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investment in prevention - Blue Cross and Blue Shield of Minnesota

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					Blue Cross and Blue Shield of Minnesota




                   i nve s t m e n t i n
           prev ention

                                     A Ten-Year Plan to Reduce
                                     Tobacco Use, Heart Disease
                                     and Cancer

                                     November 2001
November 8, 2001                                            Investment in Prevention


                                 Table of Contents
Executive Summary                                                  Page    3

Section 1. Introduction                                            Page    7
   A. Overview                                                     Page    7
   B. Goals                                                        Page    7
   C. Why Invest in Prevention?                                    Page    8
   D. Honoring the Aims of the Tobacco Litigation                  Page    8
   E. Who Will Benefit?                                            Page    9
   F. The Adverse Health Impact of Tobacco Use, Heart Disease      Page    9
           and Cancer
   G. The Adverse Economic Impact of Tobacco Use, Heart            Page 10
           Disease and Cancer
   H. Guiding Principles                                           Page 11
   I. Program Components                                           Page 12

Section 2. Investment in Prevention: Tobacco Reduction             Page   16
   A. Clinical Interventions to Reduce Tobacco Use                 Page   17
   B. Local Initiatives to Reduce Tobacco Use                      Page   22
   C. Reducing Tobacco Use in High-Risk Populations                Page   24
   D. Tobacco-Related Public Awareness                             Page   28

Section 3. Investment in Prevention: Heart Disease                 Page   31
   A. Clinical Interventions to Prevent Heart Disease              Page   31
   B. Local Initiatives to Prevent Heart Disease                   Page   34
   C. Preventing Heart Disease in High-Risk Populations            Page   36
   D. Heart Disease Public Awareness                               Page   37

Section 4. Investment in Prevention: Cancer                        Page   40
   A. Clinical Interventions to Prevent and Detect Cancer          Page   40
   B. Local Initiatives to Prevent and Detect Cancer               Page   41
   C. Preventing and Detecting Cancer in High-Risk Populations     Page   44
   D. Cancer-Related Public Awareness                              Page   45

Section 5. Management, Evaluation and Budget                       Page   48
   A. Accountability and Stewardship                               Page   48
   B. Measuring Our Progress, Sharing Our Results                  Page   49
   C. Calculating the Available Funds                              Page   50
   D. Budget Summary                                               Page   51
   E. Impact on Health Plan Competition in the Minnesota
           Health Care Market                                      Page 53
   F. Conclusion                                                   Page 54

Section 6. Endnotes                                                Page 55
Exhibits


Blue Cross and Blue Shield of Minnesota                                                2
November 8, 2001                                                  Investment in Prevention

Executive Summary

Blue Cross Has a Unique Opportunity to Improve the Health of All Minnesotans

When Blue Cross, along with the State of Minnesota, sued the tobacco companies in
1994, we did so in order to hold the tobacco industry accountable for its actions. Blue
Cross intends to honor the aims of that lawsuit by using $252 million of its tobacco
settlement proceeds to fund a ten-year, three-pronged investment in improving the health
of all Minnesotans. (See the accompanying “Plan of Action for Blue Cross and Blue
Shield of Minnesota’s Excess Surplus,” for Blue Cross’ proposal to spend an additional
$160 million of the tobacco settlement proceeds.)


The Goals are to Reduce Tobacco Use, Heart Disease and Cancer

This unprecedented investment by a health plan will focus on achieving significant
decreases in three interrelated conditions that now cost Minnesota citizens dearly in terms
of early death, significant disability, reduced productivity, and lowered quality of life —
tobacco use, heart disease, and cancer.

The ten-year Investment in Prevention consists of a coordinated set of initiatives all
aimed at achieving three primary health improvement goals by 2012. By that date, we
seek to:

•   Significantly decrease the prevalence of tobacco use
•   Significantly decrease the prevalence of risk factors for heart disease
•   Significantly decrease the prevalence of risk factors for cancer and increase early
    detection of cancer


Tobacco Use, Heart Disease and Cancer are Minnesota’s Leading Health Hazards

Tobacco use is the No. 1 preventable cause of death and disability in Minnesota.
Moreover, tobacco use causes 40 percent of heart disease and a significant percentage of
all cancers, including nearly 90 percent of all lung cancer deaths.1 It makes sense that we
use the tobacco settlement proceeds to create a brighter future for Minnesota by achieving
major gains in these three areas.

Cardiovascular disease is the leading overall cause of death in the United States and
Minnesota. In the United States, one person dies from cardiovascular disease every 33
seconds.2 In Minnesota, cardiovascular diseases cause 40 percent of all deaths, or more
than 14,000 deaths each year. The problem is especially severe in communities of color,
which suffer from higher rates of heart disease.3

Cancers are the second leading cause of death in Minnesota, accounting for 23 percent of
all deaths in the state in 1999.4 Cancers are also a significant cause of illness and lost


Blue Cross and Blue Shield of Minnesota                                                       3
November 8, 2001                                                  Investment in Prevention


productivity in both older and middle-aged people. In general, cancer mortality rates are
higher among the economically disadvantaged and among people of color.5 Some cancers
can be prevented. Reducing exposure to carcinogens like ultraviolet radiation and
cigarette smoke prevents some types, such as skin and lung cancer. In addition, early
detection and treatment can improve the prognosis for people with many other cancers.


Addressing Three Related Diseases Creates Synergies

Health behavior is complex and the root causes of disease and illness — such as tobacco
use, diet and activity patterns — are often interrelated. Tobacco use is both a root cause
of disease and a disease itself. Tobacco use (and secondhand smoke exposure), poor diet
(and obesity) and inactivity all play a significant role in heart disease and some cancers.
So addressing tobacco use, heart disease, and cancer all at once creates valuable
synergies.


We Know What Works and Have Successful Models to Guide Us

Prevention saves lives. Investment in Prevention will focus on preventing disease before
it begins. A wealth of information already exists about effective prevention approaches
for each of these three diseases. Our programs use as models the examples of
communities and entire states that have successfully reduced these diseases.

Comprehensive and long-term tobacco reduction efforts, for example, have been
markedly successful in other states: Tobacco use rates have been significantly lowered in
California, Massachusetts, Arizona and Oregon.6

Heart disease prevention programs have been implemented and studied for several decades.
The well-designed North Karelia community program, for example, used programs directed
at hypertension, diet and smoking to reduce cardiac death rates by 73 percent.7

Cancer prevention programs in many states have successfully increased rates of screening
for breast and cervical cancer. For skin and colon cancer, effective screening methods
exist but are underused.


Every Successful Initiative Has Four Essential Elements

Over the years, four core elements have proven essential to the success of population-
based health improvement initiatives. Those four elements are clinical interventions, local
initiatives, high-risk population outreach and public awareness. Successful initiatives
include all four elements in a comprehensive, integrated campaign. Investment in
Prevention is built around these essential elements.




Blue Cross and Blue Shield of Minnesota                                                       4
November 8, 2001                                                    Investment in Prevention


Tobacco Initiatives Will Help Smokers and Counteract Tobacco Industry Efforts

Reducing tobacco use requires specialized, multifaceted efforts because tobacco use is so
addictive. The nicotine level in cigarettes is formulated by tobacco companies to create a
powerfully addicted set of loyal customers. Moreover, the tobacco industry spends
                                                                                      8
approximately $144 million each year to promote its deadly product to Minnesotans.

Tobacco-focused initiatives will include efforts to equip doctors and other clinicians
across the state with the tools they need to help patients break their addiction to nicotine,
and efforts to promote and expand tobacco-cessation counseling programs outside of the
clinical setting.

We will also support communities of color as they identify and implement strategies for
addressing tobacco use, and we will provide communities working on secondhand smoke
issues with needed technical assistance. In addition, we will develop sophisticated public
awareness campaigns to counteract the powerful marketing efforts that the tobacco
industry aims at young adults and communities of color.


Heart Disease Initiatives Will Focus on Reducing Risk Factors

Heart disease initiatives will include efforts to help doctors work more effectively with
patients of diverse cultures who have hypertension, diabetes, and other risk factors for
heart disease, and efforts to support communities who want to improve screening or to
launch local programs to decrease heart disease risk factors.

We will also conduct targeted public awareness activities to increase knowledge of heart
disease among communities at risk and to promote risk-reducing behaviors. And we will
increase hypertension awareness, screening and appropriate follow-up and will promote
physical activity.


Cancer Initiatives Will Focus on Prevention and Early Detection

Cancer prevention and early detection initiatives will include efforts to encourage clinics
to fully implement appropriate clinical practice guidelines, and efforts to support cancer
screening and early detection.

We will also launch a broad-based campaign to prevent skin cancer and to help reduce the
disproportionately high incidence of cancer among high-risk communities. And we will
launch a public awareness campaign and develop cancer-prevention partnerships to
encourage healthy eating.


Investment in Prevention Complements Other Current Efforts

Investment in Prevention will complement — not compete with or duplicate — existing
local and statewide efforts by the Minnesota Department of Health (MDH) and the


Blue Cross and Blue Shield of Minnesota                                                         5
November 8, 2001                                                  Investment in Prevention


Minnesota Partnership for Action Against Tobacco (MPAAT), among others. We will
identify gaps in the statewide fabric of tobacco reduction, heart disease prevention, and
cancer prevention, and will use our resources and skills to fill those gaps, working in
close collaboration with other partners.


Investing in Prevention Saves Money as Well as Lives

Chronic diseases like tobacco use, heart disease and cancer are leading contributors to
rising health care costs. Death and disability from chronic diseases account for more than
60 percent of the nation’s direct medical care costs — approximately $655 billion a year
in 1990.9 Smoking alone is responsible for approximately 7 percent of total U.S. health
care costs.10

Health improvement programs of the kind we are proposing can generate savings of
greater than $3 for every $1 invested in those programs.11 A unique aspect of Investment
in Prevention’s statewide focus is that everyone will benefit from successful programs:
Minnesota citizens, employers, health plans and the state as a whole.


We Can Truly Make a Healthy Difference in People’s Lives

Implementing this comprehensive, prevention-focused campaign will save lives, reduce
early deaths, reduce disability, and improve the ability of thousands of Minnesotans to
lead healthy and productive lives. By reducing tobacco use and helping to prevent heart
disease and cancers, we can truly make a healthy difference in people’s lives.




Blue Cross and Blue Shield of Minnesota                                                      6
November 8, 2001                                                  Investment in Prevention


Section 1. Introduction

A. Overview

Blue Cross will use $252 million of its tobacco settlement proceeds to fund a ten-year
three-pronged investment in improving the health of all Minnesotans.

This unprecedented investment will focus on achieving significant decreases in three
interrelated conditions that now cost Minnesota citizens dearly in terms of early death,
significant disability, reduced productivity, and lowered quality of life — tobacco use,
heart disease, and cancer.

Tobacco use is the No. 1 cause of death and disability in Minnesota. Moreover, tobacco
use causes 40 percent of heart disease and a significant percentage of all cancers,
including nearly 90 percent of all lung cancer deaths.12 It makes sense that we use the
tobacco settlement proceeds to create a brighter future for Minnesota by achieving major
gains in these three areas.

Implementing this comprehensive, prevention-focused campaign will save lives, reduce
early deaths, reduce disability, and improve the ability of thousands of Minnesotans to
lead healthy and productive lives.

Blue Cross has been mindful of the concerns voiced by the Commissioner of Commerce
regarding the competitive impact that our programs might have in the health care market.
Therefore, Investment in Prevention is designed largely to benefit the health of all
Minnesotans, and not be limited to Blue Cross members. We pledge to continue to price
our products and services as if we did not have the tobacco proceeds available. For this
reason, the tobacco funds will not provide a competitive advantage to Blue Cross in
soliciting or retaining business.

This section introduces Blue Cross’ Investment in Prevention. Sections 2, 3, and 4 focus
in turn on tobacco use, heart disease, and cancer. Section 5 contains an overview of
project management, evaluation and budget, and Section 6 lists references.


B. Goals

The ten-year Investment in Prevention campaign consists of a coordinated set of
initiatives all aimed at the achievement by 2012 of three primary health improvement
goals:

•   Significantly decrease the prevalence of tobacco use
•   Significantly decrease the prevalence of risk factors for heart disease
•   Significantly decrease the prevalence of risk factors for cancer and increase early
    detection of cancer


Blue Cross and Blue Shield of Minnesota                                                      7
November 8, 2001                                                   Investment in Prevention


C. Why Invest in Prevention?

Making a substantive investment in preventing tobacco use, heart disease, and cancer
makes good sense for Minnesota citizens.

Prevention saves lives. Investment in Prevention will focus on preventing disease before
it begins. It is important to note that we are defining “prevention” broadly to include early
detection as well as primary prevention. In the case of heart disease and cancer,
Investment in Prevention efforts include not only reducing risk factors but also detecting
disease early so that intervention is more effective. Preventing these major diseases is far
less expensive in the long run than treating their disabling and deadly consequences.

A wealth of information already exists about effective prevention approaches for each of
these three diseases. Our programs use as models the examples of communities and entire
states that have successfully reduced these diseases. Comprehensive and long-term
tobacco reduction efforts, for example, have been markedly successful in other states, and
tobacco use rates have been significantly lowered in California, Massachusetts, Arizona
and Oregon.

Heart disease prevention programs have been implemented and studied for several decades.
The well-designed North Karelia community program, for example, used programs directed
at hypertension, diet and smoking to reduce cardiac death rates by 73 percent.13

Cancer prevention programs in many states have successfully increased rates of screening
for breast and cervical cancer. For skin and colon cancer, effective screening methods
exist but are underused.

Addressing three related issues creates synergies. Health behavior is complex, and the
root causes of disease and illness — such as tobacco use, diet, and activity patterns — are
often interrelated. It would be difficult, and probably less effective, to address these root
causes in isolation from the many disease conditions they cause. Investment in
Prevention, therefore, will address tobacco use, heart disease and cancer concurrently.

Tobacco use and exposure to secondhand smoke, poor diet and obesity, and inactivity all
play a significant role in heart disease and some cancers. In fact, tobacco use, poor diet
and lack of exercise combine to cause approximately 33 percent of all deaths in the
United States.14


D. Honoring the Aims of the Tobacco Litigation

When Blue Cross, along with the State of Minnesota, sued the tobacco industry in 1994,
we did so in order to hold the tobacco companies accountable for their deceit and
destruction. Blue Cross intends to honor the aims of that lawsuit by using the portion of
the proceeds that is within its control to make a significant, lasting difference in tobacco
usage and in two related health conditions: heart disease and cancer.


Blue Cross and Blue Shield of Minnesota                                                         8
November 8, 2001                                                  Investment in Prevention



The historic settlement agreement with the tobacco industry creates a one-time
opportunity to make a lasting difference. Changing the acceptability of tobacco use and
helping people who are addicted to tobacco to quit is a logical and highly appropriate use
of these funds. Because of the interrelatedness of these three diseases, tackling all three
together will enhance our overall impact.

