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172 Cards in this Set
- Front
- Back
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What percent of the global disease burden do developing countries account for?
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90% (yet they only account for 12% of global health spending)
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What percent of global health spending do developing countries account for?
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Only 12% of global health spending (2% low income countries; 9% middle income countries; 88%high income countries)
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Low-Income Scenario
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Spend less than $25 per person on health care.
Government revenues are limited by a narrow tax base. Difficult to afford health insurance User fees(out of pocket spending) represents 80% of total revenues International assistance may be source of over half country's health spending Balance of chronic and infectious disease |
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Middle-Income Scenario
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$25 to $500 person spent on health care
Growth of private health insurance Expansion of government tax base Public health insurance possible but not common Increasing levels of chronic disease |
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High Income Countries
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Most have universal health insurance coverage
Mostly public insurance of government mandated insurance Most of illness is chronic disease |
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Is Income Associated with Health Outcomes?
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The level of income is highly correlated with many health outcomes
However, within income levels, there are countries with bettwe and worse outcomes |
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Life Expectancy at Birth vs. Per-Capit Gross National Income (PPP)
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Life expectancy increases with increase in PPP
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IMR- Deathsper 1,000 Live Births < 1 year vs. Per-Capita Gross National Income (PPP)
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Negative Hyperbola
IMR- Deathsper 1,000 Live Births < 1 year decreases with Per-Capita Gross National Income (PPP) |
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Per-Capital Health Expenditures (Us$PPP) vs. Per-Capita Gross National Income (PPP)
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Per-Capital Health Expenditures (Us$PPP) increases with Per-Capita Gross National Income (PPP)
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Cause of Deaths in World
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Noncommunicable Diseases: 59%
Injuries: 9% Communicable, Maternal, Perinatal and Nutritional Conditions:32% |
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Percent of Deaths Attributable to Chronic Diseases
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40%- Low income countries
72%- Lower middle income countries 75%- Upper income countries 87%- High income countries |
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Examples of Countries with Social Insurance
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Germany
Switzerland Israel Belgium Netherlands Japan |
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Germany- Evolution
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First health insurance program - 1883
Created by Chancellor Bismarck in response to worker unrest - Karl Marx However, Chancellor Bismarck did not want to raise taxes to pay for public health insurance Required workers and employers to pay for health insurance Social insurance program (illness, accident and old age) financed by industry and workers |
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Social Insurance (Germany)
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Everyone is covered; the affluent may buy private insurance coverage
Minimum benefit package mandated by government Job-based premium- percent of wage Private sector production Government may control payment rates |
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Germany- Coverage
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Everyone below a certain income level income level is expected to join a health insurance fund (sickness fund) -everyone in a sickness fund pays the same percentage of income- it is a flat tax
Top 10% of income can purchase private insurance |
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Germany Patients
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Free choice among sickness funds
Free choice of general practitioner, specialist, and hospital Limited cost sharing |
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German Physicians
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Hospital based physicians paid salary by hospital, but can supplement salaries through private patients
Number of training slots set by a formula – control specialty mix |
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German Physicians - Ambulatory
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Private practices
Paid fee-for-service: Prospectively set volume caps No controls on specialty referrals |
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Germany - Payment
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Negotiation between sickness funds and providers
All sickness funds pay the same rate and all providers are paid based on the same formula: Known as all payor system |
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Example of Countries with National Health Service
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United Kingdom
Italy New Zealand |
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NHS - Beginnings
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1948 NHS established - good health care should be available to all regardless of wealth - continuation of WWII public health system where government provided all health care services
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National Health Service: United Kingdom
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Everyone is covered
Basic services covered by the government Supplemental private insurance possible Mostly income and corporate taxes Mostly public sector delivery system: UK is moving towards more decentralization Government sets budgets |
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United Kingdom : Patients
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Free choice of general practitioner
“Gatekeeping” - referral required for specialty care Little cost sharing |
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United Kingdom Physicians: General Practitioners--Primary Care Trusts
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Major purchaser of healthcare, led by GPs: Control 80% of NHS budget
Provide primary/community care Purchase specialty and hospital care Can serve 250,000 or more persons Retain surpluses which can be reinvested |
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United Kingdom -Hospital Consultants
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Most employed by NHS
Salaried NHS salaries are consistent across location and specialty Many supplement their salaries through private patients |
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Examples of Countries with National Health Insurance
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Canada
Sweden Denmark Norway Australia |
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Canada -Beginnings
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1972 - All provinces and territories provide universal coverage
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Canada -National Health Insurance
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Everyone is covered
Basic services covered by government Supplemental private insurance possible Most general taxes Private sector delivery system Government sets budgets |
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Canada: Patients
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Free choice of general practitioner
Little cost sharing Queues common for non-urgent procedures |
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Canada: Physicians
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General Practitioners
Provide primary/community care Paid fee-for-service |
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Canada Physicians: Hospital Consultants
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Mostly Self-employed
Paid fee-for-service |
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US health care spending paradox
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US Has Higher Than Expected Spending But Lower Than Expected Life Expectancy
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All Health Systems Have Common Elements
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Financing -How to raise the money
Pooling – How to distribute the money Coverage – What services to cover Delivery - How to organize care provision Access – How to provide access to services Each country makes different decisions about each issue |
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Financing
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*Donors & Firms*
Progressive income taxes Flat taxes – percent of wage income Premiums –set amount – can be community or experience rated Out of pocket |
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What do we mean by risk pooling
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Risk Subsidy: cross-subsidy from low-risk to high-risk (health risk)
Equity Subsidy: Cross-subsidy from rich to poor (income) Cross subsidy from productive to non-productive part of the life cycle (age) |
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Some Delivery Issues (Health Care)
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Integrated delivery systems vs. independent providers
Public vs. private provision |
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Access (Health Care)
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Financial access – ability to pay: What is the maximum percent of your income you should pay for health care
Physical access – number of providers: How close should the nearest provider be |
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All countries differ in how they provide health care
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Each country has different values and different abilities to pay
Many different ways to measure outcomes |
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Health reform implications
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Models focused on outcomes and quality
Redistribution of healthcare spending- threat to safety of net hospitals Reduction in payment rate on a per incidence of care Increases in M&A activity IT infrastructure needs to support EMR and other data connectivity across the continuum of care DSH payment reductions Taking risk with physicians on outcomes and reimbursement (e.g. Accountable Care Organizations) |
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Health Care Spending: Technology and Spending
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BCBSA report: 18%
Project Hope: 25-33% David Cutler: 50% Vic Fuchs: 81% of economists identify technology as primary cost driver in health care |
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Statutory Basis for Coverage
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Sect. 1862 (a)(1)(A), Title 18, SSA
“Notwithstanding any other provisions of law . . .no payment may be made…for items or services . . [which] are not reasonable and necessary for the diagnosis or treatment of illness or injury.” “reasonable and necessary” never defined in law or regulation |
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Reasonable and Necessary: Working definition per CMS
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Adequate evidence to conclude that the item or service:
-improves net health outcomes: That matter to patients -generalizable to the Medicare population |
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Clinical experts react to Medicare ICD policy
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“The Medicare program cannot prove that this technology does not provide a benefit, and therefore is obligated to pay for it.”
