Prevention for a Healthier America:

INVESTMENTS IN DISEASE PREVENTION YIELD SIGNIFICANT SAVINGS, STRONGER COMMUNITIES

Keeping people healthier is one of the most effective ways to reduce health care costs.

This study, which was developed through a partnership of the Trust for America’s Health (TFAH), The Urban Institute, The New York Academy of Medicine (NYAM), the Robert Wood Johnson Foundation (RWJF), The California Endowment (TCE), and Prevention Institute, examines how much the country could save in health care costs if we invested more in disease prevention, specifically by funding proven community based programs that result in increased levels of physical activity, improved nutrition (both quality and quantity of food), and a reduction in smoking and other tobacco use rates.

The researchers found that if the country reduced type 2 diabetes and high blood pressure rates by 5 percent the country could save more than $5 billion in health care costs; also reducing heart disease, kidney disease, and stroke prevalence by 5 percent could raise the savings to more than $19 billion; and with additional 2.5 percent reductions in the prevalence of some forms of cancer, chronic obstructive pulmonary disease (COPD) and arthritis savings could increase to more than $21 billion. A review of a range of evidence-based studies shows that proven community-based disease prevention programs can lead to improvements in physical activity, nutrition, and preventing smoking and other tobacco use can lead to reductions of type 2 diabetes and high blood pressure by 5 percent in one to 2 years; heart disease, kidney disease, and stroke by 5 percent in 5 years; and some forms of cancer, COPD, and arthritis by 2.5 percent in 10 to 20 years. According to the literature, the per capita cost of many effective community-based programs is under $10 per person per year.

Introduction and Key Findings

The researchers evaluated 84 studies that met their criteria to develop the assumptions for the drops in disease rates and the costs of the programs. To be included in the review, the studies had to focus on:

1) Prevention programs that do not require medical treatment;

2) Programs that target communities rather than individuals; and

3) Evidence-based programs that have been shown to reduce disease through improving physical activity and nutrition and preventing smoking and other tobacco use in communities.

Examples of the types of studies include programs that:

To build the model, the researchers evaluated:

RETURN ON INVESTMENT

In general, ROI compares the dollars invested in something to the benefits produced by that investment:

ROI = (benefits of investment - amount invested) / amount invested

In the case of an investment in a prevention program, ROI compares the savings produced by the intervention, net of the cost of the program, to how much the program cost:

ROI = ( ____net savings______ ) / cost of intervention

When ROI equals 0, the program pays for itself. When ROI is greater than 0, then the program is producing savings that exceed the cost of the program.

assumptions for the costs of the programs. In addition, the health savings costs in this model are in 2004 dollars and do not include spending in nursing homes, which is significant for these conditions. They also assumed the programs would only result in a one-time reduction in the prevalence of each disease.  For instance, they assumed type 2 diabetes rates would only drop once even though the programs would continue over time and it is likely the rates would continue to drop as the programs continued over the years. This assumption helps take into account the possibility that some people may backslide while others may continue to improve.

ROI FOR PAYERS: MEDICARE, MEDICAID, AND PRIVATE INSURERS

In addition to total dollars saved, the study looked at how this investment could benefit different health care payers.

Medicare could save more than $487 million annually in the first one to 2 years, more than $5.2 billion annually within 5 years, and nearly $5.9 billion annually in 10 to 20 years.

Annually, Medicaid could save $370 million annually in the first one to 2 years, some $1.9 billion annually within 5 years, and more than $2 billion annually in 10 to 20 years.  And, annually private insurers and individuals (through reductions of out-of-pocket costs) could see the biggest savings, with nearly $2 billion annually in the first one to 2 years, more than $9 billion annually within 5 years, and more than $10 billion annually in 10 to 20 years.

* In 2004 dollars, net savings

DIFFERENT TYPES OF PREVENTION EFFORTS YIELD DIFFERENT RETURNS

There are 3 types of prevention: primary, secondary, and tertiary.

Primary Prevention involves taking action before a problem arises in order to avoid it entirely, rather than treating or alleviating its consequences. Primary Prevention can include clinical interventions, such as specific immunizations, and broader public health interventions, such as clean water and sewage systems; fortification of food with specific nutrients, such as folic acid; and protection from carcinogens, such as second-hand tobacco smoke.

Secondary Prevention is a set of measures used for early detection and prompt intervention to control a problem or disease and minimize the consequences, while tertiary prevention focuses on the reduction of further complications of an existing disease or problem, through treatment and rehabilitation.9

Many factors influence whether specific prevention efforts result in cost-savings. For instance, prevention efforts involving direct medical treatment or pharmaceuticals often have higher costs. These Tertiary Prevention measures are aimed at trying to reverse a condition or prevent it from getting worse.

Secondary Prevention efforts, which include early detection and prompt intervention to control a problem or disease and minimize the consequences of a disease, are more cost-effective if they are targeted to at-risk populations.

The TFAH model is based on studies of strategic low-cost, community-based primary and Secondary Prevention efforts that have demonstrated results in lowering disease rates or improving health choices, but do not involve direct medical care.

A HEALTHIER AND LESS COSTLY LIFE: NOT JUST DEFERRING COSTS TO END OF LIFE

Scientists refer to this effect as Compression Of Morbidity which means extending

healthy life expectancy more than total life expectancy. Chronic disease and disability

are compressed into a smaller portion of a person’s life -- and his or her lifelong health

care management costs are lower and quality of life is improved.6, 7

The return on investment for community based disease prevention programs does not just defer high health care costs to the end of life. By increasing physical activity and good nutrition and decreasing smoking and other tobacco use, we are ensuring that more people will be healthier for longer periods of their life.

Being healthier throughout their lifetimes, these individuals might avoid developing complications or compounding conditions that may develop if they are less healthy (e.g., gain too much weight, are physically inactive, or practice poor nutrition).

A recent study by Lakdawalla, Goldman, and Shang in Health Affairs demonstrated that obese and non-obese people have similar life expectancies, but the health care costs of an obese person will be significantly higher than a non-obese person over the course of a lifetime. Therefore, higher costs are not offset by reduced longevity.

Obese people also have “fewer disability-free life years and experience higher rates of diabetes, hypertension, and heart disease.”3

As one example, a person who is obese has a higher risk for needing a knee replacement.

If the obesity is prevented, the need -- and cost -- for a knee replacement may be delayed or avoided altogether.

Also, studies have found that smokers, on average, have significantly higher health care costs than non-smokers, but smokers dying sooner does not save money.4, 5

America’s future economic well-being is inextricably tied to our health. Helping Americans stay healthier is the best way to drive down health care costs and ensure our workforce is competitive in the global economy.

The skyrocketing costs of health care are hurting the U.S. economy. Health care costs are more than 3 times higher than in 1990 and more than 8 times higher than in 1980.15 Poor health is putting our economic security in jeopardy. High health care costs are undermining business profits, causing some companies to relocate jobs overseas where costs are lower and productivity is higher.

And if we invest more in keeping Americans healthy, not only will we spare millions of people from needless suffering, we will also save the country billions of dollars.

Right now, however, America’s health care system is set up to focus on treating people once they have a health problem. Some experts describe this as “sick care” instead of health care.

The country will never be able to contain health care costs until we start focusing on how to prevent people from getting sick in the first place, putting an emphasis on improving the choices we make that affect

General Motors (GM) estimates it pays $1,500 per car produced in health care coverage

costs to employees and retirees (more than it pays for steel), and these costs are passed

onto the consumer. In addition, GM claims that rising health care costs were a critical factor

in the decision to cut 25,000 jobs (a cut that can impact up to 175,000 jobs in other sectors

Current Health and Economic Costs

ASSOCIATED WITH PHYSICAL INACTIVITY, POOR NUTRITION, AND SMOKING AND OTHER TOBACCO USE

our risk for preventable diseases. Experts

widely agree that 3 of the most important

factors that influence our health are:

1) Physical activity;

2) Nutrition (including eating foods of high

nutritional value and in the right quantities);

and

3) Whether or not we smoke.

As a nation, if we develop strategies and programs

that help more Americans become

physically active, practice good nutrition,

and stop smoking and other tobacco use

(while also helping our youth from ever

starting smoking or other unhealthy practices),

we could have a tremendous payoff

both in improving health and reducing

health care costs.