In addition, Blue Cross has a statutory obligation to improve the public’s health. As a
nonprofit health service plan, Blue Cross must:

       “promote a wider, more economical and timely availability of ... health services
       for the people of Minnesota” and to “advance the public health and the art and
       science of medical and health care within the state. ...”
                                                               Minn. Stat. § 62C.01 subd. 2.

As reaffirmed in 2000, Blue Cross’ corporate purpose is, “Making a healthy difference in
people’s lives.” By reducing tobacco use and preventing heart disease and cancers, we
can truly make a healthy difference in people’s lives.


E. Who Will Benefit?

All Minnesotans will benefit from Investment in Prevention. The health and financial
dividends reach deeply into Minnesota communities, across all age, geographic,
economic and other sectors.

Individuals benefit immediately from improved access to effective stop-smoking
treatment and improved access to health screenings for themselves, co-workers, and
family members. Over time, people will enjoy the health benefits of the increased
availability of smoke-free — that is, non-carcinogenic — restaurants and public spaces,
and more safe and accessible places to exercise. Ultimately, individuals will live longer,
healthier lives.

Communities benefit when disease is prevented and residents can contribute their talents
and energies. We all benefit when children are protected from exposure to secondhand
smoke and when their parents do not die early from preventable conditions. We all
benefit when early signs of illness are detected among our family members, neighbors,
friends and co-workers. We all benefit when racial and ethnic communities no longer
suffer disproportionate rates of illness and death due to preventable conditions.


F. The Adverse Health Impact of Tobacco Use, Heart Disease, and Cancer

Blue Cross elected to focus on tobacco use, heart disease and cancer because of the
individual and collective impact of those deadly diseases on Minnesota. This profound
impact is measured in both health and economic terms.


Blue Cross and Blue Shield of Minnesota                                                        9
November 8, 2001                                                 Investment in Prevention



Tobacco use is the leading cause of preventable death in Minnesota, as it is nationwide, and
Minnesotans pay a high price in terms of early death, disability, reduced productivity and
lowered quality of life. More deaths can be attributed to tobacco use than alcohol, drugs,
firearms, motor vehicle accidents and HIV/AIDS combined. Seventeen percent of the people
                                                                     15
who die in Minnesota each year die from a tobacco-related disease. Smoking causes chronic
lung disease, coronary heart disease and stroke, as well as cancer of the lungs, larynx,
esophagus, mouth and bladder. In addition, smoking contributes to cancer of the cervix,
pancreas, and kidneys. Even when these conditions are not fatal, they often mean months and
years of disability and reduced quality of life.16

In addition, secondhand smoke causes an estimated 65,000 nonsmoking Americans to die
each year from lung cancer and heart disease. Children are especially vulnerable to the
effects of secondhand smoke. When exposed to secondhand smoke, children suffer many
more respiratory infections.17 Workers exposed to secondhand smoke are at significant
risk as well: nonsmoking restaurant workers have a 50 percent higher risk of lung cancer
than the general population.18

Cardiovascular disease is the leading overall cause of death in the United States and
Minnesota. In the United States, one person dies from cardiovascular disease every 33
seconds.19 In Minnesota, cardiovascular diseases cause 40 percent of all deaths — or more
than 14,000 deaths each year.20 The problem is especially severe in communities of color,
which suffer from higher rates of heart disease. Regional differences also prevail.
Counties with the highest prevalence rates of ischemic heart disease include Red Lake,
                                                                         21
Clearwater, Itasca, and St. Louis in the north and Freeborn in the south. The majority of
premature deaths from heart disease can be prevented by reducing known risk factors:
hypertension, cholesterol, smoking, diabetes, obesity and physical inactivity.

Cancers are the second leading cause of death in Minnesota, accounting for 23 percent of
                                22
all deaths in the state in 1999. Cancers are also a significant cause of illness and lost
productivity in both older and middle-aged people. Almost half of all Minnesotans will
be diagnosed with cancer in the course of their lifetimes. Each year in Minnesota, 800
men and women die from colorectal cancer alone. In general, cancer mortality rates are
higher among the economically disadvantaged and among people of color.23 Some
cancers can be prevented. Reducing exposure to carcinogens like ultraviolet radiation and
cigarette smoke, for example, prevents cancers like skin and lung cancer. In addition,
early detection and treatment can improve the prognosis for people with certain cancers,
including cancers of the breast, cervix and colon.


G. The Adverse Economic Impact of Tobacco Use, Heart Disease, and Cancer

Chronic diseases like tobacco use, heart disease and cancer are leading contributors to
rising health care costs. Death and disability from chronic diseases account for more than
60 percent of the nation’s direct medical care costs — approximately $655 billion a year
in 1990.24


Blue Cross and Blue Shield of Minnesota                                                      10
November 8, 2001                                                  Investment in Prevention



Smoking, for example, causes $50 billion in direct medical costs and $47 billion in indirect
costs annually. Smoking alone is responsible for approximately 7 percent of total U.S. health
care costs.25, 26 Similarly, smokers accrue $501 billion in excess lifetime medical costs,
compared to nonsmokers.27 And maternal smoking alone is associated with $1.4 billion in
medical costs for complicated births.28

The benefits from reducing smoking are impressive. Smoking-cessation programs are one
of the best investments employers can make in employees’ health. For employers who
provide effective programs for their employees, the 10-year return on investment has
been estimated at greater than 5 to 1. Economic benefit accrues in four areas: medical
care, absenteeism, on-the-job productivity and life insurance.29

Heart disease and stroke cost Minnesota more than $2 billion dollars a year in direct
medical costs and lost productivity, or approximately $500 for each person in the state.30
Nationwide, the total cost of cardiovascular disease and stroke this year will be
approximately $298 billion.31 Heart disease alone generates the highest claims costs of
any illness tracked by Blue Cross, totaling 9 percent of all medical costs.32

Reducing risk factors for heart disease will not only result in less illness but will reduce
overall health care costs. Men who have no significant risk factors for heart disease in
middle age incur only two-thirds the annual health care costs of men who have major risk
factors. For women with no risk factors, health care costs at retirement age are only one-
half those of women who had the risk factors in middle age.33

Cancer, as the second leading cause of death in the United States, will cause an estimated
550,000 deaths this year, including 9,000 in Minnesota. In economic terms, cancer costs
the nation an estimated $180 billion a year.34 Reducing the cancer burden means
addressing behavioral and environmental factors that increase cancer risk and making
evidence-based screening services available and accessible.

By taking action now to improve people’s health, Investment in Prevention will help
contain future health care costs. Health improvement programs of the kind we are
proposing can generate savings of greater than $3 for every $1 invested.35


H. Guiding Principles

Six key principles guide our planning and implementation of Investment in Prevention.

Collaborate and develop community partnerships.
We will collaborate with local, state, and national groups to create synergy, and maximize
our ability to improve health significantly. We will work alongside communities of color
and other populations targeted by the tobacco companies and burdened by tobacco use,
heart disease and cancer, to create effective and culturally relevant solutions.



Blue Cross and Blue Shield of Minnesota                                                        11
November 8, 2001                                                  Investment in Prevention


Use proven strategies.
We will build our programs on scientifically proven interventions based on the published
peer-reviewed literature. The wealth of literature available in the scientific press, and
from the Centers for Disease Control and Prevention, the Minnesota Department of
Health and other leading health agencies, will guide our programs.

Evaluate rigorously and learn continually.
We will rigorously evaluate our programs and require and support our funded entities to
do the same. Where our programs reach into new territory to create innovative solutions
to persistent problems, we will design interventions to maximize learning. We will share
what we learn with partners across Minnesota and the nation, through annual public
reporting and scientific publications. We are committed to continuous learning and will
systematically improve our programs based on quantitative outcomes, process indicators
and participant input.

Take a comprehensive approach.
We will employ a comprehensive campaign with both short- and long-term strategies.
Tobacco use, heart disease, and cancer did not become the leading causes of death
overnight. Nor will the solutions be easy or short-term. This plan is a ten-year
commitment to a dedicated, innovative, multi-faceted health improvement campaign.

Be honest and compassionate.
We will respect and empathize with the people of Minnesota who suffer from tobacco
addiction, heart disease, and cancer. We will be mindful of the complexity of health
behavior, the power of addiction, and the influence of environmental factors. We will
demonstrate a pro-health — not anti-smoker — attitude. We will be honest and
responsible in conducting all aspects of our business, and we will adhere to the highest
ethical standards.

Meet community needs, fill gaps, and avoid duplication.
We will identify gaps in the statewide fabric of tobacco reduction, heart disease
prevention and cancer prevention, and will use our resources and skills to fill those gaps,
working in close collaboration with other partners. Our efforts will complement — not
compete with — existing local and statewide efforts. We will collaborate and coordinate
with state and local partners to assure the best use of resources to achieve the maximum
positive effect on the health of Minnesotans. Our commitment to coordinating and
avoiding wasteful duplication begins with a thoughtful, thorough assessment of
community needs; the needs assessment process will be an ongoing element of
Investment in Prevention.



I. Program Components

Public health has a long history of progress against chronic disease. That experience has
yielded a core set of interventions essential to success in population-based health


Blue Cross and Blue Shield of Minnesota                                                       12
November 8, 2001                                                     Investment in Prevention


improvement initiatives such as Investment in Prevention. These interventions have stood
the test of time and have been rigorously evaluated.

Investment in Prevention is built around a core of four proven, population-based
interventions that we are calling “Essential Elements.” They are:

•   Clinical interventions
•   Local initiatives
•   High-risk population outreach
•   Public awareness

Clinical intervention
Health care professionals of all types and in all settings play a critical role in health
improvement that extends beyond the traditional focus on treating acute disease.
Clinicians are in a position to deliver systematic, preventive health services, screen for
the early detection of certain cancers, and provide counseling to reduce tobacco addiction
and other health-risk behaviors. By providing training, technical assistance, resources and
funding, we can support clinicians to rise to this challenge and improve the effectiveness
of preventive care throughout the state.

Local initiatives
Funds and technical assistance to local communities are essential to helping citizens
address local needs. Local projects may be designed to raise awareness and engage
citizens in pro-health initiatives. Alternately, local projects can provide a specific service,
such as screening, that the community needs. Local community programs cover a wide
range of prevention activities including developing partnerships with local organizations
and conducting programs for young people, parents, community and business leaders,
health care providers and others.

High-risk populations outreach
Outreach to high-risk groups is a critical complement to the population-based approach.
In fact, no program can be effective unless the most vulnerable groups are reached. In
addition, Minnesota faces special challenges; for example, in providing services to its
increasingly diverse populations, including many recent immigrants. Meeting the
language, cultural and health needs of these populations will require special outreach,
networks, materials and tailored programs.

Public awareness
Public awareness initiatives inform people and motivate them to take specific actions to
improve their health. Such initiatives may comprise a wide range of efforts, including
paid television, radio, billboard and print advertising at both the state and local levels.
Other strategies involve working with the media, participating in local events, and
sponsoring health-promotion activities.

These evidence-based Essential Elements are distilled from the Centers for Disease
Control (CDC) and Minnesota Department of Health (MDH) guidelines.36, 37 Within each


Blue Cross and Blue Shield of Minnesota                                                           13
November 8, 2001                                                         Investment in Prevention


element the individual projects that address tobacco addiction, heart disease, and cancer
are tailored to meet priority needs and complement existing efforts. For example, the
“local initiatives” programs to address heart disease differ substantially from the “local
initiatives” programs to address tobacco use. However, as Table 1 depicts, the programs
that make up Investment in Prevention all have the four Essential Elements at their
foundation.

                                             Table 1

                  Overview of Major Investment in Prevention Programs

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Blue Cross and Blue Shield of Minnesota                                                               14
November 8, 2001                                               Investment in Prevention


No single type of intervention by itself can achieve the major impact we seek through
Investment in Prevention. The comprehensive package of programs that embody all four
Essential Elements creates an effective, synergistic campaign because each element both
builds on and strengthens the other elements.




Blue Cross and Blue Shield of Minnesota                                                   15
November 8, 2001                                                  Investment in Prevention

Section 2. Investment in Prevention: Tobacco Reduction

As described in Section 1, tobacco use is the leading cause of preventable death and
disability in Minnesota, as well as the cause of more than $1 billion in direct medical
costs to the state each year.38 Harder to quantify is the loss in human terms. One way to
look at the toll of premature deaths is to realize that more than 43,000 children under age
                                                                            39
18 lose a parent to tobacco-related disease each year in the United States.

Two additional facts are essential to understanding tobacco’s devastation and how to
reverse it:

•   First, tobacco use is addictive. The nicotine level in cigarettes is formulated by
    tobacco companies to create a powerfully addicted set of loyal customers. The
    addiction is difficult to break. Forty-six percent of people who smoke attempt to quit
    each year, but the addiction is powerful enough that only 2.5 percent succeed.40, 41

•   Second, in Minnesota alone, the tobacco industry spends approximately $144 million
    dollars each year to promote its deadly products.42 While Minnesota does have some
    financial resources to combat this assault, those funds pale in comparison to the
    spending levels of the tobacco industry.

We know what works to reduce tobacco use: programs that have effectively reduced
tobacco use have already been implemented in several states. Successful tobacco control
programs are comprehensive and include many different kinds of activities. Some
activities are designed to encourage people not to begin using tobacco, while others are
designed to help people who use tobacco and who want to quit. Additional essential
activities for an effective program include local community programs, clean indoor air
policies, increases in tobacco excise taxes, programs for high-risk populations and
appropriate evaluation.43, 44, 45

When a comprehensive, statewide program is implemented over an extended period,
tobacco use rates decline, as does the incidence of diseases and deaths caused by tobacco
use. After ten years of a comprehensive tobacco reduction program, for example, the rate
of new cases of lung cancer dropped 14 percent in California, compared to only a 2.7
percent decrease in states without a such a program. This decline corresponded with a
drop in the California tobacco use rate over the same period.46

In California, Massachusetts and other states, significant health gains have been achieved
through clinical treatment programs, local funding, statewide activities and mass media
campaigns. Blue Cross will use a similar approach to bolster existing tobacco prevention
and control activities in Minnesota in ways that will reduce tobacco use, save lives, and
improve health.

Investment in Prevention complements existing efforts by the Minnesota Department of
Health (MDH) and the Minnesota Partnership for Action Against Tobacco (MPAAT).


Blue Cross and Blue Shield of Minnesota                                                       16
November 8, 2001                                                  Investment in Prevention


MDH’s legislative mandate requires it to concentrate solely on preventing tobacco use
among 12- to 17-year olds, and MDH’s Youth Tobacco Prevention Initiative focuses on
decreasing youth smoking in Minnesota by 30 percent by 2005.

