Don Wright, MD, MPH,
Principal Deputy Assistant Secretary for Health
Prevention Evidence Base in the Reformed Healthcare System
Committee on Health, Education, Labor and Pension
Wednesday December 10, 2008
Good afternoon, Mr. Chairman, and other distinguished Members of the Committee. I am Dr. Don Wright and it is a pleasure to appear before you as the Principal Deputy Assistant Secretary for Health of the US Department of Health and Human Services (HHS). I speak for the Department from my position in the Office of Public Health and Science, OPHS.
Today, I would like to share with you how we have invested the tax payers’ dollars in building the prevention evidence base and the infrastructure that will help launch a reformed health care system: one that is person-centered, provides seamless care in the clinic and in the community, delivers disease care and services to those who are ill, and also puts prevention first by promoting and protecting the health of those who are well.
The Department’s commitment to prevention is strong and as you will see is reflected in the broad and diverse activities across the Department.
I am proud to provide testimony about our Department’s comprehensive approach to prevention, coordinated by OPHS which is led by the Assistant Secretary for Health. We are working every day to realize our vision of a Nation in which healthy people live in healthy communities, sustained by effective, efficient and coordinated health systems.
The Case for Prevention
Largely preventable, chronic diseases have replaced infectious diseases as major killers in the United States. Chronic diseases cause 7 out of every 10 deaths each year. We know that 40 percent of deaths are caused by modifiable behaviors, such as poor nutrition, physical inactivity, and tobacco. Smoking, which causes heart disease, chronic bronchitis, emphysema and contributes to a host of other chronic diseases, costs our citizens’ untold suffering and loss of years of potential life every year and our economy billions of dollars in direct and indirect costs.
Expenditures for health care in the United States continue to rise. The vast majority of health care dollars are spent on direct medical care, despite the fact that clinical care is credited with only 5 of the 30 years that were added to life expectancy during the last century. Chronic disease consumes more than a trillion dollars every year. That’s three out of every four dollars we spend on health care compared to approximately five percent of total U.S. health care dollars spent on public health and preventive measures.
There is broad agreement among experts that prevention reduces health care costs. Precisely how much money preventive medicine saves is not clear, but certainly a stronger commitment of resources to prevention could significantly reduce rates of chronic illness and dramatically relieve the suffering of millions of Americans. Through successful prevention efforts we could reduce or even eliminate health care spending on preventable diseases and conditions. By making prevention the cornerstone of our health system and policies, we could realize one of our overarching goals – to increase the quality and years of healthy life. We could improve productivity and move toward eliminating illness, injury, suffering, pain and deaths that ought not to occur.
According to the Trust for America’s Health, with an investment of $10 per person per year in proven community-based disease prevention programs, the nation could yield a net savings of more than $2.8 billion in one to two years; more than $16 billion within five years, and Return on Investment (ROI) of $5.60 for every $1; and more than $18 billion within 10-20 years, and ROI of $6.20. The Congressional Budget Office notes that “…Proposals that encourage more prevention and healthy living can help promote better health outcomes, although their net effects on federal and total health spending are uncertain.”
HHS Focus on Prevention
In 2006, Secretary Mike Leavitt named prevention one of his top priorities to improve the nation’s health and to help prevent debilitating and costly health problems. Good individual health is built on a foundation of personal responsibility for wellness, which includes participating in regular physical activity, eating a healthful diet, taking advantage of medical screenings, and making healthy choices to avoid risky behaviors. To foster this preventive culture of wellness, the Department is investing in strengthening the prevention infrastructure and science base that offer the public the support they need to make informed healthy decisions whether at the individual, community, or state level.
The National Prevention Infrastructure: The Healthy People Initiative
For three decades the Department has built a national prevention infrastructure, focused upon establishing national health goals and measurable benchmarks tracking our success. This infrastructure of government and private sector stakeholders in health, the Healthy People Initiative, provides a comprehensive set of national 10-year health promotion and disease prevention objectives aimed at improving the health of all Americans. Since its inception, Healthy People grass roots input has helped identify the most significant preventable threats to health and establish national goals to reduce these threats.
Healthy People is founded upon the notion that establishing objectives and providing benchmarks to track and monitor progress over time can motivate, guide, and focus action. Each iteration of Healthy People has been the product of a multi-year, comprehensive collaborative process that reflects the ideas and expertise of a diverse range of individuals and organizations, both federal and nonfederal, concerned about the Nation’s health.
Currently, the Department is leading the development of Healthy People 2020. The initiative, in the tradition of its predecessors, will provide the definitive vision and strategy for building a healthier Nation. Healthy People is used by virtually all of our states and numerous foreign governments to develop their health plans.