MAJOR FACTORS IN U.S. HEALTH: LACK OF PHYSICAL ACTIVITY,

POOR NUTRITION, AND SMOKING AND TOBACCO USE

In the past 3 decades, the health of Americans has changed dramatically. Adult obesity rates

In addition, after years of declines, smoking rates have levelled off, with 21 percent of adults

people at significantly higher risk for developing serious and costly diseases.

Right now, more than half of Americans live with one or more chronic disease, such as heart

The risks of developing heart disease, stroke, and kidney disease are exponentially higher if a

person is both obese and a smoker. There are other conditions related to activity, nutrition,

and smoking, but combined, these sets of diseases are the most common and costly.

People who do not engage in adequate physical activity, have poor nutrition habits, and/or

are obese are at increased risk for type 2 diabetes, high blood pressure (hypertension),

heart disease, stroke, kidney disease, some forms of cancer, arthritis, and chronic

even more serious conditions, including heart disease, stroke, or kidney disease.

disease without first being diabetic or hypertensive.

and possibly osteoarthritis of other joints. For example, obese adults are up to 4 times

who have received a doctor’s diagnosis of arthritis 68.8 percent are overweight or

Obese and physically inactive workers also suffer from lower worker productivity,

$100 per person (year 2000 costs), at a total of $495 million in direct costs ($383

million in hospital, outpatient, and professional expenses and $112 million for outpatient

heart disease, stroke, colon cancer, and osteoporosis costs were due to physical inactivity

-- about $84 million in 2000, which was $56 per member, regardless of their level of activity.

$2.1 billion it currently spends on health care costs related to physical inactivity (25 percent

of costs of coronary artery disease, stroke, hypertension, colon cancer, breast cancer,

15.7 percent in Minnesota to 31.8 percent in Mississippi, and many more do not

consuming foods with low nutritional value. On average, we consume approximately

consumption is “woefully low” and is limited to only a small range of potential

The estimates in this section characterize

likely relative magnitudes of the savings

states could realize from well-designed community-

level programs implemented

statewide. These estimates should be considered

preliminary for two reasons. First,

they are based on the estimated national

proportions of spending attributable to persons

with intervention-amenable diseases

applied to state data on spending by payer

using preliminary estimates of savings by

state and payer produced by Urban

Institute researchers. The estimates do not

take into account differences in state population

characteristics, such as the distribution

by age and ethnicity, disease prevalence,

or environmental characteristics,

such as urban/rural population distribution,

which can have a significant effect on

costs and savings. For example, state prevalences

range from 4 percent to 9.8 percent

for diabetes, 20 percent to 32.5 percent for

hypertension, and 24 percent to 37.3 percent

Second, community-based interventions target

entire communities. Health insurance

coverage in most communities is mixed with

some people covered by private insurance

and others by Medicaid or Medicare. Some

community residents are uninsured. Disease

patterns also vary by community and these

patterns may be associated with insurance

coverage, as in the case of age and Medicare

coverage. Distribution of costs of program

interventions to different payers across the

community is, therefore, not straightforward.

While the reductions in medical expenditures

can be assigned to specific payers, costs

of the intervention are not assignable.

The federal and state governments share the

costs of Medicaid, however, each state pays a

different percentage share. The following

state charts reflect the proportions that the

federal and state governments pay in each

state based on their percentage share

according to the data in the Kaiser Family

Foundation’s www.statehealthfacts.org

“Federal and State Share of Medicaid

Spending, FY 2006.

State-By-State ROI

person in strategic community-based disease prevention programs

aimed at improving physical activity and nutrition and preventing smoking

and other tobacco use.

Total Annual Intervention Costs (at $10 per person): $45,170,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings (proportion $11,500,000 $67,600,000 $75,400,000

of net savings)

Medicaid Net Savings (federal share) $2,870,000 $16,800,000 $18,800,000

(proportion of net savings)

Medicaid Net Savings (state share) $1,260,000 $7,410,000 $8,270,000

(proportion of net savings)

Private Payer and Out of Pocket Net $27,000,000 $158,600,000 $176,900,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $6,570,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of

$10 Per Person

Medicare Net Savings $2,540,000 $12,700,000 $14,200,000

(proportion of net savings)

Medicaid Net Savings (federal share) $459,000 $2,300,000 $2,560,000

(proportion of net savings)

Medicaid Net Savings (state share) $455,000 $2,280,000 $2,540,000

(proportion of net savings)

Private Payer and Out of Pocket Net $5,970,000 $29,900,000 $33,200,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $57,460,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of

$10 Per Person

Medicare Net Savings $8,510,000 $65,400,000 $73,300,000

(proportion of net savings)

Medicaid Net Savings (federal share) $2,050,000 $15,700,000 $17,600,000

(proportion of net savings)

Medicaid Net Savings (state share) $1,010,000 $7,750,000 $8,690,000

(proportion of net savings)

Private Payer and Out of Pocket Net $19,900,000 $153,300,000 $171,900,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $27,470,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of

$10 Per Person

Medicare Net Savings $5,980,000 $37,700,000 $42,100,000

(proportion of net savings)

Medicaid Net Savings (federal share) $1,580,000 $10,000,000 $11,100,000

(proportion of net savings)

Medicaid Net Savings (state share) $563,000 $3,550,000 $3,960,000

(proportion of net savings)

Private Payer and Out of Pocket Net

Savings (proportion of net savings) $14,000,000 $88,400,000 $98,700,000

Total Annual Intervention Costs (at $10 per person): $358,410,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $71,000,000 $468,200,000 $523,600,000

(proportion of net savings)

Medicaid Net Savings (federal share) $12,700,000 $84,100,000 $94,000,000

(proportion of net savings)

Medicaid Net Savings (state share) $12,700,000 $84,100,000 $94,000,000

(proportion of net savings)

Private Payer and Out of Pocket Net $166,400,000 $1,097,800,000 $1,227,600,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $45,990,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $9,890,000 $62,700,000 $70,100,000

(proportion of net savings)

Medicaid Net Savings (federal share) $1,770,000 $11,200,000 $12,500,000

(proportion of net savings)

Medicaid Net Savings (state share) $1,770,000 $11,200,000 $12,500,000

(proportion of net savings)

Private Payer and Out of Pocket Net $23,200,000 $147,000,000 $164,300,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $34,940,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $11,900,000 $62,500,000 $69,500,000

(proportion of net savings)

Medicaid Net Savings (federal share) $2,140,000 $11,200,000 $12,400,000

(proportion of net savings)

Medicaid Net Savings (state share) $2,140,000 $11,200,000 $12,400,000

(proportion of net savings)

Private Payer and Out of Pocket Net $27,900,000 $146,500,000 $163,000,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $8,290,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $3,040,000 $15,500,000 $17,200,000

(proportion of net savings)

Medicaid Net Savings (federal share)

(proportion of net savings) $547,000 $2,790,000 $3,110,000

Medicaid Net Savings (state share) $545,000 $2,780,000 $3,090,000

(proportion of net savings)

Private Payer and Out of Pocket Net $7,130,000 $36,400,000 $40,500,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $5,800,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $3,480,000 $15,400,000 $17,100,000

(proportion of net savings)

Medicaid Net Savings (federal share) $876,000 $3,880,000 $4,300,000

(proportion of net savings)

Medicaid Net Savings (state share) $375,000 $1,660,000 $1,840,000

(proportion of net savings)

Private Payer and Out of Pocket Net $8,170,000 $36,200,000 $40,100,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $173,670,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $52,963,000 $289,300,000 $322,200,000

(proportion of net savings)

Medicaid Net Savings (federal share) $11,200,000 $61,200,000 $68,100,000

(proportion of net savings)

Medicaid Net Savings (state share) $7,810,000 $42,700,000 $47,500,000

(proportion of net savings)

Private Payer and Out of Pocket Net $124,100,000 $678,300,000 $755,500,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $89,350,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $17,200,000 $115,100,000 $128,700,000

(proportion of net savings)

Medicaid Net Savings (federal share) $3,740,000 $25,000,000 $28,000,000

(proportion of net savings)

Medicaid Net Savings (state share) $2,430,000 $16,200,000 $18,200,000

(proportion of net savings)

Private Payer and Out of Pocket Net $40,300,000 $269,900,000 $301,800,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $12,590,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $3,230,000 $18,900,000 $21,100,000

(proportion of net savings)

