1. A Transforming Health System: Opportunities for Conquering Cancer Jeffrey Levi, PhD 9 th Annual WI Comprehensive Cancer Control Summit March 29, 2012

2. Assumptions  Health reform/transformation is happening regardless of the political storm Quality movement pre-dates ACA Electronic health records are separate from ACA Key elements of ACA already in place and unlikely to be repealed Key elements of ACA taking effect in 2014 are unlikely to change even if individual mandate is repealed or found unconstitutional

3. Overview: The opportunities in health reform  A new vision for access (coverage) Close to universal coverage  An expanded vision for quality Restructuring delivery systems to improve quality Performance measurement EHRs Comparative Effectiveness  Prevention moves beyond the clinic  Levers for change from a cancer perspective

4. Access  Underwriting reforms Pre-existing conditions, rate setting  Medicaid expansion What will the benefits package look like  Exchanges as just a marketplace or also a force for change (quality, prevention, workplace) Essential health benefits; provider networks

5. Quality  National Quality Strategy  Commitment to performance measurement Meaningful use of HIT New opportunities for defining public health surveillance – what we ask, how we use it  Delivery systems – ACOs, medical homes  Comparative effectiveness research

6. Prevention: It’s not just for clinicians anymore  ACA incorporates broad definition of prevention: where we live, work, learn, and play Comprehensive clinical preventive services removing financial barriers Investment in community prevention through the Community Transformation Grants  Prevention Fund drives other changes in this direction Center for Medicare and Medicaid Innovation  Population level changes that save money and improve outcomes

7. Real money for prevention  Prevention and Public Health Fund $12.5 billion over the next 10 years Mandatory funding stream  Cut as part of “doc fix” Danger of supplantation vs. emphasis on modernization and transformation  FY 13 budget request – major cuts at CDC but leveraging of consolidated chronic disase grants – what does that mean for cancer?

8. PPHF FY 2012 Cancer-related $  REACH--$40 million  Community Transformation Grants -- $226 million  Tobacco activities -- $83 million

9. True community-based prevention  Community Transformation Grants Requires detailed plan for policy, environmental, programmatic and infrastructure changes to promote healthy living and reduce disparities Replicate the National Prevention Council approach (across silos)  Targeted areas (active living and healthy eating, tobacco, clinical preventive services – hypertension and cholesterol)  Community approaches  Improve access to clinical preventive services A real investment: $900 million over 5 years

10. What might CTGs look like?  Examples of policy and structural change High impact efforts to make healthy choices easier Sustainable over time  Smoke free air laws; seat belt laws; child car seats  “Health in all policies” at state and local levels  Improved nutrition choices in schools, supermarkets, corner stores  Zoning policies  Supports implementation or capacity development  Expectations: Demonstrated ability to bring together a coalition Inclusion of state/local public health agencies in coalitions

11. National Prevention Strategy: Setting a Bigger Table for Health  Vision Working together to improve the health and quality of life for individuals, families, and communities by moving the nation from a focus on sickness and disease to one based on prevention and wellness.  Overarching goal: Increase the number of Americans who are healthy at every stage of life.  Partnerships: 17 federal agencies addressing determinants of health  Co-benefits of addressing health – mutual self interest Public sector at all levels; private sector at all levels

12. The National Prevention Council Bureau of Indian AffairsDepartment of Labor Corporation for National and Community Service Department of Transportation Department of AgricultureDepartment of Veterans Affairs Department of DefenseEnvironmental Protection Agency Department of EducationFederal Trade Commission Department of Health and Human Services Office of Management and Budget Department of Homeland Security Office of National Drug Control Policy Department of Housing and Urban Development White House Domestic Policy Council Department of Justice

13. Strategic Directions: Healthy and Safe Community Environments  Clean air and water  Affordable and secure housing  Sustainable and economically vital neighborhoods  Make healthy choices easy and affordable

14. Clinical and Community Preventive Services  Evidence-based preventive services are effective  Preventive services can be delivered in communities  Preventive services can be reinforced by community-based prevention, policies, and programs  Community programs can promote the use of clinical preventive service (e.g., transportation, child care, patient navigation issues)

