Prevention Matters

The old joke goes that two men were being chased by a bear when one of them shouted to the other one: "What are we gonna do? We can't outrun that bear!" The second man replied: "I don't have to outrun him, I just have to outrun YOU!"

That seems to have been big tobacco's philosophy earlier this week during the debate over a hike in federal tobacco taxes. Sen. Jim Webb, D-Va., offered an amendment to cut the 61-cent-a-pack tax hike to only 37 cents, and make up the difference with a new system of taxing the income of partners in hedge funds as ordinary income.

Could big tobacco have been betting that, in the current economic climate, hedge fund managers are more despised among the American public than they are? Considering that Webb withdrew the amendment due to a lack of support, was it a bad gamble? Who outran the bear?

Shortly after President Obama agreed to remove family planning funding from the economic stimulus package that's before Congress, various forces began pushing him to do the same thing with tobacco cessation programs. The Senate version of the package contains $75 million for telephone quitlines and other cessation programs, which critics are deriding as pork.

Partnership President Corinne G. Husten, MD, MPH, today urged Senators overseeing the health section of the package to retain this funding on the grounds that the funding is good fisal policy as well as good public health policy. She said the programs would create jobs and help rebuild the public health infrastructure.

"Funding additional quitlines and cessation programs will help provide more of the services needed to empower people to quit smoking," Husten said in a letter to Sens. Tom Harkin, D-Iowa, and Arlen Specter. "Doing so will produce jobs to staff and promote the quitlines and other cessation programs. Given that smoking is responsible for over 400,000 deaths each year in the United States and for $193 billion annually in healthcare costs and lost worker productivity, this is no small matter."

Husten said the funding is consistent with the Center for Disease Control and Prevention’s (CDC) Best Practices, which calls for increasing support for state quitlines so that they have the infrastructure to provide comprehensive treatment to at least 10% of all tobacco users each year. She said it was also consistent with a Call for ACTTION (Access to Cessation Treatment for Tobacco In Our Nation) by a coalition of major business, labor, insurance, health care, and government institutions. The call is a plan to provide every American with access to comprehensive tobacco cessation treatment services by the year 2020.

While Congress still needs to resolve differences between the House and Senate version of the State Children’s Health Insurance Program (SCHIP) expansion, the goal of prevention advocates to raise the Federal tobacco excise tax to $1 per pack now seems assured. Both House and Senate versions of the bill include a 61 cent increase in the Federal cigarette excise tax (current tax is 39 cents) with similar increases in the tax on other tobacco products. Tobacco control experts believe the increase, which will fully fund the SCHIP program expansion, will help an estimated 1 million adult smokers to quit and two million kids from starting.

One remaining issue of concern for Partnership is the difference in how the House version of the bill treats the tax increase on so-called little cigars. Partnership believes little cigars, which look and are packaged identical to cigarettes except for a brown tobacco wrapper, should be taxed at the same rate as cigarettes; a provision that is contained in the Senate version of the bill. Final action on the legislation is expected to be swift with Congress committed to presenting a final bill to President Obama before the scheduled congressional district work period that begins February 16.

Sen. Jim Webb (D-VA) this evening withdrew his amendment to reduce a proposed increase in the federal tobacco tax from 61 cents to 37 cents. He sought to attach the amendment to a bill that would expand the State Children’s Health Insurance Program (SCHIP). Webb had proposed replacing that tobacco tax revenue with a new system of taxing the income of partners in investment management services firms (e.g., hedge funds) as ordinary income.

Thanks to all of you who contacted your senators and urged them to oppose this amendment.

By Diane Canova,
Managing Senior Fellow for Tobacco
Partnership for Prevention
dcanova@prevent.org

We have just learned that the Senate is expected to vote today on an amendment by Sen. Jim Webb (D-VA) to the State Children’s Health Insurance Program (SCHIP) bill that would only increase the federal tobacco tax by 37 cents, instead of the proposed 61 cents. This amendment would dramatically reduce the new federal tobacco product tax rates to fund expansion of the SCHIP legislation, substituting a new system of taxing the income of partners in investment management services firms (e.g., hedge funds) as ordinary income.

Tobacco taxes are not only a good way to raise revenue, but they are a proven deterrent to tobacco use. This increase combines good fiscal policy with good public health policy.

