December 7, 2006 |
2006-R-0767 | |
PREVENTING AND CONTROLLING CHRONIC DISEASES | ||
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By: Saul Spigel, Chief Analyst | ||
You asked what other states are doing to prevent and control chronic diseases.
SUMMARY
Chronic conditions such as cardiovascular and respiratory diseases, cancer, and diabetes are major causes of death, hospitalization, long-term disability, and health care costs in the United States. They are, in some part, preventable, and if not prevented, then controllable. Promoting wellness and managing chronic diseases are long-term strategies states can implement to benefit residents and reduce the growth in health care costs.
Various national groups recommend similar strategies states can pursue to prevent chronic disease: encouraging individuals to engage in physical activity and healthy eating, obtain recommended health screenings, and control blood pressure and cholesterol; controlling tobacco use and secondhand smoke; and offering wellness programs for state employees and providing incentives for private employers to do the same. For people with chronic disease, states may be able to control health costs through disease management programs.
Most states follow these recommendations to some extent. This report provides examples of wellness programs for state employees, state encouragement for private employers to offer worksite wellness programs, statewide wellness promotion efforts, and chronic disease prevention and management programs. Many of the examples are cited as exemplary by the Centers for Disease Control and Prevention (CDC), the Council of State Governments, or the National Governor's Association.
BACKGROUND
Chronic conditions such as cardiovascular disease, cancer, diabetes, arthritis, and respiratory diseases are major causes of death, hospitalization, long-term disability, and health care costs in the United States, according to the CDC. The CDC estimates that 25 million Americans live with a chronic disease that significantly limits their daily activity. Some experts estimate that chronic diseases are responsible for 83% of all U. S. health care spending and a similar percentage of Medicaid spending, according to Partners for Solutions, a Robert Woods Johnson Foundation and Johns Hopkins University initiative to improve care for people with chronic diseases (see the partnership's website at http: //www. partnershipforsolutions. org/statistics/index. html).
Chronic diseases are, in some part, preventable, and if not prevented, then controllable. Promoting wellness and managing chronic diseases are long-term strategies states can implement to reduce the growth in health care costs. The National Conference of State Legislatures (NCSL) identifies seven strategies states can pursue to encourage healthy behavior and reduce the incidence of chronic diseases and their complications:
• Raise public awareness about the association between health status and behavior
• Improve access to healthy food and opportunities for physical activity
• Improve access to health screenings and appropriate treatment
• Ensure that public and private health insurance plans provide cost-effective services to prevent and treat chronic diseases
• Establish partnerships with business, schools, and religious organizations to promote their members' and students' wellness
• Address health disparities among racial and ethnic groups
• Ensure that health facilities and providers have the appropriate knowledge and tools (NCSL, Chronic Disease and Health Costs, A Snapshot for Legislators http: //www. ncsl. org/programs/pubs/summaries/0166603-sum. htm)
The Council of State Governments recommends several similar strategies to preventing chronic disease—promoting physical activity and healthy eating, obtaining recommended health screenings, controlling blood pressure and cholesterol, controlling tobacco use and secondhand smoke, offering wellness programs for state employees, and providing incentives for private employers to do the same.
STATE PROGRAMS
Public Employee Wellness Programs
The executive branch has been responsible for implementing most state initiatives to promote wellness among state employees. In South Dakota, the governor and the state employee health plan introduced a wellness program that includes a website, tool kits, and employee incentives. Employees, retirees, and their covered spouses can participate in the Healthy South Dakota program.
State employees and their spouses can receive up to $ 300 a year, as well as exercise equipment and memberships in fitness and nutrition centers, for joining Healthy South Dakota. They each receive $ 50 for participating in a health assessment and $ 100 for participating in the on-line wellness program and reaching one personal goal. The payments are credited to health risk and wellness accounts. Participants maintain online diaries to track their progress. These diaries help the state to determine whether the program is reducing the state insurance plan costs through individuals' healthy choices.
Some states provide health insurance premium incentives and disincentives for state employees. Four states, West Virginia, Alabama, Georgia, and Kentucky, charge lower premiums to nonsmoking employees and higher premiums to smokers.
More information about state's employee wellness programs is available from the National Governor's Association Center for Best Practices at
http: //www. nga. org/cda/files/05WELLBRIEF. pdf
Statewide Employee Wellness Programs
Several states have established programs to encourage other employers to implement employee health promotion programs. Massachusetts law requires the Department of Public Health to establish a program to reduce morbidity and mortality from preventable diseases and accidents. The law targets risk factors such as lack of exercise, smoking, poor nutrition, and alcohol and drug abuse. It calls for the department to provide education and screening for the general public and groups at special risk, including police and firefighters. The program is to encourage behavioral changes, including diet and smoking cessation, and fitness (Mass G. L. ch. 111, § 206). In response to this law, the department established a Wellness at Work Program that informs employers about how to create and operate worksite wellness programs.