15. Empowered People  Even when healthy options are available and affordable, people still must make the healthy choice  People are empowered when they have the knowledge, resources ability, and motivation to identify and make healthy choices  When people are empowered, they are able to take an active role in improving their health, supporting their families and friends in making healthy choices, and leading community change

16. Elimination of Health Disparities  Health outcomes vary widely based on race, ethnicity, socio-economic status, and other social factors  Disparities are often linked to social, economic or environmental disadvantage  Health disparities are not intractable and can be reduced or eliminated with focused commitment and effort

17. Priorities  Tobacco Free Living  Preventing Drug Abuse and Excessive Alcohol Use  Healthy Eating  Active Living  Mental and Emotional Well- being  Reproductive and Sexual Health  Injury and Violence Free Living Source: National Vital Statistics Report, CDC, 2008

18. Recommendations (Example ) Encourage community design and development that supports physical activity. Promote and strengthen school and early learning policies and programs that increase physical activity. Facilitate access to safe, accessible, and affordable places for physical activity. Support workplace policies and programs that increase physical activity. Assess physical activity levels and provide education, counseling, and referrals. Active Living

19. NPS Implementation Resources: Indicators/Key Documents IndicatorCurrent10-Year Target Proportion of adults who meet physical activity guidelines for aerobic physical activity 43.5%47.9% Proportion of adolescents who meet physical activity guidelines for aerobic physical activity 18.4%20.2% Proportion of the nation’s public and private schools that provide access to their physical activity spaces and facilities for all persons outside of normal school hours 28.8%31.7% Proportion of commuters who use active transportation (i.e., walk, bicycle, and public transit) to travel to work 8.7%20.0% Key Documents - Physical Activity Guidelines for Americans -The White House Task Force on Childhood Obesity Report to the President

20. Goal ∙ Strategic Directions ∙ Priorities

21. Recommended Actions For Partners  States, tribal, local, and territorial governments  Health care systems, insurers, and clinicians  Businesses and employers  Early learning centers, schools, colleges, and universities  Community, non-profit, and faith-based organizations  Individuals and families

22. NPS Implementation Resources: Evidence-Based Recommendations  The Guide to Community Preventive Services  The US Preventive Services Task Force  Healthy People 2020  The Institute of Medicine  Cochrane Reviews

23. Doing away with stovepipes  Thinking about interventions and populations rather than diseases Interventions are cross-cutting Social determinants of risk and poor outcomes are not going to be addressed on a disease-by-disease basis

24. Small changes matter  BC Study of Physical Activity Costs  Evidence indicates that in British Columbia, 15% of heart disease, 19% of stroke, 10% of hypertension, 14% of colon cancer, 11% of breast cancer, 16% of Type 2 Diabetes, and 18% of osteoporosis cases are attributable to physical inactivity.  If just 10% fewer British Columbians were physically inactive – that is, if the rate of physical inactivity were 34.2% instead of 38% - the province could save an estimated $18.3 million every year in avoided hospital, drug, physician and other direct costs. Added to an estimated $31.1 million in productivity gains, total economic savings to British Columbia from a 10 % reduction in physical inactivity amount to $49.4 million.  http://www.gpiatlantic.org/pdf/health/inactivity-bc.pdf

25. Small changes matter (2)  1% reduction in adult BMI at population level: nearly 16,000 fewer cases of diabetes, heart disease and stroke, and cancer (73K)  Incidence of cancer per 100,000 population related to obesity in 2020: Current trend: 1820 1% reduction in BMI: 1805 5% reduction in BMI: 1750

26. Small changes bend the cost curve

27. Where to make a difference?  Exchanges – structure, consumer rep, oversight, workplace wellness Essential Health Benefits Essential Health Providers  Community Benefit  Surveillance  Bring the National Prevention Strategy home  Community Transformation Grants and other policy efforts

28. For more information  Keep up with developments: www.healthyamericans.org/health-reform advocates@tfah.org