Chairman STARK. Dr. Fielding. STATEMENT OF JONATHAN E. FIELDING, M.D., MEMBER, BOARD OF DIRECTORS, PARTNERSHIP FOR PREVENTION Dr. FIELDING. Thank you, Mr. Chairman. I am from UCLA and I am testifying on behalf of the Partnership for Prevention. We are a group of more than 60 organizations, both public and private, that share one common desire: Better integrating prevention into national health policy and practice. And we have provided written testimony from which I would like to stress six points. Our major concern is that in discussion of health system reform, the primary objective may get lost and that primary objective must be improving the health of the American people. If we don't keep this firmly in mind, we won't be successful. Healthy People 2000 is an excellent start, but we urge that this committee use that objective as its filter for looking at all proposals. Second, prevention works and it makes good economic sense. The tools are well-developed and proven. For many of the worst health problems, prevention is not only a good alternative, it is the only alternative, from HIV to motor vehicle injuries, from low birthweight babies to measles, and from lung cancer to handgun violence. So if prevention does not have a central role, health system reform cannot succeed. Third, most people define prevention as one of three components. That is too narrow. They think about personal behaviors and clinical preventive services: Mammography immunization, diet. These were very important but there are two other aspects. First, community-based interventions; if we are going to prevent violence, if we are going to reduce children bearing children, if we are going to educate our children about health, we need to have communitybased interventions. The third part is social and economic policies. We need tax incentives. There are things that providers won't do without the proper incentives, such as getting high levels of immunization or screening children for developmental disability. Employers need incentives to continue doing work-site health promotions. Individuals need incentives. If we are going to reduce handgun availability, it is not going to be the health care system that is going to do it. We have a specific recommendation and that is that the National Health Board look at all the potential opportunities to improve health, and from an economic and national productivity point of view, prioritize them and report to the Congress so that you can better determine where the investments should be. Our fourth point is that the data collection and analysis systems that currently exist, particularly on the public health side, are insufficient to answer the trillion dollar question: Is our health system working? What components of it are working? Where, where not, how well, what do we do to refine it? So unless this is improved substantially, we are not going to be able to develop an efficient system and we are not going to be able to improve it. In some States and communities today, Public Health Services don't even have computers or have the expertise to use them. We need, therefore, a revitalized public health presence. Public health needs to be not only an equal partner but also take the lead in community programs and in social problems. Take the issue of lead. Private providers may screen for lead, but so what? What then happens to the kids? Who is going to track them and find out what the lead sources are? Who is going to make sure the houses are deleaded? Who is going to monitor them over time? Finally, one of the key reasons for underutilization of prevention today is 40 million Americans are without health insurance. You can make a giant step for the health of American people by passing universal, transportable, lifelong health insurance. In the written testimony, we have provided you a public health standard, a yardstick, a measure that you can use to assess all the bills with respect to their potential to improve the health of the American people. We would be happy to answer questions about that and other aspects. And we really appreciate the opportunity to testify before you. [The prepared statement and attachments follow:] STATEMENT OF JONATHAN E. FIELDING, M.D., M.P.H., M.B.A. PARTNERSHIP FOR PREVENTION Mr. Chairman and Members of the Committee, I am Jonathan Fielding. Thank you for the invitation to testify. I am a Professor of Health Services and Pediatrics at UCLA, the past chairman and a board member of the California Wellness Foundation,' a former state health commissioner and former vice president of health policy for a large health-care company. I am speaking today on behalf of Partnership for Prevention, a national nonprofit organization whose more than 60 members share an interest in better integrating prevention into national health policy and practice (Appendix A lists the membership of Partnership for Prevention). Until now, the national debate about health reform has focused primarily on access to care and controlling rising costs. "Health security" is also a recurring theme. These are important national goals and we agree that universal, transportable, lifelong insurance coverage for every American deserves to be a national priority. Based on the area of expertise and interest of our organization, we urge you to bring to center stage two issues which we feel hold the key to successful health system reform. First, we encourage you to adopt as an additional primary goal of any health legislation-improving the health of the American people. Second, we urge you to define prevention comprehensively, to include a wide array of personal/clinical preventive services, community-based interventions, and social policies for prevention that have been shown to improve health and well-being. PARTNERSHIP FOR PREVENTION Partnership for Prevention was founded in 1990 to provide private-sector leadership in achieving the Healthy People 2000 national health objectives. Our mission's focus is to increase the priority for prevention among policy-makers, federal and state agencies, corporations and other nonprofit organizations. In addition to coordinating the prevention-oriented efforts of our members, we endeavor to increase the resources and incentives that will lead to general adoption