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Vitality Institute Commission on Health Promotion and the Prevention of Chronic Disease in Working-Age Americans: Background Working Papers

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Vitality Institute Commission on Health Promotion and the Prevention of

Chronic Disease in Working-Age Americans: Background Working Papers

June 2014

Contents

Agriculture and Urban Design Policies ... 2

Behavioral Economics for Health ... 2

Applying Behavioral Economics Principles and Approaches to Public and Private Health Policies ... 2

Chronic Disease Prevention Priorities in the US ... 3

Cross-Sector Engagement for Health ... 3

Federal Funding for Prevention Research ... 4

Institute of Medicine Recommendations on Prevention and Health Promotion Strategies ... 4

Personal Intelligent Technologies for Health ... 5

Graduate-Level Training in Prevention and Health Promotion ... 5

Workplace Prevention and Health Promotion Programs: Implementation ... 6

Workplace Prevention and Health Promotion Programs: Potential Savings ... 6

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Agriculture and Urban Design Policies

Agriculture for Nutrition and Active Transportation for Physical Activity: Health as a Cross-sectorial Mandate

Johanna Goetzel, MA—Vitality Institute Caitlin Morris—Nike, Inc.

To reduce the health and economic burden of Non-Communicable diseases in the United States the two key drivers of nutrition and physical activity must be addressed. Calorie intake and expenditure are both heavily dependent on sectors outside of health. Opportunities exist to shift the design of critical systems to promote health through reforming agriculture, emphasizing diet improvements, and investing in active transportation, increasing physical activity. Agricultural reforms are a way to address this burden at its source. Changing subsidies to support USDA guidelines; improving nutrition literacy and reducing the price of healthy product can contribute to health goals. Similarly, stronger linkages between national transportation policy and health concerns can promote physical activity. Emphasizing heath in national transportation policy though increasing support within MAP 21 and incorporating active transport will reduce the health burden. These sectors are well positioned to be levers for disease prevention and health promotion.

Behavioral Economics for Health

Applying Behavioral Economics Principles and Approaches to Public and Private Health Policies

Kevin G. Volpp, MD, PhD—Leonard Davis Institute Center for Health Incentives and Behavioral Economics; Penn Medicine Center for Innovation; Departments of Medical Ethics and Health Policy, and Medicine, Perelman School of Medicine, University of Pennsylvania

George Loewenstein, PhD—Leonard Davis Institute Center for Health Incentives and Behavioral Economics; Carnegie Mellon University

David Asch, MD, MBA—Leonard Davis Institute Center for Health Incentives and Behavioral Economics; Penn Medicine Center for Innovation; Departments of Medical Ethics and Health Policy, and Medicine, Perelman School of Medicine, University of Pennsylvania

Many public- and private-sector program designs assume that people are fully rational and that providing information and pricing appropriately are all that is needed to achieve optimal outcomes. Work in behavioral economics, however, has delineated ways in which humans make decisions that reflect less-than-perfect rationality. A series of initiatives in behavioral economics and health are attempting to leverage those insights to design more effective health-improvement programs. Recognizing rational-world bias allows for less attention to conveying information and more to changing environments and providing incentives to help people make healthier choices. All health-improvement programs,

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Chronic Disease Prevention Priorities in the US

Scoping National Chronic Disease Prevention Priorities in the United States Mandana Arabi, MD, PhD—Sackler Institute for Nutrition Science, New York Academy of Sciences Ashkan Afshin, PhD—Harvard School of Public Health

Dariush Mozaffarian, MD, MPH, DrPH—Harvard School of Public Health

The Sackler Institute for Nutrition Science at the New York Academy of Sciences developed and conducted a study assessing disease prevention and health promotion in the United States. The project used qualitative and quantitative methodologies in three phases to achieve a clear understanding of the state of evidence and practitioner opinions. Results from the literature review found information/communication technologies were effective tools to improve NCD risk factors. Interviews preliminarily found several reemerging themes in chronic disease prevention in the workplace. Barriers of prevention expressed during the interviews included: inadequate political will; difficulty of sustained behavior change, industry resistance to change (due to misaligned incentives, lack of access to information/tools, and, frequently, too much focus on treatment and not enough on prevention. Research gaps identified included: behavior change—how to change behavior effectively; effectiveness of policies that have been implemented; and link between mental illness and chronic diseases.

