Making Health Care Work for American Families: The Role of Public Health
March 31, 2009
Richard E. Besser, M.D.
Acting Director Centers for Disease Control & Prevention U.S. Department of Health and Human Services
Good morning, I am Richard Besser, M.D. and I am honored to be serving as the Acting Director of the Centers for Disease Control and Prevention (CDC) at the time our national focus is on ways to improve our health system. As a practicing pediatrician and leader of the nation’s principal prevention agency, I recognize both the urgency of solving the problems in our health system andthe opportunities we have to improve the health of Americans as we do so. I would like to thank Chairman Pallone, Ranking Member Deal, and members of the Subcommittee for your support of prevention and public health, and for holding this hearing today to turn the spotlight to the role of prevention and wellness in health reform.
Prevention, Public Health, and Health Care Delivery – An Integrated Approach
Today, it is evident that our health system is not fully achieving its primary goal – protecting and improving our health. We are not yet achieving an acceptable return on the investment we make in health, despite spending more than any other nation. The concerns with our health system are easily enumerated – millions of Americans lack health coverage or access to care; our delivery system too often does not ensure quality, efficiency, and continuity of care; increasing health costs are burdening families, businesses, and governments; and efforts to prevent disease and promote health are implemented unevenly.
As President Obama has articulated, reforming our health system is fundamental to our economic future. If our vision for reform is too narrow, we still won’t achieve our ultimate goal of health for all Americans. It is essential that we move toward the goal of covering all Americans. In a system where all Americans are covered, we hope the cost-shifting and fragmentation of our system will end. At the same time, we will continue to bear a huge economic burden for treating preventable diseases if we don’t make prevention and wellness a cornerstone of a reformed system. In effect, we need to ensure all Americans have access to preventive services and essential public health that are critical to long term health. President Obama has made prevention a priority, including an explicit health reform principle for investing in prevention and wellness.
For too long, in discussions of health reform, health care delivery and public health approaches have been treated separately, as if they were disconnected and mutually exclusive systems. With a discussion of health reform currently a focus for the nation, it is time instead to start talking about solving our national health needs through a comprehensive system that seamlessly integrates health care delivery and prevention.
CDC and our public health partners are already working to create these connections–connections between patients and the resources in their communities that can improve their health, connections between doctors and nurses within the health care setting through better information technology, and connections between clinicians and public health officials who can provide evidence-based information to address patient and community needs. By creating more seamless integration between clinical care (which focuses on the health of a single person) and the public health system (which focuses on the health of an entire community or population), a truly reformed health system could increase access to needed health care services in the short term and reduce demand for treatment services through prevention over time. For Americans to truly be healthier, they must not only have access to treatment once sick, but they should also receive recommended screenings to detect the risk of disease early; have access to evidence-based interventions to prevent disease and injury before they occur; be supported by care systems that minimize the progression of disease once it occurs; and live, work and play in environments that promote healthy choices and behaviors.
We have also learned the importance of tracking the impact of major changes in health policies. It is crucial to have the right information to monitor changes in health following prevention initiatives or changes in service delivery. Data collected by CDC allows us to: document the health status of our population; monitor trends and disparities in health status, access to care and use of health services; and evaluate the impact and effectiveness of health policies and programs developed to improve the health of our people.
Evidence-Based Prevention Works
We have evidence that prevention and public health interventions work, both in communities and healthcare settings – preventing illness, increasing years of healthy living, improving worker productivity, and often saving health care costs. CDC is committed to basing our actions on solid evidence and rigorous evaluation, and though much remains to be done to improve this evidence base, we have clear documentation of the success of these approaches. A few examples of demonstrated prevention successes:
Immunization: Clinicians, health systems, and public health officials have worked together to save lives and health care costs through immunizations. Through childhood immunization programs this Committee has fostered, most childhood vaccine-preventable diseases have been reduced by 95% from levels before we had vaccines, and newer vaccines are already having substantial impact. For each birth cohort vaccinated with 7 routinely recommended childhood vaccines, society saves approximately $9 billion in direct health care costs over a lifetime, approximately 33,000 lives are saved, and 14 million cases of disease are prevented. Improving access to childhood vaccinations has also significantly narrowed minority and economic health disparities in the occurrence of vaccine-preventable disease. CDC is working to continue progress on preventing disease and health costs through childhood and adult immunizations, including strengthening uptake of newer vaccines licensed for adults in the past few years. We can improve quality and lower costs at the same time.
Tobacco Prevention & Cessation: Tobacco use among adolescents has been significantly reduced in several states through comprehensive media campaigns grouped with school and community education programs and policy change. Decreased tobacco use was also achieved through the use of “quitlines”, health care provider education and reminder programs in a variety of health care settings including HMOs, private practice physicians’ offices, and public health clinics. Congress recently raised the excise tax on tobacco products, a singularly important policy change that will likely further reduce tobacco use. Other policy changes under consideration at the national, state, and local levels have the potential for further impact.
