Transcript MMCGINNIS0903

Returns on Investments in Health
J. Michael McGinnis, MD
The Robert Wood Johnson Foundation
12 questions
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What kills?
What cripples?
How much does it cost?
What counts?
What’s the big picture?
How do we invest?
What’s effective?
How effective?
What’s cost effective?
How do Rx and Px compare?
What are our prevention priorities?
What else matters?
What kills?
Leading Causes of Death in U.S., 2000
1)
2) disease
• Heart
710,760
3)
• Malignant
neoplasms
553,091
• Cerebrovascular
diseases
167,661
4)
• Chronic
lower respiratory disease
122,009
5)
• Unintentional injury
97,900
6)
• Diabetes mellitus
69,301
7)
• Influenza
and Pneumonia
65,313
8)
• Alzheimer’s
disease
49,558
• Nephritis
37,251
• Septicemia
31,224
What cripples?
Leading Causes of Disability Among U.S. Adults, 1999
Arthritis/rheumatism
17.5%
Back/spine problem
16.5%
Heart trouble
7.8%
Respiratory trouble
4.7%
Deafness/hearing problem
4.4%
Limb/extremity weakness
4.2%
Mental/emotional problem
3.7%
Diabetes
3.4%
Blindness/vision problem
3.3%
Stroke
0%
2.8%
5%
10%
15%
Percent of 41.2 million persons with a disability
20%
How much does it cost?
$5,000
$3,698
$4,000
$4,001
$4,177
$4,377
$4,637
$2,738
$3,000
$2,000
$1,067
$1,000 $348
$0
1970 1980 1990 1995 1997 1998 1999 2000
National Health Expenditures, Per capita
What we spent in 1997
5000
United States
(4,095)
$PPD per capita
4000
3000
2000
1000
Switzerland
(2,611)
Germany
Luxembourg
Canada
France
Denmark
Norway
Iceland
Netherlands
Australia
Austria
Belgium
Sweden
Japan
Italy
Finland
United
King
New
Zealand
Ireland
Greece
Spain
Portugal
Czechoslova
Korea
Hungary
Poland
Turkey
0
28
26
24
22
20
18
16
14
Rank
12
10
8
6
4 3 2 1
Male life expectancy 1996
1. Japan
77.0
15. Austria
73.7
2. Sweden
76.5
16. Germany
73.6
3. Iceland
76.2
17. Belgium
73.5
4. Switzerland
75.7
18. Ireland
73.2
5. Canada
75.7
19. Luxembourg
73.0
6. Norway
75.4
20. Finland
73.0
7. Australia
75.2
21. Denmark
72.9
8. Greece
75.1
22. United States
72.7
9. Italy
74.9
23. Portugal
71.2
10. Netherlands
74.7
24. Czechoslovakia
70.4
11. Spain
74.5
25. Mexico
70.1
12. New Zealand
74.3
26. Poland
67.8
13. United Kingdom
74.3
27. Hungary
66.6
14. France
74.2
28. Turkey
65.9
What counts?
Actual Causes Of Death, 1990
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Tobacco
Diet/activity patterns
Alcohol
Microbial agents
Toxic agents
Firearms
Sexual behavior
Motor vehicles
Illicit Drug use
400,000
300,000
100,000
90,000
60,000
35,000
30,000
25,000
20,000
What counts?
Actual Causes Of Death, 2000
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Diet/inactivity patterns
Tobacco
Alcohol
Microbial agents
Toxic agents
Sexual behavior
Firearms
Motor vehicles
Illicit Drug use
500,000
400,000
80,000
60,000
60,000
40,000
35,000
25,000
25,000
What’s the big picture?
Health care
10%
Genetics
30%
Behavior
40%
Environment
5%
Social
15%
How do we invest?
Health Expenditures
Premature Mortality
Social
Population-wide effort
Environmental
Behavioral
Health Care
Medical Treatment
Genetic
What’s effective?
Immunization and chemoprophylaxis
• e.g. vaccines (childhood, influenza, pneumococcal),
folic acid, aspirin, ocular
Screening and early intervention
• e.g. newborn, colonoscopy, mammography, blood
pressure, cholesterol, chlamydia, vision, hearing
Counseling
• e.g. tobacco, alcohol, physical activity, diet, infant
feeding, child safety, STD risk
How effective?
What’s cost-effective?
Costs of prevention—examples
Immunizations
Chemoprophylaxis
CVD screening
Cancer screening
HIV counseling
CVD counseling
Blood donor screening
Autologous blood donation
Median $/QALY
$ 1,500
$ 13,000
$
3,300
$ 18,500
$
1,200
$ 74,000
$ 355,000
$ 730,000
Source: Stone, et al, AJPM 2000: 19(1)
Ranking: clinically preventable burden
Score
5
4
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QALYs saved
325,000 to 2,600,000
65,000 to 185,000
33,000 to 55,000
19,000 to 27,000
100 to 12,000
Ranking: cost effectiveness
Score
5
4
3
2
1
Cost ($)/QALY saved
Most likely cost saving
May be cost saving to 12,000
12,000 to 18,000
19,000 to 35,000
43,000 to 2,000,000
What are the prevention priorities?
What are the prevention priorities?
Service
Childhood vaccination
Adult tobacco cessation
Vision screen >65
4
Cervical cancer screen >18
Hypertension screen
Adult cholesterol screen
Breast cancer screen
Child safety counsel 0-4
Folic acid counsel
Rubella screening
CPB
5
5
5
5
5
5
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1
1
1
CE
5
4
9
3
3
2
2
4
3
1
Total
10
9
8
8
7
6
5
4
2
Source: Coffield et al, AJPM
Costs of treatment—examples
Median $/QALY
Atrial fib (anticoag with 1 RF)
Atrial fib (anticoag with 0 RF)
Diabetes (intensive glycemic control)
Hepatitis C (pegylated interferon)
Sepsis (Rx APACHE >25)
Sepsis (Rx APACHE <24)
HIV (3 drug antiretroviral)
Emphysema (lung reduction surgery)
Lung cancer (CT screening)
$
8,000
$ 370,000
$ 41,000
$ 46,000
$ 24,000
$ 575,000
$ 23,000
$ 190,000
$ 48,000
Lessons
…….we pay going in…
…….we pay coming out…
…the returns to prevention: Priceless!!
What else matters?
not just clinical assessments…
• cost benefit analysis
• cost effectiveness analysis
• ranking schemes
but public policy…
• health impact assessments
Sample HIA (local)
City of Los Angeles Living Wage
• Employees working on city contracts must be
– paid at least $7.99/hour
– provided health insurance, or an additional
$1.25/hour
• Covers approximately 10,000 workers
• Health insurance coverage more cost-effective in
reducing excess mortality than an equivalent amount
in the form of wages
• Any changes to the ordinance should consider
increasing health insurance coverage
• Applicability: many living wage ordinances throughout
the US
Source: Fielding et al, 2003
Sample HIA (state)
After-school program funding
• California ballot Proposition 49 to set aside $550 million per
year for after-school programs in grades K - 8
• Potentially significant health outcomes through effects on
education, crime, substance abuse, etc.
• Counterintuitive result: unlikely to yield any significant
health benefits. Chiefly due to:
– small magnitude of effects on key mediators
– Inadequate targeting, recruitment and retention of highrisk youth
Source: Fielding et al, 2003
Keep the big picture in mind
Health care
10%
Genetics
30%
Behavior
40%
Environment
5%
Social
15%