States target chronic disease to trim health care costs

Despite their deep divisions regarding the national health system reform law, the nation's governors share a common struggle over growing health care budgets.

At their annual winter meeting in Washington in late February, they focused on one area where they do have consensus: Prevention strategies targeting chronic conditions will be key to containing costs and improving public health.

"Regarding health care, governors don't agree on everything," Iowa Gov. Terry Branstad, a Republican, said at the National Governors Assn. meeting. "But we do agree upon the goals of reducing costs and improving outcomes for our citizens." He is among a group of state leaders who are trying to invalidate the national health system reform law in court.

State leaders used the event to swap ideas over how to ensure the sustainability of the health system and state budgets. The liberal Center on Budget and Policy Priorities reported that 29 states are contending with budget shortfalls totaling $47 billion for fiscal 2013 -- shortfalls that often prompt health program cuts.

"This is an emerging area for states: the growing understanding that prevention of health conditions that lead to high health costs is a worthwhile investment," said Alan Weil, executive director of the National Academy for State Health Policy. "States are still in the middle stages of learning what works. But we are seeing some public health interventions that are having an effect."

Such interventions, including child immunizations, tobacco prevention efforts, cancer screenings and physical activity programs, could save as many as 2 million lives and $4 billion annually, according to federal Dept. of Health and Human Services figures that were presented at the NGA meeting.

Chronic conditions such as heart disease, diabetes and cancer are among the most costly yet avoidable health problems, and "we need to move from a sick-care system, where care is delivered late, to a prevention system, where care is delivered as early as possible," HHS Assistant Secretary for Health Howard K. Koh, MD, MPH, told governors.

He highlighted a Massachusetts tobacco cessation program for Medicaid beneficiaries that cut smoking and hospitalization rates by 26% and 50%, respectively. Implemented under the state's 2006 health reform law, the program has saved $3 for every $1 invested, said Dr. Koh, a former Massachusetts public health commissioner.

Iowa's "Healthiest State" initiative was held out as a promising response to rising obesity rates. Led by Wellmark Blue Cross Blue Shield, the program seeks to boost Iowa from a health ranking of 19th in the nation to No. 1 by 2016, as measured by the Gallup-Healthways Well-Being Index.

Ten pilot communities, with help from national experts and Wellmark's financial support, will test a host of interventions in schools, businesses and the community -- such as physical activity campaigns, employee wellness programs and changes to restaurant menus -- aimed at improving health behaviors.

The collaborative effort is projected to save $16 billion over five years, said Laura Jackson, Wellmark's executive vice president of health care strategy and policy.

Physicians as key players

Michael AbouAssaly, MD, a family physician in West Burlington, Iowa, wants his community in the demonstration because it already has launched a similar program. His office offers patients weekly weigh-ins, while staff receive training in diet counseling.

One Medicare patient in the practice lost 69 pounds and went from paying $550 a month for eight diabetes medications to $55 a month for a single drug. Similar successes allowed a local employer to report $250,000 in health care cost savings in six months.

"We are all in this together," said Dr. AbouAssaly, a member of the Wellness Council of Iowa. "But disease prevention starts in the primary care office."

The Iowa Medical Society has not taken a position on the state initiative but is looking forward to the program's partnership with physicians "to support those critical health conversations that take place every day in doctors' offices."

Governors recognized physicians' role in the success of such innovations as state prescription drug monitoring programs. In Massachusetts, widespread adoption of electronic health records helps physicians track chronic diseases, said Worcester pediatrician Lynda Young, MD, president of the state's medical society.

And more patients are broaching the subject of health care costs with physicians. For doctors to facilitate those discussions, all stakeholders -- health plans, physicians, hospitals -- need to know and make known the true costs of care, Dr. Young said.

With or without the reform law

For states that support the national reform law, cost containment is critical to paying for universal coverage, the NASHP's Weil said.

Several provisions in the Patient Protection and Affordable Care Act address a national prevention and public health strategy, including coverage of preventive services without cost-sharing and grants to help states develop comprehensive healthy lifestyle programs. However, some governors questioned the lack of flexibility states have to implement their own approaches.

Weil said so-called categorical funding could present a barrier for states. "We are learning that the burden of disease is often concentrated in certain populations and communities, whereas these [targeted federal funding] streams come up with a holistic approach."

Dr. Koh said ongoing federal demonstrations are open to testing new ideas, such as taxing foods that are deemed to be of poor nutritional value. But he emphasized evidence-based practices.

Wellmark's Jackson reminded governors that such programs need not rely on government action. "There is no state money attached to [Iowa's] program. It is intended to be community- and grassroots-led."