1. Prevention:
Medicine for the Health
Economy
Peter Wolff
March 27, 2013
IHL 6049 – Integrative Wellness Management

2. State of the Nation
 Lifestyle choices, including poor nutrition, lack of
exercise, tobacco use, and excessive alcohol
consumption, are the primary causes of chronic health
conditions, leading to 70% of all deaths nationally.
 75% of health care dollars are spent on
preventable, chronic conditions.
 More than two-thirds of surveyed Americans believe
more attention needs to be placed on preventing
chronic disease.
(CDC, 2009)

3. Research Question
 How do we bend the cost curve on health?
I intentionally limited the scope of the research herein by
applying a health economics lens, with the intention of
discovering promising models of health care that fit into
existing financial structures.

4. Motivations
 Understand how integrative health and health
promotion fit into the landscape of our health economy.
 Be prepared for business and policy negotiations in
corporate, government and non-profit organizations.
 Construct a vision for a sustainable future of integrative
health and wellness.

5. The Data

6. We’re #1!
 In 2009, the United States spent more on health as a
percentage of GDP than any other nation
 USA – 17.4%
 Japan – 8.5%, while providing comprehensive health
coverage to all if its citizens
(Squires, 2012)
 The United States ranks
 22nd among industrialized nations in life expectancy
 27th internationally in infant mortality
(CDC, 2012)

7. More on Spending
Concentration of Health Care Spending in
 United States spent more than $2.6 trillion on medical
care in 2010, the U.S. Population, 2009
or $8,458 per person.
Percent of Total Health Care Spending
(≥$51,951) (≥$17,402) (≥$9,570) (≥$6,343) (≥$4,586) (≥$851) (<$851)
Note: Dollar amounts in parentheses are the annual expenses per person in each percentile. Population is the civilian noninstitutionalized population,
including those without any health care spending. Health care spending is total payments from all sources (including direct payments from individuals
and families, private insurance, Medicare, Medicaid, and miscellaneous other sources) to hospitals, physicians, other providers (including dental care),

8. Why the Inflated Costs?
 Pharma accounts for 10% of spending, with a 114%
surge in spending between 2000 and 2010
(Kaiser, 2012)
 Medical technology accounts for about 50% of the
growth in health care spending. (Smith, Newhouse, &
Freeland, 2009)
 Employee / patient ratio increased from 2.8 to 8.4
between 1970 and 2010 (Getzen, 2010, p.10)

9. Three Big Reasons
Higher prices
Medical technology
Obesity
(Commonwealth Fund: Squires, 2012)

10. Poll
 How many of you have health insurance?
 IHL survey 2012
 28% had no health insurance
 38% are managing a chronic health condition

11. Insurance – Who Has It?

12. Who Doesn’t

13. Bright Spots
 Children’s Health Insurance Program (CHIP)
 Access to care for children has improved, with the rate of
uninsured children declining to an all time low of 8% in
2010
(CDC, 2012)
 Patient Protection and Affordable Care Act (ACA)
 Provisions of the law will extend health insurance
coverage to uninsured citizens at the beginning of 2014

14. How Did This Happen?

15. Health in the Free Market
 In all other industrialized countries, access to affordable
care is centrally governed and financed through
universal insurance-based or single-payer systems
(Squires, 2012).
 In the United States, market efficiency is purported to
provide an “optimal” balance of health services for all
who need them (Reinhardt, 2001).
 Since the 1970s, we have seen greater degrees of
social inequity and unprecedented price inflation for
health services.

16. Insurance

17. Players

18. US Health Care System
 Mix of private insurance and single-payer systems
 Who pays?
 48% - US government
 34% - Private insurance companies
 11% - Personal wages or savings
 7% - Charities
(Getzen, 2010)

19. Characteristics of Insurance
 Uncertainty of an expected medical loss motivates
people to purchase insurance.
 Moral hazard is the observed change in human
behavior, to engage in more high-risk activities, due to
the presence of insurance.
 Adverse selection is a behavioral condition in which
people with the highest need for health care are also
the most likely to seek out insurance.
(Getzen, 2010)

20. Health Care Reform?
 Bill Moyers interview
 http://www.youtube.com/watch?v=7QwX_soZ1GI

21. Affordable Care Act
 Extend coverage to the uninsured
 Control costs
 Improve quality of care

22. More Coverage
 Approximately 32 million uninsured Americans will gain
health benefits
 About 50/50 split between increased Medicaid
enrollment and mandatory insurance obtained from
private plans via state-run insurance exchanges
(Washington Post, 2010)

