It seems far easier to respond to the needs of a sick individual rather than address the underlying causes of our major health problems. In spite of the fact that, in the last 100 years, every major contribution to the improvement of health status in this country has come from prevention, we have been reticent in our commitment to a robust prevention agenda. We spend massive amounts of money on caring for the sick ($2.5 trillion in 2009, which is over 17% of our GDP or $8,086 per person); yet we invest less than 1% of our total health expenditures on prevention. The Affordable Care Act (ACA), a far reaching and potentially transformative piece of legislation, gives us the opportunity to change that.
The public debate over health care reform has centered on provisions to bring more people into the system through expanded insurance coverage; what has gone largely unnoticed is that the legislation also has a strong focus on prevention. The most direct way in which the ACA addresses prevention is creation of a new Prevention and Public Health Fund with $12.9 billion allocated over 10 years for prevention and public health programs. Components of the fund include direct support of community and clinical prevention services, tobacco control and obesity prevention initiatives, and resources to strengthen state and local health departments. Of particular note is $20 million set aside for integration of primary care services into community-based mental health settings. However, the fund’s ongoing survival is far from certain. This past April, the House of Representatives passed a bill to repeal the Public Health Fund. While the Senate is unlikely to follow suit, things could change in 2013.
As important as the fund is to support needed public health programs and infrastructure, it also serves to reinforce the split between public health and clinical care. Public health is seen as something apart from healthcare, something that government and community organizations do. The more ambitious and potentially transformative provisions of the health care reform law seek to better align public health and medical care by bringing prevention and population-based strategies into clinical care.
Quality and efficiency are the twin levers for bringing public health into clinical care. The ACA has a major focus on quality measurement and improvement that will result in hospitals, physicians and other providers being incentivized to measure and report their progress on a wide range of metrics. New payment policies will reward physicians’ performance on key preventive services. New models of care such as medical homes, accountable care organizations, bundled payments and shared savings, all require health systems to meet rigorous quality targets on prevention measures. This builds on previous incentive programs for meaningful use of electronic health records. Increasing adoption of such tools as registries, clinical decision support, and health information exchange, will enable physicians to care for a panel of patients and not just those who present for care.
From the patient perspective, the ACA eliminated Medicare cost-sharing for preventive services and added an annual wellness visit, also with no cost-sharing. States can obtain support to create healthy lifestyle programs for Medicaid enrollees focused on improving health behaviors.
Increasing prevention in clinical settings is only the first step. The best opportunity for bringing a population-based approach to medical care comes from our national imperative to control health care spending. Chronic diseases such as heart disease, cancer, stroke, and diabetes are responsible for 7 of 10 deaths among Americans each year, and account for roughly 75% of our health spending. It is widely acknowledged that we cannot bend the cost curve without addressing both clinical prevention and the underlying behaviors that lead to poor health. For this reason, the ACA also created an Innovation Center within the federal Centers for Medicare & Medicaid Services. Funded at $10 billion, the Center is charged with testing and implementing innovative ideas in three domains: redesign of patient care processes, improved coordination across different settings, and improved public health to make communities healthier.
The focus on community health is the most innovative, with the greatest potential for linking patient care at the individual level to population-based interventions at the community level. No one knows just what that will look like, but if health care reform survives its many challenges we will see the first steps towards better alignment of public health and clinical care.
Dr. William J. Kassler is Chief Medical Officer for the New England Region, Centers for Medicare and Medicaid Services. He also serves as President of the New Hampshire Medical Society.