Prevention Matters

Few would argue the importance of increasing funding for community prevention. That’s the reason prevention advocates were so delighted Congress established a Prevention and Public Health Fund to “provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs.” The fund makes available $500 million in new spending in FY2010; the fiscal year ending September 30. There is a tough decision ahead to spend a great deal of money in a short period of time.

There are many worthy ideas vying for DHHS Secretary Kathleen Sebelius’ attention. She is the official charged by the new law in allocating the funds “for prevention, wellness and public health activities…”

How should the Secretary make the initial trust fund allocation given that so many deserving programs are asking for a slice from the pie?

In an Op Ed (“The Prevention Dilemma”) written for Kaiser Health News, Partnership for Prevention CEO, Dr. Robert Gould, answers the tough question.

“There will never be enough federal money to address every prevention need. What the secretary needs to decide is whether there is sufficient political courage to concentrate early prevention funding to deliver a knockout blow to the leading cause of premature death in the country? … The criteria for prioritizing this specific funding should be simple: what are the evidence-based programs that are primed and ready to go, that are proven to work, that we know will move us toward a healthier society and that we can be sure will deliver a large, measurable return on investment? By these criteria, the top priority for prevention spending should be tobacco control.”

Gould recommends DHHS focus their resources on three well tested, evidence-based components::

1) Nationwide public education campaign modeled on the highly successful Truth® campaign that dissuades thousands of young people from initiating tobacco use and encourages smoking cessation;

2) Fully funding quit lines that provide direct cessation services and significantly improve quit rates efficiently and effectively, especially among disadvantaged populations served by Medicaid; and

3) Support for existing state and community-based tobacco control programs that reach people where they live, work, play and worship.”

The Partnership leader believes the goal of this potentially historic investment is simple and most important, achievable.. Gould concludes:

“If community-based tobacco control programs could be brought to scale nationally, we have a genuine opportunity to drive smoking rates into single digits. The rapid and enduring payoff, in lives and money saved, is there for the taking. It’s a rare opportunity. I urge Secretary Sebelius to seize it.”

Sounds like good advice. Do you agree?

Ripley Forbes
Director, Government Affairs
Partnership for Prevention

The 20th Anniversary Edition of America’s Health Rankings notes a worrisome escalation in preventable diseases that will significantly increase costs in an already unaffordable medical care delivery system. Of the $2.4 trillion of annual health care expenditures in the United States, $1.8 trillion is associated with the treatment of chronic disease, such as diabetes, heart disease and cancer.


Obesity has increased nearly 130 percent since the first edition of America’s Health Rankings was issued 20 years ago. Currently, 27 percent of the population is obese. A supplemental analysis to this year’s report shows America now spends $80 billion in direct health care costs associated with obesity. Left unchecked, 43 percent of adults will be obese and obesity will add nearly $344 billion in 2018 alone to the nation’s annual direct health care costs, accounting for more than 21 percent of health care spending.


America’s Health Rankings  is an annual comprehensive assessment of the nation’s health on a state-by-state analysis. It is published jointly by United Health Foundation, the American Public Health Association and Partnership for Prevention. The data in the report comes from validated outside sources, such as the Centers for Disease Control and Prevention (CDC). The report is reviewed and overseen by a Scientific Advisory Committee, with members from leading academic institutions, government agencies and the private sector.

The 2009 Anniversary Edition shows Vermont as the healthiest state this year, while Mississippi is ranked 50th. Over the past 20 years, New York has demonstrated the most improvement in the overall health of its population.

Partnership for Prevention President/CEO Robert J. Gould, Ph.D. today issued the following statement about the revised recommendations of the US Preventive Services Task Force regarding breast cancer screening:


The US Preventive Services Task Force is the nation’s best-equipped institution to make science-based recommendations on the use of clinical preventive services. Accordingly, we accept their recommendations on breast cancer screening.


To help avoid any possible confusion about these new recommendations, we would strongly note three areas where theyhave not changed:

• Mammograms are still recommended for women 40-49 with high risk of breast cancer;

• Mammography has clearly been shown to save lives and is a vital component of our nation’s arsenal to fight breast cancer; and

• All women should talk with their physicians about their individual risks and the value of screening.

Partnership for Prevention President/CEO Robert J. Gould Ph.D. applauded the support for disease prevention and health promotion that is provided in the health reform bill to be voted on the by the House of Representatives over the weekend.