Rhode Island's Department of Public Health offers a health risk appraisal designed for state employees, Wellness Check2000, to private employers and public and private school systems that want to create a healthier workforce by helping their employees make behavioral changes. The department works with the Rhode Island Worksite Wellness Council, a public-private organization that promotes worksite health programs. “Wellness universities” are one of the council's chief methods of promoting its mission. These are daylong conferences where member companies learn strategies for building worksite wellness programs. Over 320 participants have attended these meetings since the “university” began in 2000.
The council is working with the executive branch to make Rhode Island the first “Well State” in the nation. It will achieve this status when 20% of the workforce is employed in organizations that have earned the “Well Workplace” designation from the Wellness Councils of America.
Statewide Wellness Programs
Some states have adopted a statewide approach to disease prevention and health promotion. Healthy Arkansas is a comprehensive effort that targets tobacco use, obesity, and physical inactivity through public
education, campaigns, and a website that provides strategies and information on nutrition, physical activity, and smoking cessation (http: //www. arkansas. gov/ha/home. html).
South Dakota expanded its state employee wellness website (see above) to all state residents in 2005. The site focuses on nutrition and physical activity. It contains sections geared to various populations (kids, adults, seniors, health professionals). It also offers a personal journal feature that allows people to track their progress toward individual goals.
Attachment 1, from the Council of State Government's State Official's Guide to Wellness, briefly outlines state's branch wellness initiatives. The full document is available at http: //www. healthystates. csg. org/NR/rdonlyres/D48FC4CD-1F7A-4CB6-A5B5-8DBF4ED500CC/0/WellnessSOG2006. pdf.
Chronic Disease Prevention Programs
Cancer. In November 2004, Colorado voters approved Amendment 35, a citizens' initiative that added a new 65-cent tax to the price of each pack of cigarettes, raising the state's tobacco excise tax to about the national average and potentially generating about $ 175 million a year in new revenue. The amendment requires using all of the new money for health purposes. While most of the money subsidizes health care for uninsured people, 16% (about $ 28 million per year) will is dedicated to cancer and cardiovascular disease prevention and another 16% to tobacco control.
In Alabama, only 25% of the nearly 50,000 eligible women between the ages of 40 and 64 participated in the Alabama Breast and Cervical Cancer Early Detection Program (ABCCEDP) in 2003. In response to such low participation, ABCCEDP started a health promotion class at both of the women's state prisons, which was later extended to county facilities. This experience revealed that most incarcerated women had never heard about the screening program and thus had not participated.
In January 2004, ABCCEDP, the AVON Foundation Breast Care Fund, and the Alabama Sheriffs' Association formed a partnership, known as The Butterfly Project, to educate women about the importance of early detection of breast and cervical cancers. Working with the county sheriffs' departments and state correctional facilities, project staff transport incarcerated women for breast and cervical cancer screenings at their county health departments. As a result, more than 700 women have been educated and screened.
Diabetes. Tennessee enacted a comprehensive health insurance access reform law, Cover Tennessee, in 2006. Project Diabetes is one component of this reform. It comprises three programs: (1) grants ($ 6 million) to help communities launch public awareness campaigns or expand existing ones; (2) $ 15 million to expand to all schools the state's Coordinated School Health Initiative, which includes classroom education, physical education, nutrition programs, and counseling; and (3) $ 1 million from the National Institutes of Health to start a pilot project in 10 high schools designed to persuade teens to change their eating and physical activity behaviors.
One in 10 Minnesotans currently has diabetes or is at risk for developing the disease. Although the CDC recognized Minnesota as a leader in diabetes activities, the state's activities were fragmented and uncoordinated. Policy leaders determined that developing a state strategic plan for diabetes was the first step needed. A grassroots planning process led by the Minnesota Diabetes Program and its advisory group, the Minnesota Diabetes Steering Committee, identified key issues and needs and developed the Minnesota Diabetes Plan 2010, which was released in October 2003. The plan provides the framework and baseline for coordinated population-based activities to prevent diabetes and its complications more effectively and to achieve Healthy People 2010 objectives.
Heart Disease and Stroke. In 2006, the Massachusetts legislature appropriated $ 300,000 for a statewide STOP stroke program that is intended to educate the public and healthcare providers about the warning signs of stroke, the recognition of stroke symptoms, and the importance of timely and appropriate acute care treatment.
Maine law requires the Department of Health and Human Services' Bureau of Health to establish a program to develop heart and hypertension programs throughout the state. These programs must provide (1) education about cardiovascular risks to schools, community groups, and workplaces; (2) blood pressure and cholesterol screening, referral, and follow up to the public and workers; and (3) smoking cessation. The law also requires the bureau to establish worksite high blood pressure programs to screen workers and refer those with elevated blood pressure to doctors (Me. Rev. Stat. , t. 22, ch. 273, §§ 1697-99).
In Kentucky, heart disease and stroke account for 37 % of all deaths, about 40% of all hospitalizations, and hospital costs exceeding $ 863 million in 2000. The Department of Public Health's Cardiovascular Health Program joined with the American Heart Association's Kentucky affiliate, the Kentucky Hospital Association, Healthcare Excel, and the American College of Cardiology to improve management of patient care. The partners used the American Heart Association's Get with the Guidelines - Coronary Artery Disease program to improve outcomes for hospital inpatients.
