential to health reform in the United States. CHTs are a means to those ends and should be an integral part of a changed system. PALLIATIVE CARE, QUALITY AND COSTS Diane E. Meier, M.D., FACP, Jessica Dietrich, M.P.H., R. Sean Morrison, M.D., Mount Sinai School of Medicine; and Lynn Spragens, M.B.A Spragens & Associates Palliative care programs in hospitals are a rapidly diffusing innovation (Goldsmith et al., 2008) and have been shown to both improve quality and reduce costs of care for America’s sickest and most medically complex patients (Anderson, 2007; Back et al., 2005; Brumley et al., 2007; Carlson et al., 1988; Elsayem et al., 2004; Morrison et al., 2008; Penrod et al., 2006; Smith et al., 2003; Wright et al., 2008; Zhang et al., 2009). The chronically and seriously ill constitute only 5 to 10 percent of patients but account for well over half of the nation’s healthcare costs (Kaiser Family Foundation, 2009; Potetz and Cubanski, 2009; Seow et al., 2009). Pallia- tive care programs are a solution to this growing quality and cost crisis. What Is Palliative Care? Palliative care is medical care focused on relief of pain and other sources of suffering for patients with advanced illness and their families. It is appropriate at any point in a serious illness, whether the patient is ex- pected to fully recover, will live for years with chronic illness, or is subject to progressive decline up to the time of death. Unlike hospice, palliative care is not prognosis driven, and eligibility depends strictly on need and likelihood of benefit (Figure 12-2). In contrast, hospice is a form of pallia- tive care covered by a special insurance benefit restricted to patients with a prognosis of 6 months or less who agree to forego insurance coverage of curative or life-prolonging treatments (Figure 12-3). Yet, until recently, palliative care services were typically available only to patients enrolled in hospice. Now, palliative care programs are increas- ingly found in hospitals—the main site of care for the seriously ill and site of death for 50 percent of adults on average nationwide (Brown University Center for Gerontology and Health Care Research, 2001). As of 2006, 53 percent of U.S. hospitals and 75 percent of hospitals with more than

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 THE HEALTHCARE IMPERATIVE New CMS Definition of Palliative Care Does Not Mention Prognosis Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating su ffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice. 73 FR 32204, June 5, 2008 Medicare Hospice Conditions of Participation – Final Rule FIGURE 12-2 New CMS definition of palliative care. SOURCE: Medicare Hospice Conditions of Participation—Final Rule. 73 FR 32204, June 5, 2008. Figure 12-2.eps 300 beds reported the presence of a palliative care program—an increase of 97 percent from 2000 (American Hospital Association, 2009; Goldsmith et al., 2008). Palliative medicine is now an American Board of Medical Specialties-approved subspecialty with 10 parent boards and the Accredi- tation Council for Graduate Medical Education has certified the first 55 postgraduate fellowship training programs (American Academy of Hospice and Palliative Medicine, 2009) to develop the workforce necessary to meet Medic Medicare Old Life Prolonging Care Hospice Hospice Benefitt Benefi Life Prolonging Care New Hospice Care Be re av Palliative Care em en t Dx Death FIGURE 12-3 Conceptual shift for palliative care. SOURCE: Reprinted with permission from the National Consensus Project. NCP, Figure 12-3.eps 2004.

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 COMMUNITY-BASED AND TRANSITIONAL CARE the nation’s needs (Casarett, 2000; Portenoy et al., 2006; Scharfenberger et al., 2008; Scott and Hughes, 2006; von Gunten, 2006). As outlined by the National Quality Forum (2006) and the National Consensus Project for Quality Palliative Care (2004), the essential struc- tural elements of hospital palliative care include an interdisciplinary team of clinical staff (physician, nurse, and social worker); staffing ratios de- termined by hospital size; staff trained, credentialed, and/or certified in palliative care; and access and responsiveness 24 hours per day, 7 days per week. These elements are designed to focus on better outcomes for patients through relief of physical and emotional distress; improved patient–family– professional communication and informed, patient-centered decision mak- ing; and coordination and continuity of care across the many transitions experienced by patients with complex chronic and serious illness (Morrison and Meier, 2004; National Consensus Project for Quality Palliative Care, 2004; National Quality Forum, 2006). Why Palliative Care? Despite enormous expenditures, studies demonstrate that patients with serious illness and their families receive poor quality medical care charac- terized by untreated symptoms, unmet personal care needs, high caregiver burden, and low patient and family satisfaction (Field and Cassel, 1997; Kaiser Family Foundation, 2005, 2009; Teno et al., 2004; Thorpe and Howard, 2006). Of the $426 billion spent by Medicare in 2008, 30 percent ($128 billion) was spent on acute care (hospital) services. A very small pro- portion—10 percent—of the sickest Medicare beneficiaries account for fully 63 percent of total program spending, at more than $44,220 per capita per year (Kaiser Family Foundation, 2005, 2009). How Does Palliative Care Reduce Costs? Palliative care programs target the cost drivers that lead to increased use of hospitals, specialists, and procedures, and promote delivery of coor- dinated, communicated, patient-centered care. This is done in the following ways: • These programs address pain and symptoms that increase hospital complications and lengths of stay. • Palliative care teams meet with patients and families to establish clear care goals. • Treatments are reviewed to align with those goals, and those that do not meet them are not initiated or suspended. • Patients and their teams develop comprehensive discharge plans.