“I find it hard to believe that in a country as wealthy as the US, we cannot find the funds to pay for lifesaving technology” “What Hitler was unable to do, the Medicare program is trying to finish” |
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Great Expectations for Comparative Effectiveness Research
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“Better information about the costs and benefits of different treatment options, combined with new incentive structures reflecting the information….is essential to putting the country on a sounder long-term fiscal path.”
Peter Orszag testimony, June 2007 |
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The Evidence Paradox
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18,000+ RCTs published each year
Tens of thousands of other clinical studies Systematic reviews intended to inform clinical and health policy decisions routinely conclude that evidence is inadequate |
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The CER Hypothesis
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Gaps in evidence will be reduced with greater engagement of decision makers (patients, clinicians, payers) in:
Deciding which questions to study Working with researchers on study design |
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CER in Affordable Care Act
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Creates Patient-centered Outcomes Research Institute (PCORI):Independent, private, non-profit
Funding builds to ~$600 million by 2013 Comparative clinical effectiveness: -Evidence generation – new studies -Evidence synthesis – technology assessments -Dissemination (20% of budget Multi-stakeholder governing board |
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What PCORI Can’t Do
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Research findings may not include practice guidelines, coverage recommendations, or payment or policy recommendations.
Evidence may not be used to discourage someone from choosing a treatment based on how the individual values the tradeoff between extending length of life and the risk of disability. May not use dollars per QALY (quality adjusted life year) as a threshold to determine what treatment is effective or recommended. |
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PCORI Background and Mission
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PCORI Mission: The Patient-Centered Outcomes Research Institute helps people make informed health care decisions – and improves health care delivery and outcomes – by producing and promoting high integrity, evidence-based information – that comes from research guided by patients, caregivers and the broader health care community
PCORI will produce knowledge by supporting new research and the analysis and synthesis of existing research The statutory language defining PCORI authorizes research that supports a strong “patient-centered” orientation |
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Working Definition of Patient-Centered Outcomes Research
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Patient-Centered Outcomes Research (PCOR) helps people make informed health care decisions and allows their voice to be heard in assessing the value of health care options. This research answers the following patient-focused questions:
1. Given my personal characteristics, conditions and preferences, what should I expect will happen to me? 2. What are my options and what are the benefits and harms of those options? 3. What can I do to improve the outcomes that are most important to me? 4. How can the health care system improve my chances of achieving the outcomes I prefer? |
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From CER to PCOR
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Original focus was on improving information for patients, clinicians, payers and policy makers: Better decisions in context of anticipated payment and delivery system reforms
Emphasis now shifted to primary emphasis on information needs of patients, especially “patient-centered outcomes” But health policy forces behind original interest in CER and creation of PCORI have not vanished |
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Technology and Health Care
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A “technology” defines the way in which a service or treatment is provided.
The same diagnostic test or treatment may be provided using different technologies: -Telemedicine vs. in-person physician visit -Filling prescriptions by mail order vs. in-person -Imaging using MRI, CT, or other scanning technologies. |
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Comparing Technologies
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Comparing alternative technologies to diagnose or treat may involve looking at:
Efficiency: cost to provide service or treatment Accessibility: e.g., telemedicine vs. in-person Acceptability to patient and provider Patient satisfaction with service or treatment Effectiveness: which technology leads to better outcomes? |
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Frameworks for Assessing Technology
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Cost-effectiveness methods are used to assess screening and treatment technologies where effectiveness is measured in quality adjusted life years (Insurance coverage decisions).
For many health problems, there are multiple alternative treatments available and with comparable levels of cost-effectiveness. How do we decide which is best (for a patient)? This is a quality of care question!! |
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Definition of Quality of Care
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Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM 1990)”
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Institute of Medicine (2001): Crossing the Quality Chasm
Health care must be: |
Health care must be:
Safe: avoid injury to patients Effective: evidence-based treatment Timely: reduce waits and harmful delays Patient centered: care provided responds to patient preferences, needs, and values Efficient: avoids waste Equitable: quality does not vary by personal characteristics and socio-economic status |
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Technology = Structure + Process of Care
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Donabedian’s Quality of Care Framework
Structure: Facilities, personnel, technologies, availability of services, use of electronic health records Process of Care:Access, timeliness, diagnostic and treatment processes, follow-up and management Outcomes of Care: Clinical, health status (functional status), quality of life, satisfaction with services, cost |
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Comparative Effectiveness Research (CER)
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Comparative effectiveness research is designed to inform health care decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options. The evidence is generated from research studies that compare drugs, medical devices, tests, surgeries, or ways to deliver health care (AHRQ website).