Cross-Sector Engagement for Health

Ask not what others can do for health... Leigh Carroll—Institute of Medicine

Bridget Kelly, PhD—Institute of Medicine

Paul E. Jarris, MD—Association of State and Territorial Health Officials Derek Yach, MBChB, MPH—Vitality Institute

William B. Rosenzweig—Physic Ventures

It is well accepted that the health sector alone cannot improve health, yet multisectoral programs and policies do not happen with the frequency and success needed for broad health improvements. This paper suggests that the health sector can do more to engage other sectors in better and more meaningful ways. First, the health sector can listen more to better understand what other sectors and communities want and need, and what the health sector can do to help them achieve it. Second, the health sector can develop better measures to show how health benefits from and brings value to other sectors. Through these approaches, the health sector is more likely to gain valuable support from other sectors and ultimately develop programs with greater positive impact on community well-being.

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Federal Funding for Prevention Research

US Federal Health Research Funding for Chronic Disease Prevention: A Descriptive Analysis Chris Calitz, MPP—Institute for Health and Social Policy, Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University

Keshia M. Pollack, PhD—Department Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University

Chris Millard—Institute for Health and Social Policy, Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University

Derek Yach, MBChB, MPH—Vitality Institute

Chronic non-communicable diseases (NCDs) cause the majority of premature deaths, disability, and health care expenditures in the United States (US). The burden of disease from NCDs is caused by six largely modifiable risk factors: smoking, poor nutrition, physical inactivity, alcohol abuse, drug abuse, and poor mental health. We analyzed US National Institutes of Health (NIH) funding between 2010 and 2012 for human behavioral interventions that target the modifiable risk factors of NCDs. We found that the NIH prevention portfolio comprises about 37% human behavioral studies and 63% basic biomedical, genetic, and animal studies. Approximately 65% of studies were secondary prevention versus 23% for primary prevention. We estimated that the NIH spends $2.2-$2.6 billion annually (7%-9% of total) on human behavioral interventions to prevent NCDs. The proportion of funding for prevention remained low compared to spending on discoveries and cures, and did not reflect the preventability of NCDs.

Institute of Medicine Recommendations on Prevention and Health Promotion

Strategies

Institute of Medicine Recommendations on Prevention and Health Promotion Strategies (2005-2013): A Review

Leigh Carroll—Institute of Medicine Bridget Kelly, PhD—Institute of Medicine

This paper summarizes messages drawn from Institute of Medicine reports that provide insight into why the U.S. has been slow to comprehensively adopt prevention and health promotion strategies. This review extracted information on several of the factors that prevent policy-makers from choosing to invest in prevention, including: other competing pressures and priorities, the complexity of health problems, the time lag between intervention and resulting health benefit, and underutilized existing resources. Messages across IOM reports point to opportunities for the health sector to move beyond persuasion of policy-makers to work within their environments to make it more likely that they will make policy choices that support health. IOM reports suggest that approaches adhere to several key principles, including: understanding decision-makers’ needs and how to support them; generating and coordinating good, usable information; making it easy for decision-makers to move toward health promotion; and leveraging available assets to use resources effectively.

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Personal Intelligent Technologies for Health

Personalized Prevention to Address Leading Chronic Disease Risks Gillian Christie, MPhil—Vitality Institute

Neil Adamson—Discovery Limited

Derek Yach, MBChB, MPH—Vitality Institute

Noncommunicable diseases (NCDs) are a primary cause of death worldwide. Innovative technologies have emerged to personalize prevention to address the growing prevalence NCDs. These technologies are most effective when combined with behavioral economic strategies that nudge and incentivize the individual into making healthier decisions, potentially complementing existing government approaches to public health. Nonetheless, overcoming ethical, legal, and social implications associated with personalized technology and big data is required to ensure all populations benefit from advances in health.

Graduate-Level Training in Prevention and Health Promotion

Revisiting the Disease Prevention and Health Promotion Content in US Graduate Education Susan C. Kim, JD—O’Neill Institute for National and Global Health Law, Georgetown University

Aliza Glasner, JD— O’Neill Institute for National and Global Health Law, Georgetown University Alyson Listhaus, MPH— Joseph L. Mailman School of Public Health, Columbia University Daryl Berke, MPH—Yale School of Public Health,

Tanya Baytor, LLM— O’Neill Institute for National and Global Health Law, Georgetown University

Chronic diseases affect more than half of all Americans. Rather than addressed as a public health problem, the emphasis has been to try and modify individual behaviors. This is reflected in how most health professionals, including physicians and nurses, are educated. This focus on individual, rather than the public health, has been to our collective detriment. It is time to refocus the discussion to examine health promotion and disease prevention through a public health, or population-based approach, beginning with health-related education. Public health is not simply the responsibility of the physician. Health promotion and disease prevention must actively take place in homes, schools, and workplaces. It is essential that those entering health-related disciplines, especially in the fields of public health, medicine, nursing, law, and policy have a set of competencies and skills that align with the nation’s health needs.