"I wanted you to know that Partnership for Prevention strongly supports the prevention provisions of HR 3962, the 'Affordable Health Care for America Act.' Gould said in a letter to House Majority Whip Steny L. Hoyer, D-Md.

"We believe the provisions of HR 3962 establishing a dedicated national trust fund for prevention, wellness and public health will enable thousands of U.S. communities to help citizens quit tobacco, become more physically active, and reduce their risk of life-threatening diseases," Gould added. "Only by addressing these primary drivers of poor health and high health care costs can we foster community environments that will enable American families to support healthy behaviors and healthy choices."

From the November issue of The Nation's Health:

Prevention, a touchstone of public health, has landed in the crosshairs of the national health reform debate, with cost-effectiveness pitted against the sometimes incalculable value of a healthy life....

...With such questions coming to the forefront, the task ahead is to reframe the prevention debate, said Rob Gould, PhD, president of the Partnership for Prevention. Focusing on how much money prevention costs or saves the federal budget is the wrong question, Gould told The Nation’s Health. Instead, the discussion should focus on questions of value, he said, whether the money being spent is a good investment.


"We should not be apologizing for helping people live longer and healthier lives, especially when we can deliver that life at the right cost," said Gould, an APHA member. "The good news is that the public wants prevention in health care, even if it costs more, so we’re starting from a good place in terms of public support. But we have to answer the economic questions, and we need to talk about cost in terms of value."

In September, the Partnership for Prevention released and sent to policy-makers a report on the "Economic Argument for Disease Prevention: Distinguishing Between Value and Savings," which stated that "health is a good, and goods — whether they are national security, clean water or a new car — are not purchased to save money. They are purchased for the nonmonetary benefits they provide. Shoppers do not buy groceries to save money, but they do ‘save money’ by shopping wisely."
 
The report noted that prevention can result in other benefits that usually go unmeasured in studies on cost-effectiveness, such as improving "work force productivity and corporate competitiveness," as well as the ripple effects good health can bring to households and children, educational attainment and crime rates. A similar report released in August by the Robert Wood Johnson Foundation, "Cost-Savings and Cost-Effectiveness of Clinical Preventive Care," found that even while clinic-based preventive care, such as cancer screenings, do not usually result in cost savings, such services "offer good value for increasingly scarce health care dollars."

In a recent Chicago Tribune interview, Partnership for Prevention President Robert J. Gould said making healthy choices easier will help create a "culture of health."
"If we lower the barriers to making healthier choices in the community, then we can create a culture of health in this country," Gould told Tribune reporter Julie Deardorff.

Deardorff's article undescored Gould's assertion by citing a recent report in the Archives of Internal Medicine.  That study found that people who live in "healthy" neighborhoods -- areas with plentiful opportunities for physical activity and eating well -- had a 38 percent lower rate of Type 2 diabetes than those in "unhealthy" neighborhoods.

Partnership for Prevention President Robert J. Gould today issued the following statement regarding a New York Times article about a report that breast cancer screening may be leading to overtreatment similar to that resulting from prostate cancer screening:

“The US Preventive Services Task Force has never recommended screening for prostate cancer, but it has recommended mammograms and has modified those recommendations as necessary. The proper use of screening remains an invaluable tool in breast cancer detection and treatment and in saving lives. A woman’s personal physician is the expert best equipped to help her decide what procedures should be employed in her individual circumstances. This important public discussion about screening should not discourage anyone from consulting their doctor.”

The Washington Post printed the following letter from Partnership President/CEO Robert J. Gould in its Sept. 8 edition:

"It's bad enough that in the debate over health reform, the media's only interest regarding disease prevention and health promotion seems to revolve around the question of whether prevention will save enough money to pay for the health-reform bill. But the Sept. 1 news story "Study Raises Questions About Cost Savings From Preventive Care" seemed to go further by implying that the country should fund highly effective programs for controlling diabetes only if they save money.

"The fact is, while some preventive measures save money, almost all of them provide real value in that they offer more health benefits per dollar spent than many medical treatments do. While this may not pay the freight for health reform, it will help our country stretch its health-care dollar.

"That is indeed worth something. And, oh yes, prevention measures also help people live longer and healthier lives. Isn't that what our health-care system is supposed to be about?"

