Prevention, Health Promotion, and Social Work: Aligning Health and Human Service Systems Through a Workforce for Health.

The seminal Consensus Study by the National Academies of Science, Engineering, and Medicine released in September 2019 describes the benefits of integrating health and social care service delivery, underscoring the central role of social determinants of health (SDOH) in health outcomes. Although the report's focus on the integration of health and social care contributes a much needed perspective to the national discourse on SDOH and offers a useful framework for organizing service delivery activities, the omission of prevention and health promotion throughout the report is a substantial limitation.We call for increased attention to and investment in prevention and health promotion in the proposed 5As framework. We contend that effectively addressing SDOH and improving alignment between health and social systems require reconceptualization of the traditional health care workforce and renewed state and national advocacy efforts.A paradigm shift encompassing a broader "workforce for health" that is well trained in prevention, health promotion, and advocacy is critical to addressing SDOH, improving population health outcomes, and achieving health equity. Given their professional mission, training, expertise, and scope of practice, social workers are well positioned to lead this effort.

High-Deductible Health Plans and Prevention.

High-deductible health plans (HDHPs) are becoming more popular owing to their potential to curb rising health care costs. Relative to traditional health insurance plans, HDHPs involve higher out-of-pocket costs for consumers, which have been associated with lower utilization of health services. We focus specifically on the impact that HDHPs have on the use of preventive services. We critique the current evidence by discussing the benefits and drawbacks of the research designs used to examine this relationship. We also summarize the findings from the most methodologically sophisticated studies. We conclude that the balance of the evidence shows that HDHPs are reducing the use of some preventive service, especially screenings. However, it is not clear if HDHPs affect all preventive services. Additional research is needed to determine why variability in conclusions exists among studies. We describe an agenda for future research that can further inform public health decision makers on the impact of HDHPs on prevention.

Universal health coverage and primary care, Thailand.

Thailand's policy on universal health coverage (UHC) has made good progress since its inception in 2002. Every Thai citizen is now entitled to essential preventive, curative and palliative health services at all life stages. Like its counterparts elsewhere, however, the policy faces challenges. A predominantly tax-financed system in a nation with a high proportion of people living in poverty will always strive to contain rising costs. Disparities exist among the different health insurance schemes that provide coverage for Thai citizens. National health expenditure is heavily borne by the government, primarily to reduce financial barriers to access for the poor. The population is ageing and the disease profiles of the population are changing alongside the modernization of Thai people's lifestyles. Thailand is now aiming to enhance and sustain its UHC policy. We examine the merits of different policy options and aim to identify the most promising and feasible way to enhance and sustain UHC. We argue that developing the existing primary care system in Thailand has the greatest potential to provide more self-sustaining, efficient, equitable and effective UHC. Primary care needs to move from its traditional role of providing basic disease-based care, to being the first point of contact in an integrated, coordinated, community-oriented and person-focused care system, for which the national health budget should be prioritized.

La politique de couverture sanitaire universelle de la Thaïlande a bien progressé depuis sa création en 2002. Chaque citoyen thaïlandais a désormais le droit à des services de santé préventifs, curatifs et palliatifs essentiels à tous les stades de sa vie. Néanmoins, à l'instar de ses équivalents dans d'autres pays, cette politique fait face à des difficultés. Un système principalement financé par l'impôt dans un pays où une forte proportion de personnes vit dans la pauvreté devra toujours s'efforcer de limiter l'augmentation des coûts. Des disparités existent entre les différents régimes d'assurance maladie qui fournissent une couverture aux citoyens thaïlandais. Les dépenses nationales de santé sont largement prises en charge par le gouvernement, principalement pour réduire les obstacles financiers qui empêchent les pauvres d'accéder aux services de santé. La population vieillit et le profil des maladies de la population évolue en même temps que les modes de vie des Thaïlandais se modernisent. La Thaïlande a désormais l'intention de renforcer sa politique de couverture sanitaire universelle et d'assurer sa pérennité. Nous examinons les avantages de différentes possibilités d'action et cherchons à identifier la solution la plus prometteuse et réalisable pour renforcer et assurer la pérennité de la couverture sanitaire universelle. Nous soutenons que le développement du système existant de soins de santé primaires en Thaïlande est la meilleure solution pour fournir une couverture sanitaire universelle plus autonome, efficiente, équitable et efficace. Les soins primaires doivent s'écarter de leur rôle traditionnel qui est de fournir des soins de base axés sur une maladie pour être le premier point de contact dans un système de soins intégré, coordonné, orienté vers la communauté et axé sur la personne, ce qui nécessite de donner une priorité élevée au budget national de santé.