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Historical Perspective
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1970s Congressional technology assessment agency
1989 creation of Agency for Health Care Policy and Research (AHCPR- now AHRQ) - develop guidelines and conduct outcomes research 1990’s growth of outcomes research funded by gov’t, industry, and foundations 2000’s growth in interest in comparative effectiveness research, recognizing randomized controlled trials (e.g., RCT used by FDA to approve new drugs) cannot answer all questions, are costly, and the use of medical technologies continues to change. |
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ARRA: Comparative Effectiveness
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$1.1 billion funding for “comparative effectiveness research”:
-AHRQ administers $300 million -NIH administers $400 million -Secretary HHS allocates $400 million Legislation limited use of findings from CER funded by Congress – not to be used to make coverage decisions and studies should focus on effectiveness and not costs. |
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Patient-Centered Outcomes Research Institute (PCORI)
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PCORI was created to conduct research to provide information about the best available evidence to help patients and their health care providers make more informed decisions. PCORI’s research is intended to give patients a better understanding of the prevention, treatment and care options available, and the science that supports those options.
2012 Budget $50 million |
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Patient Centered Care
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Patient-centered care (IOM 2001) – “providing care that is respectful of and responsive to individual patient preferences, needs, values, and ensuring that patient values guide all clinical decisions”
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Rationales for CER
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Answer: What treatments work, for whom, and under what circumstances.
Lack comparative information between alternative treatments. Lack of effectiveness benchmarks – only have efficacy benchmarks. Limited resources and need information to inform decisions. |
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What is Different about Comparative Effectiveness?
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Attention to what the range of decision-makers want to know: patients, providers, payers, regulators, and policy-makers.
Greater use of existing data sources to compare effectiveness. Funding of practical clinical trials, testing effectiveness in more representative populations and treatment settings. |
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Priorities for CER (IOM top 25)
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Treatment strategies for atrial fibrillation
Treatments for hearing loss in children and adults Primary care prevention strategies versus treatments for preventing falls in the elderly Dissemination and translation techniques to facilitate the use of CER Comprehensive care coordination programs, such as the medical home |
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Model of Care Delivery
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What is the best way to ensure high quality care and efficiency?:
Avoid doctors and go to emergency rooms when necessary Primary Care Physician (PCP) Medical Home or Health Home Specialty Physician in preference to PCP Health Maintenance Organizations (HMO) |
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Quality and Technology
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Health technology (Quality) needs to be examined at the population level to ensure all people are receiving beneficial care that is safe.
Assessing technology at the patient level, in the presence of alternative treatments, is complex and learning to use CER in tailoring treatment decisions is the next challenge. Cost is an important policy consideration. |
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What Percent of all Health Care Spending did people with Chronic Conditions Account for in 2004?
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85% of all Health Care Spending
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Age is a risk factor for chronic disease
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80% of older population has one or more chronic disease
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High costs of Medications
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Pharmaceuticals are about 10% health expenditures
Under law, government cannot bargain for lower rates from group purchasing. Estimated that 12-24% of costs could be saved if meds purchased from Canada. High costs driven up by new generations of drugs with only slight changes from earlier formulation. New drugs not tested on older persons |
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Dementia, aging, exercise: bad news, good news
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Two theories: disease may be inevitable as an individual ages vs. at very high age incidence levels off.
Research findings: physical activity and diet reduced risk of Alzheimer’s disease. Research methods: used DSM III criteria to ascertain dementia. Self reports of exercise. “Age-related" (ie, occurring within a specific age range) rather than as an "ageing-related" disorder (that is, caused by the ageing process itself) |
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Preventive Care
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Several vaccinations: (influenza, tetanus, pneumonia, varicella)
Cancer screening Initial “well visit” on enrollment in Medicare Counseling for life style behaviors Diet Exercise Tobacco and alcohol abuse |
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Exercise as prevention: other benefits
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Slow osteoporosis
Maintenance of homeostasis Psychological well-being |
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Dietary regulation as prevention
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Weight—propensity for Type II diabetes, reduced mobility
Cholesterol—harmful effects on arterial buildup of plaque Sodium—harmful effect on blood pressure |
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Preventive services: improvements in evidence
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Screening for cancers:
Mammography Prostate cancer Colorectal cancer Skin cancers |
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Importance of social engagement
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Example- Experience Corps:
Health of older persons improved (did not decline as fast) compared to others who did not volunteer Well-being Locus of control |
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Innovative ideas for delivery of health care for older persons
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Hospital at Home
Guided Care Medical Home (patient-centered care) |
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Improve transitions in care settings that contribute to high costs
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Issue:
national 30 day readmission rates 15-25% Intervention: empower patient and family with knowledge about medications; transitions coach Results: Readmission rates reduced from 11.9 days to 8.3 days |
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Determinants of Medical Expenditures in the Last 6 Months of Life
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Higher costs if:
Hispanic ethnicity Black race chronic disease, incl. diabetes Lower costs if: nearby family dementia |
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End of Life Care
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Palliative vs curative care: Hospice
Living wills and advance directives: (Durable power of attorney for health care) Rationing, (al la Callahan’s suggestion) |
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Hospice Care
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Hospice is a program of care and support for those who are terminally ill:
-Comfort -Hospice care is provided by a specially trained team that cares for the “whole person,” including his or her physical, emotional, social, and spiritual needs. -Hospice provides support to family members caring for a terminally-ill person. Terminal illness: 6 months or less to live Hospice services may include drugs, physical care, counseling, equipment, and supplies for the terminal illness and related condition(s). Hospice isn’t only for people with cancer. Hospice doesn’t shorten or prolong life. Hospice focuses on comfort, not on curing an illness. |
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Rationing
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Rationing care:
-By payment -By price -By government -By location -By wait time Oregon experience -Formal |
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“Rule of rescue”
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Rule: Saving the life of someone in imminent danger of dying is more important…
“NICE and its advisory bodies must use their own judgment to ensure that what it recommended is cost effective and takes account of the need to distribute health resources in the fairest way within society as a whole.” |
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What is LTC?