Please call your senators' offices today expressing your support of the full 61 cent cigarette tax and opposing the Webb amendment to lower the tax. Let us know if you have any questions or need more info.

Is individual, patient-based medical care the best way to improve health? Dr.Jonathan E. Fielding, chairman of the US Task Force on Community Prevention Services, says it's not. Dr. Fielding - who is also Director of the Los Angeles County Department of Public Health and Chairman of Partnership for Prevention's Board of Directors - discusses health reform on our first "Prevention Matters" podcast. Listen by clicking on the headphones to the right.

by Corinne G. Husten, MD, MPH, Partnership Prevention Interim President

When it comes to public health funding, President Obama’s economic stimulus package is exactly what the doctor ordered. It would provide the largest single increase in public health funding in the nation’s history. These critical appropriations will establish a community prevention infrastructure that will go far to help the nation reduce the leading drivers of chronic disease: poor nutrition, physical inactivity and tobacco use.

The plan, which is now before Congress, will result in an increase from nearly 100 prevention programs to as many as 800 programs in urban and rural communities across the nation. A Senate subcommittee has approved a version of the plan that would fund $5.8 billion for state and local programs, while the full House of representatives is slated to vote Wednesday on a version that would provide $3 billion.

This infusion of Federal funding will help implement the recommendations of the Task Force on Community Preventive Services and its nationally recognized Community Guide. The Task Force represents the nation’s only independent body dedicated to the evaluation of community prevention strategies based on systematic review of high quality research. More funding will enable the Task Force to eliminate its current backlog of research evaluations and establish a first class process for widely disseminating their findings to State and local stakeholders.

The Task Force on Community Preventive Services will play an essential role in helping communities identify priorities and select interventions that are the most effective interventions and provide the biggest health benefit. The success of community prevention will depend on the application of effective, research-based programs.

Dr. Gary Kaplan, Chairman and CEO of Virginia Mason Health System in Seattle, offers a revealing insight over at The HealthCare Blog about the perverse effects of incentives that are currently built into the U.S. health care payment system.

"At Virginia Mason, our work with employers, like Starbucks, Costco, Boeing and Microsoft, is yielding dramatic reductions in costs for those paying the bills; and better care, quicker return to work and more satisfaction for our patients. We, unfortunately, in the current payment system, reduce our profitability by doing the right thing. Despite my very supportive board of directors, they will not allow me to lead our organization into bankruptcy by doing the right thing. We need to change our payment system if we truly want to ensure universal coverage, improve quality and reduce cost."

Kaplan recently helped launch Health CEOs for Health Reform, a coalition dedicated to transforming health care and creating a more sustainable health system.

There appears to be much wringing of hands about House Speaker Nancy Pelosi's statement over the weekend that family planning saves the government money. Funny, but no one seemed similarly piqued back in December when the Congressional Budget Office stated that when preventive services reduce mortality among the elderly, "it increases both Medicare’s costs and Social Security spending."

The CBO was specifically talking about adult flu vaccinations in that instance, but it also took a similar stance in the same document on the fiscal consequences of preventive measures overall.

“Savings from preventive services would be offset by certain costs, which could more than offset the savings from prevention or early detection,” the CBO said, adding that such offsetting costs include “the cost of treating unrelated diseases that occur because of an individual’s extended life span (NOTE: italics provided by CBO).”

The notion of discounting prevention because it costs more money by saving and extending people's lives is no small matter. At a time when we're looking for ways to control chronic disases that are causing health care costs to spiral ever upward, such notions ought to get more attention.

Partnership for Prevention Interim President Corinne G. Husten, MD, MPH, co-authored a study released this week by the Centers for Disease Control and Prevention (CDC) that was the first 50-state analysis of patterns in smoking-related death rates.

“Overall, the report shows that we made progress in reducing smoking-related deaths during the period studied," says Husten, who served as director of the CDC’s Office on Smoking and Health at the time the study was conducted. “On a state-by-state level the results vary widely, but they show that tobacco continues to take its toll among adults in terms of death rates and years of life lost - particularly in states with higher smoking rates.”