Medicaid Net Savings (federal share) $682,000 $3,990,000 $4,460,000

(proportion of net savings)

Medicaid Net Savings (state share) $478,000 $2,800,000 $3,120,000

(proportion of net savings)

Private Payer and Out of Pocket Net $7,570,000 $44,300,000 $49,500,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $13,950,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $2,340,000 $16,800,000 $18,800,000

(proportion of net savings)

Medicaid Net Savings (federal share)

(proportion of net savings) $589,000 $4,220,000 $4,730,000

Medicaid Net Savings (state share)

(proportion of net savings) $253,000 $1,810,000 $2,030,000

Private Payer and Out of Pocket Net $5,500,000 $39,400,000 $44,100,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $127,140,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $32,600,000 $191,100,000 $213,200,000

(proportion of net savings)

Medicaid Net Savings (federal share) $5,860,000 $34,300,000 $38,300,000

(proportion of net savings)

Medicaid Net Savings (state share) $5,860,000 $34,300,000 $38,300,000

(proportion of net savings)

Private Payer and Out of Pocket Net $76,500,000 $448,200,000 $499,900,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $62,230,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $15,700,000 $92,600,000 $103,400,000

(proportion of net savings)

Medicaid Net Savings (federal share) $3,550,000 $20,900,000 $23,400,000

(proportion of net savings)

Medicaid Net Savings (state share) $2,080,000 $12,300,000 $13,700,000

(proportion of net savings)

Private Payer and Out of Pocket Net $36,800,000 $217,300,000 $242,400,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $29,540,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $7,670,000 $44,700,000 $49,800,000

(proportion of net savings)

Medicaid Net Savings (federal share) $1,750,000 $10,200,000 $11,300,000

(proportion of net savings)

Medicaid Net Savings (state share) $1,000,000 $5,800,000 $6,520,000

(proportion of net savings)

Private Payer and Out of Pocket Net $17,900,000 $104,800,000 $116,900,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $27,380,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $7,270,000 $41,900,000 $46,800,000

(proportion of net savings)

Medicaid Net Savings (federal share) $1,570,000 $9,110,000 $10,100,000

(proportion of net savings)

Medicaid Net Savings (state share) $1,030,000 $5,970,000 $6,660,000

(proportion of net savings)

Private Payer and Out of Pocket Net

Savings (proportion of net savings) $17,000,000 $98,400,000 $109,700,000

Total Annual Intervention Costs (at $10 per person): $41,400,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $12,000,000 $67,200,000 $74,800,000

(proportion of net savings)

Medicaid Net Savings (federal share) $3,010,000 $16,700,000 $18,600,000

(proportion of net savings)

Medicaid Net Savings (state share)

(proportion of net savings) $1,330,000 $7,410,000 $8,250,000

Private Payer and Out of Pocket Net

Savings (proportion of net savings) $28,300,000 $157,500,000 $175,500,000

Total Annual Intervention Costs (at $10 per person): $44,960,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $10,200,000 $63,400,000 $70,800,000

(proportion of net savings)

Medicaid Net Savings (federal share) $2,580,000 $15,900,000 $17,700,000

(proportion of net savings)

Medicaid Net Savings (state share) $1,110,000 $6,870,000 $7,680,000

(proportion of net savings)

Private Payer and Out of Pocket Net $24,100,000 $148,600,000 $166,000,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $13,140,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings

(proportion of net savings) $5,420,000 $26,600,000 $29,600,000

Medicaid Net Savings (federal share)

(proportion of net savings) $1,220,000 $6,020,000 $6,690,000

Medicaid Net Savings (state share)

(proportion of net savings) $723,000 $3,550,000 $3,940,000

Private Payer and Out of Pocket Net

Savings (proportion of net savings) $12,700,000 $62,500,000 $69,400,000

Total Annual Intervention Costs (at $10 per person): $55,530,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $16,000,000 $89,700,000 $99,900,000

(proportion of net savings)

Medicaid Net Savings (federal share) $2,890,000 $16,100,000 $17,900,000

(proportion of net savings)

Medicaid Net Savings (state share) $2,890,000 $16,100,000 $17,900,000

(proportion of net savings)

Private Payer and Out of Pocket Net $37,700,000 $210,300,000 $234,300,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $64,360,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $25,900,000 $128,600,000 $142,963,000

(proportion of net savings)

Medicaid Net Savings (federal share) $4,660,000 $23,100,000 $25,600,000

(proportion of net savings)

Medicaid Net Savings (state share) $4,660,000 $23,100,000 $25,600,000

(proportion of net savings)

Private Payer and Out of Pocket Net $60,900,000 $301,500,000 $335,100,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $100,930,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $24,500,000 $147,200,000 $164,300,000

(proportion of net savings)

Medicaid Net Savings (federal share) $4,990,000 $29,900,000 $33,400,000

(proportion of net savings)

Medicaid Net Savings (state share)

(proportion of net savings) $3,830,000 $22,963,000 $25,600,000

Private Payer and Out of Pocket Net

Savings (proportion of net savings) $57,500,000 $345,200,000 $385,300,000

Total Annual Intervention Costs (at $10 per person): $50,940,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings

(proportion of net savings) $15,700,000 $85,500,000 $95,300,000

Medicaid Net Savings (federal share) $2,820,000 $15,300,000 $17,100,000

(proportion of net savings)

Medicaid Net Savings (state share)

(proportion of net savings) $2,820,000 $15,300,000 $17,100,000

Private Payer and Out of Pocket Net $36,900,000 $200,600,000 $223,400,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $28,930,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings

(proportion of net savings) $6,570,000 $40,600,000 $45,300,000

Medicaid Net Savings (federal share)

(proportion of net savings) $1,790,000 $11,000,000 $12,300,000

Medicaid Net Savings (state share)

(proportion of net savings) $566,000 $3,500,000 $3,910,000

Private Payer and Out of Pocket Net

Savings (proportion of net savings) $15,400,000 $95,200,000 $106,300,000

Total Annual Intervention Costs (at $10 per person): $57,530,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $15,900,000 $90,300,000 $100,700,000

(proportion of net savings)

Medicaid Net Savings (federal share)

(proportion of net savings) $3,530,000 $20,000,000 $22,300,000

Medicaid Net Savings (state share)

(proportion of net savings) $2,170,000 $12,300,000 $13,700,000

Private Payer and Out of Pocket Net

Savings (proportion of net savings) $37,200,000 $211,800,000 $236,100,000

Total Annual Intervention Costs (at $10 per person): $9,260,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings

(proportion of net savings) $2,330,000 $13,700,000 $15,300,000

Medicaid Net Savings (federal share) $592,000 $3,490,000 $3,890,000

(proportion of net savings)

Medicaid Net Savings (state share) $247,000 $1,460,000 $1,630,000

(proportion of net savings)

Private Payer and Out of Pocket Net $5,480,000 $32,300,000 $36,000,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $17,470,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $4,880,000 $27,600,000 $30,700,000

(proportion of net savings)

Medicaid Net Savings (federal share) $1,040,000 $5,920,000 $6,600,000

(proportion of net savings)

Medicaid Net Savings (state share) $707,000 $3,990,000 $4,450,000

(proportion of net savings)

Private Payer and Out of Pocket Net $11,400,000 $64,700,000 $72,100,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $23,320,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $4,850,000 $31,200,000 $34,900,000

(proportion of net savings)

Medicaid Net Savings (federal share) $954,000 $6,150,000 $6,870,000

(proportion of net savings)

Medicaid Net Savings (state share) $787,000 $5,070,000 $5,670,000

(proportion of net savings)

Private Payer and Out of Pocket Net $11,300,000 $73,200,000 $81,800,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $12,980,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $3,670,000 $20,600,000 $23,000,000

(proportion of net savings)

Medicaid Net Savings (federal share) $659,000 $3,710,000 $4,130,000

(proportion of net savings)

Medicaid Net Savings (state share) $659,000 $3,710,000 $4,130,000

(proportion of net savings)

Private Payer and Out of Pocket Net $8,600,000 $48,400,000 $53,900,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $86,760,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $27,100,000 $146,700,000 $163,400,000

(proportion of net savings)

Medicaid Net Savings (federal share) $4,870,000 $26,300,000 $29,300,000

(proportion of net savings)

Medicaid Net Savings (state share) $4,870,000 $26,300,000 $29,300,000

(proportion of net savings)

