Healthy Vision 2010 August 30, 2006

“Framework for Health: Population-based Components of

the Health System”Eduardo J. Sanchez, MD, MPH

Commissioner, Texas Department of State Health Services

Evidence of Effectiveness

A growing body of evidence indicates that population-based interventions:– Promote health– Prevent disease– Generate a favorable Return on

Investment (ROI)– Compliment efforts of the medical care

delivery system– Reduce demand for medical care

Growth in National Health Expenditures 1980–2011 from $1,000 to $9,000

Levit et al. Health Affairs 2002;21:172–181. *Projection from Heffler et al. Health Affairs 2002;21:207–218.

0

2,000

4,000

6,000

8,000

10,000

1980 1998 2004 2011*

Per

Cap

ita C

osts

$6280 (2004)

Public Health

$

Health Care: Are We Getting Our Money’s Worth?

65 years +

MedicalCare

0 years

People of Texas

Dollars Expended$

Determinates of Premature Mortality

• 50% behavior & lifestyle

• 20% environmental exposure

• 10% access to health care

Alder, Newman “Socioeconomic Disparities in Health,” Health Affairs Vol 21 #2

Public Health

$

Health Care: Are We Getting Our Money’s Worth?

65 years +

MedicalCare

0 years

People of Texas

Dollars Expended$

Tobacco Interventions

Leading Actual Causes of DeathTexas, 2001

Tobacco is the single most preventable cause of death & disease in Texas

2181,0521,4051,8072,214

2,8513,736

11,13218,649

24,899

0 5000 10000 15000 20000 25000 30000

Fire

AIDS

Homicide

DWI**

Suicide

Drugs*

Auto Accidents

Alcohol*

Overweight/Obesity

Tobacco

Smoking Rates for Harris & Jefferson Counties 2000-2005

Reducing tobacco use requires a comprehensive & sustained approach. Gains in Harris County regressed as

resources/efforts were reduced.

10.0

12.0

14.0

16.0

18.0

20.0

2000 2001 2002 2003 2004 2005

Year

Pre

vale

nce

Jefferson Harris

• Funding for Comprehensive Tobacco Prevention and Cessation Programs

• Tobacco Excise Tax Increases

• Restrictions on Secondhand Smoke

• Coverage for Smoking Cessation

Policies That Make a Difference

Texas Tobacco Task Force ReportProgram Elements and Best Practices

• Community & School Programs

• Media Campaigns• Cessation• Enforcement• Efforts Targeted to

Diverse/Special Populations

• Surveillance & Evaluation Research

Comprehensive Program Results(For Only $3 Per Capita)

• 36% reduction in smoking, 6th-12th grade

• 26% reduction in adult smoking

Double the statewide rate of reduction

Texas Community-BasedTobacco Cessation Initiatives

• a Smoke Free Paso del Norte - $3.3 million 4-year program

• Tobacco Free Amarillo - $400,000 grant from the Amarillo Hospital District (Tobacco Settlement Funds)

Financial Returns from Investments in Tobacco Control

After 5 years a one-time investment of $68 million ($3 per capita) would save:

  More than $1 billion in medical costs

~ $400 million in productivity costs

~ 163,000 fewer smokers

This represents a 20:1 ROI

Center for Health Research, Kaiser Permanente Northwest, June 2006

Obesity Interventions

States With Highest Prevalenceof Adult Obesity

1. Mississippi2. Alabama3. West Virginia4. Louisiana5. Tennessee6. Texas, Kentucky, Michigan

“How Obesity Policies are Failing in American” Trust for America’s Health August 2005,

Adult Obesity Prevalence U.S & Texas, 1990-2004

0

5

10

15

20

25

30

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Perc

enta

ges

U. S.

Texas

Obesity (BMI >=30), BRFSS, 1990-2004

Overweight Youth in TexasCompared to National Data

0

5

10

15

20

25

30

35

40

45

1963 to69

1971 to74

1976 to80

1988 to94

1999 to2002

2003-2004

TX '00-02 TX '04-05

6-11 Yrs/4th

12-19 Yrs/8th

11th grade

Source: Hoelscher et al., 2004; Ogden et al., 2006; SPAN, 2004-2005

HealthyPeople

2010Goal

*Percent

Overweight

Obese

Can We Identify a “$3 Per Capita” Strategy To Address Obesity in Texas?

Community-based interventions

– Where we work

– Where we learn

– Where we play

– Where we pray

2006 SPAN Data Suggest School-Based Interventions Are Having An Impact

• Texas-wide, 8th graders same level of overweight as 4 years ago

• 4th graders had a slight decrease

• 11th graders showed a 1/3 increase in overweight (14.5% to 19%)

• Region 9/10 (El Paso) showed ~25% reduction in obesity among 4th graders

Cost of Gastric Bypass Surgeries

$25,000

x 1,000,000Morbidly obese Texans

$25 Billion

Comprehensive School Health Programs

4,258 Texas Public Elementary Schools

$2,500 Average Cost for Coordinated School Health

4258

x 2500

$10,645,000

1/10 of 1% reduction in obesity would pay for program

Mental Health Interventions

Mental Illness Strikes More Americans Each Year Than Other Serious Illnesses

0

5

10

15

20

25

30

% A

du

lts

Mental Illness

Serious Mental Illness

CVD Diabetes Cancer Asthma

CDC BRFSS, SEER Cancer Statistics Review, 1975-2002, “Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders”  Arch Gen Psychiatry.  Vol. 62, June 2005

Mental Health Community Crisis Services for Children and Adults

Total ER Visits

46%54%

46% of all ER visits have behavioral health issues as a basic or contributing factor

Mental Health Community Crisis Services for Children and Adults

• Reduced use of costly care settings, i.e., emergency rooms, state hospitals and jails

• Reduced need for transportation to state hospitals for short-term stabilization

• Reduced homicide and suicide• Minimized impact on the health and social

services system• Every $1 spent on mental health services saves $5

in overall health care (Am. Psychological Association)

Mental Health Community Crisis Services for Children and Adults

$0

$93

Average MonthlyER Costs

per Medicaid Client

ER COST OFFSET (- $25) Average per Client per Month27 percent reduction

Fiscal Year 2005 Texas average monthly Emergency Room (ER) costs were 27 percent lower for Medicaid clients receiving needed

DSHS community mental health treatment.

$93 Untreated(N=13,642) $68

Treated(N=33,472)

Public Health & Mental Health

• Ensure that Texans understand mental health is essential to overall health

• Expand efforts to prevent or delay onset and reduce severity of mental illness & substance abuse

• Incorporate competent mental health screening, assessment, brief intervention & referral into primary care settings

• Eliminate disparities of access, outcomes & resources

Opportunities for Texas

• Better understand epidemiology of mental health and substance abuse

• Integrate care at the local level

• Build capacity of primary care providers & ER departments to identify, treat and refer across disciplines

• Reduce barriers to treatment

Evidence of Effectiveness

A growing body of evidence indicates that population-based interventions:– Promote health– Prevent disease– Generate a favorable Return on

Investment (ROI)– Compliment efforts of the medical care

delivery system– Reduce demand for medical care

Will Strategies to Improve Access to Medical Care Improve Health?

In response to a high incidence of 911 calls for heart attacks in a given zip code, should we:

• Keep an ambulance ready to go in the community?

• Establish a primary care facility in the community?

• Improve parks, walking trails & access to fresh produce?