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Range of health, social, & residential services provided to impaired persons over an extended period
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Ways to Organize Your Thinking About Long-term Care
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Formal v informal
Site: -Home -Day care -Foster care -Assisted living facility (ALF) -Nursing home -Continuing care retirement community (CCRC) Type of care provided: -Personal / custodial -Skilled – Medicare definitions -Rehabilitation -Subacute |
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LTC in the Context of Health Care Reform
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Focus on medical house calls for older adults with chronic illness
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What are We Getting for Our Money? (LTC)
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2004 - 12 million Medicare admissions
20% readmitted within 30 days (2.4 Million) -½ occur before EVER seeing an MD -90% are unplanned, cost extra $17 Billion |
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Principles of Successful Health Care Reform
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1-5. COST!!!
6. Bipartisan 7. Preserve individual choice 8. Aligned incentives 9. Organize care around patient need 10. Deliver appropriate care to targeted population to achieve desired outcomes |
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Key Features of Medical “Home Runs”
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Exceptional care for persons with chronic illness:
-“Extraordinary means” to prevent crises -Longer visits, daily support, 24/7 urgent care -Coordinate carefully selected specialist, hospital care Efficient Service: -EXCLUSIVE focus on elders with chronic illness -Greater use of HIT |
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The House Call Medicine Clinical Model
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Continuous, comprehensive, longitudinal medical care centered in patient’s residence – not in the body part business
Coordinate ALL medical AND social services over time and setting Interdisciplinary team care Geriatrics and palliative care skill sets Strong medical component: -Physicians, nurse practitioners -House calls 24-7 access to care Full EHR Portable diagnostics Financially viable for providers and society |
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Key Elements of Clinical Model
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Passionate and skillful staff:
-Physician/ NP/ SW/ Coordinator team -24/7 access to medical staff and EHR -Build TRUST with elder and family Focus on most ill elders (Top 5%): -Patient/ caregiver satisfaction -Stop preventable hospitalizations -Compassionate, fully coordinated care across settings 300 patients per team (7-8 FTEs) |
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Outcomes of House Call Medicine
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VA - 24% reduction in VA costs and 11% in Medicare costs. Highest patient satisfaction of any VA program (83%)
VCU Medical Center- Hospital costs 60% lower. Hospital-based, mobile team treating patients with multiple chronic diseases Urban Medical House Calls in Boston, MA- Reduced hospital admissions by 29% and hospital days by 34% U Penn program- Reduced health care costs by 50% and hospitalizations by 64% |
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Translating this Experience into Policy
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Reducing costs by providing a new service designed to better address the needs of highest cost patients
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Independence at Home (IAH)
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H.R. 2560 (Rep. Markey), S. 1131 (Sen. Wyden):
-Developed by AAHCP and IAH Coalition -Bipartisan – Co-Sponsors: 13 Senators, 27 Reps Target high-cost older adults - multiple dxs, impaired function, use of hospital, high-cost hx Mobile primary care teams: -Interdisciplinary staff / mobile Dx and Rx technology -24-7 medical staff and HER Demonstration to begin fall ‘13 – 10K patients |
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IAH- New Delivery /Payment System
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Accountable care teams coordinate care across setting and time, with required savings
Metrics: Relevant clinical outcomes, Satisfaction, cost-reductions Share Savings- First 5% to Medicare, then share further savings (? 80/20) with successful providers, to fund |
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IAH Attacks Root Problems of Current Delivery Model
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Shared Savings -> Incentives for better / lower cost care:
-Case management time for complex cases: E.g. Family meeting for EOL discussions / Intensive Coordination/ urgent house calls, mobile technology -Staff-intensive team -Travel costs -Investment revenue for mobile EHR / Dx / Rx Build clinical and $$ rewards to attract providers Reduce incentives for: -Volume of procedures and admissions |
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How IAH Helps CMS
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Transform delivery of care for very ill elders
Improve safety and satisfaction Prevent high-cost events Share savings to build geriatrics workforce |
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Public Health Impact of Excessive Drinking
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80,000 deaths and 2.3 million Years of Potential Life Lost (YPLL) in the U.S. each year.
Third leading preventable cause of death $223.5 billion in economic costs in 2006, or about $1.90/drink; 72% due to lost productivity. $94.2 billion (42%) paid by government, or about $0.80/drink. |
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Binge Drinking is the Main Problem
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Responsible for over half of the deaths, two-thirds of the YPLL, and three-fourths of the economic costs due to excessive drinking.
≥4 drinks per occasion for women; ≥5 drinks per occasion for men. Generally leads to acute impairment. Most common pattern of excessive drinking in the U.S.; over 90% of excessive drinkers binge drink. Accounts for over half the alcohol consumed by adults and 90% of the alcohol consumed by underage youth |
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Global Toll of Alcohol
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Harmful use of alcohol is increasingly recognized as a global public health problem
Alcohol use was responsible for 3.8% of global deaths and 4.6% of global disability in 2004 (Rehm et al., The Lancet, 29 July 2009) This is nearly equivalent to the harm from tobacco use, even when allowing for potential health benefits of alcohol use. Unlike tobacco, the harms from alcohol are concentrated in the early years of life. |
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The Alcohol Problem
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Alcohol is the number one drug problem among young people.