La política de Tailandia sobre la cobertura sanitaria universal (CSU) ha progresado mucho desde su creación en 2002. Todos los ciudadanos tailandeses tienen ahora derecho a servicios esenciales de salud preventiva, curativa y paliativa en todas las etapas de la vida. Sin embargo, al igual que sus homólogas en otros lugares, la política se enfrenta a desafíos. Un sistema financiado en su mayoría por impuestos en un país con una alta proporción de personas que viven en la pobreza siempre tendrá que esforzarse para limitar el aumento de los costes. Existen disparidades entre los diferentes planes de seguros sanitarios que ofrecen cobertura a los ciudadanos tailandeses. El gasto nacional en salud lo soporta en gran medida el gobierno, principalmente para reducir las barreras financieras al acceso de los pobres. La población envejece y los perfiles de enfermedad de la población cambian al mismo tiempo que se modernizan los estilos de vida de los habitantes de Tailandia. Tailandia aspira ahora a mejorar y mantener su política de CSU. Se han examinado los méritos de las diferentes opciones de políticas para así identificar la manera más prometedora y factible de mejorar y sostener la CSU. Se sostiene que el desarrollo del sistema de atención primaria de salud existente en Tailandia tiene el mayor potencial para proporcionar una atención primaria de salud más autosuficiente, eficiente, equitativa y eficaz. La atención primaria debe pasar de su función tradicional de proporcionar atención básica basada en la enfermedad a ser el primer punto de contacto en un sistema de atención integral, coordinado, orientado a la comunidad y centrado en las personas, para lo cual se debe dar prioridad al presupuesto nacional de salud.

Towards a preventative approach to improving health and reducing health inequalities: a view from Scotland.

Pressures on the health system are intense. Prevention is often seen as a sustainable way to manage these pressures. However, the impact of prevention on the demand for health and social care is not fully understood. It will reflect the balance of opposing forces: reduced needs for health and social care because of improving health and increased needs associated with increasing life expectancy and the diseases of old age, mediated by how the system manages the resulting pressures. This article illustrates how some of these factors are playing out in Scotland. The article also highlights the substantial growth in the evidence base on the economics of prevention and identifies policy developments with the potential to support a shift to prevention that might help move towards more sustainable demands on the health and social care system. These include recognition of the importance of the social determinants of health, the integration of health and social care and 'realistic medicine'. The article suggests that more use needs to be made of available evidence on the economics of prevention and that all stakeholders need to be engaged in tackling the technical and political challenges posed by the shift to prevention.

Investing in illness prevention.

Emeritus Professor Alan Glasper, from the University of Southampton, discusses a new policy initiative by the Department of Health and Social Care that aims to change the focus of the NHS and provide greater investment in primary and community health care.

Prevention is Better than Cure, But who Foots the Bill? R (National AIDS Trust) v NHS England.

This case note discusses R (on the Application of National Aids Trust) v The National Health Service Commissioning Board (NHS England), The Local Government Association, The Secretary of State For Health [2016] EWCA Civ 1100. The case is an appeal on an earlier finding by the High Court that the power to commission pre-exposure prophylaxis (PrEP) lies within National Health Service (NHS) England's competence, instead of being within the realm of local authorities' responsibilities. It now forms the sole piece of judicial guidance on NHS England's duties under the National Health Service Act 2006 and is significant for the process by which the Court of Appeal reached its decision. Rather than adhere to the literal meaning of relevant legislation, the judges engaged in a holistic examination of the issue to reach a functional and sensible decision. Examining this case under the lens of both legal theory and pragmatism, comment is made on the soundness of the judges' approach and it is argued that the decision reached was the correct one. This case now forms binding precedent on this issue and the clear process by which the judges reached their conclusion may form instructive guidance for similar such problems in the future.

Promoting Prevention Under the Affordable Care Act.