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22 THE HEALTHCARE IMPERATIVE per person annually, and these programs have succeeded in lowering rates of diseases that are related to physical activity, nutrition, and smoking. The evidence shows that implementing these programs in communities re- duces rates of type 2 diabetes and high blood pressure by 5 percent within 2 years; reduces heart disease, kidney disease, and stroke by 5 percent within 5 years; and reduces some forms of cancer, arthritis, and chronic ob- structive pulmonary disease by 2.5 percent within 10 to 20 years (Trust for America’s Health, 2008). And the financial benefits are just as impressive: an investment of $10 per person per year in proven community-based pro- grams to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save the country more than $16 billion annu- ally within 5 years—a return of $5.60 for every $1 invested. The Policy Context The discussion about prevention efforts in health care has been fo- cused away from the financial implications and much more on the health benefits to people. In fact, it is common knowledge that many prevention efforts in fact do not save money, even though they have impressive health outcomes. Despite this focus in public health circles, the national debate is one that necessitates consideration of cost and dollars saved. To that end, we focused on certain types of conditions and interventions that would actually yield a positive return on investment. In so doing, we hoped to demonstrate that prevention can make sense in terms of dollars and in terms of health outcomes. Furthermore, we want to push the healthcare discussion from inside the four walls of the clinic to what is happening in communities. The high-cost conditions that plague the healthcare system can be effectively addressed through supporting healthy communities, and those prevention efforts will cost far less than addressing the problems after disease has set in. While discussions of healthcare coverage are critical, achieving good health outcomes requires healthy communities, not just healthy individu- als. What precedes healthcare coverage and clinical intervention is just as important, especially since the primary drivers of health are in people’s homes and in their communities. Health behaviors and environment drive 70 percent of patient health, yet as a country, we spend less than 5 percent on prevention efforts that would target these areas directly (CDC, 2000) (Figure 12-5). But as we focus on community-based solutions, we are quickly struck by the relationship between disparities in chronic diseases and disparities in the health of communities. Unfortunately, those same poor communi- ties where we see such high-cost health care are also least equipped to support healthy lifestyles. If you are told to eat healthily and you live in a

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2 COMMUNITY-BASED AND TRANSITIONAL CARE FIGURE 12-5 Imbalance of spending. SOURCE: Reprinted with permission from Blue Sky Initiative, adapted from Uni- versity of California at San Francisco, Institute of the Future. Figure 12-5.eps neighborhood that does not have abitmap supermarket, this limits your ability to eat healthily regardless of your desire to do so. If your doctor prescribes walking as exercise, you will have difficulty if you live in a neighborhood that does not have sidewalks or where the streets are unsafe. So, even as we discuss the implications of community-based prevention efforts, the issues here are complex and far reaching, and they require an investment com- mensurate with the role of communities in driving health. What Is Community-Based Prevention? Community-based prevention can take many forms, which makes un- derstanding these efforts as part of healthcare reform challenging. This study was based on a systematic review of the literature conducted by the New York Academy of Medicine. Examples of the types of programs that reflect this community-based approach include: • Shape Up Somerville: School food, school activities, parent and community outreach, restaurants, safe routes to school. • Healthy Eating Active Communities (HEAC): Schools, after school, neighborhoods, healthcare sector, marketing changes. • YMCA Pioneering Healthier Communities: Community coalitions, policy changes, leverage other funding.