In 2010, 10.0 million U.S. young people ages 12-20 (26.3%) reported drinking in the past month, and 6.5 million reported binge drinking (17.0%). (NSDUH) Every day, 4,500 kids under age 16 start drinking. (NSDUH) Every year more than 4,700 people under age 21 die from alcohol-related causes. (CDC ARDI) The earlier young people begin drinking, the worse the consequences are likely to be. |
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The Alcohol Consequences
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Young people who begin drinking before age 15 are five times more likely to develop alcohol problems later in life than those who wait until they are 21
They are: -Four times more likely to develop alcohol dependence -Six times more likely to be in a physical fight after drinking -More that six times more likely to be in a motor vehicle crash becuase of drinking -almost five times more likely to suffer from other unintentional injuries after drinking |
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What works: periodic review of global research literature --> Alcohol: No Ordinary Commodity
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Jointly published by WHO and Oxford University Press
Result of reviews by 15 of the most prominent scholars globally in alcohol research 2nd edition just published |
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Alcohol Evaluating the evidence: summary
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Strongest options affect affordability, availability, accessibility, drink-driving deterrence
Marketing restrictions show promise for influencing youth drinking, initiation Treatment, brief intervention will have limited effects Educational and media campaigns will have low effect |
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17 Alcohol reduction strategies with at least 2 + across the board
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Alcohol taxes
Ban on sales Minimum age of purchase laws Rationing Government monopolies Restrictions on hours/days of sale Reductions in number of outlets Enhanced enforcement of on-premise laws and regulations Community action projects Sobriety checkpoints Lower BAC limits Administrative license suspension Graduated licensing Legal restrictions on exposure to marketing Brief interventions Mutual self-help Talk therapies |
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What works? CDC Community Guide to Preventive Services (Alcohol)
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Recommended interventions:
Regulation of outlet density (physical availability) Maintaining limits on days of sale (physical availability) Increasing alcohol taxes Enhanced enforcement of laws banning sales to minors Enhanced dram shop liability law Range of DUI measures |
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Range of DUI measures
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.08 laws
Lower BACs for young or inexperienced drivers Maintaining MLDA laws Sobriety checkpoints Server intervention training Mass media campaigns on DUI Multicomponent interventions with community mobilization Ignition interlock School-based education not to ride with drinking-driver only |
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Insufficient evidence” according to CDC (Alcohol)
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Overservice law enforcement initiatives
School-based social norming campaigns Designated driver programs School-based peer organizing interventions |
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What does not work, at least in isolation: Alcohol
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The impact of education and persuasion programs tends to be small at best:
-When positive effects are found, they do not persist. -Among the hundreds of studies, only a few show lasting effects (after 3 years) (Foxcroft et al. 2003). Media campaigns – IOM/NRC study doubtful that youth-oriented campaign can work, although adult-oriented campaign might. Casswell et al. in NZ – media campaigns can soften the ground for more effective policies |
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Alcohol advertising as a risk factor
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Recently published longitudinal studies have all found that the more youth are exposed to alcohol advertising and marketing the more they are likely to initiate drinking, even after controlling for other variables.
Forms of alcohol advertising and marketing that predict drinking onset among youth: -Television beer advertisements -Alcohol ads in magazines -Alcohol ads on billboards -In-store beer displays -Beer concessions at sporting events -Per capita spending on alcohol advertising in their media market -Alcohol use in movies -Ownership of alcohol promotional items |
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Alcohol industry self-regulation: Beer Institute code
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Beer Institute code:
“Beer advertising and marketing materials should not portray or imply illegal activity of any kind...” All 32 NFL stadiums have policies limiting beer sales to 2 per customer |
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Beer Institute Advertising and Marketing Code
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Models and actors employed to appear in beer advertising and marketing materials should be a minimum of 25 years old, substantiated by proper identification, and should reasonably appear to be over 21 years of age.
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DISCUS code: Alcohol
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Advertising and marketing materials should not contain or depict overt sexual activity or sexually lewd or indecent images or language.
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Limits of self-regulation: Alcohol
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Content provisions unenforceable
Code provisions are weak and can be made weaker with impunity: E.g. 2006 changes in U.S. Beer Institute code Placement provisions require independent data source and steady monitoring |
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Center on Alcohol Marketing and Youth (CAMY): What CAMY does
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Track alcohol advertising on TV and radio and in magazines
Use standard industry sources – Neilsen, Arbitron, etc. – to measure the audiences for that advertising. Show that over and over again, kids are exposed to more alcohol advertising per person than adults. |
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Youth Are Overexposed to Alcohol Advertising in Magazines
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In 2008, youth 12–20 years old, compared to adults ≥21 years old, saw per capita
-10% more beer ads -16% more ads for alcopops -73% fewer wine ads The overwhelming majority of youth exposure (79%) came from ads placed in magazines with disproportionate youth audiences |
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Youth Are Overexposed to Alcohol Advertising on Television
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In 2009, 315,581 alcohol product commercials appeared on U.S. television:
-Youth were more likely (per capita) than adults to have seen 21% of alcohol ads (>67,000 ads) -The average TV-watching youth saw 366 alcohol ads: 1/day -23,718 ads (7.5%) played to audiences greater than the industry’s 30% threshold Trends: -Youth exposure to alcohol advertising on television grew at a rate faster than that for ≥21 years old (2004–2009) |
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Youth Are Overexposed to Alcohol Advertising on Radio
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In 2009, 1 in 11 (9%) of radio placements violated the industry's 30% standard:
-Nearly a third (32%) of advertising placements played to disproportionately youthful audiences -More than half of youth exposure came from ads placed on programs that youth were more likely to hear per capita than adults |
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Minority Youth Exposure to Alcohol
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CAMY has issued two reports on Hispanic and two on African-American youth exposure to alcohol advertising.
In 2004, compared to the average for youth: -Hispanic youth age 12 to 20 were exposed to: 20% more alcohol advertising in English-language magazines and More radio advertising for alcohol in 7 of the top 20 markets by Hispanic population in summer 2004 -African-American youth age 12 to 20 were exposed to: 34% more alcohol advertising in national magazines More radio advertising for alcohol in 6 of the top 10 markets by population in summer 2004 |
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Does the alcohol industry “target” youth?
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Cable television study:
Census of 608,591 advertisements on U.S. cable television, 2001 to 2006 Controlled for age (12-20, 21-24, 25+), gender, income, race, year, brand Each one-point increase in the percentage of the audience that was adolescent was associated with more beer (+7%), spirits (+15%), and alcopop (+22%) ads per viewer-hour, but fewer wine (-8%) ads Associations even higher for adolescent girls: +49% for spirits, +39% for alcopops ((P<.001 for all). |
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Alcohol advertising reform: national
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Institute of Medicine recommendations (2003):
Industry self-regulation needs to get better – companies should move towards a 15% maximum youth audience composition for their advertising Why 15%?: -According to the National Household Survey, there is very little current use of alcohol among those below 12. -Thus, 12-20 is the population at highest risk. |
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Young people in the population
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Youth 12-20 are 15.0% of total population 12 and above: Magazines, radio only measure 12+ population.