Private Payer and Out of Pocket Net $63,500,000 $344,100,000 $383,200,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $19,010,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

1-2 Years 5 Years 10-20 Years

Medicare Net Savings $3,520,000 $24,000,000 $26,800,000

(proportion of net savings)

Medicaid Net Savings (federal share) $901,000 $6,140,000 $6,870,000

(proportion of net savings)

Medicaid Net Savings (state share) $366,000 $2,490,000 $2,790,000

(proportion of net savings)

Private Payer and Out of Pocket Net $8,260,000 $56,300,000 $63,000,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $192,920,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $72,200,000 $366,500,000 $407,600,000

(proportion of net savings)

Medicaid Net Savings (federal share) $12,963,000 $65,800,000 $73,200,000

(proportion of net savings)

Medicaid Net Savings (state share) $12,963,000 $65,800,000 $73,200,000

(proportion of net savings)

Private Payer and Out of Pocket Net $169,300,000 $859,400,000 $955,600,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $85,310,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $21,700,000 $127,900,000 $142,600,000

(proportion of net savings)

Medicaid Net Savings (federal share) $4,970,000 $29,100,000 $32,500,000

(proportion of net savings)

Medicaid Net Savings (state share) $2,850,000 $16,700,000 $18,700,000

(proportion of net savings)

Private Payer and Out of Pocket Net $51,000,000 $299,800,000 $334,500,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $6,360,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $1,950,000 $10,600,000 $11,800,000

(proportion of net savings)

Medicaid Net Savings (federal share) $462,000 $2,520,000 $2,800,000

(proportion of net savings)

Medicaid Net Savings (state share) $240,000 $1,300,000 $1,450,000

(proportion of net savings)

Private Payer and Out of Pocket Net $4,570,000 $24,900,000 $27,700,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $114,610,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $33,200,000 $185,200,000 $206,300,000

(proportion of net savings)

Medicaid Net Savings (federal share) $7,150,000 $39,800,000 $44,400,000

(proportion of net savings)

Medicaid Net Savings (state share) $4,780,000 $26,600,000 $29,700,000

(proportion of net savings)

Private Payer and Out of Pocket Net

Savings (proportion of net savings) $77,900,000 $434,200,000 $483,800,000

Total Annual Intervention Costs (at $10 per person): $35,230,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $8,040,000 $49,600,000 $55,400,000

(proportion of net savings)

Medicaid Net Savings (federal share) $1,960,000 $12,100,000 $13,500,000

(proportion of net savings)

Medicaid Net Savings (state share)

(proportion of net savings) $928,000 $5,720,000 $6,390,000

Private Payer and Out of Pocket Net $18,800,000 $116,300,000 $129,900,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $35,890,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $8,700,000 $52,200,000 $58,300,000

(proportion of net savings)

Medicaid Net Savings (federal share) $1,920,000 $11,500,000 $12,963,000

(proportion of net savings)

Medicaid Net Savings (state share) $1,200,000 $7,200,000 $8,040,000

(proportion of net savings)

Private Payer and Out of Pocket Net $20,400,000 $122,500,000 $136,700,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $123,770,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings

(proportion of net savings) $39,900,000 $213,600,000 $237,800,000

Medicaid Net Savings (federal share) $7,900,000 $42,200,000 $47,000,000

(proportion of net savings)

Medicaid Net Savings (state share) $6,450,000 $34,500,000 $38,400,000

(proportion of net savings)

Private Payer and Out of Pocket Net $93,600,000 $500,900,000 $557,600,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $10,790,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $3,840,000 $19,800,000 $22,000,000

(proportion of net savings)

Medicaid Net Savings (federal share) $752,000 $3,880,000 $4,320,000

(proportion of net savings)

Medicaid Net Savings (state share) $629,000 $3,240,000 $3,610,000

(proportion of net savings)

Private Payer and Out of Pocket Net $9,000,000 $46,500,000 $51,700,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $41,950,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $10,700,000 $62,963,000 $70,200,000

(proportion of net savings)

Medicaid Net Savings (federal share) $2,670,000 $15,600,000 $17,400,000

(proportion of net savings)

Medicaid Net Savings (state share) $1,180,000 $6,940,000 $7,750,000

(proportion of net savings)

Private Payer and Out of Pocket Net $25,100,000 $147,600,000 $164,700,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $7,700,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $1,910,000 $11,300,000 $12,600,000

(proportion of net savings)

Medicaid Net Savings (federal share) $447,000 $2,650,000 $2,960,000

(proportion of net savings

Medicaid Net Savings (state share) $239,000 $1,420,000 $1,590,000

(proportion of net savings)

Private Payer and Out of Pocket Net $4,480,000 $26,600,000 $29,700,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $58,860,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $17,000,000 $94,900,000 $105,800,000

(proportion of net savings)

Medicaid Net Savings (federal share) $3,910,000 $21,800,000 $24,300,000

(proportion of net savings)

Medicaid Net Savings (state share) $2,200,000 $12,200,000 $13,600,000

(proportion of net savings)

Private Payer and Out of Pocket Net $39,900,000 $222,700,000 $248,100,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $225,180,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $41,400,000 $283,600,000 $317,300,000

(proportion of net savings)

Medicaid Net Savings (federal share) $9,040,000 $61,800,000 $69,200,000

(proportion of net savings)

Medicaid Net Savings (state share) $5,850,000 $40,000,000 $44,800,000

(proportion of net savings)

Private Payer and Out of Pocket Net $97,200,000 $665,000,000 $744,100,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $24,220,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $2,570,000 $24,100,000 $27,100,000

(proportion of net savings)

Medicaid Net Savings (federal share) $654,000 $6,140,000 $6,900,000

(proportion of net savings)

Medicaid Net Savings (state share) $269,000 $2,530,000 $2,840,000

(proportion of net savings)

Private Payer and Out of Pocket Net $6,030,000 $56,600,000 $63,600,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $6,210,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $2,280,000 $11,600,000 $12,963,000

(proportion of net savings)

Medicaid Net Savings (federal share) $479,000 $2,450,000 $2,720,000

(proportion of net savings)

Medicaid Net Savings (state share) $340,000 $1,730,000 $1,930,000

(proportion of net savings)

Private Payer and Out of Pocket Net $5,350,00 $27,300,000 $30,300,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $74,720,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $16,600,000 $104,000,000 $116,100,000

(proportion of net savings)

Medicaid Net Savings (federal share) $2,990,000 $18,600,000 $20,800,000

(proportion of net savings)

Medicaid Net Savings (state share) $2,990,000 $18,600,000 $20,800,000

(proportion of net savings)

Private Payer and Out of Pocket Net $39,100,000 $243,800,000 $272,300,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $62,060,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $15,700,000 $92,800,000 $103,500,000

(proportion of net savings)

Medicaid Net Savings (federal share) $2,830,000 $16,600,000 $18,500,000

(proportion of net savings)

Medicaid Net Savings (state share) $2,830,000 $16,600,000 $18,500,000

(proportion of net savings

Private Payer and Out of Pocket Net $36,900,000 $217,500,000 $242,700,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $18,110,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $6,540,000 $33,600,000 $37,400,000

(proportion of net savings)

Medicaid Net Savings (federal share) $1,710,000 $8,820,000 $9,810,000

(proportion of net savings)

Medicaid Net Savings (state share) $635,000 $3,260,000 $3,620,000

(proportion of net savings)

Private Payer and Out of Pocket Net $15,300,000 $78,800,000 $87,600,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $54,990,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $16,600,000 $91,200,000 $101,600,000

(proportion of net savings)

Medicaid Net Savings (federal share) $3,450,000 $18,900,000 $21,000,000

(proportion of net savings)

Medicaid Net Savings (state share) $2,530,000 $13,900,000 $15,400,000

(proportion of net savings)

Private Payer and Out of Pocket Net $39,000,000 $213,900,000 $238,300,000

Savings (proportion of net savings)

Total Annual Intervention Costs (at $10 per person): $5,060,000

Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment

of $10 Per Person

Medicare Net Savings $1,380,000 $7,880,000 $8,700,000

(proportion of net savings)

Medicaid Net Savings (federal share) $268,000 $1,530,000 $1,710,000

(proportion of net savings)

Medicaid Net Savings (state share) $227,000 $1,290,000 $1,440,000

(proportion of net savings)

Private Payer and Out of Pocket Net $3,230,000 $18,400,000 $20,600,000

Savings (proportion of net savings)

In order to identify effective community-based

disease prevention programs and the results

and costs of these programs, TFAH consulted

with NYAM to conduct a comprehensive literature

review. Overall, the literature review

identified 84 studies that met their criteria as

effective “public health interventions.” (See

Background box on page 40 for more detail.)