of efficient, effective preventive approaches to health improvement. Last year, Partnership conducted an analysis of national and state proposals for health reform and convened a panel of experts to discuss the inclusion of prevention in health-care reform. This work concluded that preventive services and programs offer Americans the possibility of longer, healthier, and more productive lives (the conference report describes six principles that could guide the formulation of prevention-oriented reform policy, see Appendix B). IMPROVE THE PUBLIC'S HEALTH Current legislative proposals are concerned with the cost of extending insurance coverage for medical care expenses to those now either under-insured or uninsured, as well as the reduction of the rate of overall cost increases for health and medical services. However, we find it disturbing that the debate thus far includes relatively limited discussion of the prospects for measurable improvement in the health status of our population. We believe that the most important objective of health reform should be the improvement of health. In this regard, prevention should have an integral role. We urge that you support more emphasis on prevention not only because it is important, but because it is effective. Over the past years efficient and effective techniques have been developed to improve the public's health through preventive opportunities. "Prevention" is a popular concept. However, many of its most promising opportunities are often overlooked because it is so narrowly defined in the eye of the public. Most often it is associated only with clinical preventive services--mammography, prenatal care, immunizations and other screening services. But even within the category of clinical preventive services are major missed opportunities. For example, there are scientifically valid ways to identify individuals with depression, the precursor of suicide. As many as 15% of Americans are victims of depression every year, with reduced personal and economic productivity and often adverse effects on family function. Yet, despite the existence of good treatment for these health problems, readily available, inexpensive and efficient screening tools to find those at risk are woefully underutilized. Substance abuse is another serious and common problem. Experts estimate that one in four Americans is directly or indirectly affected by this disease. Perhaps even more alarming is recent data which indicate that illicit drug use is increasing again among our teenagers (Thomas, 1994). Both preventive and remediable measures are available but their use is limited. Both clinical and community settings could make better use of 1 The largest foundation devoted exclusively to disease prevention and health promotion prevention interventions, including drunk driving legislation and the use of screening questionnaires to identify the disease and refer individuals to appropriate treatment. Therefore, prevention needs to be integrated as part of an efficient system of health services to meet the health needs of defined populations. And prevention needs to be defined comprehensively to include: a core set of personal/clinical preventive services, social policies for prevention (Appendix C describes the components of prevention). USE OF PREVENTIVE SERVICES If health system reform is to improve the public's health it must support more effective use of proven clinical preventive services, well documented by the U.S. Preventive Services Task Force. We support the funding of a core package of clinical prevention services in any health system reform proposal. Further, we recommend that the type of process used by the U.S. Preventive Services Task Force, careful periodic assessment of all available literature on efficacy, efficiency, effectiveness and cost-effectiveness of each potential clinical preventive service, be integrated into the mechanisms to determine and revise core benefits. The process will need to identify specific criteria, including disease burden and efficacy and effectiveness of each intervention, periodically weigh the evidence, and prioritize, based on available funds. However, we believe that health system reform must also support multi-sector community-based programs and services that have health objectives, and support social and economic policies when these can make a significant contribution to health. To illustrate our view of a comprehensive approach to prevention, consider the issue of violence. Crime and related violence have become the number one concern of Americans--and for good reason. Violence took the lives of 2,428 children in 1992, 67% greater than six years earlier. A larger percentage of perpetrators of serious crime suspects are juveniles. Further, the rise in violence is mirrored by a jump in child neglect and abuse cases, which are serious risk factors for delinquency (Loose and Thomas, 1994). Some Americans are afraid to leave their homes--to send their children to school or to go to work. Clearly, violent communities are not healthy communities. Even if every person in a community with a high crime rate had good health habits and tested negative on all screening tests, their community would not be a healthy place to live. To prevent violence requires a multifaceted approach. During my tenure as chairman of the California Wellness Foundation we initiated a program with four interactive components--a leadership program, community action program, policy program and research program. Careful evaluation of this and other violence prevention initiatives will help us to better understand the best remedies to this problem. Community health approaches complement personal health approaches and are of equal importance. Yet most health system reform proposals do not even mention this key health issue. One opportunity is to make health plans more accountable for community health. However, while this may work to improve immunization rates and increase mammography screening, it is not sufficient to deal with many problems such as violence or adolescent childbearing. We therefore urge the Committee to : build in provisions for more multi-sectoral efforts to address these and other health problems, and provide strong incentives for collaboration