Youth 12-20 are 13.0% of the total population 2 and above:Television measures 2+ population. A 30% youth audience threshold means youth are twice as likely to be in the viewing/reading/listening audience. |
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CAMY modeling of impact of various scenarios:
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Beam Global standard:
-If adopted by the rest of the alcohol industry, would reduce youth exposure on television by nearly 14% and in magazines by more than 10% NRC/IOM 15% standard (modeled for last 10 months of 2004): -Youth exposure to alcohol advertising would have fallen by 20% -Alcohol industry spending on television advertising would have fallen by 8% -There would have been virtually no effect on the industry’s ability to reach either 21 to 34 year-olds or 21 to 24 year-olds. |
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Progress in reducing youth exposure to Alcohol
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Magazines (2001-2008):
-Youth exposure down by 53% -Adult exposure down by 37% -Drop in how much more advertising youth 12 to 20 saw than adults 21+:Beer and ale: 58% to 24% /Distilled spirits: 52% to 16% Radio: -Samples of radio advertising, summer of 2003 and 2004 -Number of markets where youth heard more alcohol advertising than adults fell from 92 of 104 in 2003 to 55 of 104 in 2004 Television: -spending has increased, youth exposure rising |
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Facts About Mental Illness
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Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD), and borderline personality disorder. 2
Mental illnesses are treatable, but not yet curable. It is estimated that mental illness affects 1 in 5 families in America. 4 of the 10 leading causes of disability in the U.S. are mental disorders: 1 The Global Burden of Disease Study (WHO, World Bank 1996.) revealed that mental illness, including suicide, accounts for over 15% of the burden of disease in established market economies, such as the U.S. This is more than the disease burden caused by all cancers combined. |
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Mental Illness and Children
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Mental health problems affect one in every five young people at any given time.
Half of all mental illness begins by age 14, according to NIMH research. Only about a third of children with mental disorders are identified and receive any mental health services. Undetected and untreated mental disorder leads to school failure/dropout, substance use, violence. Three of every four children whose mothers bring them to a pediatric emergency department for non-urgent complaints screen positive for mental illness. 4 Research shows that early identification and intervention can minimize the long-term disability of mental disorders. 5 WHO: by 2020, childhood psychiatric disorders will rise by over 50%, to become one of the five most common causes of morbidity, mortality, and disability among children. 6 |
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Suicide is a Serious Public Health Problem
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Suicide is a major problem among younger people – 3rd leading cause of death in the 10-24 year age group.
In 2007, 14.5 % of U.S. high school students reported that they had seriously considered attempting suicide during the 12 months preceding the survey. More than 6.9 % of students reported that they had actually attempted suicide one or more times during the same period. Over 600,000 youth report having made a suicide attempt serious enough to require medical attention. Suicide is now the 10th leading cause of death among all Americans (range:10-80 years), with more than 36,000 deaths annually. Each year almost twice as many Americans die from suicide than homicide - 16,765 homicides in 2000. An American dies by suicide every 16 minutes; nearly 80% are males |
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The Problems People with Serious Mental Illness Face:
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Stigma and social isolation
Limited access to insurance Fragmented, acute care services for chronic illnesses Public fear of violence Lack of adequate housing 85% unemployment rate Co-morbidity and premature death due to cardiovascular, respiratory and metabolic disorders |
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Morbidity and Mortality (Mental Illness)
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While the causal relationship between physical and mental illness is not fully understood, mental illness can contribute to the onset of physical illness.1
Depression has emerged as a risk factor for chronic illnesses such as hypertension, cardiovascular disease and diabetes, and it is an independent cardiac risk factor. 2 The risk of onset for coronary artery disease in patients with depression is 1.6 times that of the general population.3 Children and adolescents who suffer from depression are more likely to suffer from physical health problems, including asthma and obesity, in adulthood.4 As a mortality risk factor, the effect of depression is comparable in strength to smoking.5 An October 2006 NASMHPD study describes an alarming finding that people with serious mental illness experience twenty-five years of lost life due to physical not mental disorders. 6 |
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Psychiatric Medication Side Effects
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Side Effects:
-Sedation -Movement disorders -Heart problems -Weight gain -Diabetes Black Box warning: -A black box warning means that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects. -Required on all antidepressants which may result in increased risk of suicidal tendencies in children and adolescents. |
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Schizophrenia Treatment - A Failing Mental Health System?
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The Schizophrenia Patient Outcome Research Team (PORT) Study was a five-year study to identify treatments and services that have been proven to effectively reduce the symptoms of schizophrenia and thus improve functional status and recovery.
The study examined the treatment received by hundreds of individuals with schizophrenia to see if average patients were receiving effective treatments. The results were as follows: -Only 29.1% of people with schizophrenia received the appropriate dosage of anti-psychotic medication -Fewer than half of the people with schizophrenia who also suffered from depression received antidepressant medication -Fewer than one in ten families received even minimal education and support yet up to 60% are regular caregivers The PORT study makes clear the healthcare system routinely fails to provide adequate care for persons with schizophrenia. |
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Mental Illness and Homelessness
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Approximately one-third of the estimated 744,000 Americans who are homeless have serious mental illnesses. One-half have substance-use disorders. 1
People who are homeless frequently depend on the highest-cost public service systems – emergency rooms, hospital psychiatric beds, detox centers, residential treatment programs and jail cells. This is a huge and unnecessary burden on health, mental health and correctional systems. 1 In 2001, a University of Pennsylvania study that examined 5,000 homeless people with mental illnesses in New York City found they cost taxpayers an average of $40,500 a year for their use of emergency rooms, psychiatric hospitals, shelters, and prisons. 2 Families are the fastest growing segment of the homeless population, accounting for almost 40% of the nation’s homeless. The average homeless family is composed of a young, single mother and two children under the age of 6. 1 Children (6-17yrs) who are homeless have high rates of mental illness. One in three homeless children have at least one major mental disorder. 1 |
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Are Jails The New Asylum?