The Affordable Care Act (ACA) of 2010 placed a substantial emphasis on public health and prevention. Subsequent research on its effects reveals some notable successes and some missteps and offers important lessons for future legislators. The ACA's Prevention and Public Health Fund, intended to give public health budgetary flexibility, provided crucial funding for public health services during the Great Recession but proved highly vulnerable to subsequent budget cuts. Several programs that aimed to increase strategic thinking and planning around public health at the state level have proven to be more enduring, suggesting that the convening authority of the federal government can be a powerful tool for progress, especially when buttressed by some funding. Most important, by expanding insurance and mandating a minimum level of coverage, the ACA both increased access to clinical preventive services and freed up local public health budgets to engage in population health activities.

A mobile revolution for healthcare? Setting the agenda for bioethics.

Mobile health (mHealth) is rapidly being implemented and changing our ways of doing, understanding and organising healthcare. mHealth includes wearable devices as well as apps that track fitness, offer wellness programmes or provide tools to manage chronic conditions. According to industry and policy makers, these systems offer efficient and cost-effective solutions for disease prevention and self-management. While this development raises many ethically relevant questions, so far mHealth has received only little attention in medical ethics. This paper provides an overview of bioethical issues raised by mHealth and aims to draw scholarly attention to the ethical significance of its promises and challenges. We show that the overly positive promises of mHealth need to be nuanced and their desirability critically assessed. Finally, we offer suggestions to bioethicists to engage with this emerging trend in healthcare to develop mHealth to its best potential in a morally sound way.

Standards of Evidence for Conducting and Reporting Economic Evaluations in Prevention Science.

Over a decade ago, the Society for Prevention Research endorsed the first standards of evidence for research in preventive interventions. The growing recognition of the need to use limited resources to make sound investments in prevention led the Board of Directors to charge a new task force to set standards for research in analysis of the economic impact of preventive interventions. This article reports the findings of this group's deliberations, proposes standards for economic analyses, and identifies opportunities for future prevention science. Through examples, policymakers' need and use of economic analysis are described. Standards are proposed for framing economic analysis, estimating costs of prevention programs, estimating benefits of prevention programs, implementing summary metrics, handling uncertainty in estimates, and reporting findings. Topics for research in economic analysis are identified. The SPR Board of Directors endorses the "Standards of Evidence for Conducting and Reporting Economic Evaluations in Prevention Science."

Physical activity and health services utilization and costs among U.S. adults.

The objective of this study was to examine the relationship between physical activity and health services utilization and costs among adults aged 18 or older in the U.S. Data came from the Medical Expenditure Panel Survey-Household component from 2007 through 2011 (n=117,361). Regular physical activity was defined as spending half an hour or more in moderate or vigorous physical activity at least three times a week. The following categories of self-reported health services utilization and costs were examined: preventive, office-based, outpatient, inpatient, emergency department, home health, and prescription medicines. The association of physical activity and health services utilization and costs was estimated using two-part models. Adults who engaged in regular physical activity were more likely to use preventive (ORs ranged from 1.06 to 1.34, p<0.05) and office-based services (OR=1.05, 95% CI=1.01-1.10, p<0.05). Combining results from both parts of the two-part models, physically active adults incurred significantly lower utilization of inpatient (0.09 vs 0.12 visit per person), emergency room (0.18 vs 0.19 visit per person), home health care (1.21 vs 1.92 visit per person), and prescription medicines (12.66 vs 13.75 number of prescriptions per person) and spent $27 less per capita expenditures for office-based visits, $351 less for inpatient visits, and $52 less for home health care visits. Promoting regular physical activity may reduce health care costs through decreasing demand for secondary and tertiary care services.

The ACA's Zero Cost-Sharing Mandate and Trends in Out-of-Pocket Expenditures on Well-Child and Screening Mammography Visits.