We have gathered testimony from around the country that has shaped the framework for Healthy People 2020. The stakeholders believe that now is the time for our Nation to join together to address determinants of health - factors that directly influence health - such as physical environment, social environment, individual behavior, genetics and health care delivery systems. It is an exciting time at HHS as we begin to consider the objectives for the next decade that could have the greatest impact on these determinants of health.
Thanks to the Department’s investment in prevention science, there is a growing evidence base confirming the benefits of multiple prevention practices. Today, I will highlight the solid science of physical activity, nutrition, clinical preventive services, community preventive services and communication.
This year, the Department, through a collaborative effort developed and released the first-ever Federal Physical Activity Guidelines for Americans. Additionally, OPHS, in collaboration with CDC and other agencies, developed easy to understand, actionable guidance to help Americans fit a healthy level of physical activity into their lives.
Becoming and remaining physically active is one of the most important steps that Americans of all ages can take to improve their health. The Guidelines provide science-based information to help all Americans aged 6 years and older improve their health through appropriate physical activity. A communications toolkit for supporting organizations was developed to provide resources to encourage people to get the amount of physical activity they need.
Another important influence on health, nutrition, also has an impressive emerging science base which illustrates how to stay healthy by making healthy food choices.
HHS works with the Department of Agriculture to develop the Dietary Guidelines for Americans. Issued every five years, the Dietary Guidelines reflect the most accurate science, serve as the cornerstone for Federal nutrition policy, and are one of our most important tools for empowering Americans to enhance their health and help prevent lifestyle-related chronic disease. This year, HHS published the first-ever bilingual "Road to a Healthy Life, Based on the Dietary Guidelines for Americans" for Hispanic and Latino families nationwide. Obesity rates have increased in this population, and research shows that this audience needs better understanding of how to apply our national nutrition guidelines.
This publication is just one example of HHS’s focus on Eliminating Health Disparities and work toward achieving a nation where children, families, and communities have equitable opportunities for attaining optimal health, regardless of race/ethnicity, geography or any other demographic characteristic.
Two additional factors that impact health are taking advantage of proven clinical preventive services and community-based prevention support services.
The Agency for Healthcare Research and Quality (AHRQ) supports the U.S. Preventive Services Task Force -- an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services [http://www.preventiveservices.ahrq.gov]. The task force rigorously evaluates clinical research to assess the merits of preventive services, including screenings, counseling services and preventive medications, for people without signs or symptoms of disease. The USPSTF library of recommendations currently includes over 125 evidence-based recommendations. In 2008, the USPSTF released 12 recommendations: 3 preventive services for pregnant women; 3 services for children; and 6 services for adults. These included new recommendations on screening for diabetes; prostate and colorectal cancer; and, counseling to promote breastfeeding.
AHRQ ensures that Americans receive these proven clinical preventive services by developing tools and products to facilitate the dissemination and use of the evidence-based USPSTF recommendations. Each year, AHRQ publishes The Guide to Clinical Preventive Services, a pocket-sized book formatted for clinicians to consult for prevention guidance in their daily practice. AHRQ also has created the electronic Preventive Services Selector, a Website that allows clinicians to search USPSTF recommendations during an office visit based on a patient’s age, sex and risk factors. The Selector can also be downloaded to a clinician’s PDA or Blackberry. AHRQ is currently working to embed the Selector into electronic health records.
To accomplish this work, AHRQ also builds and leverages public-private partnerships. Partnering with the National Business Group on Health and CDC, AHRQ supported the publication, A Purchaser’s Guide to Clinical Preventive Services, to move the science of clinical prevention into benefit coverage decisions. Over 250,000 copies have been distributed. In its Hispanic Elders Learning Network, AHRQ, working with federal and local partners, mobilized, organized, and coordinated local DHHS and community resources to reduce disparities in health outcomes among Hispanic elders in eight communities.
In addition, AHRQ is moving the field of prevention science by investing in research to improve our understanding of the preventive health care needs of patients with multiple chronic conditions. The ultimate goal of this work is to develop personalized, patient-centered decision aids for patients and their providers. In collaboration with the Office of Disease Prevention and Health Promotion, the website, My healthfinder (www.healthfinder.gov) provides personalized prevention recommendations specific to the user’s age, gender and pregnancy status. It was designed to be understandable and actionable for everyone, including people with limited health literacy.