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Northwestern University conducted a study of 1,829 teenagers in a juvenile detention center over four years. Nearly 60% of males and more than two thirds of females were found to be suffering from at least one mental or substance abuse disorder.
More than 106,000 teens are currently in custody in U.S. juvenile facilities. Many poor and minority youth with psychiatric disorders slip through the cracks in the juvenile justice system. 1 |
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Recent National Progress: Mental Health Parity & Health Reform
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The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) passed Congress and was signed into law by President George W. Bush in 2008.
The Patient Protection and Affordable Care Act (health care reform) was passed by Congress and signed into law by President Barack Obama on March 23, 2010. Additional changes to the law were made through the reconciliation process and were signed into law on March 30, 2010. Together, these laws are commonly referred to as the Affordable Care Act (ACA). |
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Mental Health Parity
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Quantitative (e.g., co-pays, deductibles) and non-quantitative (e.g., medical management techniques) benefit limitations must be no more restrictive for mental health and substance abuse benefits than for medical/surgical benefits under MHPAEA.
No separate lifetime or annual benefit limits on mental health or substance abuse benefits* No separate deductibles for mental health and substance abuse services Co-pay amounts must not be greater than those for substantially all medical and surgical services Equitable medical management of access to services required If medical/surgical services are offered in any of six benefit classifications, they must also be offered for MH and substance abuse services Interim final regulations now in effect, but no final regulations. |
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The Affordable Care Act and Mental Health
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Expands access to coverage
Creates and expands consumer protections on health insurance coverage Establishes new demonstration projects to improve access and quality while reducing costs Strong focus on prevention |
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ACA: Key Mental Health Provisions
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Qualified health plans in the Exchange and small group and individual plans will be required to offer a defined, minimum benefit package that includes mental health and substance abuse coverage
Mental health parity protections newly extended to plans in the Exchange and adult Medicaid coverage New Medicaid and Medicare improvements and demonstration projects, e.g., Patient Centered Medical Home, co-location of care, etc. Authorized improvements in mental health services and suicide prevention in the Indian Health Service Authorized Centers of Excellence for Depression, Post-Partum Depression efforts Workforce training and expansion Public Health Outreach and Education CLASS Act, long-term care insurance |
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Key Attributes of Effective Clinical Communities
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1) Establish a small, strong ‘integrating core’
2) Have a clear theory of change~ but are able to adapt 3) Identify and provide resources and training 4) Deal with conflict and hold community together 5) Foster a sense of community 6) Collect and use data wisely 7) Use hard and soft tactics 8) Recognize the importance of context |
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How clinical communities work
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Operate through a small vertical integrating core, but derive their force from horizontal links between members
Mobilize the collective action, social norms, reciprocity and cooperation of all participants Encourage participatory, collaborative forms of decision making “Light on their feet” -Adapt work dynamically in response to learning and contribution of members, and local context |
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Interdisciplinary Science
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Biologic - evidence-based practice
Human Factors – identifying and mitigating barriers Epi/HSR – design and evaluation Psychological – adaptive challenges Sociological – clinical communities Economics – socio- economic incentives Systems Engineering |
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Improving Care: CUSP
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Educate staff on science of safety
Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools |
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Improving Care: Translating Evidence Into Practice (TRiP)
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Summarize the evidence in a checklist.
-Wash your hand, clean skin with chlorhexadine, avoid femoral site, use barrier precautions, ask daily if you need the catheter Identify local barriers to implementation Measure performance Ensure all patients get the evidence: -Engage -Educate -Execute -Evaluate |
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Why Improving Care via CUSP and TRiP worked:
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Guided by science (biologic, clinical, human factors and systems engineering, psychology, sociology, economics, epidemiology, informatics, biostatistics)
Had clear theory of change Kept score with measure clinicians believed valid Modified locally to fit context Focused on adaptive work Unit level intervention with senior support Framed CLABSI as a social program capable of being solved Created a community |
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Health Information Domains
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Consumer-Patient
Provider: physician, nurse, dentist Public Health Research and Policy Business applications |
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Why do we need Health Information Technology (HIT)?
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Largely paper-based systems have existed.
Fragmented systems: each provider and insurer utilizes own forms and codes. Patients generally lack access to their own medical information. Public health relying on paper reports to identify outbreaks of infectious diseases. |
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Health Information Technology: Billing and Administrative Data
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Today it is almost entirely electronic.
Health Insurance Portability and Accountability Act (HIPAA) law required (1996): -Standardization of transactions and codes -Standards of security and privacy protection Many users: providers, insurers, health system managers, policy analysts, and researchers. |
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Health Information Technology: Medical Records
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Electronic health records (EHR) that are interoperable
Records accessible when and where needed |
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Issues for EHR
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About one-third of doctor’s offices have a basic EHR and growing numbers are interoperable:
-Exceptions are the VA and large health plans and in some states with operating Health Information Exchanges (HIE). Interoperability requires standards that govern the structure of content and transmission. Confidentiality: Concerns about -A national unique patient identifier -Sharing medical information with any provider |
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Incentives for EHR Adoption
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ARRA provides financial incentives for EHR adoption through Medicare and Medicaid payments.
Incentive payments provided for “meaningful uses of EHR.” -Incentives begin in 2011-2014 -Meaningful use requirements change over time |
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Meaningful Uses: Staged Implementation
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I. Electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes.
II. Continuous quality improvement at the point of care and the exchange of information in the most structured format possible, e.g., electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results III. Decision support for national high priority conditions, patient access to self management tools, and access to comprehensive patient data and improving population health. |
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Continuity of Care Record (CCR)
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A snapshot in time: A core data set of the most relevant facts about a patient’s healthcare.