According to the report, smoking rates in the U. S. took a downward plunge and the states with the highest smoking rates had the highest death rates from smoking. Kentucky, the leader, had a smoking death rate of 371 deaths out of every 100,000 adults age 35 and older, a rate that was almost one-and-a-half times higher than the national median of 263 per 100,000. Utah, the lowest state in the list had a death rate of 138 per 100,000.

The report highlighted that the smoking rates in fell in 49 of the 50 U. S. states with only Oklahoma showing an increase. In the four-year period ending in 1999 the annual rate of smoking related deaths fell from 288 per 100,000 people, to 263 per 100,000 in the five years ending in 2004.

"The patterns in this study to some degree predate our expanded efforts in tobacco prevention and control over the past decade," Husten said. "As we continue to monitor these data, they will take into account the programs that have been implemented since then, and we expect to see additional progress.

“Unfortunately, we’re still not providing the resources recommended by the CDC to combat the problem," she said. "If we were to do so, we would see even more progress. Every death from tobacco use is preventable, and any death from tobacco is one too many. It is unconscionable that we are allowing 1200 Americans to die each day because we are unwilling to implement the interventions that have been proven to work.

“This is the first time that we have analyzed patterns in attributable mortality rates," she said. "These data give us important information that is not available from just looking at the number of deaths, but this information is complicated and should not be viewed in isolation. First, we only have two data points, so we really can’t talk about 'trends' until we have more data. Second, smoking causes 19 diseases, including 10 types of cancer and chronic lung disease. So, while the impact on heart disease deaths is rapid, it takes longer to see the impact of our programs on these other diseases.”

"Impending health care reform could take advantage of the extensive medical services system, at little additional cost, to accomplish many previously unattainable health goals for the nation. We could eliminate causes of disease and offer protection to all citizens," Anthony Robbins and Phyllis Freeman, co-editors of the Journal of Public Health Policy, noted recently in The Pump Handle. "Repeated references to “access to prevention services,” however, belie a failure to understand the difference between insuring personal health services and assuring public health gains. The distinction is a strategic one."

The pair resurrected a piece they authored for the Journal back in 1994 in the midst of Hillary Clinton's health care initiative. The piece spelled out specific steps for having the medical care system contribute to protecting the health of the population, more than just treating people seeking care. Those steps were 1) detecting problems in patients that may provide early warning of health threats to others in the community and reporting these to public health authorities for investigation; 2) acting on public health alerts–based on studies of harmful exposures in the environment– to target preventive, diagnostic, and therapeutic services to members of the population at risk; and 3) being part of systematic efforts to assure that every patient receives services of high public health value, such a vaccination, even if the patient is not sufficiently aware of the risks and benefits to seek these services.

"If our new President and the Congress accept the pervasive perception that universal access to medical services will address all important health needs, our nation will miss a magnificent opportunity to prevent disease and to hold off unnecessary medical care expenditures," they write in 2009. "Moreover, if Congress and the President do not get it right now, the door of political opportunity may not open for many years for a second chance."

Partnership for Prevention's Chairman today urged Congress to increase and stabilize resources for the U.S. Task Force on Community Preventive Services.

"...The Task Force on Community Preventive Services, supported by CDC staff, has had erratic and consistently insufficient funding. It has only been able to cover a minority of the possibly effective community policies and programs, and it has had virtually no funding to disseminate its findings," Jonathan Fielding, MD, MPH, testified before the Senate Subcommittee on Health, Education, Labor and Pensions.

Fielding, who is Director and Health Officer at the Los Angeles County Department of Public Health, also serves as the chairman of the community preventive services task force. He said the clinical services group "has been more comprehensive because it has a clearly delineated domain (clinical medicine) and has had a sustained, although inadequate, funding base." He urged more funding for both groups. While Fielding didn't specify a funding source, the $2.35 billion in CDC funding proposed in the House's version of the economic stimulus bill could be one possible source.

Fielding also echoed Partnership's recommendation that Congress enact legislation identifying a specific source and a specific annual amount for the sustained funding of core public health activities at the state and local levels. Using tobacco control as an example, he said many state and local health departments "have no sustained funding, and almost none have sufficient funding to implement the recommendations of the Centers for Disease Control and Prevention."

Partnership for Prevention invites health officers, deputy directors, and program directors in state and local public health departments to help us learn more about the practical information they need to select community-based prevention programs and policies. These leaders are invited to complete an online survey that can be found by clicking here.