between all of those agencies and interests that can play a constructive role. There are times when social and economic policy can have a greater impact on health than alternative preventive measures. As an example, mandatory seat belt legislation has had a much greater and faster impact than decades of media public education to "buckle up." Similarly, proposed changes in the welfare system probably contain greater potential to affect adolescent childbearing than educational campaigns promoting abstinence or contraception. Likewise there are great opportunities to improve health through tax policy. America is the world leader in employer-sponsored health promotion programs. These programs have been shown to reduce the frequency and severity of risk factors for heart disease, cancer and other serious health problems and to reduce absenteeism. A major stimulus to these programs has been the inherent incentives for the many self-insured and other experience-rated employers to invest in health promotion to reduce their health benefit costs. If health system reform removes this incentive without a substitute, many of the 81% of worksites with some health promotion activity (U.S. Department of Health and Human Services, 1992) are likely to reduce or abandon their programming. Another example is the relatively low taxation of tobacco products in the United States compared to other developed nations. We have ceased to make progress in reducing smoking among teenagers. Yet continued progress could be virtually assured by increasing tobacco taxes because adolescents experimenting with tobacco are more deterred by price increases than are already addicted adults. To prevent drinking, preliminary data suggest that new taxes on alcoholic beverages could reduce alcohol consumption and alcohol-related injuries and death (Chaloupka, 1993). Similarly, policy experts are considering whether a tax on handguns and assault weapons might contribute to the prevention of violence. Most health system reform proposals under consideration rely on market mechanisms to control costs. While competition can help achieve cost efficiency, Congress has a vital interest in determining where national social policy objectives may diverge from the economic incentives to health plans under a reformed system. If a preventive procedure will not reduce health-care costs, health plans may not implement the procedure unless it is a required core benefit. For example, developmental screening of young children may not be cost-justified within a plan but should be considered essential to maximize national social productivity. Perhaps health plans should get a bit more money if they fully utilize prevention practices with proven efficacy. Similarly, since a great deal of health activity is performed outside the professional care sector, perhaps financial incentives could be designed to encourage health plans to improve the "self-care" of their members. Self-care-tooth brushing, treatment of minor injuries, etc.--is often defined as the decisions undertaken by individuals for their own or family's health benefit (Silten and Levin, 1979). Partnership for Prevention supports programs to improve informed medical decision-making by patients and their health providers. These decisions include those pertaining to personal habits as well as utilization of appropriate health services. Some Americans have too much health care because they demand and receive unnecessary diagnostic and therapeutic procedures. As former surgeon general C. Everett Koop said, "More is not always better and may be hazardous to a patient's heath" (Russell, 1994). Interlocking incentives can create a system of prevention with rewards for good outcomes linked to prevention. Some of these outcomes could be medical. Why not provide incentives for a low rate of complication in diabetics, a low percentage of breast cancers found beyond an early stage, a low percentage of pregnancies diagnosed after the first trimester, etc. Incentives might also be related to social outcomes such as the rate that frail elderly are maintained in an independent environment through close coordination of health-care providers and social and other community agencies, the frequency of adolescent childbearing, or suicide. A health plan that can demonstrate superior outcomes and better use of prevention should have a marketing advantage and get more subscribers. TRACKING HEALTH STATUS Improving health requires the data to know where the problems are, their dimensions and changes over time. Unfortunately, much essential data are lacking at all levels--national, state, community, and health plan. Data are also unavailable for many population segments defined by age, ethnicity, race or family constellation. Public health agencies at all levels are poorly equipped and staffed in health information technology. As a result, in some cases it is impossible to estimate the extent of disease burden or determine the results of preventive interventions. If we are to improve the health of Americans, these agencies must have resources to track health problems and changes in health status. Attention must also be given to assuring the privacy of individuals' medical records. Health plans should share this responsibility for their subscribers, and feed into public systems. Currently, most plans do not have the automated collection, aggregation and analysis systems and processes to develop sophisticated outcome-based report cards. WHAT IS THE ROLE OF PUBLIC HEALTH? What should be the role of "public health" in a new health-care landscape? We believe that public health roles need to be strengthened so that public health is not only an equal player in personal health-care delivery systems, but can take the lead role in community interventions and social programs and policies. Public and personal health services need to be integrated. In the future, health plans may take over some traditional public health functions, such as lead screening. However, once an elevated lead level is found, strong linkages to an effective public health presence will allow coordination of deleading, and arrangements for temporary housing, notifying other families that their children are at high risk and arranging for them to be screened. |