Organized and transportable. Prepared by a practitioner at the conclusion of a healthcare encounter. To enable the next practitioner to readily access such information. May be prepared, displayed, and transmitted on paper or electronically. |
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Public Health Information
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Public health departments operate many program-specific information systems, but cannot link data on individuals across systems. What are examples of public health information systems?
Very little information is available on the health of local and state populations beyond death and birth data. National Center for Health Statistics (NCHS) provides national health data, but surveys do not have the numbers for describing state and local health Environmental data: -Exposures (pollution: water, ground, and air) -Risks (defines exposures creating health risks) Occupational data -Safety in the workplace Highway Safety data Crimes and Law Enforcement data |
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Issues for Public Health
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Integrated data systems are needed to maximize the value of public health data, including electronic surveillance.
Communities need access to their health data. Federal and state funding is for individual programs, not for integrated information infrastructure. |
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Realizing the Potential of HIT
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Comprehensive knowledge-based network of interoperable systems
Capable of providing information for decision-making (from patient to policy) when and where needed. (Not a central repository of personal medical data and public health data) |
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Personal Health Record (PHR)
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Intermediate Solution
PHR is owned by the patient with the potential to integrate information coming from billing, medical records, and patient recorded information. Patient can decide how to share content of PHR, if at all. Microsoft and Google supporting PHR and software vendors expected to develop applications. |
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Individual Mandate (ACA)
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All Americans required to have health insurance
-Exceptions include: financial hardship, religious objections, American Indians, uninsured less than 3 months, insurance would cost more than 8% of income, or earning too little to file Federal income tax Penalty for failure to have insurance: greater of $695 per person per year or 2.5% of household income |
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Affordable Coverage (ACA)
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Exchange will subsidize coverage if affordable employer insurance not available:
-Premium subsidy for 100%-400% of poverty-level income: cost no more than 2% of income at 133% of poverty-level with sliding scale up to 9.5% of income for 400% of poverty level ($88,200 in a family of four) -Limits on amount of cost sharing by income Estimated cost $350 billion for 2010-2019 Estimated health insurance rebates in 2012 = $1.3 billion |
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Minimum Coverage (ACA)
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No lifetime caps on benefits are allowed – many policies currently have lifetime benefit caps
Preventive services coverage not subject to copay and deductibles Cannot deny coverage for pre-existing conditions Mental health and substance coverage have parity with medical coverage |
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Employer (ACA)
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Employers with 50 or more employees must provide health insurance that meets or exceeds coverage standards or pay penalties
Possible concern: How many employers may find the penalty more attractive than providing health insurance coverage? |
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Medicaid (ACA)
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Expands Medicaid coverage to include 133% of the poverty income level
Increased Medicaid enrollment initially subsidized by Federal government Medicaid payments to primary care providers for primary care services will be increased to 100% of Medicare payment levels in 2013 and 2014 with 100% Federal financing |
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Overall Cost ACA
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Cost over next 10 years is $938 billion
Cost financed by: -Savings from Medicaid and Medicare -New taxes and fees Overall impact: reduces projected deficit by $124 billion over ten years and reduces projected uninsured by 32 million in 2019 |
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Issues Likely Unresolved ACA
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Projected growth in Medicare program costs likely to continue as retiree population grows
-Is the proposal to end Medicare as an insurance program and give people vouchers to buy insurance an improvement? Health reform reduces numbers of uninsured but not everyone will have health insurance Improving quality performance of health system and increasing efficiency |
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Medicare Program Costs ACA
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Cost drivers:
-Persons over age 65 increase from 13% to 20% by 2030 -Annual increases in Medicare costs higher than GDP growth in most years driven principally by technology and inflation with only 1% attributable to aging of Medicare population |
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Medicare and Health Reform ACA
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Increase Medicare payroll tax by 0.9% in 2014
Change payment for Medicare Advantage plans Reduce annual price updates Establish an Independent Payment Advisory Board to submit legislative proposals to reduce per capita growth in Medicare spending Create an Innovation Center at CMS |
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Who will be uninsured? (ACA)
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Illegal immigrants
Persons unwilling to pay for health insurance and willing to take risk of being caught and paying penalty Persons who feel they are unable to afford health coverage even with the subsidies |
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Quality of Care
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Medical errors in hospitals kill more Americans each year than automobile accidents
National study of quality of care found only 55% of the care meets standards based on scientific evidence Trend to pay for quality or pay for performance |
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Policy Context
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Health care costs: Number 1 policy issue unless health reform “bends the cost curve”
Quality of care: Appears most Americans focus on “choice of physician and hospital” as the key to quality. Is an informed choice possible? Equity: Insurance for everyone is a desirable goal most Americans endorse but few are willing to pay more to achieve this goal. |
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Policy Process: Where do policy issues come from?
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Budgeting process when there is a lack of resources (taxes less than expenditures)
Advocacy: constituents seek help from President and Congress as do other stakeholders External threats and opportunities |
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Policy-making Process
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Building support for issue and position
Identifying key stakeholders and their positions Developing political strategy: which stakeholders will support, will not oppose, and will oppose; what is their political capital; and are there reasonable compromises negate opposition? Leadership: Who in Congress will assume a leadership role or will the President? |
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Policy Outcomes
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Incremental reforms are most common but you have witnessed a major reform
Timing may be critical to success Compromises to gain support likely to weaken reform Implementation is an uncertain process, requires leadership and budget appropriation Evaluation of policy implementation important to assess if reforms are making a difference |
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Key roles of Public Health
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Surveillance: Focus on population health
Policy Development Assessment |
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Your Role and Mine in Policy
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Be knowledgeable of health care issues
Learn about the perspectives of all the stakeholders Use good science as a basis for advocacy and focus on what will benefit people’s health Advocate for ethical treatment of all people Don’t be discouraged: History shows a few people can provide the leadership to achieve important policy changes |