These interventions included both community-

based programs and policy changes. The

studies focused on how programs or policy

changes resulted in improved health or positive

behaviour changes within either an entire

community or a particular at-risk targeted

community. They did not include medical

interventions, such as pharmaceutical, doctor based,

or clinical-based studies.

Overall, however, the researchers found the

literature evaluating community-based disease

prevention programs to be limited, and outcomes

were not reported in a standardized

way. In the review, no studies directly included

information about all of the areas modelled

for this project, which include: the expenses

of diseases, a community-based disease prevention

program, data on the impact of interventions

on diseases over time, and the per

capita cost of implementing the program.

Experts at the Urban Institute developed a

composite based on the available data reported

in the literature to derive assumptions for

costs and health impacts.

Accordingly, TFAH calls for increased evidence-

based research into community-based

disease prevention programs that explicitly

include information about the impact of interventions

on diseases over time and the costs

for the programs. This type of research would

help policymakers better determine how to

effectively invest in public health programs

and assist those in the field in determining the

potential cost of identified programs.

Methodology

BACKGROUND ON LITERATURE REVIEW

The full bibliography of the literature review is available in Appendix A. The studies included

in the literature review had to meet the following criteria:

health or behaviour change related to the 8 diseases most impacted by physical activity,

nutrition, and tobacco use (type 2 diabetes, high blood pressure, heart disease, kidney

disease, stroke, some forms of cancer, COPD, and arthritis);

health care setting.

The researchers narrowed down more than 300 peer-reviewed journal articles and study

descriptions to the 84 that were included in the review.

studies from 1975 to 2008, cross checked findings in The Guide to Community

authors directly when possible to ask them about disease rate changes, behaviour changes,

or cost data.

without obvious selection bias; or C) (if no other studies were available) pre-post studies

did not meet these criteria were eliminated.

A majority of the 84 studies looked at programs that addressed a number of related health

factors, such as weight, nutrition, and physical activity. Researchers often call these studies

“multifactorial.” Eleven of the studies examined mass media or social marketing campaigns.

Six of the studies focused on intensive counselling to support lifestyle changes. One study

focused on the impact of a cigarette tax in reducing smoking. Two studies examined

employer-based health promotion efforts.

While this report focuses on health care costs of adults, it also includes studies about

interventions targeted at children because these studies have shown that these interventions

have an impact on improving the health of the parents and families of those children and also

improves the health of the children as they enter adulthood.

There are many other disease prevention efforts that may be effective or show promise

that may not be part of model because they did not meet all of the criteria for inclusion.

In 2002, the U.S. Centers for Disease Control and Prevention (CDC) funded an environmental

change intervention to prevent obesity in high-risk, early elementary-aged children

in Somerville, Massachusetts. The Shape Up Somerville team put together a program for

the first to third graders that focused on increasing physical activity options and improving

dietary choices. Prior to the intervention, Tufts researchers found that 46 percent of

Somerville’s first to third graders were obese or overweight based on the BMI for age percentile.

After one year of Shape Up Somerville, on average the program reduced one

pound of weight gain over 8 months for an 8-year-old child. Based on conversations with

the Somerville project leaders, project researchers estimate that citywide the per capita

The intervention included:

posters, food staff training, new vegetarian recipes, daily fresh fruit.

that focused on increasing healthy food consumption, decreasing unhealthy food consumption,

increasing physical activity and decreasing sedentary time. The Club implemented

Cool Moves -- creative ways to include physical activity into classroom hours.

demonstrations, and physically active games for education. The program also had a field

trip to an organic farm where students were able to participate in the harvesting process.

to the community containing updates on the project, health tips and healthy food

coupons.

Up Approved.”

• Offer low fat dairy products

• Offer some dishes in a smaller portion size

• Offer fruits and vegetables as side dishes

• Have visible signs that highlight the healthier options

height and weight, as well as how to counsel families of overweight or obese children.

from the Robert Wood Johnson Foundation through the Active Living by Design Initiative.

They then hired a Pedestrian/Bike Coordinator for the City and created Safe Routes to

School maps and distributed them to all the parents of first to third graders. The Mayor

authorized all crosswalks to be repainted and to have bike racks installed at all elementary

schools.

Wellness Policy in 2006.

In 1988, the state of California voted to enact Proposition 99,

the California Tobacco Tax and Health Promotion Act.

Proposition 99 increased the tax on cigarettes and other tobacco

products from $0.10 to $0.35. The revenue from the tax was

allocated to a variety of health promotion projects including:

school-based programs discouraging children from smoking;

patients who cannot afford to pay;

other programs or for fire prevention measures.

Three years after implementation of Proposition 99

researchers found a 9 percent reduction rate in cigarette sales

in California and a decrease in the prevalence of cigarette

smoking among adults from 26.7 percent in 1988 to 22.2 percent

in 1992. This means that the act reduced cigarette consumption

by close to 705 million packs between January 1989

and December 1991. A 2001 analysis found that there are

“approximately one million fewer smokers in California than

would have been expected [and] per capita cigarette consumption

The results of Proposition 99 suggest that placing a tax on certain

products and using the revenue from the tax for educational and

health programs can have a substantial effect on public health.

Greater Options in Transportation, better known as GO Boulder, is a program in Boulder, Colorado, aimed at providing

residents with more transportation options than cars.

Through the multi-sectoral program that works with residents,

intergovernmental agencies and businesses in the community

Boulder has been able to develop a sustainable transportation

system. GO Boulder uses incentives, such as Walk

and Bike Week and commuter awards, to encourage people

to walk, bike, or take the bus.

From 1990 to 1994, Boulder showed a 3.5 percent increase in the

number of pedestrian trips and a 2.2 percent rise in bike trips.

Also, unlike the nearby city of Denver where population as well as

single occupancy vehicle use increased, the population in Boulder

continued to grow without a rise in single occupancy vehicle use.

Healthy Eating, Active Communities (HEAC), a program

funded by The California Endowment, brings together community

residents and public institutions, and works with local

government and with private businesses, in an effort to prevent

childhood obesity by improving the environment children

inhabit. The program, at a cost of $7 annually per capita

in the target communities with minimal additional expenses

for technical assistance, has already accomplished significant

changes in the food and physical activity environments and

policies in these communities, including new parks, input into

city general plans, healthier food marketing in local stores,

healthier foods in hospital, public health department, and

public park vending machines, and increased physical activity

opportunities in schools and after school programs.

Within 6 California communities HEAC focuses on forming a

partnership between a community-based organization, school

districts and a public health department to implement strategies

to improve nutrition and physical activity environments. In each

community the partnership works in 5 sectors including:

on campus, and advocating for increased compulsory

PE for grades K-12, as well as more opportunities for non-competitive

physical activity.

and recreation departments.

produce, providing safer walkways and parks, and limiting

the promotion of unhealthy foods.

Permanente, training health care providers to incorporate

more prevention and health promotion into clinical practice,

and engaging physician champions to advocate for improving

access to healthy foods and physical activity.

of unhealthy products to children in and around

schools, and via television, internet and other media.

HEAC aims to effect policy change that will improve environments

for healthy eating and active living. Also, in January

2007, HEAC participated in the first California Convergence

meeting, which aims to promote statewide improvements in

food and physical activity environments, and is a core partner

within the emerging ongoing work of Convergence.

The YMCA has a Pioneering Healthier Communities Program

in more than 64 communities across the country that focus

on:

1) raising the visibility of lifestyle health issues in the national policy debate, and

2) encouraging and supporting local communities to develop more effective strategies to promote healthy lifestyles.

In 2003, the YMCA of Greater Grand Rapids, Michigan created

the Activate West Michigan coalition in partnership with

local government, community organizations, schools, and

healthcare, corporate, and non-profit leaders. They initiated

a “Healthy U” health and wellness program, which included

physical fitness and nutrition education for elementary and

middle-school students after school hours both at schools and

community centres. In addition, students exercised at the

YMCA gym at least once a week. After a year, the children

made improvements on strength and flexibility tests.