Statement from Robert J. Gould, President/CEO, Partnership for Prevention:

Senator Kennedy’s passing is an inestimable loss to government, to history and to the cause of health reform. A summary of his accomplishments shows that every piece of major health care legislation passed over the last four decades has borne his imprint. His lifelong devotion to the cause of making quality health care available to every American speaks volumes about his heart and his character.

Our thoughts today are with the senator’s family and friends. To those who share his dream of health reform, we would suggest that the greatest tribute would be to take to heart his own words:

“For all those whose cares have been our concern, the work goes on, the cause endures, the hope still lives, and the dream shall never die.”

Insurers are talking up a proposal backed by Partnership for Prevention that was successfully added to the House version of the health reform bill. Gannett's Maureen Groppe cited the amendment, sponsored by Rep. Lois Capps, D-Calif., in a story about "a move by Democrats to replace references to “health-care reform” with references to “health-insurance reform.”

"Dallas Salisbury, head of the Employee Benefit Research Institute, said a proposal to eliminate copays for preventive and wellness care could have the biggest impact on individual behavior," Groppe writes.

“'Employers and insurers that have experimented with this, at the point that they eliminate those copays, they do get dramatic increases in the number of employees that use the services,' Salisbury said.

"The Partnership for Prevention estimates that only 67 percent of women 40 and older get screened for breast cancer. An additional 3,700 lives could be saved each year if 90 percent did, according to the organization, which wants Congress to remove deductibles and copays for preventive services.

“'The main purpose of cost-sharing is to discourage the use of medical services,' said Robert J. Gould, the group’s president. 'But clinical preventive services are currently underutilized.'"

The question of why prevention doesn't save money continues to dominate media coverage of health reform issues as they relate to disease prevention and health promotion. The most recent example was Michelle Andrews, who wrote a piece entitled "The Problem with Prevention" for The New York Times' online "Prescriptions" page. The "problem" is, of course, is that experts say prevention won't save as money, contrary to claims made by President Obama and others.

Partnership President Rob Gould was interviewed for the piece, and he cautioned that value, not savings, is the proper question for consideration.

"The key is to invest in measures that provide the most bang for the prevention buck — high clinical value at a reasonable cost," Andrews writes. 'The right question to ask is whether it’s a cost-effective use of health dollars,' said Rob Gould, president of the Partnership for Prevention, a nonprofit that promotes preventive health.

"Judged this way, certain preventive services, but not all, may be considered worthwhile, in that while they may not save money, their cost is considered reasonable for the years of sickness and the deaths that they help people avoid," Andrews says. "By those criteria, effective prevention includes colorectal cancer screening for adults ages 50 and older, adult flu shots and screening for high blood pressure in appropriate patients."

But Andrews also notes that even those services may run afoul of the Congressional Budget Office scoring that holds that "the lower mortality rates that result … could increase federal spending for Social Security and Medicare.”

This prompted the following response from one reader: "I’m waiting with bated breath for the stunning argument... that the cheapest way of all is to have NO health care system."

Partnership President Robert J. Gould, PhD, warned in an interview for NPR's "All Things Considered" that prevention is being undervalued in the current health reform debate on Capitol Hill.

Even when congressional budget scorekeepers do concede that some prevention and wellness programs work as intended, Gould said, "they warn us that living longer would cost the government more money because people would be using additional Social Security and Medicare payments.

"So if the answer to the question is that people living longer and healthier lives is a problem, then you're asking the wrong question," he said.

He citied a study by Partnership's National Commission on Prevention Priorities, which reviewed the 25 clinical preventive services most highly recommended by the U.S. Preventive Services Task Force. It found that five of those services actually save money, while another 12 were still considered cost-effective - costing less than $50,000 per additional year of life they would provide. He said that compares with $900,000 per year for a mechanical device to keep alive a patient with congestive heart failure.

The following is a guest post from Partnership for Prevention President Robert J. Gould, PhD, and Executive Vice President Corinne G. Husten, MD, MPH., that appeared on the blog for the Robert Wood Johnson Foundation's Commission to Build a Healthier America.

When the answer is that living longer is a problem, you know you’re asking the wrong question.