When completed, send an email to akristensen@prevent.org with “survey completed” in the subject line and receive a $25 gift certificate to Amazon.com. On Thursday, February 5th from 1:30 p.m. to 3:00 p.m. EST, Partnership will host a web conference with leaders in state and local public health departments to explore in greater depth their information needs. To register for the conference please click here. You’ll receive a $75 Amazon.com gift certificate after registering and participating.

A study published online by the New England Journal of Medicine found that, a simple 19-item checklist reduced deaths and complications from surgery by more than a third. The list is requires members of the surgery team to coordinate and confirm their individual understandings and actions and it even includes a surgical team "time out" before incision.

One of the lead authors told NBC News the checklist was expected to produce maybe 10-15 percent improvement, but that he was very surprised to see 38 percent improvement in reduced deaths and complications. And 93% of the surgeons participating in the study said they would want the checklist to be used if they were ever in surgery. As Brady Augustine noted in MedicaidFrontPage, "it seems that our health care system has focused so much on high-tech wizardry, that we have forgotten that the simple things often make the biggest difference."

The House has unveiled its version of the economic stimulus legislation, and the $825 billion package proposes spending $150 billion for health care - including $4 billion for preventive care.
Those figures don't include the expansion of SCHIP that the House has already approved.

The health-related totals don't suggest a major refocusing on prevention. Less than 5 percent of health care spending currently goes for prevention. Its share of the stimulus health spending would come to about 3.5 percent.

Writing for The New Republic, Harold Pollack quotes a couple of folks who shared some painful observations about the realities facing prevention advocates in the health reform debate:

"Two colleagues of mine introduced a sad note of caution. Roseanna Ander noted the perennial political challenge: There is nothing more compelling than the elaborate rescue of a cute toddler, Baby Jessica, who falls down a well. And there is nothing more boring than debating whether to put a $500 fence around wells before any identified toddler falls in.

"McCormick Foundation Professor Jens Ludwig adds a dollop of Chicago bluntness:

"'The public health constituency includes every thoughtful person who understands the value of prevention. Yet to paraphrase Adlai Stevenson, that isn't enough. I recommend making these interventions much less efficient, to broaden and intensify their political support. President-elect Obama should figure out what a sensible public health investment would be--and then triple it. For example, authorizing legislation should outsource HIV testing to Halliburton, and require that every time someone is tested, a farmer, a corrections officer, a hunter, a teacher, a firefighter, an autoworker, a former hedge fund trader, a TV evangelist, and a diversity counselor must be present, at public expense.'

"This seems a tad cynical, but hey, it might work."

While most aspects of health reform require Congressional action. the new president will find that he has the authority to take action in many areas without waiting for Congress. Partnership for Prevention has compiled a list of such recommendations for President-elect Obama, and today sent him a letter urging him to:

• Direct federally sponsored health insurance programs to provide coverage for, and encourage use of, those clinical preventive services recommended by the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices
• Direct federal agencies to ensure their buildings and installations are healthy worksites and to offer comprehensive worksite health promotion programs
• Order the Secretary of HHS to mobilize the work of the various federal agencies responsible for programs key to achieving the nation’s Healthy People goals and objectives
• Create an inter-departmental National Obesity Council to develop a comprehensive and coordinated national strategy for combating the obesity epidemic, and
• Submit the Framework Convention on Tobacco Control to the Senate for ratification

Healthcare Economist took a look at Partnership for Prevention's recent recommendations to Congress and registered some concerns. In short, they think we're creating a new universal prevention care program that invites cost-shifting, coverage creep and carve-outs. He also says effective preventive care would increase health care costs by increasing longevity and improving the quality of life, and smacks of paternalism.

Partnership Interim President Corinne Husten today sent the following response:

"Thanks for calling attention to Partnership for Prevention’s recent recommendations on prevention as part of the health reform debate. We’re glad you recognize some benefits, but I think a careful reading of our proposals will dispel some of the concerns you’ve raised.

"For one thing, we aren’t “introducing ‘federally funded insurance programs,’” but merely proposing changes in programs that are already established (e.g. Medicare, Medicaid, VA, etc.). We simply propose eliminating cost-sharing requirements (which research shows is a barrier) for high-value clinical prevention services in these existing programs. And because this proposal isn’t for new insurance programs, that should negate the concerns about coverage creep, carve-outs and cost-shifting.