In addition, the community helped support the program. For

example, school children started gardens at various sites in

the community. Two inner city farmers’ market programs

provided access to healthy foods, samples of vegetables, and

education about cooking vegetables. According to a survey,

90 percent of people who attended the markets wanted additional

markets and had learned from this experience.

Attleboro, Massachusetts and Rapid City, South Dakota looked

at ways to promote increased physical activity through

Pioneering Healthier Communities projects. The YMCA’s partnered

with local leaders, schools, hospitals, public health officials,

health care providers, business leaders, and the media.

In Attleboro, the coalition focused on a walking school bus program,

a pedometer steps challenge among fourth and fifth graders,

a healthy kids day, and building a bike trail and non-motorized connections

to commuter rail stations. It also sponsored healthy eating

through improving the nutrition of foods in schools and recruiting

a local supermarket to provide a “Healthy Snack of the Week”

to school and hospital cafeterias. Zoning laws were also changed

to allow for more sidewalks and streetscapes.

In Rapid City, civic leaders required that new building include

sidewalks and smarter development practices, such as building

bike lanes, wider sidewalks, and adding trees, benches,

and walk signals in downtown areas.

fast food and vending machine use.

secondary

strength and flexibility

homework, chose not to smoke, drink or use drugs

In 2005, the French government launched the EPODE campaign with the goal of lowering

childhood obesity rates in 5-12 year olds through a 5-year plan of intervention in 10 towns

situated across the country.

The plan takes a multi-sectoral approach by involving parents and families, general practitioners,

school nurses, teachers, towns, businesses, and the medical community. The 3 fundamental

steps are:

informed through public meetings, brochures, posters, and media coverage.

diagnose and treat obese children.

education into the school day. Also, school menu planning is targeted and children are taught

how cook with fresh fruits and vegetables and be given access to food tasting workshops.

In order to track progress, the BMI of each child is calculated, recorded, and sent to his or

her parents. Parents of those who are overweight or obese will be encouraged to consult

their family physician.

Anecdotal evidence suggests that obesity has (at least) remained constant in the intervention

towns while it doubled in control areas. Mothers of children participating in the intervention

have reported weight loss as well. The complete results will be available in 2009

upon completion of the 5-year plan.

In Oslo, Norway a group of researchers sought to test the effects of a community-based

intervention to increase physical activity among low-income individuals, according to a 2006

study. A comprehensive intervention program was implemented, at a reported cost of 0.59

Euros per capita (approximately $0.93 US dollars), in an effort to change the Behaviors of

individuals. The intervention efforts included:

reminders such as the benefit of using stairs instead of elevators, and stands with health

information were set up as well as mass media activities.

sessions at no cost during the intervention.

walking trails were labelled within the district, lighting on streets improved and trails

were maintained during the winter to keep them safe.

The follow up after 3 years showed that compared to the control community, the intervention

group reported an 8-9 percent increase in physical activity, 14 percent fewer individuals gained

weight, 3 percent more quit smoking, and there were significant decreases in blood pressure.

The Urban Institute researchers developed a

model to estimate how investing in community-

based disease prevention could lead to

lower health care costs. This model is based

on the literature review led by NYAM and data

on disease rates and associated medical expenditures.

The model addressed 3 questions:

1. How much do people with selected preventable

diseases spend on medical care?

2. If the rates of these conditions were

reduced, how much of these expenditures

could be saved?

3. How would these savings be distributed

across payers?

Based on the review of the literature, the

researchers considered 1) the costs of the

most expensive diseases related to physical

inactivity, poor nutrition, and smoking; 2) program

cost assumptions; 3) disease rate reduction

assumptions; 4) cost savings estimates;

and, 5) limitations and notes about the model.

The model is used to compare costs of a given

intervention with its expected effects on medical

care expenditures to assess the potential

return on investment in community-based disease

prevention programs. As an example of

potential return, the model looks at an investment

of $10 per person per year for successful

community-based disease prevention programs

related to improving physical inactivity

and nutrition, and preventing smoking and

other tobacco use. Based on findings reported

in the literature, the researchers assumed

that such strategic interventions could reduce

uncomplicated diabetes and high blood pressure

rates by 5 percent in one to 2 years; heart,

stroke, and kidney disease by 5 percent within

5 years, and cancer, arthritis, and COPD by 2.5

percent within 10 to 20 years.

The researchers at NYAM and the Urban

Institute determined the most expensive set

of diseases that have shown potential to be

reduced through physical activity, nutrition,

and smoking interventions. These include:

heart disease, selected types of cancers, selected

lung diseases, diabetes, hypertension,

heart disease, stroke, arthritis, and kidney disease.

None of these diseases can be prevented

entirely; some individuals develop these

conditions due to genetics or other factors

unrelated to activity, nutrition, or smoking.

by Thorpe, et. al. to determine the most expensive

diseases, and then a review by NYAM of the

literature to determine which of the most

expensive diseases respond to physical activity,

The Urban Institute used data from the

Medical Expenditure Panel Survey (MEPS)

from 2003 to 2005 (adults only, excluding

people in nursing homes or other institutions)

to estimate the health care costs of

the diseases nationally.

Based on the literature review and consultation

with a medical advisor, the diseases were

grouped into categories, using 3 broad groups

of conditions: 1) uncomplicated diabetes

and/or high blood pressure 2) diabetes and/or

high blood pressure with complications (heart

disease, stroke, and/or kidney disease); and 3)

selected cancers (those amenable to community-

based prevention), arthritis, and chronic

obstructive pulmonary disease (COPD).

DISEASE GROUPINGS USED IN THE MODEL

Blood Pressure

Blood Pressure

disease, and/or stroke

kidney disease and/or stroke

Disease, Kidney Disease, and/or Stroke

Of the studies that outlined potential costs

or where project staff contacted researchers

to determine costs, most had costs estimated

to be in the range of $3-$8 per person.

exceeded $10. Those identified were primarily

interventions that focused on

intensive coaching and one-on-one or

small group counselling where administrative

costs were higher and evaluations and

measurements were intensive.

In order to determine an estimate, in addition

to reviewing the available literature,

TFAH and Prevention Institute consulted a

set of experts who agreed that $10 is a high,

and therefore, a conservative assumption

for the costs of community-based programs.

FINANCIAL BURDEN OF SPECIFIC DISEASES

The Urban Institute researchers conducted regression analyses to estimate the percent of

health care costs attributable to each disease group. Diabetes, high blood pressure, heart

disease, stroke, kidney disease, cancer, arthritis, and COPD account for almost 38 percent

of America’s health care costs. Significant numbers of cases of these diseases could be prevented

or delayed with increases in physical activity, good nutrition, and smoking cessation.

(Based on current disease rates, including all insurance payers, does not include people in

institutionalized care)

Diabetes, high blood pressure, or a combination of 9.4 percent

the 2 diseases

Diabetes or high blood pressure who also have heart 16.0 percent

disease or stroke and/or kidney disease

Heart disease or stroke and/or kidney disease who do 6.2 percent

not have diabetes or high blood pressure

Cancer 3.1 percent

Arthritis 1.1 percent

COPD 2.0 percent

Carleton Cardiovascular Disease Mass media campaign, At 5 years: 2,925 men and women

(1995) (CVD), Coronary Heart community programs aimed Risk for both 18-64 [control (1,665);

Disease (CHD), Stroke at 71,000 people. Intervention CVD and CHD intervention (1,260)]

population randomly down 16 percent

generated, compared to a

reference community. Cost:

$15 per person per year.

Farquhar CVD, CHD, Stroke Mass media campaign, At 5 years: 971 men and women 25-74

(1990) community programs aimed at CHD risk down 16 percent; [control (480);

122,800 people. Intervention CVD mortality risk down intervention (491)]

population randomly 15 percent;

generated, compared to a Prevalence of smoking

reference community. The down 13 percent;

organizational and educational Blood pressure down

program was delivered at a 4 percent;

per capita cost of about $4 Pulse down 3 percent;

per year. Cholesterol down 2 percent.

Fichtenberg CVD, CHD, Stroke Cigarette tax: $0.25 increase At 3 Years: California population

(2000) on the price of cigarettes CHD mortality down

with $0.05 of the net tax for 2.93 deaths/yr/100,000

an anti-tobacco educational population per year;

campaign. Amount smoked down

2.72 packs/person/yr.