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Workplace Prevention and Health Promotion Programs: Implementation

Making the workplace a more effective site for prevention of major chronic diseases in adults

Katherine Tryon, MA, MBBS—Vitality Institute Howard Bolnick, MBA, FSA—Discovery Limited Jennifer Pomeranz, JD, MPH—Temple University Nicolaas Pronk, PhD—Harvard School of Public Health Derek Yach, MBChB, MPH—Vitality Institute

Much of the burden of major non-communicable diseases (NCDs) is preventable by addressing unhealthy behaviours and biometric risk factors. Efforts to realise the potential of disease prevention in the US have fallen behind peer countries, and workplace disease prevention is a major gap. We discuss the hurdles to effective use of the workplace for health promotion and disease prevention in the US, including limited leadership and advocacy, poor alignment of financial incentives, limitations in research quality and investment, regulation that does not support evidence-based practice, and few community-employer partnerships. We make recommendations to address these hurdles, to enable the workplace to be a key part of the effort to prevent NCDs. Among them: companies including the health status of employees as part of financial reports, improved training on workplace prevention, better alignment of public and private incentives, and critical improvements in the evidence base.

Workplace Prevention and Health Promotion Programs: Potential Savings

Quantifying the Preventability of Chronic Diseases in the US Based on the latest Burden of Disease Data

Howard Bolnick, MBA, FSA—Discovery Limited

Ali Mokdad, PhD—Institute for Health Metrics and Evaluation, University of Washington Francois Millard, FIA, FSA, MAAA—The Vitality Group

Jonathan Dugas, PhD—The Vitality Group Derek Yach, MBChB, MPH—Vitality Institute

Trends in the burden of disease and major risks between 1990 and 2010 as well as estimates on the preventable fraction and projected to the 2040s impact on disability-adjusted life years under a few scenarios. Within these, the preventability of workplace programs with and without full engagement is explored.

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Workplace Prevention and Health Promotion Programs: ACA and Regulatory

Issues

The Affordable Care Act and state coverage of clinical preventive health services for working-age adults

Jennifer Pomeranz, JD, MPH—Temple University Tony Yang, ScD, LLM, MPH—Temple University

Significant public health challenges facing the U.S. stem from preventable disease. The Patient Protection and Affordable Care Act (ACA) dedicated substantial resources towards prevention. Among other reforms, the ACA requires Medicaid and private health insurers to cover clinical preventive services for adults, pursuant to recommendations by the U.S. Preventive Service Task Force. This paper examines the infrastructure upon which these recommendations are based, the requirements related to risk factors for leading causes of preventable disease in adults associated with tobacco and alcohol use, unhealthy diet, and inactivity, and coverage requirements for private plans and Medicaid. The paper provides and assesses data comparing the health statuses of populations in, and preventive services offered by states taking the ACA Medicaid expansion versus those in states declining to expand coverage. The paper suggests legislative and other methods to increase preventive clinical service requirements and notes outstanding issues for future research.

Workplace Wellness Programs: How Regulatory Flexibility May Undermine Success Jennifer Pomeranz, JD, MPH—Temple University

The Patient Protection and Affordable Care Act revised the law related to workplace wellness programs, which have become part of the nation’s broader health strategy. Health-contingent programs are required to be reasonably designed. However, the regulatory requirements are lax and might undermine program efficacy in terms of both health gains and financial return. The paper proposes a method for the government to support a best practices approach by considering an accreditation or certification process. The paper additionally discusses the need for program evaluation and the potential for employers to be subject to litigation if programs are not carefully implemented.

Workplace Wellness Programs and the “Reasonable Design” Requirement Jennifer Pomeranz, JD, MPH—Temple University

Workplace wellness programs have become part of the nation’s broader health strategy. The federal government revised the law related to health-contingent programs and provided further explanation for the requirement that they must be reasonably designed. However, the reasonable design requirement is lax and might undermine program efficacy in terms of both health gains and financial return. State governments have begun proposing and enacting laws to address this concern. The paper suggests that the federal government should enact stronger floor requirements to foster the use of best practices nationally. Government standards must reflect market-based realities, but must also foster employers’ investment into practice- and evidence-based programs. Such an investment should produce positive health outcomes for employees and provide a cost benefit to employers.

References

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