BACKGROUND: Starting in September of 2010, the Patient Protection and Affordable Care Act required most health insurance policies to cover evidence-based preventive care with no cost-sharing (no copays, coinsurance, or deductibles). It is unknown, however, whether declines in out-of-pocket costs for preventive services are large enough to prompt increases in utilization, the ultimate goal of the policy. METHODS: In this study, we use a nationally representative sample of ambulatory care visits to estimate the impact of the zero cost-sharing mandate on out-of-pocket expenditures on well-child and screening mammography visits. Estimates are made using 2-part interrupted time-series models, with well-woman visits serving as the control group because they were not covered under the zero cost-sharing mandate until after our study period. RESULTS: Results indicate a substantial reduction in out-of-pocket costs attributable to the Affordable Care Act. Between January 2011 and September 2012, the zero cost-sharing mandate reduced per-visit out-of-pocket costs for well-child visits from $18.46 to $8.08 (56%) and out-of-pocket costs for screening mammography visits from $25.43 to $6.50 (74%). No reduction was apparent for well-woman visits. CONCLUSIONS: The Affordable Care Act's zero cost-sharing mandate for preventive care has had a large impact on out-of-pocket expenditures for well-child and mammography visits. To increase preventive service use, research is needed to better understand barriers to obtaining preventive care that are not directly related to cost.

The Italian National Health Service expenditure on workplace prevention and safety (2006-2013): a national-level analysis.

BACKGROUND: The World Health Organization (WHO) stated that countries' health policies should give high priority to primary prevention of occupational health hazards. Scant data are available on health expenditure on workplace prevention and safety services and on its impact on occupational health outcomes in Italy and in other European countries. STUDY DESIGN: objective of the present study was to systematically retrieve, analyse and critically appraise the available national-level data on public health expenditure on workplace prevention and safety services as well as to correlate them with occupational health outcomes. METHODS: National-level data on total public health expenditure on prevention services, its share spent on workplace prevention and safety services as well as on number of workers receiving appropriate health surveillance were derived from the national public health expenditure monitoring system over a 8-year study period (2006-2013). An analytic approach was adopted to explore the association between health expenditure and occupational health services supply. RESULTS: The Italian National Health Service spends almost € 5 billion per year on preventive care, of which 13.3% are spent on workplace prevention and safety programmes (€ 645 million, € 10.6 per capita). There is wide heterogeneity between Italian regions. CONCLUSIONS: Our findings are useful for health systems and policies analysis, national and international comparisons as well as for health policy makers to plan, implement and monitor occupational health prevention programmes.

How Medicare preventive services can bolster the hospital-physician enterprise.

Medicare preventive services offer hospital-owned physician practices an opportunity to increase revenue.

The relationship between socio-economic factors and responsiveness gaps in primary, preventative and health promotion services.

OBJECTIVE: To examine whether there are individual level factors such as socio-economic status that may predict disparities in the public's experiences with and expectations of their health-care providers. DATA SOURCES/STUDY SETTING: Primary data were collected in 2010. The sample comprised of 1211 Israeli citizens above the age of 18. STUDY DESIGN: Participants were randomly approached at one points in time and presented with statements regarding practices they experience and practices that are important to them related to primary care, preventive care and health promotion. We calculated a difference scores for each health-care area. We measured socio-economic status (SES) with three separate variables relating to income, education and living location. DATA COLLECTION/EXTRACTION METHODS: Employees of a professional telephone survey firm conducted the survey. Multiple regression was used with the responsiveness gap in each of three health-care areas as the dependent variables. PRINCIPAL FINDINGS: We found that level of education is negatively related to the extent of the responsiveness gap in both primary and preventive health care and that income is negatively related to the responsiveness gap in health promotion. CONCLUSIONS: Personal characteristics such as SES are related to people's perceptions about the extent of the responsiveness gap. Policy makers can now expend efforts and resources in minimizing such responsiveness gaps among specific populations.

[Conflicting Rules and Incentives for Health Promotion and Prevention in the German Statutory Health Insurance (GKV)]. / Normen- und Anreizkonflikte für die gesetzlichen Krankenkassen in Gesundheitsförderung und Prävention.