CVD Mass media campaign, At 4 years: 2,206 men and women

community programs aimed amount of tobacco grams/ 16-69 [control (1,358);

at 56,000 people. Intervention day decreased 8 percent; intervention (848)]

population randomly 11 percent fewer

generated, compared to a people smoked.

reference community. Cost:

$10 per year per adult over

the age of 16.

Gutzwiller CVD, CHD, Stroke Mass media campaign, At 4 years: 481 men and women

(1985) community programs aimed Hypertension down 16-69 with hypertension

at 56,000 people. Intervention 7 percent. (>160/95 mm Hg) [control

population randomly (117); intervention (364)]

generated, compared to a

reference community. Cost:

$10 per year per adult over

the age of 16.

Haines, CVD, CHD, Stroke 12-week employee walking At 3 months: 60 women in their forties

et. al. program on a college campus. 1 percent decrease in BMI;

(2007) No cost information available, 3.4 percent decrease in

but such programs are hypertension;

extremely low cost and often 3 percent decrease in

have positive ROIs. cholesterol;

5.5 percent decrease

in glucose

Herman CVD, Nutrition Improving access to fruits and At 6 months: 451 low income minority

(2008) vegetables among women who +1.4 servings per 4,186 kJ women 18 years and

enrolled for postpartum services (1,000 kcal) of fruits and older [control (143);

at 3 Women, Infants, and vegetables intervention (308)]

Children program (WIC) sites in

Los Angeles. Participants were

assigned either to an intervention

(farmers’ market or supermarket,

both with redeemable food

vouchers) or control condition

(a minimal non-food incentive).

Interventions were carried out

for 6 months, and participants’

diets were followed for an

additional 6 months. No cost

information, but minimal

administrative costs to assign

and track participation.

Osler and CVD Mass media campaign, At year one: 1,196 men and women

Jespersen community programs aimed 39 percent eating less fat; 20-65 [control (629);

(1993) at 8,000 people. Intervention 10 percent decrease intervention (567)]

population randomly generated in smoking;

and compared to a reference 28 percent increase in

community. Cost: $6 per capita. physical activity.

Prior CVD Worksite health promotion, At 3.7 years: 808 high-risk smokers

(2005) 15 minute cardiovascular risk 12.6 percent decrease in 16-76 years old

factor screening, individualized amount smoked;

counselling to high-risk 3.3 percent decrease in

employees. Cost: $20 per diastolic BP;

employee (note this is a 7.8 percent decrease

high risk population). in cholesterol.

Rossouw CVD Mass media campaign, At 4 years: 4,087 men and women

(1993) community programs aimed Men decreased tobacco 15-64 [control (1305);

at 122,800 people. Intervention intake per day by 0.7 percent, intervention (2,782; high

population randomly generated, women by 0.3 percent; Men risk; 1,198 (43 percent)]

compared to a reference decreased smoking prevalence

community (separate high risk by 1.1 percent, women by

group also). Cost: $5-$22 2.5 percent; Men decreased

per capita. diastolic BP by 2.5 percent,

women by 3 percent; Men

decreased systolic BP by 2.5

percent, women by 3.0

percent. High risk at 4 years:

Men decreased tobacco intake

per day by one percent,

women by 0.8 percent; Men

decreased smoking prevalence

by 2 percent, women by 8.2

percent; Men decreased

diastolic BP by 3 percent,

women by 2.8 percent; Men

decreased systolic BP by 1.3

percent, women by 1.7

percent.

Economos, Nutrition, “Shape Up Somerville” -- After one year, on average First to third grade

et. al. Physical activity comprehensive effort to prevent the program reduced one children in Somerville

(2007) obesity in high-risk children in pound of weight gain over

first to third grade in Somerville, 8 months for an 8 year old

MA. Improved nutrition in child.

schools, health curriculum,

after-school curriculum, parent

and community outreach,

worked with community

restaurants, school nurse

education, safe routes to school

program. Cost: Between $3-$4

per person.

EPODE Nutrition Multisectorial 5-year plan Obesity has at least 5-12 year olds in 10

(2004) involving parents and families, remained consistent in towns in France

medical providers, school nurses, targeted towns while it

teachers, towns, businesses, and doubled in control areas.

media campaigns. Estimated Mothers have reported

cost: Approximately 2 Euros weight loss as well.

($3.17 USD) per person.

Jenum, Physical activity Provided information through After 3 years, compared to Low-income adults

et. al. leaflets and mass media, the control group, the in Oslo, Norway

(2006) individual counselling, walking intervention group had an

groups, and increased accessible 8-9 percent increase in

areas for safe recreation. physical activity, 14 percent

Estimated cost of 0.59 Euros fewer individuals gained

($0.93 US dollars) per person weight, 3 percent more

quit smoking, and significant

decreases in blood pressure

rates were reported.

Hu et al Smoking cessation California Proposition 99 -- After 3 years, cigarette sales Population of California

(1994) increased taxes on cigarettes and dropped 9 percent and

other tobacco products from smoking among adults

10 cents to 35 cents. decreased from 26.7

percent in 1988 to 22.2

percent in 1992.

review and consultations with a physician,

the Urban Institute researchers made

assumptions about the length of time it could

take for community-based disease prevention

programs focusing on increasing physical

activity, improving nutrition, and reducing

smoking to have an impact on health.

Building on estimates from a range of studies,

the researchers modelled an investment

of only $10 per person into effective programs

to increase physical activity and good

nutrition and prevent smoking, and a reduction

in rates of uncomplicated diabetes and

high blood pressure of 5 percent in one to 2

years; complicated diabetes and high blood

pressure as well as non-diabetic, non-hypertensive

heart disease, stroke and/or kidney

disease of 5 percent within 5 years; and cancer,

arthritis, and COPD of 2.5 percent within

10 to 20 years.

In order to determine the effect on diseases,

the researchers translated the results of programs

as presented in articles into the effect

these changes could have on diseases or limiting

disease progression. The literature

outlines the connections between changes

in behaviour and the impact on health. For

instance, increased physical activity, reduced

Body Mass Index (BMI), or lowering systolic

blood pressure have been shown to delay or

prevent types of disease development. In

addition, studies describe how different diseases

progress. Results can be seen in

reducing type 2 diabetes, for example, in

just one to 2 years. This reduction would

inevitably have an effect on the complications

of diabetes, most notably heart disease,

kidney disease, and stroke, although reductions

or delays in these conditions would

take longer to be realized than reductions in

uncomplicated diabetes or high blood pressure

(an estimated 5 years as opposed to one

to 2 years). Cancers, arthritis, and COPD

SOME PREVENTION EFFORTS HAVE NO DIRECT COST WHILE HAVING BIG HEALTH BENEFITS

Not all community-based disease prevention programs have direct costs. In fact, some

strategies, like tobacco taxes, can generate revenue.

rates, which lead to improved health and lower health care costs. Specifically, research indicates

that every 10 percent increase in the real price of cigarettes reduces overall cigarette

consumption by approximately 3 to 5 percent, reduces the number of young-adult smokers

by 3.5 percent, and reduces the number of kids and pregnant women who smoke by 6 or

reduce smoking rates years ago (in internal company documents revealed in anti-smoking

lawsuits), stating, for example, that “if our consumers have fewer opportunities to enjoy

physical activity. For example, in Davis, California, a carefully designed bike network,

which includes a dedicated traffic lane for bikers, has led to 25 percent of all trips in the

city being by bike (compared to one percent nationally), and a decision by the city to

information) contributes to reducing obesity. One study has suggested that menu labelling

in Los Angeles could significantly slow the rate of weight increases in the population,

would take the longest to be affected, taking

10 to 20 years before disease prevention programs

could help bring about reductions in

disease rates. The model assumes a onetime

reduction in diabetes and/or high

blood pressure, even though the sustained

investment in prevention programs included

in the model could likely result in greater

declines. The researchers acknowledge that

all of these diseases may develop unrelated

to physical inactivity, poor nutrition, or

smoking. The model focuses on the estimated

share of these disease rates that could

be affected by these factors.

SMALL CHANGES CAN HAVE A BIG IMPACT ON HEALTH

The research shows that even small changes in behaviour can have a major impact on health.