The Guide to Community Preventive Services summarizes what is known about the effectiveness, economic efficiency, and feasibility of interventions to promote community health and prevent disease. The Task Force on Community Preventive Services, an independent decision making body convened by CDC for HHS, makes recommendations for the use of various interventions based on the evidence gathered in rigorous and systematic scientific reviews of published studies conducted by review teams for the guide. The findings from the reviews are published in peer-reviewed journals and also are made available online. The task force has published over 100 findings across 16 topic areas, including tobacco use, physical activity, cancer, oral health, diabetes, motor vehicle occupant injury, vaccine-preventable diseases, prevention of injuries due to violence, and social environment.
Additional HHS Prevention Activities
As I mentioned earlier, there is tremendous work going on within HHS in the area of prevention which supports and expands upon the framework established by the Healthy People initiative. I’d like to share some other examples which represent the diversity of the contributions that HHS makes.
The HealthierUS initiative is a national effort to improve people's lives, prevent and reduce the costs of disease, and promote community health and wellness. It focuses the nation’s attention on high impact prevention practices: getting and staying physically active, eating a nutritious diet, avoiding risky behaviors and getting preventive screenings.
Among its many educational and scientific efforts, the Office of the Surgeon General heads a prevention initiative, Healthy Youth for a Healthy Future to help prevent overweight and obesity in children. This initiative seeks to increase public awareness of the child obesity epidemic and to share information about effective community efforts to reduce child overweight and its consequences. To date, the Acting U.S. Surgeon General visited more than 30 cities to learn about local programs and meet with public health stakeholders and community leaders to discuss local prevention, physical activity and nutrition programs.
The Office of HIV and AIDS Policy (OHAP) is using the power of new media to reach untapped audiences who are at risk for HIV/AIDS—giving people the information they need on HIV at the time and in the format they want it. New media is a highly effective, low-cost way of reaching at-risk individuals with HIV prevention, testing, and treatment messages—and AIDS.gov is spearheading HHS’ use of new media to prevent the spread of HIV/AIDS.
The Office of Population Affairs (OPA) manages the Title X program, the only Federal program solely dedicated to family planning services with a mandate to provide “a broad range of acceptable and effective family planning methods and services,” and related preventive health services such as information and education, routine gynecological care, clinical breast examinations, Pap tests, and sexually transmitted diseases (STDs) and HIV/AIDS prevention education, testing and referral services. In addition, the Adolescent and Family Life (AFL) program provides discretionary demonstration grants to develop, to implement and to test innovative approaches through two initiatives: (1) prevention programs promoting abstinence among adolescents; and (2) care programs providing health, education and social services to pregnant and parenting adolescents, their infants, teen fathers, male partners and their families.
The Office on Women’s Health (OWH) educates and advocates for healthy behavior and choices among women and girls to prevent illness and improve health outcomes. To address this priority, the OWH conducts media campaigns such as the National Lupus Awareness Campaign to increase awareness of the disease and to promote early detection of it; supports programs to end violence against women on college and university campuses; funds programs to encourage the use of a public health systems approach with an evidence-based strategy and a gender focus to improve service delivery and to increase access to care; and, implements programs that address cardiovascular diseases, obesity prevention, and other diseases that affect the health and well-being of women and girls. These efforts and others, address another OWH priority area – reduction of the leading causes of death for women and girls
The President's Council on Physical Fitness and Sports is an advisory committee of volunteer citizens who advise the President through the Secretary of Health and Human Services about physical activity, fitness, and sports in America. Among other activities, it leads and oversees the President's Challenge -- a program that encourages all Americans to make being active part of their everyday lives.
The Office of the Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary on policy development in health, disability, aging, human services, and science, as well as economic policy. ASPE conducts research and evaluation studies, develops policy analyses, and estimates the cost and benefits of policies and programs including the Department’s prevention activities.
The Office on Disability (OD) works collaboratively with Federal agencies and nonfederal partners to develop and coordinate policies aimed at improving the health and lives of persons with disabilities, for example, promoting the Surgeon General’s Call to Action (CTA) to Improve the Health and Wellness of Persons with Disabilities through the national action plan, and physical activity for youth with disabilities in conjunction with the President’s Healthier US Initiative through the OD’s “I Can Do It, You Can Do It!.” During emergency or catastrophic events, OD helps to ensure that medical and general shelters are accessible for persons with disabilities.
The Administration on Aging (AoA) has been a principal partner with the Centers for Medicare and Medicaid Services (CMS) in providing outreach, education and personalized counseling, through the Aging Services Network, to inform and encourage beneficiaries to take advantage of Medicare’s Part D and preventive benefits including: flu and pneumonia shots; screenings for cardiovascular disease, colorectal cancer and diabetes, the “Welcome to Medicare” physical exam, and diabetes self-managing training. AoA is partnering with CDC, AHRQ, CMS and HRSA and private philanthropy to help community-based aging services provider organizations, such as senior centers, to implement science-based prevention-focused models that have proven effective at helping seniors to better manage their chronic conditions, reduce their risk of falling, and improve their nutrition and physical activity. AoA and its HHS partners are working with eight metropolitan communities to address the serious health disparities affecting Hispanic seniors, the fastest growing minority group within the older population.
