Eating more fruits and vegetables, and getting 150/min a week of moderate activity are cornerstones of prevention, yet we know people struggle to meet these weekly goals. The marketplace for health and wellness is significant: according to Statista, in 2017, it totaled $167 billion in the US, with an expected growth of 2.3% in 2018.
Making a case for Prevention
There are three tiers of prevention: primary, secondary, and tertiary. In primary prevention, we are looking to prevent the first occurrence of disease; these efforts can include supporting healthy food and activity environments so that people can engage easily in healthy behaviors (exercise, etc.,). Secondary prevention is concerned with managing early indications of disease, like addressing diabetes risk if someone has prediabetes (HgA1c 5.7%-6.5%), or preventing a heart attack or stroke by controlling high blood pressure with diet, exercise and blood pressure medication to dampen the progression to disease. Tertiary prevention focuses on managing symptoms of illness with a goal to reduce further impact.
The Burden of Chronic Disease
According to the Centers for Disease Control (CDC), seven of the top ten causes of death are related to chronic diseases. They report that in 2012, over half of US adults had at least one chronic condition, with 46% of deaths being attributed to heart disease and cancer. The annual healthcare spending in the USA is over 2.7 trillion dollars, 85% of which is attributable to chronic illness. Given the trajectories and costs, the business case for all kinds of prevention should be compelling – but there are challenges.
The nature of the healthcare industry in the USA means every year during open enrollment; people can choose to have a new health plan for their health care needs. As a consequence, the market has considerable churn, leading to investments that can yield benefit in a 1-2 year business cycle. Primary prevention often has a multi-year time horizon to produce results, so this is often the reason investments aren’t made. Given that the data on the burden of disease is showing increases over time, are we reaching a tipping point where investments make sense? Health systems like Montefiore in New York are investing in housing as a means to provide stability to a high-risk segment of the population they care for; it becomes a less expensive alternative to having their members cycle through the emergency room several times a year.
Employers are also making significant investments in prevention as part of their workforce health strategy, as they recognize the opportunity to influence health during the work week positively.
Medicare Diabetes Prevention Program
In April, the Centers for Medicare and Medicaid Services (CMS) began covering the Diabetes Prevention Program (MDPP) as a means to reduce the burden of diabetes in those receiving care. The original DPP program demonstrated that a 5-7% weight loss in addition to 150/min a week of moderate activity could prevent or delay progression to diabetes in 58% of study participants. Multiple translation studies of the Diabetes Prevention Program in different settings (community, health care, employer, etc.,) have also demonstrated this finding since the original paper was published in 2002. CMS also funded several innovation grants to examine the implementation of DPP in settings like YMCAs; their conclusions formed the current version of MDPP which is in the process of deploying nationally. Data from CDC demonstrates that 90% of people are unaware of their risk for diabetes, and those interested in finding out more can follow this simple risk test to learn more: https://doihaveprediabetes.org.
In the May edition of Diabetes Care, the American Diabetes Association (ADA) reported that the costs associated with diabetes had increased 27% from 2012-2017, and was $327 billion in 2017 alone (adjusting for inflation). Growth in prevalence and cost occurred primarily in those over 65, so CMS’s investment in addressing this population is prudent. As healthcare systems deploy MDPP, it is likely that other segmentation strategies will emerge to ensure engagement in these intensive lifestyle behavior programs, whether delivered in-person or via online applications.
Time for a Paradigm Shift?
In the current issue of the New England Journal of Medicine, Kathleen Pryor and Kevin Volpp from the University of Pennsylvania propose it is time for a paradigm shift in prevention. They showcase the DPP as an example of value-based payment that can work in promoting prevention programs, rather than pay all costs upfront; reimbursement is tied to performance which includes program completion and outcomes. While much of healthcare in the USA still revolves around fee-for-service models, it is clear that value-based payments are gaining ground.
Do we hold Prevention to a Higher Standard?
Pryor and Volpp argue that we do, and in my experience, I have to agree with them. Rather than just looking at effectiveness and safety, investments in prevention are also asked to generate a positive return on investment (ROI). Given the long tail for specific prevention efforts (i.e., for a disease to develop), it is often a challenge to demonstrate ROI on a short-term time horizon.
The current model of healthcare in most developed countries revolves around medication prescribing, which can be relatively easy to accomplish, even if data on medication adherence show it is not as easy for the person taking the medicines. Pryor and Volpp discuss data from people who are one-year post-heart-attack reflecting that only 40-45% take their medications as prescribed, so opportunities to optimally support people in managing their health continue to grow.
Behavioral interventions, like the DPP, require a different skill set; behavior change, delivered at scale, will provide new opportunities and challenges for those undertaking them. The good news is that lay people can be trained to deliver the DPP with fidelity. The burden of disease in the USA is so significant that new models to address disease prevention are necessary, and the rise of digital therapeutics means these models can be delivered at scale via smartphones which over 70% of Americans own. We are indeed in the midst of a disruptive moment in healthcare.
Thanks for reading- Trina
(Opinions are my own)
Spend on Health and Wellness in the USA in 2017
Making a case for Prevention
CDC Chronic Conditions
Montefiore Health System
CDC Prediabetes Risk Test
Paradigm Shift in Prevention- Pryor and Volpp NEJM