For example:

significant health improvements for many individuals. A physically active lifestyle plays an

important role in preventing many chronic diseases, including coronary heart disease,

Brownson Physical Activity Cardiovascular Disease Of people who had access to walking trails, 38.3 percent

(2000) used them. Of these users, 55.2 percent increased their

amount of walking.

CDC Physical Activity, Diabetes By losing 5 to 7 percent of body weight and getting

(2005) Weight Loss just 2 1/2 hours of physical activity a week, people with

pre-diabetes can cut their risk for developing type 2 diabetes

by about 60 percent.

Dauchet Nutrition Cerebrovascular Disease Risk of stroke was decreased by 11 percent for each

(2005) additional portion per day of fruit and 3 percent for each

additional portion per day of vegetables.

Felson Weight Loss Arthritis 40 percent increase in risk per 10-lb weight gain and

(1997) 60 percent increase in risk per 5-unit BMI increase.

HHS Nutrition Cardiovascular Disease, A 10 percent decrease in cholesterol levels may result

(2003) Cholesterol in an estimated 30 percent reduction in the incidence of

coronary heart disease.

Joshipura, Nutrition Cardiovascular Disease Each additional serving of fruits or vegetables per day

et. al. was associated with a 4 percent lower risk for coronary

(2001) heart disease.

Nutrition Cardiovascular Disease 22 to 30 percent of CHD deaths are due to dietary

factors, especially increased consumption of cholesterol

McGinnis and saturated fat and a decreased consumption of fibre.

& Foege Nutrition Cancer The proportion of all cancer deaths attributable to diet is

(1993) 35 percent.

Nutrition Diabetes 45 percent of diagnosed cases are due to poor diet, inactivity,

and obesity.

Nanchahal Weight Loss CVD Every kilogram of weight gain after high school increased

(2005) risk of congenital heart disease by 3.1 percent in men.

Hamman Weight Loss Diabetes 16 percent reduction in diabetes risk per kilogram of

(2006) weight lost.

costs estimated in the regression analyses and

the size of the effects of prevention programs

reported in the literature, the Urban

Institute researchers estimated the medical

care expenditure savings that would result

from implementation of such an intervention.

They then applied this formula to the

example of a program that reduces the prevalence

of uncomplicated diabetes and high

blood pressure by 5 percent in the short run.

Because the model is based on adults only

and excludes nursing home expenditures,

the expenditure number used in this example

excludes spending on nursing homes and is

adjusted to account for spending on children.

The savings (S) from reduction of

condition j:

Where:

disease cluster j

Share of costs refers to estimated costs

attributable to disease cluster j

Expenditures is total medical expenses

(Preliminary Estimates)

The savings from 5% reduction in

uncomplicated diabetes and

hypertension in the U.S.:

= (0.05) * (0.094) * $1,235 billion

= $5.8 billion annually

The researchers note that the estimates are

likely to be conservative. As noted above, the

model assumes costs in the higher range and

benefits in the low range. Furthermore, the

model does not take into account any costs of

institutional care. Chronic disease often leads

to disability or frailty that may necessitate

nursing home care, so exclusion of these costs

may underestimate the return on investment

in reduction of disease.

While the model is still being elaborated to

address many of these issues, some known limitations

of the model as reported here include:

in the prevalence of diabetes and hypertension

over time. The literature on the

duration of the effects of intervention is

small, with effects usually reported over

no more than 3 to 5 years.

This model is based on current disease

prevalence and does not take into

account trends in prevalence. For example,

diabetes is increasing while heart disease

is declining, but the model estimates

savings based on the current prevalence.

competing morbidity risks, it does not

take into account changes in mortality.

However, in the short (one to 2 years)

and medium run (5 years), changes in

mortality are likely to be small.

dollars. Thus, it does not take into account

any rise in medical care expenditures or

changes in medical technology.

cost of the interventions and does not

reflect the cost of the basic infrastructure

required to implement such programs.

variations in community demographics such

as distribution of race/ethnicity, age, gender,

geography, or income. The intervention

effect is treated as constant across groups.

This study shows that the country could save substantial amounts on health care costs if we invest strategically in community-based disease prevention programs. We could see significant returns for as little as a $10 investment per person into evidence-based programs that improve physical activity and nutrition and lower smoking rates in communities.

Not only could we save money, many more Americans would have the opportunity to live healthier lives.

Physical activity, nutrition, and smoking are 3 of the most important areas to target for prevention, and as this study shows, community based programs can generate a significant return both in terms of health and financial savings. There is a wide range of other disease prevention efforts that target these and other health problems and have a beneficial impact on the health of Americans.

Until the country starts making a sustained investment into disease prevention programs, we will not realize the potential savings. We need to make the investment to see the returns.

TFAH and RWJF launched the Healthier America Project in 2007 to find ways to improve the health of the nation. The project has set a number of goals, including:

For America to become a healthier nation, prevention must become a driving force in our health care strategy and become central to discussions about how to reform health care in the U.S. For too long, disease prevention has been considered too difficult to implement programs on a wide-scale basis.

One challenge has been to get policymakers to invest, given the already high health care costs and difficulties in showing the impact of many community-based prevention programs.

Understanding the return on investment is an important step to help determine -

• what types of programs to invest in,

• how much should be invested, and

• how the programs could be funded.

This study identified a range of community based programs that have been shown to have a positive impact on improving the health of communities by increasing physical activity, improving nutrition, or preventing or helping people quit smoking. These programs are designed to help improve the health and well-being of large segments of the population without direct medical treatment.

Instead, community disease rates are decreasing and health is improving through increased access to safe places to be active, affordable nutritious foods, and support to help prevent or quit smoking.

Insurance providers, including Medicare, Medicaid, and private payers, would directly benefit from investments made in community-based prevention. In addition, communities would benefit from improved health and productivity of the workforce and citizens in those communities.

In addition, the country must make improving research into community-based disease prevention programs a priority. Since these programs hold so much potential for improving the health of Americans in addition to saving health care costs, it is important to gain an increased understanding about what programs are most effective and how to best target efforts in communities, including evaluating costs and outcomes. This research is important to help policymakers determine the most effective ways to invest for the highest returns in health and savings.

Investing in prevention is investing in the future health and wealth of the nation.

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54 The search was conduced using PubMed.

The search strategies contained the following

elements:

The researchers searched for the following

chronic diseases, cancers, and infectious diseases:

Cardiovascular Diseases, Diabetes Mellitus,

Cerebrovascular Disorders, Coronary Disease,

Brain Ischemia, Heart Diseases, Chronic

Obstructive Pulmonary Disease, Asthma,

Osteoarthritis, Kidney Diseases, Breast

Neoplasms, Colorectal Neoplasms, Uterine

Pancreatic Neoplasms, Cervical Neoplasms,

Lung Neoplasms, Communicable Diseases.

The researchers searched for the following

terms for public health interventions, modifiable

behavioral changes, or biological risk

factors:

Public Health, Risk Factors, Risk, Life Style,

Health Promotion, Exercise, Smoking,

Smoking Cessation, Sexual Behavior, Food

Services, Fruit, Mass Screening, Breast

Feeding, Air Pollution, Community Health

Services, School Health Services, Healthy

People Programs, Cholesterol, Body Mass

Index, Blood Pressure, Prevention.

The researchers searched for the following

epidemiological study design keywords:

Program Evaluation, Intervention Studies,

Prospective Studies, Case-Control Studies,

Longitudinal Studies, Follow-Up Studies,

Survival Rate, Hospitalization, Proportional

Hazards Models, Incidence, Data Collection,

Randomized Controlled Trials as Topic, Time

Factors, Regression Analysis, Diet Surveys,

Cohort Studies, Outcome Assessment

(Health Care), Workplace, Cross-Sectional

Studies, Disease Progression, Risk

Assessment, Pilot Projects, Effectiveness.

Terms were searched as both keywords and as

Medical Subject Headings (MESH).

55 Study quality rankings were ranked A-D based

on study designs of: A) randomized controlled

studies; B) quasi-experiental studies without

selection bias; C) pre-post studies with no

comparison group, or comparison groups

with likely selection bias; D) study design of

lower quality than the above. Studies that met

the criteria for A-C were included in final literature

review. This schema is from Center for

Health Care Strategies, Inc. (2007). The ROI

Evidence Base: Identifying Quality

Improvement Strategies with Cost-Saving

Potential in Medicaid. Retrieved from

<http://www.chcs.org/usr_doc/ROI_Evidenc

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