The Centers for Disease Control and Prevention’s (CDC′) primary focus is on protecting health, rather than treating illness, and carries out that mission through health promotion, prevention and preparedness, rather than disease care; and on creating holistic approaches for improving the population’s health across all stages of life, not narrowly defined activities. CDC efforts on a set of fundamental Health Protection Goals are designed to accelerate health improvement, reduce health disparities, and protect people at home and abroad from current and new health threats. These goals drive research priorities, policy development, and programs and interventions.
The National Institutes of Health (NIH) supports a broad spectrum of research on prevention, including efforts to improve nutrition, increase physical activity, and reduce sedentary behaviors. In the area of obesity prevention, for example, NIH-funded scientists are investigating a variety of behavioral and environmental interventions in children and adults; in diverse populations, with an emphasis on those disproportionately affected by obesity; and in a variety of sites, including schools, the home, worksites, primary care practices, and other community settings. Preventing the serious diseases associated with obesity is also a research focus. For example, the multi-center HEALTHY study is testing a middle school-based intervention to reduce risk factors for Type 2 diabetes, including overweight and obesity. Components of the HEALTHY study include changes in school food services and physical education classes, along with activities to promote healthy behavior and family outreach. Through its translational research efforts, the NIH supports studies to explore potentially cost-effective ways to bring the results of intervention studies to broader community settings and medical practice.
At the same time, the NIH is pursuing research that may inform the development of new strategies to prevent (as well as treat) obesity. These include basic research avenues as well as epidemiologic and other studies to provide insights into potential contributors to obesity, such as economic factors and aspects of neighborhoods that may influence eating patterns and activity. Finally, through its information, education, and outreach activities, the NIH is disseminating research results to patients, healthcare providers, and the public. For example, the NIH is currently updating its Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. In a major national public education and outreach effort for children, the NIH’s We Can! (Ways to Enhance Children’s Activity and Nutrition) program is designed to help children 8-13 years old stay at a healthy weight. We Can! is based on evidence from research findings. The program focuses on parents and families in the home and community settings, and many national partners and supporting organizations are promoting We Can! messages and materials.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has made progress in reducing drug and alcohol misuse and abuse.
SAMHSA reports that illicit drug use has dropped more than 20 percent among teens. To continue to drive these numbers down, SAMHSA supports community-driven substance abuse prevention and mental health promotion programs through Strategic Prevention Framework State Incentive Grants and Drug-Free Community grants.
SAMHSA is concurrently emphasizing mental health prevention activities. It is important to note that half of all lifetime cases of diagnosable mental illnesses begin by age 14 and three-fourths by age 24. Furthermore, 1 in 12 adolescents experience a significant depressive episode each year, underscoring the need for an upstream approach. This past year SAMHSA expanded its efforts in prevention beyond Suicide Prevention to include a new imitative called Project LAUNCH.
Project LAUNCH promotes the wellness of young children 0 to 8 years of age. It is grounded in the public health approach by promoting coordinated programs that take a comprehensive view of health, addressing the physical, emotional, social and behavioral aspects of wellness. The first six grants under this program were awarded this past September.
Centers for Medicare and Medicaid Services
Promoting preventive health is an underlying component of all Centers for Medicare & Medicaid Services (CMS) programs, initiatives, and outreach efforts to Medicare beneficiaries, providers, partners and caregivers. Preventative health efforts are thoroughly entrenched in the CMS’ outreach and education activities.
Medicare: Medicare covers many important screenings and other prevention benefits to help people with Medicare live healthier and more active lives. When beneficiaries become eligible for Medicare, they are offered a “Welcome to Medicare” physical to assess their overall health condition. Medicare also covers cardiovascular disease and diabetes screenings, glaucoma tests, osteoporosis screenings, mammography, cervical cancer screenings, prostate cancer screenings, colorectal cancer screenings, influenza and pneumococcal vaccinations, and smoking cessation counseling.
Most recently, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorized the HHS Secretary to add coverage (beginning in 2009) of additional preventive services recommended by the U.S. Preventive Services Task Force and determined through the Medicare National Coverage Determination process to be reasonable and necessary for Medicare beneficiaries. In making such determinations, the Secretary may consider the relation between predicted outcomes and the cost of such services.
