1. Returns on Investments in Health J. Michael McGinnis, MD The Robert Wood Johnson Foundation

2. 12 questions What kills? What cripples? How much does it cost? What counts? What’s the big picture? How do we invest? What’s effective? How effective? What’s cost effective? How do Rx and Px compare? What are our prevention priorities? What else matters?

3. What kills? 1) 2) 3) 4) 5) 6) 7) 8) Heart disease710,760 Malignant neoplasms553,091 Cerebrovascular diseases167,661 Chronic lower respiratory disease122,009 Unintentional injury 97,900 Diabetes mellitus 69,301 Influenza and Pneumonia 65,313 Alzheimer’s disease 49,558 Nephritis 37,251 Septicemia 31,224 Leading Causes of Death in U.S., 2000

4. What cripples? Leading Causes of Disability Among U.S. Adults, 1999 Percent of 41.2 million persons with a disability

5. How much does it cost?

6. What we spent in 1997 (4,095) (2,611)

7. Male life expectancy 1996 1. Japan77.015. Austria73.7 2. Sweden76.516. Germany73.6 3. Iceland76.217. Belgium73.5 4. Switzerland75.718. Ireland73.2 5. Canada75.719. Luxembourg73.0 6. Norway75.420. Finland73.0 7. Australia75.221. Denmark72.9 8. Greece75.122. United States72.7 9. Italy74.923. Portugal71.2 10. Netherlands74.724. Czechoslovakia70.4 11. Spain74.525. Mexico70.1 12. New Zealand74.326. Poland67.8 13. United Kingdom74.327. Hungary66.6 14. France74.228. Turkey65.9

8. What counts? Actual Causes Of Death, 1990 Tobacco 400,000 Diet/activity patterns 300,000 Alcohol 100,000 Microbial agents 90,000 Toxic agents 60,000 Firearms 35,000 Sexual behavior 30,000 Motor vehicles 25,000 Illicit Drug use 20,000

9. What counts? Diet/inactivity patterns 500,000 Tobacco 400,000 Alcohol 80,000 Microbial agents 60,000 Toxic agents 60,000 Sexual behavior 40,000 Firearms 35,000 Motor vehicles 25,000 Illicit Drug use 25,000 Actual Causes Of Death, 2000

10. What’s the big picture? Genetics 30% Environment 5% Social 15% Behavior 40% Health care 10%

11. How do we invest? Medical Treatment Health Expenditures Premature Mortality Behavioral Genetic Health Care Environmental Social Population-wide effort

12. What’s effective? Immunization and chemoprophylaxis e.g. vaccines (childhood, influenza, pneumococcal), folic acid, aspirin, ocular Screening and early intervention e.g. newborn, colonoscopy, mammography, blood pressure, cholesterol, chlamydia, vision, hearing Counseling e.g. tobacco, alcohol, physical activity, diet, infant feeding, child safety, STD risk

13. How effective?

14. What’s cost-effective?

15. Costs of prevention—examples Median $/QALY Immunizations$ 1,500 Chemoprophylaxis$ 13,000 CVD screening$ 3,300 Cancer screening$ 18,500 HIV counseling$ 1,200 CVD counseling$ 74,000 Blood donor screening$ 355,000 Autologous blood donation$ 730,000 Source: Stone, et al, AJPM 2000: 19(1)

16. Score QALYs saved 5325,000 to 2,600,000 465,000 to 185,000 333,000 to 55,000 219,000 to 27,000 1100 to 12,000 Ranking: clinically preventable burden

17. ScoreCost ($)/QALY saved 5Most likely cost saving 4May be cost saving to 12,000 312,000 to 18,000 219,000 to 35,000 143,000 to 2,000,000 Ranking: cost effectiveness

18. What are the prevention priorities?

19. ServiceCPBCETotal Childhood vaccination5510 Adult tobacco cessation54 9 Vision screen >6545 9 Cervical cancer screen >1853 8 Hypertension screen53 8 Adult cholesterol screen52 7 Breast cancer screen42 6 Child safety counsel 0-414 5 Folic acid counsel13 4 Rubella screening11 2 Source: Coffield et al, AJPM What are the prevention priorities?

20. Costs of treatment—examples Median $/QALY Atrial fib (anticoag with 1 RF)$ 8,000 Atrial fib (anticoag with 0 RF)$ 370,000 Diabetes (intensive glycemic control)$ 41,000 Hepatitis C (pegylated interferon)$ 46,000 Sepsis (Rx APACHE >25)$ 24,000 Sepsis (Rx APACHE <24)$ 575,000 HIV (3 drug antiretroviral)$ 23,000 Emphysema (lung reduction surgery)$ 190,000 Lung cancer (CT screening)$ 48,000

21. Lessons …….we pay going in… …….we pay coming out… …the returns to prevention: Priceless!!

22. What else matters? not just clinical assessments… cost benefit analysis cost effectiveness analysis ranking schemes but public policy… health impact assessments

23. Sample HIA (local) City of Los Angeles Living Wage Employees working on city contracts must be –paid at least $7.99/hour –provided health insurance, or an additional $1.25/hour Covers approximately 10,000 workers Health insurance coverage more cost-effective in reducing excess mortality than an equivalent amount in the form of wages Any changes to the ordinance should consider increasing health insurance coverage Applicability: many living wage ordinances throughout the US Source: Fielding et al, 2003

24. Sample HIA (state) After-school program funding California ballot Proposition 49 to set aside $550 million per year for after-school programs in grades K - 8 Potentially significant health outcomes through effects on education, crime, substance abuse, etc. Counterintuitive result: unlikely to yield any significant health benefits. Chiefly due to: –small magnitude of effects on key mediators –Inadequate targeting, recruitment and retention of high- risk youth Source: Fielding et al, 2003

25. Keep the big picture in mind Genetics 30% Environment 5% Social 15% Behavior 40% Health care 10%