Replacing the Shouts of Recess with the Deliberations of Research

During the August Congressional recess much of the coverage on health care reform has been spent showing us the cacophony of shouts and yells heard around the country during Town Hall meetings.

But at the same time, with less fanfare and attention, a more measured and productive conversation has been occurring. One that actually has the potential to help make us a healthier country and provide us with a more cost effective system of care.

Since my August 5 post, "What If Benjamin Franklin Ran the Congressional Budget Office?," there has been growing interest and attention surrounding the methods of the Congressional Budget Office for scoring costs and savings in general and more specifically as it relates to health reform.

The CBO is a valuable resource for elected officials for measuring the economic value of specific legislation. But what we are realizing is that doesn't mean that it automatically scores what we as Americans value, especially as it relates to our health.

Americans want to live longer, healthier and happier lives. In order to do so they and we make investments in our health, education and well-being that are intended to pay dividends throughout our lives. However, the CBO scoring is limited to only measuring those that pay off in the short term, within 10 years.

This means that while common sense tells us that investing in educating our children, staying healthy, getting checkups to find and treat disease early etc, are invaluable to us as individuals and to the country as a whole, the CBO finds no "economic value" because of its limitations in scoring.

It's as if your car dealer came out and told you there is no value in keeping oil in your car, or getting regular oil changes -- their mechanics are great and will do the repairs when the car breaks down.

In the last month, many organizations have weighed in on the topic and are calling on our leaders to look beyond the narrow focus of the 10-year horizon. Members of organizations such as American Public Health Association, the American Cancer Society, American Association of Diabetes Educators, the YMCA, National Changing Diabetes Program, National Commission on Prevention Priorities, Trust for America's Health, Nurse-Family Partnership, Partnership for Prevention, U.S. Preventive Medicine, and others have voiced an interest in reevaluating CBO's current mandate as it relates to health and healthcare legislation.

Now comes a new study from the University of Chicago that has just been published by Health Affairs. The research presents results that combine the economic approach with epidemiologically-based data to project federal costs for diabetes under alternative policies.

The research's authors developed a model that incorporates critical findings from major clinical trials, illustrating that an investment in early, aggressive treatment for diabetes has payoffs in reduced complications that increase over time, with a significant amount of the health and hence economic value accruing after the usual 10-year CBO window. The model, based on published clinical trial data, captures the expenses of diabetes prevention and management along with cost reductions over 10-year and 25-year periods. This is critical information for Congress to have when considering Health Care Reform proposals.

So why is this new research so valuable?

• First, their paper shows that this kind of long-term analysis can be done and done well. The data exists and can be compiled in a meaningful, credible way.


• Second that doing the analysis matters...a lot. Their analysis shows that a short-term view like CBO takes can make the net costs seem much greater than they actually are. And the good health outcomes seem much less than they really are.


• Third and finally, their analysis uses one of the most serious, common and costly of diseases, diabetes, and shows us that hundreds of thousands of people could have serious disability like blindness, amputations and kidney failure needing lifelong dialysis prevented or delayed for many years if our medical care system was better designed. This is huge. It doesn't get better than this.

Diabetes is one of those conditions where the science has progressed light years since the CBO was formed. And this paper shows us what the fruits of that science could be. But this same approach could be applied equally well to a growing number of preventative health investments where we have reliable data that shows us the effects of investment and the implications of disease progression.

In this paper the authors show how we can combine epidemiological science with economic analysis to better see the true costs and where we get the best value over the longer term. We need to do this more, not just in health and medical care, but for investments in our children as well.

As Congress resumes its discussions around health care, I hope they are not unduly distracted by the loud catcalls given so much media attention during their recess. But rather I hope that they turn their ear to a more deliberate and fruitful dialogue among the medical and health community that is pointing the way towards improving the health and health care of all Americans.

Dr. James Marks is currently the Senior Vice-President, Director of the Health Group at the Robert Wood Johnson Foundation and is former Assistant Surgeon General, Director of the Centers for Disease Control's National Center for Chronic Disease Prevention and Health Promotion.