The Congressional Budget Office recently issued a memo identifying areas where Congress could save money in a health reform bill. When it came to disease prevention and health promotion, the logic in its response was troubling.Promoting healthier lifestyles may help reduce the prevalence of costly chronic diseases, the CBO said, but the "overall budgetary effect also depends on the cost to the government... by people who live longer." It said such people could cost the government more in terms of health care costs and Social Security payments generated during their additional years of life.

Too often, the notion of investing more in prevention is being summarily dismissed on the grounds that prevention “doesn’t save money.” Such assertions have been repeated of late by articles in CQ (here for subscribers) and The Wall Street Journal. Those critics are asking the wrong question, and the answer to that question turns logic on its head. The proper question should be: what gives us the most bang for the buck?

Here are the facts: some preventive measures save money, while some don’t. Some medical treatments cost more than others. In each case, some are more effective than others in terms of improving health. But those facts should not result in a blanket dismissal of prevention. Even when preventive measures cost money, they offer tremendous benefits at a relatively low cost.

Partnership for Prevention conducted an extensive review of clinical preventive measures – those that can be performed in a doctor’s office. We found five measures that, if used more broadly, could altogether save an additional 100,000 lives a year. Three of those measures – daily aspirin use, tobacco cessation counseling, and colorectal screening – actually save money as well as lives. The other two – flu immunizations for older adults and breast cancer screening – save lives and are still more cost-effective than most medical treatments. Even so, all of those preventive measures remain under-utilized, due partly to lack of public awareness and partly to deductibles, co-pays and lack of coverage that can discourage clinicians from recommending those services and discourage patients from having them performed.

In a separate study, we reviewed the 25 preventive services recommended by the US Preventive Services Task Force. It found that six of them actually saved money, while 12 were highly cost-effective in that they cost less than $50,000 for each year of life saved. That compares with an LVAD device that helps keep alive heart failure patients who can’t get a transplant – which costs $900,000 per each year of life saved.

As for helping people live longer, prevention pleads guilty as charged. But should we really put proponents of prevention in the Orwellian position of apologizing for helping people live longer, healthier lives? Expensive medical treatments for people who are already sick also help people live longer. But isn’t that the whole purpose of our health care system?

Our current system doesn’t provide value, as evidenced by our low ranking in health status among industrialized countries. But prevention can help change that, because prevention provides great value. The investment to cover and pay for preventive services produces tremendous returns, and providing and increasing utilization of these services will create a much more efficient health care system.

Meanwhile, private-sector companies are reporting phenomenal results from implementing science-based wellness and prevention programs in the workplace. Safeway CEO Stephen Burd said in a recent Wall Street Journal op-ed that the wellness program his company started in 2005 has kept its health care expenses flat while those expenses increased by 38 percent nationally. Dow Chemical Company says that its wellness program saved the company more than 9,000 employee absentee days last year alone and had a return on investment that was equal to seven cents a share of company stock. Pitney Bowes estimates that its health promotion initiatives have saved the company $40 million over nine years.

Perhaps that’s why a recent survey of Americans by the Trust for America’s Health and the Robert Wood Johnson Foundation showed that 77 percent of Americans believe prevention will save money. Even more importantly, it showed that 72 percent of Americans favor increased investment in prevention, even if it didn’t save money.

It’s critical that we conduct widespread cost-effectiveness research to find out what delivers the most health at the least cost are critical. Prevention measures should be a part of that research, so that we can find the way in which our health care system can make the most effective and the most efficient use of both prevention and treatment services. In the meantime, we hope Congress will increase the nation’s investment in high-value preventive services that help people live longer, healthier lives.

Is prevention a “panacea for cost savings?” No, but that’s not the question. The real question is: is prevention a proven, cost-effective way to improve our health and our health system. The answer to that question is “yes.”

The American public and business community "get it" when it comes to the value of using disease prevention and health promotion to help reform the country's health care system, Partnership for Prevention President Robert J. Gould, PhD, said at a recent press conference on Capitol Hill.

Gould made the remarks at an event discussing a new survey that shows that public considers prevention the top priority in health reform. The survey, commissioned by Trust for America's Health and the Robert Wood Johnson Foundation, showed 72 percent support increased support for prevention programs, even if they don't save money.

"The public gets it, and business executives get it," said Gould. "Addressing the worsening health status of workers is critical to controlling future health care spending... And the polling data released today confirms the American public's support."

Gould said Partnership's "Leading by Example" initiative has helped CEOs at more than 40 American companies - including many Fortune 500 corporations - promote and implement effective worksite wellness programs.