The Minnesota Partnership for Action Against Tobacco (MPAAT) is the second major
agency working with tobacco settlement funds to reduce tobacco use on a statewide basis. An
independent, nonprofit public foundation, MPAAT was formed to support tobacco reduction
research and to promote tobacco cessation. Some of the organization’s major efforts include a
statewide telephone quit line, community grants to reduce secondhand smoke, and a media
campaign about secondhand smoke.

Blue Cross has worked closely with MPAAT since it was formed in 1998. Through this
close collaboration and coordination, the strengths of the two organizations have been
used to produce effective programs. Blue Cross staff have served on MPAAT’s ad hoc
planning committees, its board of directors, and its research advisory committees.
Collaborative projects have included the Minnesota Tobacco Helpline, which provides
telephone cessation counseling to all Minnesotans. This project is a coordinated effort of
all the state’s major health plans. Other examples of past collaboration include two
research reports that discussed major findings of surveys conducted jointly by MPAAT
and Blue Cross. MPAAT does fund community tobacco reduction programs, but due to
budget constraints, many Minnesota communities receive no funding from MPAAT.

Like MDH, MPAAT uses its resources to make an important contribution to Minnesota’s
comprehensive tobacco reduction effort. These necessary and useful efforts are not
sufficient by themselves, however, to change the patterns of tobacco use in Minnesota,
especially given the sophisticated, ongoing efforts by the tobacco industry to recruit new
smokers and to portray smoking as socially desirable. Blue Cross is committed to
collaborating further with MPAAT and MDH, to identifying and filling important gaps,
and to using the unique capabilities of each organization to bring about the greatest
reduction in tobacco use.

Investment in Prevention fills essential gaps by helping doctors and other clinicians to
assist smokers more effectively; increasing support for community-based efforts;
expanding work with high-risk groups to reduce tobacco use in their populations; helping
teens quit smoking; disentangling the economic effects of tobacco use and the benefits of
smoke-free environments; and helping to change public attitudes and public policy.


A. Clinical Interventions to Reduce Tobacco Use

The treatment of tobacco use can be provided in many different settings. Clinical
interventions include not only direct counseling and treatment but also the underlying
education and system enhancements that help physicians identify their patients who
smoke and encourage them to seek treatment. In clinical practice, the most successful
tobacco treatment programs are supported by reimbursement practices, clinical and
systems procedures, clinician education, and incentives for providers.47


Blue Cross and Blue Shield of Minnesota                                                      17
November 8, 2001                                                   Investment in Prevention



Clinical initiatives are most successful when they are aimed at and available to everyone
who receives care at a given clinic, an approach that Blue Cross strongly supports. Clinic-
based initiatives to reduce tobacco use can benefit all patients, regardless of their insured
status.

More than 70 percent of smokers want to quit.48 Most of those smokers are willing to use
assistance to reach their goal. The challenge is to reach this majority — and the many
important subsets of people within the population of smokers — with motivating
information, counseling, effective medications, and personal strategies. Thus we include
cessation counseling, counseling recruitment, and related strategies within the category of
clinical interventions. Blue Cross will conduct four types of interventions to improve the
treatment of tobacco addiction in Minnesota:

•   Clinic and hospital interventions: Centers of Excellence
•   Training and tools for medical and dental professionals
•   Programs to help individuals quit smoking
•   Enhanced recruitment into smoking-cessation programs

Each initiative is briefly described below.

Î Clinic and Hospital Interventions: Centers of Excellence
  Research has shown that physicians can have significant impact on their patients’
  health behaviors by screening and intervening with patients. This program will enable
  primary care clinics and hospitals to develop expertise in providing preventive
  services that can influence patients’ health behaviors. The Centers of Excellence
  program will fund and facilitate the development of state-of-the-art tobacco-reduction
  and health improvement programs using quality improvement methodologies to
  identify, assess, advise, track and monitor smoking status and other health risks and
  health care services.

    As part of the Centers of Excellence program, clinics will set ambitious goals for
    improving the delivery of these services (for example, “95 percent of all adults who
    visit the clinic will be assessed for tobacco use and the results documented at a
    standard location”) and will work toward achieving those goals. Techniques such as
    designated roles to ask about tobacco use, “no missed opportunity” visits, standing
    orders, and consumer-driven information delivered via the Web, may be used to reach
    the goals.

    Participating clinics will work with local public health agencies to develop
    complementary strategies in their community. Historically, it has been challenging for
    a medical practice focused on acute care to have the time and resources to create
    synergy with community initiatives, but the Centers of Excellence program will
    reward clinics for building on and coordinating with what is happening inside and
    outside of clinics to decrease tobacco use.



Blue Cross and Blue Shield of Minnesota                                                         18
November 8, 2001                                                   Investment in Prevention



    Minnesota clinics and hospitals will be invited to submit proposals for funding to
    support the development of Centers of Excellence. Facilities funded for the Centers of
    Excellence program will follow local and national guidelines for reducing health risk
    behaviors and promoting health and will share their learning with other clinics and
    hospitals. These programs will create systems to screen, summarize, and provide
    information to patients about behaviors and psychosocial factors affecting their
    health. Multidisciplinary teams will be encouraged to develop interventions and
    measure progress toward goals. As technology advances, electronic medical records
    may be used for tracking, recall and/or reminders to patients.

    The Centers of Excellence program differs significantly from current Blue Cross
    clinical programs. This program will enable clinics and hospitals to focus dedicated
    resources on improving their health care systems to more effectively identify and treat
    patients who use tobacco and to track their level of improvement. The dedication to
    disseminating knowledge and lessons learned beyond the participating clinics to the
    larger clinical community will ensure a broad reach and benefit.

Î Training and Tools for Medical and Dental Professionals
  Even with supportive systems, policies, and environmental prompts, individual
  physicians are not likely to assess and treat tobacco use consistently unless they know
  how to counsel patients effectively — what to say and when. This program will
  provide both practical resources and leadership so that clinicians routinely and
  effectively treat tobacco use and dependence.

    In collaboration with national experts, Blue Cross will develop, test and disseminate
    targeted education and supporting materials to help clinicians intervene more
    effectively with their patients who use tobacco. Educational efforts will include how-
    to information on intervening both with patients who are willing to quit and with
    those who are not, and information on effective treatment. Specialized modules will
    be created for use with specific target populations and for special patient populations.
    These efforts will also help physicians successfully integrate cessation interventions
    across the clinical setting and with other clinicians.

    As part of a comprehensive approach to equipping physicians and other clinicians to
    assess and treat tobacco dependence effectively, Blue Cross will tailor strategies to
    the venues and media through which clinicians learn, including medical school and
    continuing medical education as well as professional journals. We will continue and
    expand our support for tobacco-related continuing education by awarding clinician
    scholarships to the Mayo Clinic’s nationally recognized Nicotine Dependence
    Seminar.

    Oral health professionals are also in a unique position to identify the needs of their
    patients who use tobacco, to advise and assist those patients, and to arrange for follow
    up. The dental profession is a largely untapped resource for providing advice and



Blue Cross and Blue Shield of Minnesota                                                        19
November 8, 2001                                                  Investment in Prevention


    brief counseling to tobacco-using patients, and there are good reasons to believe that
    dentists can be effective in this role.

    Blue Cross will collaborate with Minnesota’s community of dental professionals to
    identify, refine or develop clinician education, systems tools and consumer education.
    Dental practices will evaluate the clinical processes, provider and consumer
    educational materials, and required dental resources to implement a tobacco-use
    treatment program. Based on best practices, a program will be established to support
    widespread, statewide adoption of effective interventions.

Î Smoking Cessation Programs
  Phone-Based Tobacco-Cessation Counseling
  In addition to the cessation assistance that is available through physicians and clinics,
  Minnesota residents can also access a smoking-cessation program from their home or
  workplace. With the May 2001 launch of Minnesota’s Tobacco Helpline, high
  quality, science-based quit-smoking counseling became widely available to
  Minnesotans. The Helpline, administered by the Minnesota Partnership for Action
  Against Tobacco (MPAAT), serves as a triage center for all callers by connecting
  insured callers with their health-plan-based counseling program and providing no-cost
  counseling services to uninsured or underinsured callers. The Helpline is a
  collaborative project of MPAAT and the state’s major health plans.

    Blue Cross members who call the Helpline are automatically transferred to the
    BluePrint for Health® stop-smoking program. Every adult member of any Blue Cross
    and Blue Shield of Minnesota health care plan is eligible to receive tobacco-cessation
    counseling through our BluePrint for Health program.

    The BluePrint for Health stop-smoking program is a telephone-based counseling
    service designed to help smokers quit in their own way and at their own pace, without
    pressure or judgment. The program was designed in partnership with Behavioral
    Solutions, LLC, and is based on the internationally recognized stages-of-change
    model developed by James Prochaska, Ph.D. Since its inception in June 2000, more
    than 11,000 people have participated in the Blue Cross program, which was recently
    awarded the top prize by the American Association of Health Plans in its Addressing
    Tobacco in Managed Care program.

    Individuals enroll in the program by calling a toll-free number. No doctor’s referral or
    copay is required. A smoking-cessation specialist asks a series of questions about the
    individual’s smoking behaviors, concerns, motivation and interest in quitting. A
    computerized “expert system” then analyzes this information and creates customized
    strategies to help the smoker move toward quitting successfully. A personalized
    report is immediately shared during the phone call. The participant also receives his
    or her report via mail, along with a BluePrint for Health manual that includes
    additional strategies and tools to help the smoker move toward quitting. Over the next
    six months, the specialist calls the participant three more times to update the initial
    assessment and provide support tailored to the specific needs of the individual. The


Blue Cross and Blue Shield of Minnesota                                                        20
November 8, 2001                                                  Investment in Prevention


    written assessments can be completed by mail rather than over the phone and
    participants can switch between the mail and phone options.

    The BluePrint for Health stop-smoking program recommends but does not require the
    use of pharmaceutical quit aids in conjunction with the cessation counseling. All fully
    insured Blue Cross members and many self-insured Blue Cross members have access
    to pharmaceutical quit aids as part of their current health benefit. To avoid any unfair
    competitive advantage, the Investment in Prevention plan does not include
    reimbursement for pharmaceutical quit aids for Blue Cross members.

    The expected outcome of the BluePrint for Health stop-smoking program is, quite
    simply, that more Blue Cross members will attempt to quit smoking and that,
    ultimately, more will succeed. We will rigorously monitor participation, satisfaction
    and outcomes, and we will report “quit rates” for participants at both six and twelve
    months after they have participated in the program.

    Internet-Based Tobacco-Cessation Counseling
    People who smoke have widely differing needs for quit-smoking assistance as well as
    important differences in learning style, time availability and financial resources.
    Today quit-smoking counseling and assistance is widely available to Minnesotans
    either by phone or through doctors’ offices. These services help thousands of
    Minnesotans begin the difficult and important process of quitting smoking. The
    Internet offers a third avenue of possible cessation counseling that remains largely
    untapped in Minnesota. Internet-based programs have the significant added benefit of
    being accessible whenever the participant has time or needs extra support.

    Blue Cross will partner with an expert organization to make scientifically sound
    Internet-based quit-smoking counseling available to all Minnesotans. The interactive
    program will complement the current phone-based counseling programs that are
    available and will at the same time provide a viable alternative that may be easier to
    schedule and more attractive to many people. Since Internet-based counseling is still a
    fairly recent development, this Blue Cross initiative will include a rigorous evaluation
    component. We will assess the characteristics of those smokers who opt to use the
    Internet system for quitting and will in turn learn from those participants how better
    to meet their needs and how best to recruit others who could benefit from the
    program.

Î Recruiting Minnesotans into Stop-Smoking Programs
  The common goal of all currently available tobacco cessation counseling programs is
  to attract and recruit the thousands of Minnesotans who want to quit smoking, and to
  provide them with effective services. Currently, Minnesotans are recruited for
  Minnesota’s Tobacco Helpline and the Blue Cross program through televised
  commercials. Members of other health plans are recruited through physician referrals
  and some direct mail (strategies that Minnesota’s Tobacco Helpline and Blue Cross
  also employ).



Blue Cross and Blue Shield of Minnesota                                                        21
November 8, 2001                                                   Investment in Prevention


    Despite these parallel efforts, many people who would like to quit smoking are
    unaware that phone-based quit-smoking counseling programs are available, or may
    incorrectly assume that cost prevents them from participating. This lack of knowledge
    combines with a lack of confidence in one’s own ability to quit smoking — a problem
    that is most severe in the most addicted smokers.49

    This enhanced recruitment effort will be directed at all Minnesotans, not just Blue
    Cross members. Under this initiative Blue Cross proposes to collaborate with
    interested Minnesota health plans and Minnesota’s Tobacco Helpline to make
    televised recruitment strategies as effective as possible, to dedicate significant
    resources to radio-based outreach — including non-English language programming
    — and to simplify and increase recruitment for all of the available programs.

    Radio ads, which are economical and can be aired in small communities as well as in
    the major population centers, will also be used and targeted as appropriate to specific
    sub-populations, including communities of color.


B. Local Initiatives to Reduce Tobacco Use

Recommended by the Centers for Disease Control and Prevention as a key part of an
effective tobacco reduction effort, support for local initiatives is another essential part of
the Blue Cross Investment in Prevention campaign.50 Local citizen groups and community
organizations best know the issues, opportunities and needs for expertise in their
communities. To fill important gaps in the current availability of assistance, Blue Cross
will create three interrelated programs:

•   Funding to local community groups working on tobacco issues
•   Technical assistance for communities
•   Technical assistance for employers

The funding and technical assistance provided by Blue Cross will enable local groups
throughout Minnesota to reduce tobacco use, reduce exposure to secondhand smoke,
inform and support local businesses, and reduce the harm caused by tobacco in their
communities.

Î Funding for Local Community Groups
  This program will provide funding to help communities that seek to implement clean
  indoor air policies and other effective policies to reduce tobacco use. Community
  clean indoor air campaigns are initiated and led by coalitions of local people who seek
  to benefit their community. Funds will enable communities to combat tobacco
  industry-funded misinformation campaigns about secondhand smoke and related
  issues. The tobacco industry and its allies outspend health advocates significantly in
  local policy change campaigns. Therefore, adequate targeted resources are necessary
  to help communities.