OBJECTIVES: This study examines what role the German statutory health insurance (GKV) has in health promotion and prevention, if regulations and incentives are consistent, and if the politically-intended strengthening of prevention has been achieved. METHODS: We compiled the regulations and incentives of the German Sozialgesetzbuch V as the legal basis for health promotion and prevention of the GKV and studied their effects and interactions. Using annual financial reports of GKV we determined how the spending in prevention overall and in specific fields of prevention has -developed. RESULTS: The responsibilities of the GKV in health promotion and prevention lack a clear scientific foundation. Regulations have been incrementally added following changing ideas in prevention and health promotion policies. Currently, different norms and a variety of incentives lead to inconsistent and conflicting aims. Only 2% of all expenditures of the GKV are for health promotion and prevention, mainly spent for medical measures like preventive medical check-ups or vaccination. While spending of the GKV in general is rising, expenditures for prevention have decreased since 2009. CONCLUSIONS: There is a need to harmonise the different regulations in health promotion and prevention and to correct currently inconsistent incentives in the GKV. Given the similar evidence base there seems to be no reason why responsibilities for health promotion and primary, secondary or tertiary prevention should be regulated by different normative constructs. Incentives should account for the different aims of health insurers and their members. Financial incentives to increase spending in prevention may be particularly effective when there is no short-term -financial interest for the health insurer.

Aboriginal involvement in caring-for-country: an economic case study in primary preventative health.

OBJECTIVE: Firstly, to demonstrate the involvement of Aboriginal people in caring-for-country as a case study of how appropriately targeted non-medical primary preventative health strategies can be a cost-effective approach to addressing chronic disease among Indigenous people. Secondly, to demonstrate the use of an analogous approach in addressing the global chronic disease pandemic. METHOD: A review of prior biomedical and economic research based on the involvement of Aboriginal people in caring-for-country is used to: (a) exemplifying the cost effectiveness of a non-medical preventative health intervention; and (b) the process by which such an approach might be applied across a broader context. RESULTS: The presented results demonstrate one non-medical primary preventative health approach to addressing the health burden affecting Indigenous peoples. CONCLUSIONS: The suggested steps in optimising the cost effectiveness of such an approach demonstrate how it could be applied in addressing the global chronic disease pandemic.

Standardizing economic analysis in prevention will require substantial effort.

It is exceedingly difficult to compare results of economic analyses across studies due to variations in assumptions, methodology, and outcome measures, a fact which surely decreases the impact and usefulness of prevention-related economic research. Therefore, Crowley et al. (Prevention Science, 2013) are precisely correct in their call for increased standardization and have usefully highlighted the issues that must be addressed. However, having made the need clear, the questions become what form the solution should take, and how should it be implemented. The present discussion outlines the rudiments of a comprehensive framework for promoting standardized methodology in the estimation of economic outcomes, as encouraged by Crowley et al. In short, a single, standard, reference case approach should be clearly articulated, and all economic research should be encouraged to apply that standard approach, with results from compliant analyses being reported in a central archive. Properly done, the process would increase the ability of those without specialized training to contribute to the body of economic research pertaining to prevention, and the most difficult tasks of predicting and monetizing distal outcomes would be readily completed through predetermined models. These recommendations might be viewed as somewhat forcible, insomuch as they advocate for prescribing the details of a standard methodology and establishing a means of verifying compliance. However, it is unclear that the best practices proposed by Crowley et al. will be widely adopted in the absence of a strong and determined approach.

Commentary on Crowley et al.'s research priorities for economic analysis of prevention.

Economic theory provides a textbook ideal for how to conduct efficiency analysis that determines optimal resource allocation. The real world is not, however, an ideal place. This article suggests that common sense should be allowed to temper zealous commitment to textbook ideals. The spirit and the process of economic evaluation may be as important as the "final answer" expressed as a summary statistic.

Research priorities for economic analyses of prevention: current issues and future directions.

In response to growing interest in economic analyses of prevention efforts, a diverse group of prevention researchers, economists, and policy analysts convened a scientific panel, on "Research Priorities in Economic Analysis of Prevention" at the 19th annual conference of the Society for Prevention Research. The panel articulated four priorities that, if followed in future research, would make economic analyses of prevention efforts easier to compare and more relevant to policymakers and community stakeholders. These priorities are: (1) increased standardization of evaluation methods, (2) improved economic valuation of common prevention outcomes, (3) expanded efforts to maximize evaluation generalizability and impact as well as (4) enhanced transparency and communicability of economic evaluations. In this paper, we define three types of economic analyses in prevention, provide context and rationale for these four priorities as well as related sub-priorities, and discuss the challenges inherent in meeting them.