CMS is currently conducting or developing several prevention demonstration projects, for example, the Cancer Prevention and Treatment Demonstration for Racial and Ethnic Minorities and a Senior Risk Reduction Demonstration.
Medicaid: While States are the primary administrators of Medicaid and State Child Health Insurance Program (SCHIP), CMS is responsible for supporting States in their efforts to achieve safe, effective, efficient, patient-centered, timely and equitable care.
CMS works with States to implement several quality/prevention efforts including smoking cessation counseling, prenatal care, neonatal improvement outcomes, asthma management, immunizations for children and adults, and Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, lead screening, cancer screenings, and obesity prevention initiatives.
The mission of Food and Drug Administration (FDA) is to prevent illness and injury through the regulation of foods and medical products. FDA continues to implement recommendations contained in the FDA Obesity Working Group Report of 2004.
- In an Advance Notice of Proposed Rulemaking (ANPRM) on the Revision of Reference Values and Mandatory Nutrients, November 2007, FDA addressed comments on two prior food labeling ANPRMs (serving size & prominence of calories).
- FDA is increasing awareness/use of nutrition facts on labels in making individual choices regarding food through the following activities:
- Promoting “Spot the Block -- Get Your Food Facts First” launched with the Cartoon Network, March 2007.
- Expanding “Make Your Calories Count,” an interactive learning tool.
- Developing curriculum with National Science Teachers Association
The Health Resources and Services Administration (HRSA) is the primary Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable including people living with HIV/AIDS, pregnant women, mothers and children. For example, community-based and patient-directed Community Health Centers serve populations with limited access to health care, low income, no insurance, limited English proficiency, as well as migrant and seasonal farm workers, individuals and families experiencing homelessness, and those living in public housing.
Health centers provide comprehensive, primary health care and preventive care services. In 2007 health centers served over 16 million patients. Many programs within HRSA contain prevention as a key component such as The Maternal and Child Health Services Block Grant Program providing grants to States to reduce infant mortality, to provide access to comprehensive prenatal and postnatal care for women, and to increase the number of children receiving health assessments and follow-up diagnosis and treatment. In addition, the Healthy Start program provides intensive services tailored to the needs of high risk pregnant women, infants and mothers in communities with exceptionally high rates of infant mortality. To increase the healthcare workforce who can provide preventive services to vulnerable populations, HRSA funds programs to recruit and retain physicians in rural hospitals and clinics. HRSA’s telehealth program uses information technology to link isolated rural practitioners to medical institutions over great distances.
The Indian Health Service (IHS) has a Prevention Initiative to bring more focus on preventive health care within IHS and among Tribally operated programs. The IHS Prevention Task Force (PTF), with broad representation from IHS and Tribal programs, is responsible for identifying the key components for a coordinated and systematic approach to preventive health activities at all levels of health care for American Indians/Alaskan Natives. The work of the IHS Prevention Task Force is fully integrated with past and on-going health initiatives within HHS, such as Healthy People 2010 and more recently the Secretary's Steps to a Healthier US.
The focus areas of the Prevention Initiative are also entirely consistent with the priorities of the IHS Strategic Plan and performance measures identified in the congressionally directed Government Performance and Results Act (GPRA) reporting system. Additionally, the PTF receives guidance from the Policy Advisory Committee which consists of Tribal leaders, at the national and local levels, and representation from other federal agencies (e.g., CDC, NIH) that focus on health promotion and disease prevention.
HHS Prevention Budget
I am profoundly honored to be a part of this robust Prevention Infrastructure and Science Base that holds great promise for helping us realize our vision, which is worth repeating here - A Nation in which healthy people live in healthy communities, sustained by effective, efficient and coordinated health systems.
The FY 2009 President’s Budget includes discretionary funds to support prevention activities across the Department and to sustain this Prevention Infrastructure and Science base. Additionally, the FY 2009 Budget includes mandatory funds for prevention efforts in Medicaid and Medicare.
As my description of HHS activities illustrates, our disease prevention efforts cut across agencies and missions. Encouraging Americans to make healthy choices, contributes to the creation of a culture of wellness, which is, after all, everybody’s business.
The Department’s investment in a comprehensive prevention infrastructure and growing prevention and communication science base sets the stage for health care reform in which the public should be able to expect seamless, coordinated care and the best support for making healthy decisions that science has to offer.
It is accurate to say that whatever the specifics of future efforts to reform American health care, a consensus exists that the system of the future will be founded upon prevention and recognition of its value. Put another way, if prevention is the future - and it is - then the future is now.
Last revised: April 19, 2011