Tackling Obesity through Community-Based Action: Through the “Healthy Communities” program, CDC has supported local communities in implementing evidence-based interventions in community-based settings including schools, workplaces, community organizations, health care settings, and municipal planning, and in achieving local changes necessary to prevent obesity and related risk factors. Special focus has been directed toward populations with disproportionate burden of disease. Communities receive funds to spark local-level action, change community conditions to reduce risk factors for obesity, establish and sustain state-of-the-art programs, test new models of intervention, create models for replication, and help train and mentor additional communities.
Health Disparities: Gaps between racial and ethnic groups do not narrow without an intense focus or specific policies to bring about change. An example of a CDC initiative has been the Racial and Ethnic Approaches to Community Health Program, which has made significant gains in changing behaviors to reduce health disparities in communities where interventions were implemented. Tailored interventions reduced smoking rates in Asian-American communities, increased use of blood pressure medication in American Indian Communities, and increased cholesterol screenings in African American and Hispanic communities. In Choctaw County, AL the percent of African-American women who received mammography screenings increased from 29% to 61%, and totally eliminated a previous black/white screening gap. In Dallas County,AL a lower mammography screening rate among African American women (30%)compared to white women (50%)was virtually eliminated withinthe same time frame.
HIV Prevention: There is a strong and growing evidence base for behavioral interventions that have shown significant effects in eliminating or reducing sex- or drug-related risk behaviors, reducing the rate of new HIV/STD infections, or increasing HIV-protective behaviors, and the magnitude of the HIV epidemic and its disproportionate impact on minority populations makes it essential that we implement these interventions. These include approaches to reducing HIV or STD incidence or HIV-related risk behaviors or promoting safer behaviors. The testing and treatment of HIV and other STD′s can also be an effective tool in preventing the spread of HIV, and CDC has promoted routine HIV screening for adults, adolescents, and pregnant women in health care settings in the United States. This allows individuals that test positive to take advantage of the therapies that can keep them healthy and extend their lives and prevent them from infecting their partners.
Healthcare Associated Infections (HAIs): On a national scale, hospitals participating in CDC’s National Healthcare Safety Network (NHSN) have decreased central line-associated bloodstream infections in intensive care units by 4-5 percent per year from 1997 to 2007. Through CDC supported community-wide efforts in southwestern Pennsylvania, local hospitals have successfully reducedbloodstream infections by as much as 70 percent by fully implementing CDC’s evidence-based prevention recommendations. Subsequent collaborations with AHRQ, the Veterans Health Administration, and a variety of healthcare organizations and foundations have shown similar impact. These substantial decreases in healthcare-associated infections, if replicated on a national basis have the potential to yield results in reducing disease, deaths, and consequent healthcare costs.
Prevention of Falls Among Older Adults: Rates of elder falls have been reduced in communities through evidence-based interventions, including home modification, prescription drug review, vision checks, and exercise programs. We know that health costs due to falls are significant, and that individuals who fall are at a higher risk for an earlier death. According to a study by Stevens et.al. published in Injury Prevention, research has demonstrated that elder fall prevention programs produce significantly higher benefits in medical and economic cost savings than is required to implement them.
We are confident that dissemination of proven preventive health interventions can result in major health gains as well as significant cost savings in future health care costs. The modeling work of Dr. Jeffrey Levi and his colleagues at the Trust for America’s Health (TFAH) shows a nearly six to one return on investment to investments in community preventive interventions. Building on this work, we need on a continuous basis to demonstrate the cost savings in future health care costs and return on investment for evidence-based programs to ensure that these investments can be an integral part of reforming our health system.
These interventions are also evaluated and documented by the Task Force on Community Preventive Services, which is chaired by my colleague Dr. Jonathan Fielding. The Task Force documents evidence-based intervention successes in the Guide to Community Preventive Services, providing information and recommendations on more than 200 proven programs and policies that communities can implement to improve health. The Task Force conducts systematic reviews of interventions before making recommendations, so communities can consider the effectiveness, cost, and return on investment before deciding how to tackle their specific health issues. More broadly, the public health community is eager for additional comparative effectiveness research to focus on documenting the effectiveness of community level interventions, similar in scope and approach to research being generated to compare medical treatments.
As demonstrated by these examples and the excellent work being done by our colleagues here today, the potential for significant health impact exists when we disseminate interventions we know work and more seamlessly integrate the health care delivery system with state, local, and community-based organizations that deliver prevention interventions.