Blue Cross and Blue Shield of Minnesota                                                          22
November 8, 2001                                                  Investment in Prevention


    The immediate beneficiaries of a successful clean indoor air campaign are the
    residents of that particular community, especially the workers formerly exposed to
    cancer-causing secondhand smoke. Contrary to tobacco-industry claims, we know
    from the experience of other communities and entire states that smoke-free
    environments do not hurt local businesses. In addition, there is evidence that
    businesses and communities actually benefit economically.51

    A broad range of organizations — including local public health departments, local
    medical societies, and community coalitions comprised of representatives from
    multiple sectors, voluntary nonprofit health organizations and others — will be
    eligible to participate in this program. Examples of activities that could be funded
    include conducting and disseminating results of community opinion polls and surveys
    and educating local residents about the harms of secondhand smoke. These activities
    will help local coalitions to better understand a community’s needs and interests, and
    this understanding will in turn inform community dialogue and facilitate effective
    problem solving.

    Blue Cross’ community funding represents a new addition to local tobacco-control
    activities. As a health plan, for example, we can fill a specific niche by providing a
    significant share of our community funding to health care organizations, since those
    organizations are currently involved only sporadically in community-based efforts.
    Securing direct financial resources will enable health care organizations to increase
    their involvement in addressing secondhand smoke issues. Currently, no other
    organization is providing funds specifically earmarked in this way.

Î Technical Expertise for Communities
  This program will fund technical assistance to community representatives as they
  seek to reduce tobacco use in their communities. The objective is to educate
  community leaders on what works best and to counteract misinformation provided to
  local business owners by tobacco industry representatives. This technical assistance
  program will develop and disseminate expertise on topics not included in any other
  technical assistance programs available in the state.

    Areas of primary focus will include new research findings in tobacco control, how to
    implement clean indoor air policies, legal issues related to tobacco use, the economics
    of tobacco use, and the applicability of national tobacco reduction programs to local
    situations.

    In addition, interested physicians from communities that are working to eliminate
    exposure to secondhand smoke will be made available as expert resources to support
    tobacco-reduction policy initiatives in their local communities or at the state level.
    Physicians are often respected community members who can influence other
    community leaders. They are trusted information sources who can speak passionately
    about the damage from tobacco use and secondhand smoke exposure that they see
    every day in their medical practices. As we partner with local physicians and with the
    Minnesota Medical Association, we expect that Minnesota communities who are


Blue Cross and Blue Shield of Minnesota                                                       23
November 8, 2001                                                   Investment in Prevention


    considering protections against secondhand smoke will be joined by knowledgeable
    area physicians who will actively and effectively support clean indoor air policies.

Î Technical Assistance for Employers
  In two 1999 surveys of workers in Minnesota, only 64 percent and 74 percent of
  respondents reported that their workplace was smoke free.52, 53 Smaller employers are
  less likely than large employers to have human resource departments to help them
  formulate and implement an effective policy that protects employees from exposure
  to secondhand smoke.

    For a small employer, changing from a policy that allows smoking in buildings to one
    that bans smoking can be difficult. Small businesses understandably do not want to
    risk alienating valued employees who smoke. Moreover, the smaller the company, the
    more a change in policy can appear to target the specific individuals who smoke.

    To recognize these issues and provide customized help in coping with them, Blue
    Cross will provide interested small employers with technical assistance on how to
    implement a smoke-free policy. Blue Cross will fund one or more entities with
    technical expertise in this arena. Small Minnesota-based employers that want to create
    a smoke-free environment but face barriers that they cannot surmount without
    assistance will then have no-cost access to this expert resource. The technical experts
    will assist employers as needed with communications, policy development,
    articulating health benefits, transition planning, celebrating milestones and/or
    supporting smokers during the transition to a smoke-free building or campus.

    The implementation of smoke-free workplace policies provides additional incentive
    for workers to quit smoking, yet many people who currently smoke are reluctant to
    try to quit because they fear the negative side effects of cravings, weight gain, and
    loss of stress relief.54 Working in partnership with selected, interested employers and
    other expert resources, Blue Cross will seek to pilot and evaluate work-site
    approaches that can improve recruitment into quit-smoking programs by helping
    current smokers address those barriers.


C. Reducing Tobacco Use in High-Risk Populations

No comprehensive campaign to reduce tobacco use can be successful without specialized
outreach to high-risk populations. High-risk populations are racial, social, economic or
ethnic communities with elevated smoking rates or a disproportionate number of tobacco-
related diseases, or those who have been particularly targeted by the tobacco industry.55
In addition to taking a population-based focus, our tobacco reduction campaign will
include a specific focus on five at-risk populations:

•   Communities of color
•   Low-income populations
•   Teens

Blue Cross and Blue Shield of Minnesota                                                       24
November 8, 2001                                                  Investment in Prevention


•   Gay and lesbian populations
•   Young adults (see Subsection D, Public Awareness, below)

We will launch specific initiatives focusing on each of these populations. Each initiative
will complement existing efforts and will help fill identified gaps. The remainder of this
section contains summaries of the major initiatives to address tobacco use within each of
these special populations.

Î Communities of Color: Diverse Racial and Ethnic Groups and Nations
  (DREGAN) Initiative
  This ambitious, innovative project has four interrelated goals:

    •   Build the capacity for tobacco reduction within Minnesota's communities of color
    •   Increase support within each community for tobacco reduction initiatives
    •   Design and implement culturally relevant intervention programs to reduce tobacco
        use within each community
    •   Measure the effectiveness of the program in reducing tobacco use in each
        community

    Several studies conducted at the national level show that tobacco use in communities
    of color is disproportionately high and that those groups are specifically targeted by
    the tobacco industry. Yet those groups vary widely in their cultures, languages, health
    status and approaches to health improvement. Successful health improvement
    interventions can only be accomplished if they occur in the context of those
    communities and are “owned” by community members.

    DREGAN focuses on Minnesota's four major communities of color — the African
    and African-American, Asian-Pacific Islanders, Chicano/Latino and Native American
    communities. Each of these four major groups also has subgroups that are unique in
    many ways.

    In 2000, Blue Cross and the Minnesota Partnership for Action Against Tobacco began
    discussing the creation of a collaborative project to reduce tobacco use in conjunction
    with representatives of Minnesota’s four major communities of color. The DREGAN
    project was formally launched in 2001 and began working in partnership with
    organizations that represent or are involved with Minnesota’s communities of color.

    Investment in Prevention will allow us to expand this initiative. DREGAN will
    extend its partnerships and its impact by providing more funding to community
    networks to help them intervene and measure their progress. In the initial years,
    DREGAN is focused on reducing tobacco abuse. The goal of the tobacco reduction
    project is to change community norms and measurably reduce tobacco abuse and
    related health problems in each of the communities participating in this project.




Blue Cross and Blue Shield of Minnesota                                                       25
November 8, 2001                                                  Investment in Prevention


    Culturally relevant intervention programs will be designed and implemented with the
    intent of building long-term relationships with communities of color, measurably
    reducing tobacco use in each community, and increasing public support for tobacco
    harm reduction initiatives. The effect of this long-term project on tobacco use will be
    measured at regular intervals.

    Community representatives clearly regard tobacco use as inextricably linked to the
    burden of chronic diseases they experience. Therefore, we will enlarge the DREGAN
    scope to embrace a broader focus on other pertinent health issues.

Î Low-Income Populations: Addressing Barriers to Effective Treatment
  Low-income awareness and recruitment campaign
  MinnesotaCare and Prepaid Medical Assistance Program (PMAP) enrollees have
  smoking rates that are dramatically higher than rates of the general Minnesota
  population. Blue Cross’ Adult Tobacco Prevalence Survey, conducted in 1999,
  reported that 48.3 percent of adult PMAP members and 31 percent of adult
  MinnesotaCare members smoked. The same survey also documented the fact that the
  majority of these individuals want to quit smoking and desire assistance in doing so.56

    All MinnesotaCare and PMAP enrollees are entitled to use the phone-based quit-
    smoking counseling service. These enrollees are recruited through mass media, along
    with the general public. However, additional targeted efforts are needed to draw low-
    income members into the program in greater numbers. To facilitate that increase in
    participation — and ultimately an increase in successful quitting — we will launch
    direct-mail campaigns specifically targeted at PMAP and MinnesotaCare adult
    smokers.

    While PMAP and MinnesotaCare members currently have coverage for effective quit-
    smoking medications — nicotine patch, gum, inhaler and spray, and Zyban® — we
    know that many are unaware of this coverage and consider cost to be a major barrier
    to using the medications and attempting to quit smoking. This targeted campaign will
    address the perceived cost barrier by clearly explaining that there is no cost for the
    phone-based counseling program and that they are eligible for access to
    pharmaceutical support. Additional outreach and recruitment strategies will be added
    as needed, as we learn how to break down barriers and increase members’
    understanding of what support is available to them and how to obtain it.

    Nicotine patches for uninsured Minnesotans
    The Minnesota Partnership for Action Against Tobacco’s statewide Tobacco Helpline
    makes telephone-based cessation counseling available to all uninsured Minnesota
    residents. This program provides state-of-the-art phone counseling; however, many
    individuals who do not have current health care coverage cannot afford the over-the-
    counter medications that can increase their chances of quitting successfully.

    Therefore, in collaboration with MPAAT, Blue Cross will provide nicotine patches to
    uninsured Minnesota residents who contact the Minnesota Tobacco Helpline. This


Blue Cross and Blue Shield of Minnesota                                                       26
November 8, 2001                                                    Investment in Prevention


    program will complement the Helpline and will assist another sector of low-income
    Minnesota residents in their efforts to quit smoking.

Î Tackling Teen Tobacco Use: Adolescent-Specific Smoking Cessation and
  Awareness
  While the State of Minnesota has focused significant resources on preventing young
  people from starting to smoke, services to help teens quit smoking are virtually non-
  existent. This gap has been recognized at the federal level as well. Long (and
  incorrectly) considered a disciplinary problem for the schools to handle, teen smoking
  is now being recognized as a serious concern requiring medical and public health
  attention.

    The 2000 Minnesota Youth Tobacco Survey found that 32 percent of high school
    students (grades 9-12) were current smokers. Boys and girls were equally likely to be
    current cigarette smokers. Seventeen percent of high school students were frequent
    smokers and 15 percent were moderate smokers. Most teen smokers want to and have
    tried to quit. Nearly two-thirds of all current high school smokers would like to quit
    smoking cigarettes, and 61 percent of all current high school smokers tried
    unsuccessfully to quit at least once in the past year. Further, of those who tried to quit
    in the past year, nearly three-fourths attempted to quit two or more times.57, 58

    There is a growing awareness that adolescents, as well as adults, need effective
    assistance to quit smoking. Relatively few quit-smoking interventions, however, have
    been specifically developed for teens and rigorously evaluated. To bridge this gap,
    Blue Cross will fund demonstration projects aimed at documenting the success of
    existing tobacco cessation programs for teens and developing innovative new
    programs to serve the unique needs of teen smokers. Potential participants could
    include health professionals as well as community organizations, youth sports
    associations, and other youth clubs or associations.

    In addition to funding cessation programs, Blue Cross will contribute to heightening
    teen and preteen awareness by continuing to sponsor Smoke-free Kids and Soccer.
    This program is a partnership between the Minnesota Youth Soccer Association, the
    Minnesota Department of Health, Blue Cross, and the children, parents and coaches
    of Minnesota. On the national level, the Centers for Disease Control and Prevention
    sponsor the project.

    The program provides parents and coaches with educational materials aimed at
    keeping youth smoke free. Because soccer is one of the fastest growing youth
    participation sports in the nation and is embraced by kids from many racial, ethnic,
    income and geographic communities, we regard this effort as a useful complement to
    other youth-focused efforts.

Î Gay and Lesbian Populations
  The Centers for Disease Control and Prevention have identified the gay, lesbian,
  bisexual and transgender (GLBT) population as an at-risk group and a focus for


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    tobacco-reduction efforts. This population has higher than average smoking rates and
    is specifically targeted by the tobacco industry, for example via bar night promotions
    and developing a cigarette produced and marketed specifically to gay men. Some
    GLBT organizations, like some other groups, are also dependent on funding from
    tobacco companies to support cultural events.59

    Through this initiative we will develop and implement evidence-based strategies for
    reducing tobacco use and exposure to secondhand smoke among GLBT residents of
    Minnesota. The first phase of the project will build relationships with organizations
    experienced in tobacco control in the GLBT communities, such as the GLBT Tobacco
    Control Coalition and the Gay and Lesbian Medical Association. We will work with
    those organizations to increase awareness of 1) the dangers of secondhand smoke, 2)
    tobacco industry targeting, and 3) high smoking rates within GLBT communities. In
    this phase we will also determine the effectiveness of GLBT-focused tobacco
    reduction strategies in other states and assess their applicability to Minnesota. The
    second phase will design and implement intervention programs in collaboration with
    Minnesota’s GLBT health care providers or other interested organizations.

    We will fund a series of coordinated initiatives including awareness-raising
    campaigns or events, GLBT health care provider interventions, GLBT-targeted
    smoking classes and recruitment strategies, promotion of tobacco-free policies, and
    assisting GLBT community organizations to expose and find alternatives to tobacco
    industry influence and funding. Similar educational and intervention efforts have
    proven effective in other communities and will benefit the GLBT community and the
    health care providers serving that community.


D. Tobacco-Related Public Awareness

All states that have successfully reduced tobacco use had major public awareness
campaigns as an essential element of their comprehensive programs. Comprehensive
programs in California and Massachusetts that included paid public awareness campaigns
have been the most successful in reducing tobacco use among adults, slowing the
initiation of tobacco use among young people, and protecting children from exposure to
secondhand tobacco smoke.60 In just one year, a comprehensive Florida prevention
program anchored by an aggressive mass media campaign produced significant declines
in tobacco use among middle-school and high-school students.61

Public awareness programs work because they undermine the influence of the tobacco
industry’s most important weapons — marketing and promotion. In Minnesota alone, the
tobacco industry spends $144 million a year to advertise its products.62 Successful
counter-marketing programs both prevent young people from beginning to use tobacco
and help smokers quit. According to the Centers for Disease Control,63 effective counter-
marketing efforts should:

•   Combine messages on prevention, cessation, and protection from secondhand smoke;


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    target both young people and adults; and address both individual behavior and public
    policies.
•   Include grassroots promotions, local media advocacy, event sponsorships, and other
    community tie-ins to support and reinforce the statewide campaign.
•   Maximize the number, variety, and novelty of messages and production styles, rather
    than communicate a few messages repeatedly.
•   Use nonauthoritarian appeals that avoid direct exhortations not to smoke and do not
    highlight a single theme, tagline, identifier, or sponsor.

Just like successful tobacco control programs in other states, we will use mass media and
other communications channels to inform Minnesotans of the issues raised by tobacco
use in their communities, its consequences, and the steps they can take to reduce its use.
We will encourage people to take action and to make use of effective interventions.

Mass media will also support other program components, including clinical cessation
efforts and community events. A variety of electronic and print media will be used to
deliver messages that fit with current topics and programs. As described below, we will
make special efforts to reach high-risk groups, especially young adults and communities
of color. These two populations have special needs, because of their rates of smoking and
because of barriers they face in obtaining health information and clinical care.