23. Prevention

24. Chronic Disease
 The rising tide of health care costs are running parallel
to the rise in obesity.
 Obesity was responsible for 27 percent of the rise in
inflation-adjusted health spending between 1987 and
2001 (Thorpe, Florence, Howard & Joski, 2004).
 Across all payers, obese people had per capita medical
spending that was 42 percent greater than spending for
normal-weight people in 2006
(Finkelstein, Trogdon, Cohen & Dietz, 2009)

25. Obesity Trends* Among U.S. Adults, BRFSS 1990 (1)
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%

26. Obesity Trends* Among U.S. Adults, BRFSS 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

27. Obesity Trends* Among U.S. Adults, BRFSS 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

28. Obesity Trends* Among U.S. Adults, BRFSS 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

29. Obesity Trends* Among U.S. Adults, BRFSS 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

30. Obesity Trends* Among U.S. Adults, BRFSS 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

31. Obesity Trends* Among U.S. Adults, BRFSS 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%

32. Obesity Trends* Among U.S. Adults, BRFSS 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%

33. Obesity Trends* Among U.S. Adults, BRFSS 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%

34. Obesity Trends* Among U.S. Adults, BRFSS 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%

35. Obesity Trends* Among U.S. Adults, BRFSS 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%

36. Obesity Trends* Among U.S. Adults, BRFSS 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

37. Obesity Trends* Among U.S. Adults, BRFSS 2002
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

38. Obesity Trends* Among U.S. Adults, BRFSS 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

39. Obesity Trends* Among U.S. Adults, BRFSS 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

40. Obesity Trends* Among U.S. Adults, BRFSS 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

41. Obesity Trends* Among U.S. Adults, BRFSS 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

42. Obesity Trends* Among U.S. Adults, BRFSS 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

43. Obesity Trends* Among U.S. Adults, BRFSS 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

44. Obesity Trends* Among U.S. Adults, BRFSS 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

45. Quality of Preventive Care
“When lawmakers discuss providing access to and
funding for prevention, they usually mean reimbursing
clinical screenings performed in a doctors office”
(Goetzel, 2009).
“Statistically, nationwide, anywhere from 50%, and in
some places 80%, of patients have chronic conditions and
preventive health needs that are not being met”
(Brown, 2012).

46. Prevention in the ACA
 Although the ACA catalyzed the National Prevention
Strategy effort with a call to shift the focus from
sickness and disease to prevention and wellness, no
explicit funding for health promotion initiatives like
behavior change, lifestyle choices, and self-care
practices is included, only recommendations.
 Sequestration is impacting the relatively small budget
allocated for preventive screenings.

47. Prevention in the ACA
 Employers have the ability to encourage participation in
wellness programs by using discounts or incentives
valued at up to 30 percent of insurance premiums
costs.

48. Possible Solutions
 Accountable Care Organization (ACO)
 Employer-based Prevention Clinics

49. Integrative Primary Care
 Patient Centered Medical Home (PCMH)
 More time with patients is shared between
doctors, advanced-practice nurses, physician
assistants, health educators, social workers and
pharmacists

50. Cost and Quality
 In the Colorado pilot, acute inpatient admissions
declined 18 percent and emergency department visits
dropped by a 15 percent. The control groups in the
study saw increased utilization.
 High satisfaction - 97 percent of participants in the
Colorado study said they would recommend the
medical home to family and friends.
 The New York medical home pilot demonstrated per
patient per month cost reductions of 14.5 percent for
adults and 8.6 percent for children compared to the
control group

51. Integrative Primary Care
 Employer-based Prevention Clinic
 The short-term objective is reducing utilization of
expensive emergency room visits and hospital
care, but the long-term justification is creating a
healthier workforce by preventing and managing
chronic disease.

52. Cost and Quality
 Given their business orientation, most employers are
seeking a financial return on the cost of implementing a
program.
 Worker focused programming is not encumbered with
institutional limitations.
 Employers free to adopt complementary and alternative
modalities of healing, such as meditation, yoga, or
Traditional Chinese medicine.

53. Trends
Pa ent-
Centered Worksite
Medical Home Preven on
Clinic
Primary Care Health
Insurance
Preven on with CAM
Biomedicine
Employment
Preven on with
Primary Care