Sunday, November 09, 2008 comments on legislation introduced by Senator Clinton to create a federal trust for prevention health services.

It's not apparent from this (necessarily) short summary that the legislation will enable prevention efforts that "look upstream" for prevention opportunities. An obvious step would be education for new parents that enables them to influence health behaviors in early childhood.

Educating parents can have significant near-term benefits: a UCLA research project found that health literacy training for Head Start parents produced significant savings for Medicaid by helping parents learn to care for common childhood illnesses instead of bringing their children to emergency rooms and clinics for care.

October 14, 2008
Trust Wellness

New legislation dropped in the final days of a Congressional session obviously isn't going anywhere. But it does signal what that legislator thinks is important and plans to push next year. And when that legislator is Sen. Hillary Rodham Clinton and the bill involves health care, it merits close attention.

On October 1st, the junior senator from New York introduced a bill that would channel existing payments by both public and private insurers for preventive health services into a new Wellness Trust, which would then pay for all preventive services in this society. You can think of it as Medicare Part "P," except that it isn't just for the nation's elderly.

The new Wellness Trust would be run by 7-member board appointed by the president and approved by the Senate. Under S. 3674, the Wellness Trust in its first year of operation would commission and then issue reports on the best way to supplement the existing health care workforce with certified "prevention health workers"; establish new reimbursement systems that would "align incentives" with health promotion and disease prevention goals; and analyze current expenditures on prevention, which the bill estimates at 1 to 3 percent of health care costs or $20 billion to $60 billion.

A year in, with those reports in hand, the trustees would then begin collecting all payments made by Medicare, Medicaid and insurance companies for existing prevention services. The agency would then designate its own "prevention priorities." These would include community-based strategies like tobacco and alcohol counseling or diabetes prevention education, as well as the usual clinical services like the colonoscopies, mammograms and vaccinations that most people associate with preventive care.

With these priorities and money in hand, the Wellness Trust trustees would enter into contracts with certified prevention providers to deliver the services deemed the highest priorites "without regard to the insurance status of such individuals."

The legislation tracks closely to a report that Jeanne Lambrew, now at the University of Texas, wrote for the Hamilton Project at the Brookings Institution, which was created by former Secretary Treasury and Citicorp board member Robert Rubin to serve as a policy think tank for the next Democratic administration.

There's an outside chance the proposal will find a receptive ear in the next administration, whoever is elected. Prevention is included in the health care planks of both candidates. Yet neither has stressed the issue on the campaign trial.

That's not surprising. The conventional wisdom that recently emerged from the health care policy world is that strategies for preventing chronic disease -- which is responsible for 75 percent of all health care expenditures -- don't pay. They only add another layer of cost to the system and won't lower other health care expenditures for many years, if at all.

In my view, that's hogwash. Some prevention interventions lower costs, and some cost far more than they are worth -- just like health care interventions. For a critique of the new conventional wisdom on prevention, intially laid out in a New England Journal of Medicine article, see this GoozNews post.

The Clinton bill pushes back even harder. By centralizing all the money spent on prevention in a single agency, the government could deploy those limited resources in the most cost-effective manner. Moreover, it could target the populations most in need of prevention information, advice and services -- low and moderate-income people who are the most at risk of chronic disease because of poor education, low income, high stress, poor diet, and the lack of exercise that lead to unidentified or untreated pre-disease conditions like hypertension, high blood sugar, smoking, and alcohol abuse.

Right now, the prevention priorities of the nation are driven by who is best insured and a member of what University of Minnesota bioethicist Carl Elliott has called the worried well: educated consumers who know how to demand every high-end preventive service that health care providers can dream up. Have you been told yet that you ought to get a heart scan just to make sure there aren't any blockages forming in your arteries? I have, and I didn't appreciate the pressure to spend money out of my own pocket to get something I probably don't need.

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