Î Combating Tobacco Industry Targeting of Young Adults
  In recent years, there has been an alarming increase in tobacco use rates among 18- to
  24-year-olds. Tobacco use rates among college students throughout the country are at
  a high level. In 1998, approximately 38 percent of students were current tobacco
  users.64

    Research conducted by the University of Minnesota in 1999 shows even higher
    tobacco use rates among its student population. Forty-two percent of University of
    Minnesota students report that they are current tobacco users, which represents a 60
    percent increase since 1992.65 One of the most alarming observations is that now
    many more college students begin using tobacco once they have started college. This
    increase can be attributed in part to the shift in tobacco industry marketing to young
    adults. To counter that shift, we will conduct a public awareness campaign directed at
    this group.

    All phases of this campaign will be conducted in partnership with interested
    community organizations. The goals of this campaign are: to develop a thorough
    understanding of the attitudes and behaviors of 18- to 24-year-old Minnesotans as
    they relate to tobacco use; to identify counter-marketing strategies that would
    resonate with this age group based on the knowledge gained through the research; and
    to design and implement a counter-marketing campaign to reach this high-risk
    population.

    The campaign may use non-traditional communication venues, since preliminary
    knowledge suggests that traditional approaches, such as paid electronic advertising on

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    television and radio, may not be effective. Instead, the campaign will use grassroots
    approaches to convey key messages. This campaign may be unlike any currently
    taking place in Minnesota. The Centers for Disease Control and Prevention and others
    have identified the need for such work, and small pilot projects have reached out to
    the college population.

Î Countering Tobacco Industry Promotions: A Campaign with Communities of
  Color
  Reducing tobacco use rates in communities of color is an important goal. For decades,
  the tobacco industry has unfairly targeted specific ethnic groups with its marketing,
  resulting in disproportionate tobacco use, and consequent death and disease, in these
  communities. This project will use counter-marketing to undermine the tobacco
  industry’s message.

    A counter-marketing program involving communities of color will build the capacity
    in those communities to recognize that the tobacco industry is targeting them. While
    the counter-marketing campaign may use traditional media outlets such as radio,
    newspaper, billboard, bus-side and bus-stop advertisements to reach its audience,
    other approaches will be explored as well. For example, we may choose to focus our
    counter-marketing on getting our message out at sports and music events, because the
    tobacco industry currently sponsors such events as a way to target communities of
    color. Special attention will be focused on reaching women in these communities with
    specific, relevant messages.

    We will use state-of-the-art marketing techniques to determine how to reach the most
    people with the resources dedicated to this project. This counter-marketing program
    will be developed in close coordination with the four communities-of-color networks
    being established through DREGAN. Network staff and community partners will help
    us ensure that the program will be effective in reaching the target audiences. The
    community networks will also provide input into which specific tobacco reduction
    issue the counter-marketing program should focus on, whether reducing exposure to
    secondhand smoke, quitting smoking, preventing people from starting to smoke or
    some other issue.




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Section 3. Investment in Prevention: Heart Disease

As described in Section 1, heart disease is the leading cause of death among Minnesotans.
Atherosclerosis, the underlying disease process of the major forms of cardiovascular
disease, is a slowly progressive condition that begins in childhood. It is associated with
several modifiable risk factors including high blood pressure, tobacco use, physical
inactivity, diabetes, obesity and poor diet. Controlling modifiable risk factors for the
general public and for individuals is key to preventing heart disease and its
                66
complications.

A number of important initiatives to prevent heart disease exist in Minnesota, including
Fitness Fever, efforts to support healthy nutrition among school children, and various
efforts sponsored by the American Heart Association and other groups. The resources and
reach of those programs, however, are far outstripped by the challenge. In fact, Minnesota
has not been investing significant resources for comprehensive initiatives to prevent heart
disease throughout the state. Gains made in the 1980s in identifying and controlling
hypertension, for example, have not continued in recent years.

The Minnesota Department of Health is now embarking on a three-year cardiovascular
health planning initiative. Our heart disease prevention campaign, described below, will
complement and energize that effort. Blue Cross, through Investment in Prevention, can
have a significant impact on Minnesota’s efforts to prevent heart disease by focusing on
key initiatives. Together, and in coordination with public and private partners, these
initiatives will achieve lasting results.

Blue Cross’ heart disease campaign will focus on clinical interventions, including
clinician education and training and cultural competency; local initiatives, including
public screenings, nutrition and physical activity programs; outreach to high-risk groups;
and programs to raise public awareness about key heart disease risk factors. Designed to
benefit all Minnesota residents, this cluster of initiatives will improve control of
hypertension, reduce cholesterol levels, help to detect and control diabetes, increase
physical activity, improve diet and lessen obesity. Over time, these changes will reduce
heart disease and decrease premature death and disability.


A. Clinical Interventions to Prevent Heart Disease

Clinical interventions are an important key to preventing heart disease. Since more than
70 percent of the population pays at least one visit to a medical clinic each year, the
opportunity for intervention is great.67 Each visit presents an opportunity to help patients
reduce their risk of heart disease. But lack of training, lack of supportive clinical systems
and guidelines, cultural misunderstandings and other factors leave both patients and
clinicians with unmet needs. The initiatives described below will support clinicians and
patients as we move toward the integrated, systematic, and respectful delivery of proven
services that will help prevent heart disease.



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Î Enhanced Diagnosis and Treatment: Clinician Education and Training
  Recent reports published within the medical and popular press indicate that
  significant percentages of people with hypertension are going untreated, despite
  having visited a physician at least once in the previous year. Gaps exist between
  published guidelines for managing hypertension and the daily practices of primary
  care practitioners. Because of these gaps, Blue Cross will invest in a major effort to
  provide the support that will ensure that Minnesota clinicians are routinely diagnosing
  and effectively treating their patients who have hypertension, according to current
  clinical management guidelines.

    This initiative will make providers more aware of, and will help them comply with,
    both published guidelines for managing hypertension and accepted techniques for
    measuring blood pressure. By focusing efforts on primary care providers across the
    state and on providers serving high-risk groups defined by location (Northeastern
    Minnesota) and race (African-Americans), we will achieve the broadest impact.
    Success in influencing high-risk populations requires a combination of population-
    based, statewide efforts plus targeted outreach.

    Blue Cross will make state-of-the-art continuing medical education programs, as well
    as independent learning aids, available to primary care practices throughout
    Minnesota. Blue Cross will develop initiatives to improve screening and treatment
    processes in selected settings, for the purpose of identifying ways to improve the
    practical treatment of hypertension. Successful models can then be publicized and
    used in other practice settings around the state.

    In addition, on-site, in-clinic training will provide opportunities for busy clinicians to
    update their knowledge and improve their skill in diagnosing and managing
    hypertension. These initiatives will detail pharmaceutical and other innovations for
    helping patients manage hypertension more effectively, will provide on-site health
    improvement programs, and will offer training through personal presentations, self-
    study CD-ROMs, and other means. Clinical networking forums will supplement the
    on-site initiatives.

    Following and building on the lessons learned from focusing on hypertension, the
    focus will shift over time to other cardiovascular risk factors — hypercholesteremia,
    diabetes, diet and exercise.

Î Cultural Competency
  Blue Cross will provide training to clinicians to address two subjects. First, we will
  provide a range of opportunities for clinicians to improve their skills in preventing
  chronic diseases among patients from communities of color, by focusing on
  diagnosing and treating hypertension and on other heart disease risk factors, including
  diet and exercise.




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    Second, we will offer training that addresses cultural competency issues and that
    identifies and removes barriers to treatment. Training methods will include self-taught
    modules, traditional classes, and Web-based training.

    In select clinics where special needs are identified, we will provide funding to support
    facilitated group meetings of hypertensive patients who face significant cultural or
    language barriers that limit their treatment. Experienced health educators will work
    with clinicians and groups of patients who face common problems in their treatment.

Î Cardiovascular Disease Collaboration with ICSI
  The Institute for Clinical Systems Improvement (ICSI) is a unique collaboration of
  Minnesota health care organizations dedicated to championing quality health care and
  to helping member clinics to identify and quickly implement best clinical practices
  for their patients. ICSI’s programs have four elements: commitment to improvement,
  scientific groundwork for health care, support for quality improvement, and advocacy
  for health care quality. ICSI is an independent, nonprofit entity that provides health
  care quality improvement services to 27 medical groups. The combined medical
  groups represent over 4,000 physicians. Blue Cross and Blue Shield of Minnesota,
  HealthPartners and Medica are primary sponsors and equally provide most of ICSI’s
  financial support. PreferredOne and UCare Minnesota are associate sponsors. Blue
  Cross is proud to co-sponsor this unique cross-plan effort.

    Blue Cross will work with ICSI to collaboratively develop and support a
    cardiovascular disease program for primary care clinicians. This collaborative project
    will employ the model currently used by ICSI and its medical groups, wherein clinics
    are encouraged to develop their own goals and progress measures and to share those
    results with one another through annual networking forums. By coordinating with
    ICSI, Blue Cross will develop a special technical assistance and support program for
    the cardiovascular disease program. We anticipate that this support program will
    include clinician training, resource development and coaching.

Î Tailored Health Risk Profiles and Follow-Up
  A first step toward improving heart health is to understand one’s current health status
  and identify existing risk factors. Self-assessments, or health risk profiles, work by
  feeding participant-supplied information about family medical history, personal
  medical history, and health behaviors into a computer-based system that rates and
  ranks these factors against scientific evidence. The end result — a personalized
  assessment of health status and risks — is the starting place for improving individual
  health.

    Blue Cross will make these health assessments available to all interested
    Minnesotans. The assessments may be completed via mail, phone, or the Internet. An
    assessment tool for calculating an individual’s risk of developing heart disease will
    include factors, including age, gender, cholesterol levels, smoking status, and blood
    pressure, validated by the Framingham Heart Study.68



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    The individual participant receives an estimate of the 10-year risk of developing heart
    disease, a series of health improvement recommendations and action steps, and
    tailored information and resources to help change specific health behaviors. For some
    participants, recommended follow-up will involve a visit to their doctor to obtain
    important tests such as a blood pressure check or cholesterol test. For others,
    recommendations may focus on dietary changes or becoming more physically active.

    At regular intervals, the health risk profile will be repeated to monitor individual
    progress and to evaluate whether the resources were effective in supporting the
    necessary behavioral changes. The program will be designed to complement the care
    that participants receive from their doctors and equip them to better follow their
    doctor's recommendations.


B. Local Initiatives to Prevent Heart Disease

Local initiatives offer a major opportunity to prevent heart disease. Community-based
organizations, including voluntary health associations, local coalitions, city and county
public health organizations, and other groups of concerned citizens are best positioned to
assess and respond to specific community health needs. While local community
organizations may have the will and a great deal of expertise, they often lack sufficient
funding and technical assistance, and they have numerous competing demands on their
resources.

Î Local Community Public Screenings
  A number of organizations within the state, representing a wide range of
  constituencies, share Blue Cross’ ambition to reduce heart disease. In many instances,
  these groups are intimately involved with high-risk populations and can support
  changes in behavior that can help control health risk factors. Through a program of
  funding to these community groups, Blue Cross will support efforts to reduce heart
  disease.

    During the first few years of the program, emphasis will be on more clinically
    oriented risk factors: hypertension, lipids and diabetes. Blue Cross will provide
    community funds to help discover and manage these risk factors. These efforts will
    complement or reinforce the work of medical providers.

    Improved detection mechanisms must be complemented by the resources to help
    people manage their degree of risk. A portion of program resources will be devoted to
    developing and distributing materials to support individuals managing their own risk
    factors. In addition, we will seek to increase existing screening and counseling for
    homebound and other at-risk individuals.

    A range of organizations may qualify to apply for this program. These include
    community-based nursing organizations, county and city health departments, and
    voluntary health associations focused on relevant disease categories. Employers or


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    retailers who want to provide preventive and self-management services to their
    employees or customers could also be potential funding recipients.

    As the program focus shifts over time to address diet and physical activity, many of
    the same organizations could play a constructive role and could be eligible to receive
    support. In addition, other groups could also become involved, particularly those who
    create opportunities to make increased physical activity more accessible to a larger
    number of people. Municipalities, park districts and recreation boards are examples of
    the range of potential collaborators who might become involved in addressing this
    broader agenda.

Î Safe and Accessible Community Recreation
  Working with the Minnesota Department of Health, local communities, local parks
  and recreation departments and other key agencies, Blue Cross will support
  community efforts to encourage physical activity, to provide safe ways for children to
  walk or bicycle to school, and to provide safe play areas outside of school.

    We will partner with public and community organizations as well as Minnesota
    companies in creative and exciting ways. These partnerships will help encourage and
    provide recreational options for children, as well as reach the adults involved with
    those children.

    Kids Walk to School is one example of a community-based program that could be
    modified and adopted by local communities under this program. Developed by the
    Centers for Disease Control and Prevention, Kids Walk to School aims to increase
    opportunities for daily physical activity by encouraging children to walk to and from
                                               69
    school in groups accompanied by adults.

    Funding will be targeted at communities demonstrating the greatest readiness and
    need, and at those with the greatest challenges to providing safe and accessible
    recreational choices for people of all ages. Community-designed and cooperatively
    constructed playgrounds and pathways not only result in safe, enjoyable places for
    children to be active, but build community and social connections in the process.

Î Healthy Food Choices
  Blue Cross will provide funds to organizations that can influence the dietary choices
  youth make in and outside of school. Many schools do not actively encourage
  students or employees to choose healthier foods at school. Blue Cross will fund
  selected community-based organizations that will work with schools to adopt healthy
  food choice policies, provide students and employees with healthy options, and
  encourage and reward students and school employees to choose healthier foods.

    In this area, as with other program activities, Blue Cross will seek to leverage creative
    partnerships and foster collaboration between citizen groups, recreation centers, local
    businesses, school districts, student councils and parent-teacher organizations. With
    the necessary focus and resources, local communities can develop a creative program


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    that respects the fund-raising needs of schools and supports the nutritional health of
    students.


C. Preventing Heart Disease in High-Risk Populations

Death rates from heart disease are higher among many groups of Minnesotans than they
are for the general population. For the American Indian population in Minnesota, the
death rates from 1990 to 1998 were 33 percent higher than the total for the state and 44
percent higher than the total for the American Indian population nationwide. Disparities
also exist for African-American women in Minnesota. Screening rates are troubling as
well. African-Americans and Hispanics in Minnesota, for example, are much less likely
                                                                            70
than whites to have had their blood pressure checked in the last six months.