Comments

[DanaHaza]

08:03 AM on 09/16/2009

Dr. Marks draws important attention to the need for a change in the way health care costs are calculated. Diabetes, as Dr. Marks notes, is a perfect example of a chronic, progressive disease that is debilitating and very expensive if it’s ignored. Major clinical trials show that with comprehensive and effective treatment, patients can avoid the painful and costly complications of diabetes that often develop over a longer period of time. When considering these issues, the Congressional Budget Office looks only at a 10-year window of time. It doesn’t capture the health improvements—and thus potential savings—that accrue over the course of many years. The true value and benefits of comprehensive and effective interventions to avoid costly complications often do not manifest within that time period. To address this knowledge gap, the National Changing Diabetes® Program (NCDP) supported the study conducted by Michael O’Grady, Ph.D. and a team of researchers from the University of Chicago that led to the new scoring model described in Health Affairs. This new model provides accurate, scientific analysis of long-term costs and benefits associated with early treatment and disease prevention, specifically for diabetes. NCDP and many of our member organizations also support The Preventive Health Savings Act of 2009, which will update existing budget law. We now have the tools to give us a true picture of the costs and benefits of preventive care. Let’s put them to use.

Dana Haza
Senior Director
National Changing Diabetes® Program (a Novo Nordisk program)

[jkimbrell]

03:30 PM on 09/11/2009

The thoughtful commentary of Dr. Marks and the insightful analysis presented in the referenced Health Affairs article offer key guidance to how our policy-making should be based. The value of those circumstances that, in the end, contribute to any level of prevention should be considered not only in light of the full duration of the health value but also the breadth of the net impact in both resource terms and human terms across the domains of society. With all of this in mind, perhaps CBO would be well served considering the European notion of “Health in All Policies,” which fundamentally assumes longer term and broader value of health as an outcome than apparently that of the CBO calculus. Health impact assessments (HIA’s), which provide a framework for evidenced-based analysis to inform such EU policy-making, is already being adopted by a growing number of U.S. communities. This nation will no doubt be better served when federal policy-makers come to their brand of enlightened policy innovation as prompted by Dr. Mark’s commentary. --Joe Kimbrell

[LarryCohen]

12:39 AM on 09/10/2009

Dr. Marks is right to call for a more inclusive scoring method that accounts for savings that are currently left out entirely. Key among these savings are those from quality prevention strategies that sometimes do take longer than 10 years to yield benefits but also have the greatest effect by keeping people from needing medical care in the first place. In fact, we know that many prevention strategies not only improve health but reduce medical costs, in less than 10 years. As one example, Prevention Institute co-authored a study with Trust for America’s Health that showed a $5.60 return for every $1 invested in community prevention within 5 years.
In the history of our nation, landmark, life-changing public policies have not been the result of conservative and incremental changes. Rather, it is the heroic experiments that have time and again changed the course of the country. We can not allow cautious bureaucracies to make decisions at the expense of the tremendous potential we have right now to improve the health and wellbeing of all Americans. We must not be afraid to ask for the elements that we know are necessary to successfully reform health.

[DaveHoffman]

09:02 PM on 09/07/2009

This information is critical for policymakers to understand and incorporate in the decision making that will take place n the coming weeks. It is essential that they also understand that prevention takes many forms and is carried out in clinical settings and communities. Jeffrey Levi also points out that this scoring is an artifact that seems to be driving decisions. Clearly we can do better for America than a limited understanding this concept, prevention, that has potential to move us to be a healthier nation and have dramatic impact on what we pay fro healthcare in the future.

[gbenjamin]

10:17 AM on 09/07/2009

This study adds to the growing body of research that shows the need for a more modern methodology to define savings from investments in prevention. The Congressional Budget Office as well as the Office of Management and Budget need to update their methods to address this new knowledge. Not only do they need to add epidemiologic data but they also need to look at the savings from other spheres outside of health care. Numerous benefits occur from people living longer and more productive lives.

[TaylorW]

12:36 PM on 09/06/2009

I am interested to know how the RWJF defines "prevention." What elements, therapies, approaches constitute prevention in its broadest sense? Right now we appear very stuck in a small box that begins around initial diagnosis, with preventive approaches designed to control worsening of the condition and reduction of a negative impact.

Does RWJF include other activities and approaches within the definition, such as: ensuring schools embed nutrition and exercise into K-12; or aggressive funding of research that will define an individual's personal potential for health; or application of stress reduction techniques? Our knowledge of the biology behind these areas has expanded to an astonishing degree in recent years and is no doubt going to rocket ahead in the next decades. Does this not require broadening the definition of "prevention," and change the value equation substantially, in particular for planning a health system for the next 20 years?