Accelerating Prevention through the American Recovery and Reinvestment Act
The Department of Health & Human Services (HHS) is utilizing the funding through the American Recovery and Reinvestment Act (ARRA) to accelerate the implementation of these proven prevention efforts in both healthcare and community settings. In addition to helping stimulate jobs, this funding will provide the nation with a foundation on which to build its prevention activities as part of health reform. The ARRA provided $1 billion under the Prevention and Wellness fund in three critical areas: improving access to immunizations, reducing health care associated infections, and implementing evidence-based clinical and community-based prevention and wellness strategies that target chronic disease rates.
These new investments will allow us to pursue initiatives in the following areas as a “down payment” on health reform:
- Immunizations: With a new investment of $300 million under the ARRA, we will work with our partners to expand access to vaccines and vaccination services through vaccine purchases, improving the infrastructure for immunization programs; and expanding efforts to educate the public and health providers about vaccines.
- Healthcare Associated Infections: With $50 million under the ARRA, we will make the first significant direct investment in state efforts to monitor and reduce healthcare associated infections
- Prevention and Wellness: With a new $650 million in ARRA funding, HHS is developing an investment strategy for evidence-based clinical and community interventions to reduce chronic disease rates. This Department-wide signature initiative will develop and implement community approaches with targeted evidence-based interventions that address known determinants of chronic diseases. This initiative will support prevention efforts across the lifespan (children, adolescents, adults, and seniors) and will seek to address issues such as geographic, racial and ethnic disparities.
The ARRA also includes important investments in health information technology and comparative effectiveness research, and we are working with our colleagues in HHS to develop these initiatives. As in other areas I have discussed, there is tremendous potential to use these new investments not only to improve the clinical care system, but to address the full range of information and evidence needed to support a reformed health system. Similarly, we are hopeful that we will be able to work with other federal and private sector partners on plans for implementing the ARRA to leverage opportunities to improve health through investments in workforce development, transportation, education, nutrition, and other areas.
A Prevention and Wellness Agenda for Health Reform
Health reform will be developed in an inclusive and collaborative process that considers all serious ideas that, in a fiscally responsible manner, achieve the common goals of constraining costs, expanding access, and improving quality. As articulated in the President′s February budget blueprint, one of the principles guiding the Administration′s efforts includes investing in proven public health measures and ensuring access to proven preventive interventions. This will involve changes to our health care delivery system, expanded adoption of proven community-based interventions, and efforts across all sectors that promote health.
The goal of public health is that all Americans live in communities that:
- Create positive opportunities for health, including opportunities for physical activity and access to healthy food choices – shifting to a greater focus on wellness.
- Provide greater access to effective, evidence-based clinical and community prevention interventions (along with support needed to ensure their use) as well as evidence-based community health interventions.
- Provide effective support for management of health conditions, starting with costly chronic diseases, so that the consequences (both cost and health) are minimized.
- Protect them from harm, including from tobacco use, environmental hazards, contaminated food, hazardous worksites, risk of injury, and unsafe medical practices that lead to healthcare associated infections.
We can put prevention to work across America with approaches that lead to a healthier population, diminish health disparities, and reduce health costs. This can be accomplished through a broad national prevention agenda, building on proven interventions. Building on interventions currently in existence this will allow us to:
- Provide tools and support to individuals to enable them to take responsibility for their own health, and opportunities for individuals to help improve the health of their communities.
- Provide solid evidence upon which personal, community, and policy decisions that promote prevention and wellness can be made
- Ensure rigorous tracking, monitoring, and evaluation so that we can measure performance and ensure accountability.
- Work more effectively with state and local health agencies and other key elements of the public health infrastructure to ensure that we can provide the tools and technical support needed to achieve positive health outcomes in communities across the U.S.
- Tailor interventions to reduce health disparities and improve health outcomes for populations most at risk.
- Use policy levers to improve health, including those in areas not traditionally recognized as health-related policies. As an example, we can use multiple approaches to address obesity, where it is important that we create greater opportunities for physical activity and improved nutrition.
- Eliminate tobacco use through policy interventions as well as comprehensive tobacco control programs, we can have a major impact on this leading cause of chronic disease and health costs.
- Reform the delivery system to promote a more seamless integration of individual, clinical, mental health, and community efforts – including those in immunization, protection from HIV and STDs, and prevention of violence – that in combination can make us healthier.
The problems in the health system remain a fundamental concern of families, communities, businesses, and policymakers. A deepening recession adds urgency to already recognized shortcomings in the current health system: families feel the health consequences of decreased economic opportunity along with insecurity in their coverage for medical care; and businesses increasingly face competitive pressures. Health care costs are a growing part of state and federal budgets. The President is committed to reform that makes health care affordable and accessible.
We look forward to working with the Subcommittee to help make prevention a practical reality as part of this national health reform effort.