"Secondly, we don’t claim our proposals are cost-saving, but they are cost-effective. There’s an important difference between the two. Health care costs money, whether it’s from a surgical procedure, a prescription drug, or from a preventive service. Cost-effective measures provide more value in terms of health benefits per dollar spent than other measures. Instead of singling out prevention for a requirement that it save money, we need to compare preventive measures with other forms of health care to see which ones provide the most value. And preventive measures seek to reduce the prevelance of chronic diseases that are driving health costs through the roof and that have increased out-of-pocket health expenses by 40 percent over the last decade.

"As for your statement that effective preventive care can increase longevity and improve the quality of life, we plead guilty as charged, and we think that’s a good thing. If living longer costs more, then surgeons and emergency room docs may also want to claim their share of the credit for that. Saving lives is, after all, a big reason for having a health care system, and I think we’d all agree that that premature death as a cost-savings strategy is bad politics, bad policy and bad economics (just ask the folks who lived through the Black Plague). The reasonable alternative is to identify and apply the treatments and preventive measures that provide the most value. Right now, 95 percent of medical spending goes to treatment while less than 5 percent goes to prevention. The results – a high-cost, low-yield health care system compared to other countries - suggest that this is not a proper balance.

"Regarding your concerns about paternalism, our proposals would not tell anyone how to live, but they would help people who want to make healthy choices be able to afford those choices. "

Health Beat notes that smoking has become concentrated among groups of people who are suffering from anxiety and other problems that make quitting and responding to outreach and education efforts much more difficult.

"Today’s smokers are among society’s most vulnerable citizens. They deserve help," they note. Meanwhile, they note that Medicaid, Medicare and private health programs are uneven in their coverage of tobacco cessation programs

That's among the many reasons Partnership for Prevention last year convened national leaders from the business, labor, healthcare and government communities to draft a plan to strengthen access to evidence-based tobacco cessation techniques. The plan, which has been endorsed by three former Surgeons General and three former HHS Secretaries is available online at http://acttiontoquit.com/ .

Chlamydia and gonorrhea are still on the rise, with an estimated 1.4 million cases in the United States. That's according to the Centers for Disease Control and Prevention, which released the 2007 Sexually Transmitted Disease Surveillance data today. It also shows continuing racial disparities, and a heavy burden of disease among women.

The Chlamydia rate in women was found to be three times that of men, and although it is easily diagnosed and treated, it’s often asymptomatic and goes undetected. When left untreated, Chlamydia can cause infertility—affecting a woman’s chance to have children later in life. The US Preventive Services Task Force recommends that all sexually active women age 25 years and younger be screened each year for Chlamydia infection. Screening and treatment with antibiotics can prevent pelvic inflammatory disease, infertility, and other reproductive health problems.

Partnership for Prevention has joined CDC in an effort to prevent these lifelong consequences of untreated STDs. Along with eight other organizations that make up the steering committee, Partnership is leading the recently established National Chlamydia Coalition, whose mission is to reduce the rates of Chlamydia and its harmful effects among sexually active adolescent and young adults.

To join the mailing list for the National Chlamydia Coalition, send an email to cjohnson@prevent.org

President-elect Barack Obama has announced the nomination of Bill Corr, executive director of the Campaign for Tobacco-Free Kids, as deputy secretary of HHS. The nomination requires Senate confirmation.

Corr served as chief of staff to then-HHS Secretary Donna Shalala, and worked in Congress as an aide then-Senate Majority Leader and HHS Secretary-designate Tom Daschle (D-S.D.), and Rep.Henry Waxman (D-Calif.), who is chair of the House Energy and Commerce Committee. Corr led a team assembled by Obama to review and evaluate HHS. He is known as a strong supporter of prevention, and for being a calm but knowledgable hand on health and political matters.

A record crowd is expected to flock to Washington, D.C., next week to hear Barrack Obama's inaugural address, while millions more will watch it via television around the world. At a time when the country is debating how to reform the health care system, wouldn't it be a good time to call for a commitment to prevention?

Corinne G. Husten, Partnership for Prevention's interim president, thinks so. In a letter to Obama this week, she urged him to give prevention a prominent mention.