[RBrownson]

11:31 AM on 09/06/2009

Dr. Marks provides timely and valuable insights into the current debate about costs and health reform. An ironic challenge within the discussion on reform is that on one hand we reflexively value prevention (“An ounce of prevention is worth a pound of cure”) yet we often hold prevention to a higher burden of proof than other well accepted practices, in particular the treatment of existing disease. While most preventive measures, like medical treatments, are not cost saving, many are an excellent value compared with other services funded by the government or the private sector. While models examining cost effectiveness may be too complex for a simple sound bite, they clearly show in aggregate that preventive and public health programs deliver significant benefits. The cost effectiveness of prevention and treatment are about equal and therefore deserve more equal investments in a reformed health system.

[JeffreyLevi]

12:51 PM on 09/04/2009

To some degree, the debate around CBO scoring is one where the tail seems to be wagging the dog. CBO scoring was originally meant to be a technical tool to guide policy makers. It often seems now that policy makers allow themselves to be controlled by the technical operation they designed. What Jim's post raises is the fundamental question in this debate: should sound public health principles drive our decision making about prevention and care? Our goal in health reform should be to improve the health of the nation, or it isn't really worth doing. Health reform should assure that we invest in cost-effective approaches. But setting arbitrary limits on our investments based on whether they save money (rather than lives) or how quickly an intervention or service might save money undercuts and distracts from the real reason Americans support health reform: they want to lead healthier lives. And their time horizon for those healthier lives is far more than 10 years.

[fdscutchfield]

09:48 AM on 09/04/2009

Jim Marks, the Senior VP of Robert Wood Johnson Foundation has identified the fatal flaw in CBO’s analysis of the financial benefits of prevention when he points out that benefits occur after 10 years and using that as a guideline short changes, if you will, prevention. This same short sightedness permeates our commercial insurance industry. “Why pay for prevention, all you are doing is saving money for Medicare, not our insurance company. “ The long time interval between chronic disease prevention efforts, hypertension control, management of lipids, obesity, tobacco don’t happen overnight, the cancer and heart disease morbidity and mortality take awhile to work. Not only that, CBO didn’t measure quality of life, and many of the diseases prevented by our efforts have a profound effect on a person’s ability to enjoy life. Unless that is factored in, as well, then we lose a great benefit from prevention. Public health and prevention don’t have the flash and trash of a new stunning medical miracle, but are the bread and butter of health status. The contribution of public health and preventive medicine to our life span over the last century, including its impact on quality of life, are truly remarkable achievements that receive little or no attention.

[jfcostich]

06:34 PM on 09/03/2009

The other issue is distinguishing between prevention that is effective on a population basis and wide deployment of expensive tests for relatively rare conditions. Whether prescribing clinicians are risk-averse or just unwilling to take the time to target high-risk populations is immaterial--the volume and cost of unnecessary screening is so great as to demand more nuanced analysis.

[James S. Marks]

08:33 AM on 09/04/2009

Thanks for the comment. You are, of course, right that these issues are much more nuanced than can be usually discussed in this kind of setting. Targetting the high risk usually provides better value in that any preventive screening or treatment will be more apt to find or prevent the condition of interest. Targetting lower risk individuals will find or prevent more cases but less efficiently and hence at greater cost/case. This is part of the reason that people argue for cost effectiveness studies especially in analyzing preventive interventions. But because we spend so much for medical care and some of that care is also low yield as to impact I would argue that it is just as important that we do the same kind of cost effectiveness assesment for therapeutic interventions not just preventive ones. And apply the same kinds of judgements of which ones we should pay for. That kind of level playing field should get us the best outcomes at the reasonable overall costs... and identify where additional research could be valuable. Thanks again

[kbatch]

03:14 PM on 09/03/2009

Over the last few weeks of health care debate, and after moving into a research position managing cost effectiveness and comparative effectiveness studies, I have been grateful for the excellent work of the Robert Wood Johnson Foundation. I hope the news media, which has done a less-than-stellar job reporting on CBO findings, will take a serious look at this report and disseminate the information as responsible journalists are obligated to do.

[James S. Marks]

08:35 AM on 09/04/2009

Thanks for the kind comment. And as you can see from my response to the earlier comment. I am a supporter of cost effectiveness work and comparative effectiveness. We spend so much more than any other country for medical care we really need to do more to make sure we are getting better value for our dollars.