In recent decades the greatest declines in death rates due to heart disease have been
among those at the highest income and educational levels. Heart disease rates are highest
among people of lower socioeconomic status. These differences have been attributed to
the greater prevalence of risk factors within lower socioeconomic populations.71

The success of the state’s newest initiative to eliminate disparities in health status
depends in part on the collaboration, commitment, resources, and innovation of private
partners. Blue Cross is committed to working with communities of color and other high-
risk groups to develop, implement, and measure broad-based and targeted heart-disease
prevention programs. In addition, Blue Cross will work with individuals already
diagnosed with heart disease to reverse the progress of the disease.

Î Targeted Media and Communications to Reach Communities of Color
  Blue Cross will support a targeted media and communications campaign, tailored to
  communities of color. The targeted campaign will support the statewide campaigns to
  promote nutrition and physical activity, as described in Section 3. D., below. Blue
  Cross will develop partnerships with communities of color, and together we will
  develop and disseminate educational materials to support the statewide campaign.

    Information will be provided in the appropriate language, in a culturally relevant
    manner, and through the channels most likely to reach groups at risk. These channels
    will include community clinics, faith-based and other community organizations, and
    media outlets that reach these groups.

    As noted above, these educational campaigns will require that we collaborate with a
    wide range of organizations. We will seek collaborative relationships with media
    outlets, with appropriate companies already marketing to target populations, and with
    community-based organizations whose credibility, stature, and existing
    communications channels are useful to this effort.




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Î Specialized Programs for Improving Diet and Reversing Heart Disease
  Coronary artery disease (CAD), which causes debilitating chest pain or heart attack in
  millions of Americans each year, is in large part a preventable condition. Eating a
  healthy diet, exercising regularly, and not smoking have been proven to significantly
  reduce rates of death from coronary artery disease.

    A rigorous prevention program that assists Minnesotans to address modifiable risk
    factors of high cholesterol, hypertension, diabetes, smoking, sedentary behavior and
    obesity will reverse CAD and reduce the incidence of heart attacks and strokes. As a
    result, fewer cardiac surgeries will be necessary, the need for cholesterol-lowering
    and other cardiac drugs will be reduced, and associated health care costs will
    decrease.

    Studies have demonstrated the effectiveness of small group work with individuals at
    risk, engaging them in a risk-stratified program that involves comprehensive lifestyle
    changes. These programs have included several features:72

    •   A low-fat diet
    •   Moderate aerobic exercise
    •   Stress management
    •   Group support

    In partnership with key clinical providers, Blue Cross will help support such
    programs at selected clinics or hospital sites. Interested physicians, clinics, and
    hospitals will educate, monitor, and support program participants. Appropriate
    eligibility requirements will be established to make efficient use of these resources.
    Blue Cross will coordinate data collection, evaluate outcomes and report findings.


D. Heart Disease Public Awareness

Public awareness campaigns are an integral part of a successful effort to improve heart
health and prevent heart disease. One of the principal challenges to be overcome in
improving cardiovascular health is making people aware of the risks they face and the
steps they can take to reduce those risks. Many people fail to recognize that heart disease
is the single greatest threat to their health. In a recent survey, for example, only 8 percent
of women correctly identified heart disease as their greatest threat, while 62 percent
thought cancer was their greatest threat.73

Public awareness campaigns using mass media can positively affect people’s knowledge
and behavior. Such campaigns have made a positive impact on several heart disease risk
factors, including tobacco use, physical inactivity and diet.74, 75

The purpose of our public awareness campaigns is to raise awareness of the targeted
heath risks, increase individual and group understanding of their own susceptibility,



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motivate people to act, and describe specific and accessible steps individuals can take.
Messages will be carefully crafted and tested to assure that they are meaningful,
culturally relevant, and practical. Both a statewide approach to the general public and
targeted outreach to higher-risk groups are necessary for success.

Î Public Awareness Campaign against Hypertension
  Blood pressure awareness programs increased public awareness in the late 1970s and
  1980s, but national data over the last decade suggest that public awareness of the
  importance of high blood pressure as a health risk factor has declined.76 Our public
  awareness campaign against hypertension aims to reverse that decline and to improve
  the public’s understanding of the importance of various cardiovascular risk factors.

    The awareness campaign will include:

    •   Television ads addressing blood pressure, cholesterol, and diabetes, strategically
        placed on statewide broadcast schedules to maximize reach into the population of
        adults 35 or older. In later years, advertising design and media placements will be
        reevaluated so that a broader age range, including younger members of the
        population, can be addressed.
    •   Newspaper print ads, placed in the most significant media markets, designed to
        reach relevant age ranges. In select markets (papers in Northeastern Minnesota,
        and publications directed toward the African-American communities), additional
        placements will be scheduled.
    •   Other print media, such as flyers and brochures, distributed through various
        outlets appropriate for reaching particular communities of interest
    •   Web-based media used to reach targeted subsets of the population

    These communications and outreach activities will also be carried out in coordination
    with efforts to engage and support providers and others in the community who can
    play meaningful roles in helping to control cardiovascular risk factors. For example,
    screening events, for which publicity can be developed, will be staged in conjunction
    with primary care providers and other clinicians across the state.

    These events will further encourage providers around the state to have a sense of
    ownership and broaden their role in detecting and managing hypertension,
    hyperlipidemia and diabetes. The involvement of trusted community providers also
    serves to heighten the impact of the messages and activities on the community
    audience.

Î Public Awareness Campaign Supporting Physical Activity
  Blue Cross will develop a statewide campaign to promote physical activity,
  particularly focusing on high-risk communities and addressing cultural issues relating
  to physical activity. The campaign will encourage individuals to increase their level
  of physical activity, but will also encourage people to work within their communities
  to provide exercise equipment and facilities. The campaign will stress the importance



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    of walking, sports, and noncompetitive activities for people of all ages, and will
    highlight the importance of safe places to exercise, including trails, malls,
    playgrounds, and community centers.

    Blue Cross will engage influential spokespeople, including youth peers, celebrities
    and others who can help serve as role models, particularly to younger people who are
    establishing dietary and exercise habits that will influence their health for years to
    come.




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Section 4. Investment in Prevention: Cancer


Cancer is the leading cause of death in Minnesota for persons between the ages of 35 and
74. Each year an estimated 20,600 Minnesotans are diagnosed with cancer and 9,000 die
from the disease.77 There are, of course, multiple types of cancer, and subtypes within
many of those. The cancer component of Investment in Prevention will focus on selected
cancers — breast, cervical, lung, skin and colon cancer — that cause the greatest number
of deaths and for which prevention or early detection can make a difference in health
outcomes.

Minnesota currently benefits from several state-level cancer control initiatives. Most
notably, the Minnesota Department of Health offers no- or low-cost breast and cervical
cancer screening to uninsured or underinsured women over age 40. Similarly, MDH
offers free or low-cost services to women with cervical abnormalities needing follow-up.
In addition, the state and its partners are currently joining forces against colorectal cancer
and also testing strategies to recruit more women to have mammograms.78

The cancer prevention and early detection initiatives that Blue Cross will launch as part
of Investment in Prevention will complement existing services and fill gaps. In addition
to supplementing and creating synergy with existing breast, cervical and colon cancer
initiatives, we will launch a large-scale skin cancer prevention initiative and continue our
tobacco reduction efforts in order to prevent lung cancer.

Designed to benefit all Minnesotans, these initiatives will significantly contribute to an
increase in the early detection of breast, cervical, colon, and skin cancers, as well as
improved nutrition, increased physical activity, and decreased tobacco use, which will
also lead to decreased cancer.


A. Clinical Interventions to Prevent and Detect Cancer

Our clinical interventions to prevent cancer and increase the early detection of cancer fill
a serious gap. Competing priorities, strained resources, and a focus on treating acute
disease can overshadow the need to provide preventive services. The constellation of
initiatives described below will aid in the prevention and early detection of the targeted
cancers by providing clinicians with training, resources, systems, and incentives. The
public screening events will improve access and remove barriers to obtaining potentially
life-saving tests.

Î Innovations and Advances: Clinician Education and Training
  Educational programs to help clinicians prevent and detect cancer need to be
  delivered through diverse channels. As part of a comprehensive approach, Blue Cross
  will use several coordinated strategies and will tailor programs to the venues and
  media through which clinicians learn — in medical school, at the clinic, through
  continuing medical education (CME) and through professional journals.


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    In addition, our on-site training approach will give busy clinicians the opportunity to
    update their skills in effectively preventing and detecting cancer. Initiatives will
    include consultations on innovations in cancer screening and health education
    programs, one-hour CME training sessions, and self-study CD-ROMs. Clinicians will
    also receive training in participatory communication styles, which patients find more
    satisfying and which prompt them to adhere to the physician’s recommendations.

    These on-site initiatives will be supplemented by direct mailings to clinicians, clinical
    networking forums, and scholarships to attend continuing medical education
    programs. The initiatives will work to set the agenda in clinics for focusing on these
    sometimes-overlooked preventive issues. Where science and opportunity dictate,
    cancer prevention and early detection training and educational approaches will be
    combined with other health improvement and disease-detection focuses.

Î Recognizing Quality: Guideline Incentive and Awards Program
  We know that clinicians can more consistently and effectively screen and counsel
  their patients for the risk factors and early signs of cancer and heart disease when they
  have supportive office systems and guidelines in place. Blue Cross will reward clinics
  that invest the up-front effort to establish cancer and heart disease prevention and
  detection systems, and systems for recognizing and addressing tobacco use. Our
  Quality Incentive Program will encourage clinicians to adopt and effectively
  implement the Institute for Clinical Systems Improvement (ICSI) clinical practice
  guidelines for the early detection and screening of cancer. Clinics that implement
  heart disease and tobacco use guidelines will also be eligible for the Quality Incentive
  Program.

    In addition to the incentive program for all eligible clinics, a special awards program
    will recognize clinics that demonstrate measurable improvement in implementing 1)
    cancer prevention and screening programs, 2) heart disease prevention and screening
    programs, or 3) recognizing and treating tobacco dependence. Award criteria will be
    based on reaching established goals for specific measures identified in the relevant
    ICSI guidelines.

    The awards program will reward clinicians, clinics, and community systems both
    financially and by publicly recognizing their efforts. The literature indicates that
    properly developed guidelines and appropriate financial incentives can be effective in
    improving clinical practice, which in turn supports better health outcomes for
    patients.


B. Local Interventions to Prevent and Detect Cancer

As with tobacco use and heart disease, an important component of our cancer prevention
and early detection program is providing targeted funding to selected local communities.
Community organizations are well positioned to draw local residents into existing



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screening services, form coalitions to tackle persistent nutrition problems, and work with
local businesses and restaurants to develop innovative programs.

Our community cancer prevention and early detection funding may be used to address
any of the cancers listed earlier, according to the needs and interests of each community.
We will provide support for effective cancer prevention and early detection interventions
that fill existing program gaps in each community. Some communities may focus on
early detection. Others may focus on the behaviors — like diet, smoking and sun
exposure — that are risk factors for some cancers.

Through the three programs outlined below, Minnesota communities will be invited to
build communities of excellence focused on preventing cancer, increasing early detection
and changing behaviors, such as poor nutrition and inactivity. Funding will be made
available to communities that build strategies to bring together major stakeholders —
such as public health, medical, business and other leaders — to promote prevention and
early detection of cancers.

Î Community Action to Increase Cancer Screening
  This program will provide funding to selected communities to increase cancer
  screening and early detection. Communities can choose the type of cancer they wish
  to address, although the new resources must complement, not duplicate, existing
  efforts in the community. Funding will be used to implement proven strategies to
  increase screening rates among the selected populations. Communities may wish to
  select high-risk groups, including groups who have lower rates of screening or higher
  cancer rates, in order to maximize the impact of the screening program.

    Communities could choose several different kinds of activities, including special
    screening events, communications about the need for and availability of local
    screening programs, or special efforts to reach high-risk groups. A variety of
    organizations may apply for these funds, including for-profit and not-for-profit
    groups, health care providers, voluntary health organizations, and others.

Î Community and Worksite Projects to Improve Nutrition
  Helping people to recognize that they need to eat more healthfully and motivating
  them to adopt healthier eating habits are keys to preventing cancer.

    There is extensive evidence that eating fruits and vegetables protects against cancer, a
    conclusion that both the National Cancer Institute and the American Cancer Society
    support. The evidence is most conclusive in suggesting that fruits and vegetables
    protect against cancers of the mouth and pharynx, esophagus, lung, and stomach, and
    that vegetables protect against cancers of the colon and rectum. People who consume
    at least five servings of fruits and vegetables a day are about one-half as likely to
    develop cancer as people who consume only one or two servings a day. The specific
    evidence of a dose response, in which increasing intake confers increasing protection
    in a graded manner, adds to the strength of the case for eating fruits and vegetables.79



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    For more than ten years, many states (although not Minnesota) have successfully
    implemented programs to increase the consumption of fruits and vegetables. The
    5 A Day for Better Health program — sponsored nationally by the Centers for
    Disease Control, the National Cancer Institute, and the Produce for Better Health
    Coalition, a collaborative of produce manufacturers and retailers — has increased
    produce consumption in several states. Blue Cross will support community groups in
    projects to promote fruit and vegetable consumption on the local level. Through
    grocers, restaurants and other partners, this program will provide consistent messages
    and information to consumers.

    Community projects could be modeled after successful efforts like The Black
    Churches United for Better Health project of North Carolina. In the North Carolina
    project, churches in African-American communities received tailored 5 A Day
    messages, educational sessions and encouragement to increase fruit and vegetable
    consumption at church meals. Local grocery stores held recipe contests and
    encouraged people to plant victory gardens and establish food cooperatives. Local
    health department and cooperative extension staff assisted in implementing these
    efforts. The project resulted in a significant increase in fruit and vegetable
    consumption in these communities.80

    Other projects could be directed at worksites, to support community groups or
    employers who implement worksite nutrition programs. One model is the Treatwell
    5 A Day Worksite Nutrition Intervention in Massachusetts. The project used a variety
    of educational techniques to help employees improve their diet. The project produced
                                                                                81
    a significant increase in fruit and vegetable consumption among employees.

    Collaboration will be a key feature of these community projects, and the funded
    entities will be expected to work with both public and private sector organizations.
    Collaboration with national partners will enable Minnesotans to use existing
    educational materials when appropriate.

Î Save Your Skin: Skin Cancer Prevention
  Skin cancer is the most common form of cancer in the United States. In 2001 alone,
  skin cancer will claim the lives of almost 9,800 people. The good news, as U.S.
  Surgeon General Dr. David Satcher puts it, is that “Skin cancer can be prevented. The
  challenge lies in changing the attitudes and behaviors that increase a person’s risk of
  developing skin cancer.”82

    No wide-scale effort currently provides Minnesotans with potentially lifesaving
    information and resources. Minnesotans may not know what science has proven to be
    effective in raising awareness of skin cancer risks and what simple actions people of
    all ages can take to reduce their risks.