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2 THE HEALTHCARE IMPERATIVE What these efforts share is that they are community based, they leverage existing resources in their communities toward supporting healthy behav- iors and healthy environments, and they are employing evidence-based prevention practices. The Research Effort In the economic model developed for this report, we focused on those diseases that were expensive, chronic, and most amenable to community- based prevention. In looking at the interventions themselves, we studied the types of intervention, their effects on disease, and their associated costs. The data for this study came from a literature review and the Medical Expen- ditures Panel Survey (MEPS), pooled from 2003-2005. While the literature supports that community-based interventions can have an impact of 10 per- cent on negative health outcomes, we modeled conservatively at 5 percent. Similarly, the data regarding per capita costs were widely variable, so we chose a conservative estimate of a cost of $10 per capita for these interven- tions. Unfortunately, one of the challenges we faced during the research was the wide variation in quality of studies and in information available about the prevention efforts themselves, their costs, and their impacts. Community-Level Interventions Can Reduce Chronic Disease Levels Again, the findings from the research are groundbreaking. Regardless of chronic condition targeted, most interventions targeted fell into four cat- egories: physical activity, nutrition, obesity, and smoking cessation. In each case, the community-based prevention efforts reduced or delayed the inci- dence of disease. The current healthcare system focuses on management of disease or disability, but here, primary prevention delays or prevents disease or disability all together. These findings are more significant when you con- sider that these chronic diseases have not been found to shorten life, only to make a larger proportion of life under the influence of disease. While some suggest that prolonging life is only pushing costs into the future, there is growing evidence to support the compression of morbidity—the extension of healthy life expectancy rather than the extension of total life expectancy by compressing chronic disease and disability into a smaller proportion of life. Thus there is a potential net savings in healthcare costs even as life is extended. Related to this report’s findings, the need for prevention efforts will only continue to grow. Trust for America’s Health just released its annual obesity report, where we found that, on average, among the 55 to 64 age cohort, the obesity rates are 10 percent higher than the current 65 and older age cohort. The opportunity is ripe for prevention efforts aimed at

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2 COMMUNITY-BASED AND TRANSITIONAL CARE this 55 to 64 cohort to obviate some of the high costs of obesity-related disease that we will certainly be seeing as they age into retirement and go onto Medicare. The Numbers Again, an investment of $10 per person per year in proven community- based programs to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save the country more than $16 bil- lion annually within 5 years—a return of $5.60 for every $1 invested. Out of the $16 billion, Medicare could save more than $5 billion; Medicaid could save more than $1.9 billion; and private payers could save more than $9 billion within 5 years (Table 12-4). Within 10 to 20 years, the United States could recoup more than $18 billion, a return on investment of $6.20 for every $1 (Table 12-5). Caveats and Limitations The estimates generated are likely to be conservative. As noted above, the model assumes costs in the higher range and benefits in the low range. Furthermore, the model does not take into account any costs of institutional care. Chronic disease often leads to disability or frailty that may necessitate TABLE 12-4 Net Savings by Payer: 5 Percent Impact at $10 per Capita Cost (in 2004 dollars) 1-2 Years 5 Years 10-20 Years Medicare $487 million $5.213 billion $5.971 billion Medicaid $370 million $1.951 billion $2.195 billion Private Payers/Out of Pocket $1.991 billion $9.380 billion $10.285 billion SOURCE: Reprinted with permission from Trust for America’s Health, 2008. TABLE 12-5 Net Savings: 5 Percent Impact at $10 per Capita Cost (in Millions) (in 2004 dollars) Short Medium Long U.S. (Mid-term ROI: 5.60:1) Care Cost Savings $5,784 $19,479 $21,387 Intervention Costs $2,936 $2,963 $2,963 Net Savings $2,848 $16,543 $18,451 Short Run: 1 to 2 Yrs. • Medium Run: 5 Yrs. • Long Run: 10 to 20 Yrs. NOTE: ROI = return on investment. SOURCE: Reprinted with permission from Trust for America’s Health, 2008.

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2 THE HEALTHCARE IMPERATIVE nursing home care, so exclusion of these costs may underestimate the return on investment in reduction of disease. While the model is still being elaborated to address many of these is- sues, limitations of the model as reported here include the following: • The model assumes a sustained reduction in the prevalence of dia- betes and hypertension over time. The literature on the duration of the effects of intervention is small, with effects usually reported over no more than 3 to 5 years. • The model assumes a steady-state population. This model is based on current disease prevalence and does not take into account trends in prevalence. For example, diabetes is increasing while heart dis- ease is declining, but the model estimates savings based on the current prevalence. • While the model does take into account competing morbidity risks, it does not take into account changes in mortality. However, in the short (1 to 2 years) and medium run (5 years), changes in mortality are likely to be small. • The model calculates all savings in 2004 dollars. Thus, it does not take into account any rise in medical care expenditures or changes in medical technology. • The model incorporates only the marginal cost of the interventions and does not reflect the cost of the basic infrastructure required to implement such programs. • The intervention effects do not account for variations in com- munity demographics such as distribution of race/ethnicity, age, gender, geography, or income. The intervention effect is treated as constant across groups. Conclusion These findings have already translated into healthcare policy reform. The stimulus bill invested $650 million to introduce community-based prevention programs and study their impacts. Even so, the paradigm shift is significant. To paraphrase the President, we want to reach people before they set foot in a doctor’s office. However, the community prevention pro- grams that make that possible push the understanding of many about what healthcare interventions are. Representatives in both houses of Congress have raised questions about the “amorphous” definitions of these preven- tion programs. After all, these efforts are not about buying medicine or introducing a new clinical treatment, so how can they be real? How can they make a difference in healthcare spending and in real health outcomes for Americans? But with this report and the growing consensus around evidence-based, targeted investment in prevention, the viewpoints of many

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