"Your historic address will rightfully challenge the nation in many areas," she wrote. "I urge you to challenge our congress to make prevention the vanguard of health reform. Keeping people healthy and preventing disease must be an important part of the solution in fixing our high-cost, low-yield health system."

Matthew Holt asks in The Health Care Blog: "Anyway we may not have enough general surgeons according to their trade group, but why should the head of public health for the nation be a surgeon. Shouldn’t they be an epidemiologist? And why are they a general? Don’t we waste enough money on the military as it is?"

While Matt meant it in jest, these are actually pretty common questions. Actually, the term "Surgeon General" does not mean that the holder of the title must be a surgeon or that he/she is a general. The office was established in the 1870s, when the term "surgeon" was commonly used to refer to any physician. And "general" is not meant as a military reference, but as a title that means "supervising" - the same way it's used in "Attorney General," "Postmaster General," or "Inspector General."

That inevitably begs the question: if he/she is not a general, why does he/she wear a uniform? That is because the Surgeon General is a member of the Commissioned Corps of the U.S. Public Health Service, which is one of the federal government's seven uniformed services, along with the Army, Navy, Marines, Air Force, Coast Guard, and Secret Service. The uniform closely resembles that of the Navy, because the Commissioned Corps was originally begun as a government network of hospitals for merchant seamen. The Corps reports to the Secretary of Health and Human Services.

To top it off, there are no generals in the Navy ranking system, and the Surgeon General actually holds the rank of admiral in the Commissioned Corps.

The National Health Statistics Group reports that health care spending in 2007 grew 6.1%. The overall response to that news has been an interesting mix - one that gives you the impression that while the oncoming train is still headed for your car stuck on the crossing, at least it's slowed down a bit.

Several media reports focused on the fact that it was the lowest level of growth in health care spending in nine years. But, as Forbes noted, since the total economy grew by only 2.3% in 2007, the 6.1% hike in health care costs still means everyone’s losing ground.

Drug costs grew by only 5%, as a number of low-priced generics came on the market. But hospital and doctor spending grew 7.3% and 6.5%, respectively, and health insurance premiums grew by 6 percent.

Meanwhile, Health Affairs published a study that shows out-of-pocket medical expenses in the U.S. have grown by 40% over the last decade. Study author Kathy Paetz says it's due largely to the fact that middle-aged Americans today are 10 percent more likely to suffer from more than one chronic disease. Prevention, anyone?

The media has been having a lot of fun with Barrack Obama's efforts to quit smoking. Columnist Michael Kinsley recently did a piece that simultaneously did a "gotcha" by speculating that Obama had violated his pledge to stop smoking while calling on people to let him smoke lest a nicotine fit gives him an itchy trigger finger with our nuclear arsenal. USA TODAY recently joined the fun with an editorial suggesting Obama deserved the scorn of late-night comedians if he doesn't quit. They paired this with an opposing view which held that Obama should be allowed to have an occasional puff so his faculties aren't clouded in a time of crisis.

Partnership for Prevention's Corinne G. Husten has now called the media on this little game. "Some folks seem determined to cast (Obama) either as villian or victim..." Husten wrote in a letter pubslished by USA TODAY. "Both narratives make for good drama, but neither is realistic or constructive." She pointed out that 70 percent of the millions of U.S. smokers say they want to quit, but they are hampered by uneven smoking cessation treatment benefits provided by private and government insurance programs.

"People in this situation don't need vilification or indulgence," she said. "They need our support, and they need access to the full range of tools that can help them.

Providing universal health care won't be nearly enough to truly reform the American health system, says the director of the Centers for Disease Control and Prevention. In a recent column in the Atlanta Journal Constitution, Dr. Julie Gerberding says universal access to quality health care services "would address no more than 25 percent of the gap between our current health status and that of the world’s healthiest nations."

"Health doesn’t only happen in the doctor’s office or the hospital bed," Gerberding wrote in an op-ed piece.

"We have to promote changes and policies that build health opportunities into everyday life — walkable streets, nutritious school lunches, health education and fitness programs for all students, smoking cessation programs and easy access to parks and gyms," she said. "Transportation, housing, agriculture, environment and education legislation abounds with opportunities to leverage better health — at an investment price that brings far better value than dollars spent treating chronic diseases once they occur."