    Exposure to the sun's ultraviolet (UV) rays appears to be the most important factor in
    the development of skin cancer. Skin cancer is largely preventable when sun



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    protection measures are consistently used. Approximately 70 percent of American
    adults, however, do not protect themselves from the sun's dangerous rays.

    These facts highlight the need for educating children and adults about the preventive
    measures they can take to reduce or avoid UV exposure. Research suggests that
    healthy behavior patterns established in early childhood can influence future behavior
    and sometimes set lifetime patterns. Parents, health care providers, and community
    organizations can play a major role in reinforcing sun protection behaviors, such as
    staying out of direct sunlight or timing outdoor activities for hours when UV light is
    less intense. They can also help change attitudes about exposure to the sun, such as
    the prevailing attitude that a person looks more attractive with a tan.83

    Given the importance of skin cancer, the fact that it is largely preventable, and the gap
    between what is currently being done in the state and what could be done, Blue Cross
    will launch a community funding and clinical outreach effort to improve
    Minnesotans’ sun-protection behaviors and help prevent skin cancer. Eligible entities
    and community partners will include clinics, community and voluntary health
    organizations, citizen groups, outdoor sports and recreation groups, and other
    organizations.


C. Preventing and Detecting Cancer in High-Risk Populations

In Minnesota, cancer death rates are significantly higher for non-whites than for whites.
While overall cancer incidence rates are similar for whites and non-whites, racial and
ethnic disparities in incidence exist for certain cancers for which prevention or early
detection can make a difference.84

Initiatives to eliminate these disparities by raising awareness, building local expertise,
and increasing screening will move Minnesota toward a higher standard of health for all
of its people.

Î Community Action to Reduce Cancer Disparities: Assessment and Outreach
  Blue Cross will work to reduce the prevalence of cancer among communities of color
  by collaborating with community networks, community health clinics, the Minnesota
  Department of Health’s Office of Minority Health, local health departments,
  voluntary health organizations, and other interested groups. Instead of going to
  communities with a predetermined set of problems or solutions, we will work with
  community-based partners to jointly assess community needs and jointly determine
  which cancer-related priorities should be tackled and how best to address those
  priorities.

    Blue Cross will fund a series of efforts to support:

    •   Community needs assessments or surveys to identify priorities and existing
        resources and inform the development of local action plans


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    •   Involvement of community leaders, community groups, and minority-owned
        media to organize community health forums which highlight next steps needed to
        address the disparities in cancer
    •   Culturally and linguistically appropriate health education materials that fill
        identified gaps and meet community information needs

Î Reducing Barriers to Prevention and Early Detection
  In addition to surveying community needs, providing culturally relevant educational
  materials, and developing local action plans, there is a need to actively address
  barriers to prevention and early detection.

    There are a number of promising strategies for improving the rates at which high-risk
    groups get important cancer screening tests and follow medical advice to obtain
    additional tests as needed. One example is telephone-based counseling, which has
    been shown to enhance adherence following abnormal Pap smears among low-income
    minority women. Tailored phone prompts and physician reminders are also promising
    strategies for increasing mammography rates.

    To address the gaps in prevention and early detection, Blue Cross will work with
    community, scientific, and other partners to design, implement, and evaluate
    innovative and science-based solutions.


D. Cancer-Related Public Awareness

While Minnesotans have access to a number of no- or low-cost cancer screening
programs, there is currently no broad-based campaign to raise public awareness of cancer
risks nor a sufficiently funded and aggressive campaign to motivate individuals or the
population toward cancer-preventing behaviors. To supplement community and clinical
programs, we will conduct several different cancer-prevention and early-detection
campaigns. As with other cancer prevention activities, these awareness-raising campaigns
will help increase cancer screening rates and reduce behaviors that can cause cancer.
Collaboration with leading public and private agencies and consortia will be a
cornerstone of these efforts. These campaigns will have three purposes:

•   To increase awareness of the risk of cancer
•   To provide information about ways to prevent cancer
•   To encourage the use of cancer-prevention and early-detection services and programs

Cancer prevention and early detection awareness campaigns have been used effectively in
other states to improve diet and to increase breast cancer screening rates. When combined
with effective screening programs and community education efforts, awareness
campaigns can help reduce cancer rates.




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Î Statewide and Targeted Awareness Campaigns for Cancer Screening
  A number of smaller-scale efforts exist to raise public awareness of cancer risks and
  screening options. However, lack of significant or sustained funding hampers many of
  these efforts. The work of committed health experts to raise awareness of colorectal
  cancer, for instance, could reach far more people with its message that the cancer is
  “preventable, treatable, and beatable” if the campaign were supported by additional
  resources.

    Blue Cross will work with statewide leaders in cancer prevention and early detection
    to identify the gaps in cancer communications and to develop and financially support
    efforts to fill those gaps.

    A unified campaign focusing on the risk factors that underlie many leading cancers
    will be developed in collaboration with existing consortia, building on their expertise
    and maximizing the effectiveness of resources. In addition to emphasizing risk
    factors, the public awareness campaign will describe the available screening options
    and will motivate people to take advantage of them.

    The campaigns will include both statewide communications and more local and
    targeted communications. Messages will reach out to high-risk groups in language
    and content that is culturally relevant. Partnerships with community organizations
    representing these high-risk groups will be at the center of the targeted campaigns.

Î Statewide Nutrition Media Campaign
  As discussed earlier in this section, cancer and nutrition are closely linked. Concrete
  evidence exists that dietary changes do substantially reduce the risk of certain cancers.
  Blue Cross will support a statewide 5 A Day nutrition education campaign aimed at
  establishing healthier eating habits among the general population and among high-
  risk families and diverse racial and ethnic populations. The specific focus of the
  campaign is to increase consumption of fruits and vegetables to a minimum of five
  servings per day.

    A broad array of communication channels will be used, including TV, radio,
    newspapers and point-of-purchase advertising. The campaign will use proven
    approaches to behavioral change that apply marketing principles and techniques to
    health issues. The campaign also will include carefully designed, culturally
    appropriate messages, educational and promotional materials, multimedia and
    advertising, all designed to influence behavior and change attitudes about the value of
    healthy eating.

Î Statewide Cancer Prevention Partnership
  Many different organizations are now involved in cancer prevention and early
  detection, and many more may become involved in these new efforts. In order to
  coordinate these activities throughout the state, we will support a partnership between
  all participating organizations. Through regular meetings and frequent
  communications between organizations, we can make these cancer prevention and


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    early detection activities both efficient and more effective. Blue Cross will support
    this work by providing funds to an organization that can work effectively with all
    interested parties throughout the state.




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Section 5. Management, Evaluation and Budget

A. Accountability and Stewardship

Science Council
Blue Cross will convene a scientific council to guide program design and evaluation. The
council will have eight to 10 nationally recognized experts in tobacco reduction, heart
disease prevention and cancer prevention. The Science Council will meet regularly and
will bring a national perspective and external scientific oversight to Investment in
Prevention. The council will:

•   Assure links to state-of-the-art health behavior change programs
•   Validate measurement strategies
•   Provide advice on identifying, designing, and implementing programs
•   Oversee and champion dissemination strategies

Annual reporting
Blue Cross is committed to sharing information about Investment in Prevention with both
regulators and the public. We are committed to developing knowledge, communicating
innovations, and building the science base.

Blue Cross will issue an annual report to the public and to the Department of Commerce,
detailing the use of the funds, providing an overview of ongoing programs and programs
under development, and describing both process and outcome evaluations.

Financial management and regulatory oversight
Blue Cross currently has the necessary policies and procedures to ensure that the tobacco
proceeds are appropriately accounted for and managed. We will manage this as a distinct
pool of funds. As a regulated company and a company that services multiple local and
national government programs (for example, MinnesotaCare, Minnesota Comprehensive
Health Association, Medicare), Blue Cross has in place the necessary internal accounting
systems controls and management reporting mechanisms to manage a distinct pool of
funds such as the tobacco proceeds and associated expenses. We anticipate that the
Minnesota Department of Commerce will review expenditures within its regulatory
jurisdiction, as it does for all other Blue Cross programs.

Blue Cross considers all of its proposed expenditures for the prevention programs
described in this plan to be ordinary and necessary business expenses directly related to
its statutory purpose and mission of helping to improve the health of Minnesotans.

Blue Cross is mindful that its first duty is its obligation to pay the covered claims of its
policyholders. Therefore, Blue Cross retains the right to slow down its expenditures of
these other tobacco proceeds if emergent circumstances arise, such as meeting the
minimum surplus level imposed by statute or the capital requirements imposed by the
Blue Cross and Blue Shield Association.


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Internal management
The Blue Cross and Blue Shield of Minnesota board of trustees will monitor Investment
in Prevention and will authorize any significant changes in its focus. The chief medical
officer, under the direction of the chief executive officer, is responsible for implementing
the plan.

The Center for Tobacco Reduction and Health Improvement is the primary department
within the company that will develop, implement, and evaluate the health improvement
programs. The Center will also be responsible for coordinating programs with external
statewide partners to assure synergy and avoid wasteful duplication.

The Center, formed in 1998 following Blue Cross’ historic settlement against the tobacco
industry, now has a team of medical, public health and health services research
professionals dedicated to improving health. In the past two years the Center has won
three national awards for program excellence.


B. Measuring Our Progress, Sharing Our Results

Blue Cross is committed to rigorous evaluation of our program and projects, and to the
public and scientific sharing of those results. Our evaluation effort comprises three
elements:

•   Comprehensive program evaluation
•   Project-level evaluations
•   Sharing results and lessons learned

Comprehensive Program Evaluation
Over the next ten years, the comprehensive program evaluation effort will be structured
to answer three basic questions in the areas of tobacco reduction, heart disease
prevention, and cancer prevention:

•   Did Minnesotans’ knowledge, attitudes, and behavior change?
•   Did the Blue Cross programs contribute to these changes?
•   What was the return on investment from these programs?

Blue Cross will answer these questions using rigorous research designs and multiple data
sources. Based on input from the Science Council and others, the methods may include
cross-sectional and cohort surveys, using appropriate control groups whenever feasible.
Data sources will include primary data from surveys and medical records, and secondary
data from a variety of sources, including Blue Cross administrative claims data and vital
statistics data maintained by the Minnesota Department of Health and other public
agencies.

We will measure the effect of our programs on the attitudes and behaviors of adult
Minnesotans and of health care practitioners. Our measurement strategies will include

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documentation of changes in adult Minnesotans’ knowledge and awareness of tobacco
use and cardiovascular and cancer risk factors, and the rate of discovery and control of
these risk factors among adults.

Project-level Evaluation
Each of the major initiatives within Investment in Prevention will be assessed for impact.
Each will have its own set of evaluation questions and its own measurements taken at
baseline and follow-up whenever possible. For example, a physician survey and series of
clinic visits will determine the extent to which physicians and other clinicians have
implemented tobacco-reduction practice guidelines in their practices.

Sharing Results
Blue Cross is committed to sharing the results of our research and evaluation projects.
We will continue to share our findings, best practices, and lessons learned from all three
areas of the comprehensive program. In addition to the annual public reporting described
earlier, we will give national and local conference presentations, publish scientific journal
articles, and write collaborative research reports for use by the general public.

This commitment to dissemination is already evidenced by the reports we have written
and published with the Minnesota Partnership for Action Against Tobacco, the Minnesota
Department of Health, and the Minnesota Smoke-Free Coalition. These reports include
“Secondhand Smoke: Knowledge Attitudes and Behaviors of Minnesotans” and “Quitting
Smoking: Nicotine Addiction in Minnesota.” In addition to these collaborative reports,
Blue Cross will author its own new series of reports on its unique data or program
evaluation results.


C. Calculating the Available Funds

As noted in Blue Cross’ Plan of Action, the sum of the tobacco investments and the
present value of future payments from the tobacco industry, less payments previously
approved by the Commissioner, is approximately $439 million, as of August 31, 2001. Of
this amount, Blue Cross has reserved approximately $60 million for taxes and the Plan of
Action spends another $160 million on designated programs.

By spending $160 million on the Plan of Action, Blue Cross’ taxes will be reduced by
approximately 20 percent of that amount. Blue Cross intends to apply this tax benefit to
the Investment in Prevention programs, thereby increasing the available amount of money
to approximately $252 million. Blue Cross will invest these proceeds, as provided under
applicable law, and will apply any investment income to the Investment in Prevention
programs. As provided in the August 1998 Consent Order, Blue Cross is permitted to
begin the Investment in Prevention program upon the Commissioner’s approval of the
Plan of Action. The actual amount available for these programs will be subject to a
number of factors. For instance, investment performance and tax law changes could have
a significant impact on the amount of funds available for use.



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D. Budget Summary

Blue Cross has allocated $252 million to the Investment in Prevention. This represents
the full amount of the tobacco settlement received by Blue Cross plus investment
earnings, minus the sum of 1) taxes, 2) payments to be made to reduce Blue Cross’ excess
surplus (see “Plan of Action for Blue Cross and Blue Shield of Minnesota’s Excess
Surplus, November 2001”), and 3) a $21 million contribution to the Blue Cross and Blue
Shield of Minnesota Foundation made in 1998 with the approval of the Commissioner of
Commerce.

Blue Cross intends to invest this amount in the initiatives described in this plan over at
least the next 10 years. The total amount spent will far exceed $252 million because Blue
Cross will reinvest the investment earnings and tax benefits on this amount in additional
program spending. While the actual amount spent will depend on investment
performance, timing of spending and tax considerations, the projected total spending
exceeds $375 million. The vast majority of these funds will be directed to all
Minnesotans. Over the 10 years, only $15 million is directed exclusively toward Blue
Cross members, via the BluePrint for Health stop-smoking program.

Investment in Prevention will make comparable-sized investments in tobacco use, heart
disease and cancer over the life of the program (Chart 1.) For projected annual spending
by topic, see Chart 2 below.


                           Chart 1. Total Spending by Topic


                     Cancer
                      31%                                        Tobacco
                                                                  38%




                              Heart disease
                                 31%




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                                    Chart 2. Annual Spending by Health Category


     Dollars, in millions   40
                            35
                            30
                            25
                            20
                            15
                            10
                             5
                             0
                                 2002      2004        2006     2008           2010

                                                Tobacco       Heart      Cancer

                                      Estimated Expenses
As described above, Investment in Prevention will devote money to clinical interventions,
local activities, high-risk populations, and public awareness, with particular emphasis on
local activities, as illustrated in Chart 3 below. The level of spending in each category
does not reflect the relative importance of that category, but simply the cost of
accomplishing the planned projects.