The partners launched a statewide training program in April 2003 in which 142 people from 57 hospitals across the state participated. The Cardiovascular Health Program funded the training costs and the annual fee for a patient management tool. As a result, 26 hospitals across the state are conducting this prevention program. Their teams receive regular technical assistance via telephone conference calls by the American Heart Association, the Cardiovascular Health Program, and the project's information technology manager.
More detailed descriptions of these and other programs are available at http: //www. cdc. gov/nccdphp/publications/exemplary/.
Chronic Disease Management
Background
Disease management programs identify people with certain health problems and then intervene to manage their care. Methods differ, as do the diseases the programs address. Many private insurers have adopted disease management practices, as have many states, particularly for use in their Medicaid programs.
The Disease Management Association of America says disease management programs should contain:
1. ways to identify patients for participation;
2. evidence-based guidelines for care and medication;
3. treatment that includes physicians and support service providers;
4. patient education (which may include prevention and behavior modification programs);
5. evaluation, such as patient satisfaction, expenditures, and use of health care services; and
6. routine reporting and communication between patients, providers, and health plans.
A National Conference of State Legislatures chart of states' disease management programs is available at http: //www. ncsl. org/programs/health/StateDiseasemgmt1. htm.
Vermont Blueprint for Health
The Vermont Blueprint for Health, begun in 2003 by Governor James Douglas, is led by a public-private partnership that includes state government, health insurance plans, business and community leaders, health care providers, and consumers. The legislature adopted it in 2006 as part of Act 191, which created the state's Catamount Health Plan.
The blueprint is based on a chronic care model developed by an organization called Improving Chronic Illness Care. The model addresses the issues of self-management support, delivery system design, and clinical information and decision support systems.
The Vermont Blueprint is pursuing change in four broad areas: patient self-management, provider practice change, information system development, and community development. It has adopted the following goals and strategies for each area.
Self-management: Vermonter's with chronic conditions will be effective managers of their own health.
• Implement a chronic disease self-management program designed to help people learn to effectively manage and live with chronic disease.
• Implement educational programs at retail establishments.
• Increase attendance at current disease specific self-management programs.
Provider Practice: The proportion of individuals receiving care consistent with evidence-based standards will increase.
• Educate and engage the provider community and their support staff on the chronic care model, use of clinical guidelines and decision support tools, and integration of information technology into practice workflow.
• Identify barriers and incentives to providing evidence-based standards of care and implementing the chronic care model.
• Implement a regional roll out of the Blueprint initiative in two or three communities.
Health Information System: A chronic care information system (CCIS) will be available to providers and will support chronic disease prevention, treatment, and management for effective individual and population-based care.
• Develop a statewide CCIS and patient registry including system design, technical assistance, governance, and business rules for secure information sharing.
• Develop and pilot the CCIS and registry application as part of a regional implementation strategy.
Community Activation and Support: Vermonters will live in communities that support healthy lifestyles and have the ability to prevent and manage chronic conditions.
• Inventory walking and bike paths and other community resources.
• Implement new or expand existing physical activity programs in pilot communities.
• Develop criteria and award grants to communities for programs and services that support chronic disease prevention and management, and link communities to the health care system.
• Develop methods for sharing successful evidence-based projects.
Act 191 requires the Office of Vermont Health Access (OHVA), the state's Medicaid agency, to develop a chronic care management program, consistent with the Blueprint's policies and standards, and contract with a private company to serve 25% of Medicaid, Dr. Dynasaur (children's medical insurance), and the Vermont Health Access Plan (for adults not eligible for Medicaid) enrollees. OHVA must also come up with a plan for reimbursing Medicaid health providers for chronic care, including incentives for care coordination, and for tieing future reimbursement increases to Blueprint performance measures.
More information about Blueprint for Health is available at http: //healthvermont. gov/blueprint. aspx.
The Indiana Chronic Disease Management Program (ICDMP)
ICDMP is aimed at people with diabetes, asthma, congestive heart failure, and hypertension and others who are at high risk of chronic disease. It was developed by the state Medicaid program and the Department of Public Health (DPH). The program's goal is to build a comprehensive, sustainable, locally based infrastructure that will help improve the quality of health care in all populations. It provides support to primary care providers, integrates primary care with case management, and teaches participants self-management skills.
The main components of the ICDMP include:
1. Program management: Medicaid and DPH are jointly responsible for program management including policy development, contracting, and performance monitoring.
2. Primary care: The primary care physician is the focal point of patient care. Key ICDMP elements are designed to provide information and resources to support the physician, including dissemination of evidence-based guidelines.
3. Case management: A call center monitors patient status and follows up based on established protocols, and a nurse care manager network provides more intense follow-up and support to high-risk patients.
4. Patient data registry: An electronic data registry is available to physicians and can be used for all patients. The registry contains Medicaid patients' claims and case management data.
5. Measurement and evaluation: Program performance measures use claims history data and individual health outcomes indicators for both an intervention and control group.
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