"Increasingly, corporate executives are not just speaking out on the high cost of health care," he said. "They are creating compelling models to produce a healthier workforce."

Gould noted that President Obama last month held a roundtable discussion wtih business executives who were praised for their corporate efforts to contain health care costs. The dozen or so executives in attendance included those from three "Leading by Example" companies - Johnson & Johnson, Safeway, and Pitney Bowes.

Another "Leading by Example" company, Dow Chemical Co., recently testified on Capitol Hill that its worksite wellness programs last year saved 9,000 employee absentee days and yielded a return on investment equal to seven cents per share of company stock.

"Employer wellness programs are a win-win proposition for both the employee and the employer," he said. Even so, he said, many businesses - particularly small businesses - could use tax incentives to help them establish such programs.

To view a video recording of Gould's remarks, click here.

A new survey shows that Americans overwhelmingly support increasing prevention funding, even if it doesn't save money. The survey, commissioned by Trust for America's Health (TFAH) and the Robert Wood Johnson Foundation (RWJF) found that 72 percent of those surveyed agree with the statement that "investing in prevention is worth it even if it doesn't save us money, because it will prevent disease and save lives."

Poll participants ranked prevention as the most important health care reform priority. Seventy percent ranked it between an eight and 10 on a scale of zero to ten, where zero means not at all an important health care priority and 10 means very important. Forty-six percent rated prevention as a 10 out of 10. Overall, prevention was rated higher than all other proposals, including providing tax credits to small businesses and prohibiting health insurers from denying coverage based on health status.

The poll, conducted by Greenberg Quinlan Rosner Research and Public Opinion Strategies, found that 86 percent of Democrats, 71 percent of Republicans, and 70 percent of Independents supporting investing more in prevention. It also found that 77 percent of Americans agreed with the statement that "prevention will save us money."

Partnership for Prevention President Robert J. Gould took part in a press conference with TFAH yesterday to say the results are consistent with Partnership's experience working with corporations to establish worksite wellness programs.

"The public gets it and CEOS are getting it," Gould said. "One of the most hopeful trends in disease prevention and health promotion over the past several years has been the movement among corporations to promote health and wellness through worksite-based programs. More companies "are taking proactive measures to improve the physical health of their employees and the fiscal health of their organizations," he said.

To view video of Gould's remarks, click on the media player below. If you don't see a media player, click here.

Robert J. Gould, a behavioral scientist who has helped lead some of the nation’s most successful social marketing campaigns, has been named president of Partnership for Prevention. The appointment by Partnership’s board of directors was announced today by Dr. Jonathan E. Fielding, chairman of the board.

“Rob’s unique combination of behavioral science expertise, proven leadership, achievements in applying social marketing to health promotion and his passion for the mission of Partnership make him the right choice,” said Fielding, who is Director of Los Angeles County’s Department of Public Health and chairman of the US Community Preventive Services Task Force.

“I look forward to helping Partnership maintain the momentum it has gained in making science-based prevention a priority as policymakers grapple with re-shaping our country’s approach to health and health care,” said Gould. “Americans don’t just want better health care. They want and deserve health policies and programs that help them stay healthy.”

Gould brings to partnership more than 30 years of experience in health promotion, including more than 20 years with global communications firm Porter Novelli.

As leader of Porter Novelli’s Health and Social Marketing practice, he worked on anti-tobacco accounts that included the award-winning ‘truth’ campaign with the Florida Department of Health and the follow-on national ‘truth’ campaign with the American Legacy Foundation. He also worked with public and private non-profit organizations that included the American Cancer Society, the National Cancer Institute, the National Institute on Drug Abuse, the National Heart Lung and Blood Institute, Centers for Disease Control and Prevention and the American Heart Association. In the early ‘90s, Gould was the lead researcher in the development of the now iconic Food Guide Pyramid for the United States Department of Agriculture.

From 2001 to 2007, he was a partner at Porter Novelli and managing director of its Washington office – the second-largest operation within the firm.

In 1978, he received a PhD in social psychology at the University of Maryland, where he subsequently developed and taught a four-course marketing specialty track for its Masters of General Administration Degree program. He also taught in the Executive Masters program and administered its masters thesis program. Gould graduated Phi Beta Kappa from Bucknell University in 1973.