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Returns on Investments in Health
J. Michael McGinnis, MD
The Robert Wood Johnson Foundation
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12 questions• 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?
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What kills?
1)
2)
3)
4)
5)
6)
7)
8)
• Heart disease 710,760• Malignant neoplasms 553,091• Cerebrovascular diseases 167,661• Chronic lower respiratory disease 122,009• Unintentional injury 97,900• Diabetes mellitus 69,301• Influenza and Pneumonia 65,313• Alzheimer’s disease 49,558• Nephritis 37,251• Septicemia 31,224
Leading Causes of Death in U.S., 2000
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What cripples?
Leading Causes of Disability Among U.S. Adults, 1999
2.8%
3.3%
3.4%
3.7%
4.2%
4.4%
4.7%
7.8%
16.5%
17.5%
0% 5% 10% 15% 20%
Stroke
Blindness/vision problem
Diabetes
Mental/emotional problem
Limb/extremity weakness
Deafness/hearing problem
Respiratory trouble
Heart trouble
Back/spine problem
Arthritis/rheumatism
Percent of 41.2 million persons with a disability
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How much does it cost?
$4,637$4,377$4,177
$4,001$3,698
$2,738
$1,067
$348
$0
$1,000
$2,000
$3,000
$4,000
$5,000
1970 1980 1990 1995 1997 1998 1999 2000
National Health Expenditures, Per capita
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What we spent in 1997
Rank
12346810121416182022242628
$PP
D p
er c
apita
0
1000
2000
3000
4000
5000
United States
SwitzerlandGermanyLuxembourg
CanadaFranceDenmarkNorwayIcelandNetherlandsAustraliaAustria
BelgiumSwedenJapanItalyFinland
United KingNew ZealandIrelandGreeceSpainPortugalCzechoslovaKorea
HungaryPoland
Turkey
(4,095)
(2,611)
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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
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What counts?
Actual Causes Of Death, 1990
• Tobacco 400,000
• Diet/activity patterns 300,000
• Alcohol 100,000
• Microbial agents 90,000• Toxic agents
60,000• Firearms
35,000• Sexual behavior 30,000• Motor vehicles
25,000• Illicit Drug use
20,000
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What counts?
• Diet/inactivity patterns 500,000• Tobacco 400,000• Alcohol 80,000• Microbial agents 60,000• Toxic agents 60,000• Sexual behavior 40,000• Firearms 35,000• Motor vehicles 25,000• Illicit Drug use 25,000
Actual Causes Of Death, 2000
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What’s the big picture?
Genetics30%
Environment5%
Social 15%
Behavior
40%
Health care
10%
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How do we invest?
Medical Treatment
Health Expenditures Premature Mortality
Behavioral
Genetic
Health Care
Environmental
Social
Population-wide effort
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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
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How effective?
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What’s cost-effective?
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Costs of prevention—examples
Median $/QALY
Immunizations $ 1,500Chemoprophylaxis $ 13,000CVD screening $ 3,300Cancer screening $ 18,500HIV counseling $ 1,200CVD counseling $ 74,000Blood donor screening $ 355,000Autologous blood donation $ 730,000
Source: Stone, et al, AJPM 2000: 19(1)
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Score QALYs saved 5 325,000 to 2,600,000 4 65,000 to 185,000 3 33,000 to 55,000 2 19,000 to 27,000 1 100 to 12,000
Ranking: clinically preventable burden
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Score Cost ($)/QALY saved 5 Most likely cost saving 4 May be cost saving to 12,000 3 12,000 to 18,000 2 19,000 to 35,000 1 43,000 to 2,000,000
Ranking: cost effectiveness
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What are the prevention priorities?
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Service CPB CE TotalChildhood vaccination 5 5 10Adult tobacco cessation 5 4 9Vision screen >65 4 5 9Cervical cancer screen >18 5 3 8Hypertension screen 5 3 8Adult cholesterol screen 5 2 7Breast cancer screen 4 2 6Child safety counsel 0-4 1 4 5Folic acid counsel 1 3 4Rubella screening 1 1 2
Source: Coffield et al, AJPM
What are the prevention priorities?
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Costs of treatment—examples
Median $/QALY
Atrial fib (anticoag with 1 RF) $ 8,000Atrial fib (anticoag with 0 RF) $ 370,000Diabetes (intensive glycemic control) $ 41,000Hepatitis C (pegylated interferon) $ 46,000Sepsis (Rx APACHE >25) $ 24,000Sepsis (Rx APACHE <24) $ 575,000HIV (3 drug antiretroviral) $ 23,000Emphysema (lung reduction surgery) $ 190,000Lung cancer (CT screening) $ 48,000
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Lessons
…….we pay going in…
…….we pay coming out…
…the returns to prevention: Priceless!!
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What else matters?
not just clinical assessments…
• cost benefit analysis
• cost effectiveness analysis
• ranking schemes
but public policy…
• health impact assessments
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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
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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 high-risk youth
Source: Fielding et al, 2003
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Keep the big picture in mind
Genetics30%
Environment5%
Social 15%
Behavior
40%
Health care
10%
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