                                        Chart 3. Spending by Type of Program

                                          High risk                      Clinical
                                         populations                  interventions
                                            19%                           17%




                                                                                Public
                                                                               awareness
                                                                                 26%

                                          Local
                                         activities
                                           38%



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Through August 2001, Blue Cross has spent approximately $11.4 million of its normal
operating funds to prepare for the Investment in Prevention. The majority of these funds
have been devoted to programmatic activities such as the establishment of the Center for
Tobacco Reduction and Health Improvement; development and implementation of the
telephone counseling program referenced under the Tobacco Reduction section of the
plan; and funding of the Institute for Clinical Systems Improvement, a key partner in the
clinical interventions envisioned by the plan. A portion of the funds have been devoted to
non-programmatic activities as well; for example, legal costs associated with filing and
defending Plans of Action submitted to the Commerce Department. Blue Cross intends to
reimburse its operating fund for these expenditures.

Finally, Blue Cross will incur costs to administer its proposed “Plan of Action for Blue
Cross and Blue Shield of Minnesota’s Excess Surplus,” by which it distributes excess
surplus amounts due to the tobacco settlement. Blue Cross will pay for these
administrative costs out of the Investment in Prevention funds. Most of the administrative
costs will arise due to the refund program proposed under the plan, and are expected to
total up to $3 million.

Notwithstanding the funds devoted to reimbursement of past expenditures and Plan of
Action administrative costs, significant funds will be available to fund programs to
reduce tobacco use, and prevent heart disease and cancer. By addressing these three most
deadly and costly diseases, the Investment in Prevention will truly make a healthy
difference in people’s lives.


E. Impact on Competition in the Minnesota Health Care Market

Blue Cross does not believe that the Investment in Prevention program should be subject
to any market analysis because the program is entirely paid by non-excess-surplus funds.
Nonetheless, Blue Cross has designed the Investment in Prevention so that it will not
significantly affect competition in the Minnesota health care market. Competition can
only be harmed if all of the following are present: Blue Cross is able to obtain a dominant
share of the market; Blue Cross can prevent its existing competitors from expanding their
business in the future; and Blue Cross can prevent new competitors from entering the
market.

Blue Cross’ programs do not have this effect. The Plan of Action spends $160 million in
a manner that has little (if any) market impact. Of this amount, $100 million will be
directed to all Minnesotans, and $60 million will be directed to an excess surplus refund.
Because the refund is based on past enrollment, it cannot affect future enrollment
decisions. The Investment in Prevention similarly provides benefits to all Minnesotans,
with only a small portion directed to Blue Cross members. The one designated program
directed solely to Blue Cross members will not have a significant impact on premiums
and will not enable Blue Cross to obtain a dominant market share or prevent future
competition.



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F. Conclusion

Ten years from now, Investment in Prevention will have improved the health of
Minnesotans by significantly decreasing the prevalence of tobacco use, decreasing the
prevalence of the risk factors for heart disease and cancer, and increasing the rates of
early detection of cancers.

Ten years from now, all Minnesotans will have benefited from Investment in Prevention.
The health and financial dividends will have reached deeply into Minnesota communities,
across all age, geographic, economic and other sectors. More people of all ages will have
quit smoking. Others will never have started. All Minnesotans will enjoy greater access to
smoke-free workplaces and public spaces. Individuals, families, and whole communities
will be informed and motivated to take action to improve their health. Healthy and
appealing nutritional and exercise options will be the norm, not the exception, in many
communities. People across Minnesota will understand and act on the need to get
appropriate screening tests to detect cancers. The gaps in health status between
Minnesota’s different racial and ethnic groups will have significantly decreased and will
be progressing toward outright elimination.

Success of this sort does not come easily. An effective, comprehensive health
improvement plan requires time, significant human and financial resources, and a deep
commitment to staying the course.

Using science-based approaches, in partnership with like-minded organizations and
individuals, and inspired by a vision for the future, Blue Cross and Blue Shield of
Minnesota, through Investment in Prevention, will make a healthy difference in
Minnesota throughout the next decade and beyond.




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Section 6. Endnotes

Executive Summary
1
  U.S. Department of Health and Human Services. Reducing Health Consequences of
Smoking: 25 Years of Progress. A Report of the Surgeon General. U.S. Department of
Health and Human Services, Public Health Service, Centers for Disease Control, Center for
Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS
Publication No. (CDC) 89-8411, 1989.
2
 Centers for Disease Control and Prevention. National Center for Chronic Disease
Prevention and Health Promotion. About Cardiovascular Disease (fact sheet). 2001.
3
 Minnesota Department of Health. Healthy Minnesotans Public Health Improvement Goals
2004—September 1998. St. Paul MN.
4
    Minnesota Department of Health. Minnesota Health Statistics 1999—February, 2001.
5
 Minnesota Department of Health. Healthy Minnesotans Public Health Improvement Goals
2004—September 1998. St. Paul MN.
6
 Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco
Control Programs—August 1999. Atlanta GA: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health, August 1999.
7
  Puska P, Vartiainen E et al. Changes in Premature Deaths in Finland: Successful Long-
term Prevention of Cardiovascular Diseases. Bulletin of the World Health Organization.
76(14) (1998):419.
8
    Federal Trade Commission. Report to Congress. Cigarette Report for 1999. Issued: 2001.
9
 Centers for Disease Control and Prevention. Chronic Disease Prevention. Revised final FY
1999 Performance Plan and FY 2000 Performance Plan. Centers for Disease Control and
Prevention.
10
  Centers for Disease Control and Prevention. Medical-Care Expenditures Attributable to
Cigarette Smoking -- United States, 1993. Morbidity and Mortality Weekly Report. July 08,
1994 / 43(26);469-472.
11
  Fries JF, Koop CE, et al. Reducing Health Care Costs by Reducing the Need and Demand
for Medical Services. The New England Journal of Medicine. 329:5 (1993):321-325.

Section 1. Introduction
12
   U.S. Department of Health and Human Services. Reducing Health Consequences of
Smoking: 25 Years of Progress. A Report of the Surgeon General. U.S. Department of
Health and Human Services, Public Health Service, Centers for Disease Control, Center


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for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
DHHS Publication No. (CDC) 89-8411, 1989.
13
 Puska P, Vartiainen E et al. Changes in Premature Deaths in Finland: Successful
Long-term Prevention of Cardiovascular Diseases. Bulletin of the World Health
Organization. 76(14) (1998):419.
14
 McGinnis JM, Foege WH. Actual Causes of Death in the United States. Journal of the
American Medical Association 270 (1993): 2207-12.
15
 Minnesota Department of Health. Healthy Minnesotans Public Health Improvement
Goals 2004—September 1998. St. Paul MN.
16
  US Department of Health and Human Services. Reducing Health Consequences of
Smoking: 25 Years of Progress. A Report of the Surgeon General. U.S. Department of
Health and Human Services, Public Health Service, Centers for Disease Control, Center
for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
DHHS Publication No. (CDC) 89-8411, 1989.
17
  National Cancer Institute. Health Effects of Exposure to Environmental Tobacco
Smoke: The Report of the California Environmental Protection Agency. Smoking and
Tobacco Control Monograph no. 10. Bethesda, MD U.S. Department of Health and
Human Services, National Institutes of Health, National Cancer Institute, NIH Pub. No.
99-4645, 1999.
18
  Siegel, M. Involuntary Smoking in the Restaurant Workplace: A Review of Employee
Exposure and Health Effects. Journal of the American Medical Association. 270 (4):
(1993): 490-493.
19
  Centers for Disease Control and Prevention. National Center for Chronic Disease
Prevention and Health Promotion. About Cardiovascular Disease (fact sheet). 2001.
20
 Minnesota Department of Health. Healthy Minnesotans Public Health Improvement
Goals 2004—September 1998. St. Paul MN.
21
     Blue Cross and Blue Shield of Minnesota. Health in Minnesota. September 1999.
22
     Minnesota Department of Health. Minnesota Health Statistics 1999—February, 2001.
23
 Minnesota Department of Health. Healthy Minnesotans Public Health Improvement
Goals 2004—September 1998. St. Paul MN.
24
  Centers for Disease Control and Prevention. Chronic Disease Prevention. Revised final FY
1999 Performance Plan and FY 2000 Performance Plan. Centers for Disease Control and
Prevention.
25
     Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical

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November 8, 2001                                                 Investment in Prevention



Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public
Health Service. 2000.
26
  Centers for Disease Control and Prevention. Medical-Care Expenditures Attributable to
Cigarette Smoking -- United States, 1993. Morbidity and Mortality Weekly Report. July
08, 1994 / 43(26);469-472.
27
  U.S. Department of Health and Human Services. Smoking and Health in the Americas.
Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service,
Centers for Disease Control, National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 1992; DHHS Publication No. (CDC) 92-8419.
28
 Centers for Disease Control and Prevention. Medical-Care Expenditures Attributable to
Cigarette Smoking During Pregnancy -- United States, 1995. Morbidity and Mortality
Weekly Report November 07, 1997 / 46(44);1048-1050.
29
 Warner KE, Smith RJ. Health and Economic Implications of a Work-Site Smoking
Cessation Program: A Simulation Analysis. Journal of Occupational and Environmental
Medicine. 38:10 (1996) 981-992.
30
 Minnesota Department of Health. Healthy Minnesotans Public Health Improvement
Goals 2004—September 1998. St. Paul MN.
31
     American Heart Association. 2001 Heart and Stroke Statistical Update. 2001.
32
 Blue Cross and Blue Shield of Minnesota. Special Projects Department. Internal
Report. 1999.
33
  Daviglus ML, Liu K, Benefit of a Favorable Cardiovascular Risk-Factor Profile in
Middle Age with Respect to Medicare Costs. The New England Journal of Medicine.
339:16 (1998): 1122-1129.
34
     American Cancer Society. Cancer Facts and Figures 2001.
35
  Fries JF, Koop CE, et al. Reducing Health Care Costs by Reducing the Need and
Demand for Medical Services. The New England Journal of Medicine. 329:5 (1993):321-
325.
36
     Minnesota Department of Health. Strategies for Public Health. October 1998.
37
  Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco
Control Programs — August 1999. Atlanta GA: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health, August 1999.




Blue Cross and Blue Shield of Minnesota                                                     57
November 8, 2001                                                 Investment in Prevention



Section 2. Investment in Prevention: Tobacco Reduction
38
   Centers for Disease Control and Prevention. State Tobacco Control Highlights—1999.
Atlanta GA: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 1999.
39
  Leistikow BN, Martin DC, et al. Estimates Of Smoking-Attributable Deaths at Ages 15-
54, Motherless or Fatherless Youths, and Resulting Social Security Costs in the United
States in 1994. Preventive Medicine 30(5) (2000):353-60.
40
 Centers for Disease Control and Prevention. Treating Tobacco Use and Dependence.
Fact Sheet. June 2000. U.S. Public Health Service.
41
  Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco
Control Programs—August 1999. Atlanta GA: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health, August 1999.
42
 Federal Trade Commission. Report to Congress. Cigarette Report for 1999. Issued:
2001.
43
  Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco
Control Programs—August 1999. Atlanta GA: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health, August 1999.
44
  National Institutes of Health. Strategies to Control Tobacco Use in the United States: A
Blueprint for Public Health Action in the 1990’s. U.S. Department of Health and Human
Services, Public Health Service, National Institutes of Health, National Cancer Institute. NIH
Publication No. 92-3316, October 1991.
45
  Institute of Medicine. State Programs Can Reduce Tobacco Use. National Academy of
Science. National Cancer Policy Board. Institute of Medicine. National Research Council.
2000.
46
  Centers for Disease Control and Prevention. Declines in Lung Cancer Rates--
California, 1988--1997. Morbidity and Mortality Weekly Report. December 01, 2000.
49(47);1066-9.
47
 Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence.
Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human
Services. Public Health Service. 2000.
48
 Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco
Control Programs—August 1999. Atlanta GA: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center for Chronic


Blue Cross and Blue Shield of Minnesota                                                     58
November 8, 2001                                              Investment in Prevention



Disease Prevention and Health Promotion, Office on Smoking and Health, August 1999.
49
 Blue Cross and Blue Shield of Minnesota, Minnesota Department of Health, Minnesota
Partnership for Action Against Tobacco. Quitting Smoking: Nicotine Addiction in
Minnesota. July 2001.
50
 Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco
Control Programs—August 1999. Atlanta GA: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion, Office on Smoking and Health, August 1999.
51
 Hyland A, Cummings KM, & Nauenberg E. Analysis of Taxable Sales Receipts: Was
New York City’s Smoke-Free Air Act Bad for Restaurant Business? Journal of Public
Health Management Practices 5:1 (1999): 14–21.
52
 Blue Cross and Blue Shield of Minnesota, Minnesota Department of Health, Minnesota
Partnership for Action Against Tobacco, Minnesota Smoke-Free Coalition. Secondhand
Smoke: Knowledge, Attitudes, and Behaviors of Minnesotans. November 2000.
53
 Shopland DR, Gerlach KK, et al. State-Specific Trends in Smoke-Free Workplace
Policy Coverage: The Current Population Survey Tobacco Use Supplement, 1993 to
1999. Journal of Occupational and Environmental Medicine. 43 (2001):680-686.
54
 Blue Cross and Blue Shield of Minnesota, Minnesota Department of Health, Minnesota
Partnership for Action Against Tobacco. Quitting Smoking: Nicotine Addiction in
Minnesota. July 2001.
55
 Minnesota Department of Health. Healthy Minnesotans Public Health Improvement
Goals 2004—September 1998. St. Paul MN.
56
 Blue Cross and Blue Shield of Minnesota, Minnesota Department of Health, Minnesota
Partnership for Action Against Tobacco. Quitting Smoking: Nicotine Addiction in
Minnesota. July 2001.
57
 Minnesota Department of Health, Center for Health Statistics. Teens and Tobacco in
Minnesota: Results from the Minnesota Youth Tobacco Survey. August 2000.
58
 Blue Cross and Blue Shield of Minnesota, Minnesota Department of Health, Minnesota
Partnership for Action Against Tobacco. Quitting Smoking: Nicotine Addiction in
Minnesota. July 2001.
59
  Gay and Lesbian Medical Association. Healthy People 2010: Lesbian, Gay, Bisexual
and Transgender Health. 352-375.
60
 Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco
Control Programs—August 1999. Atlanta GA: U.S. Department of Health and Human


Blue Cross and Blue Shield of Minnesota                                                  59
November 8, 2001                                                 Investment in Prevention



Services, Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health, August 1999.
61
  Centers for Disease Control and Prevention. Tobacco Use Among Middle and High
School Students, Florida. 1998-1999. Morbidity and Mortality Weekly Report. April 2,
1999. 48(12);248-253.
62
 Federal Trade Commission. Report to Congress. Cigarette Report for 1999. Issued:
2001.
63
 Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco
Control Programs—August 1999. Atlanta GA: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion, Office on Smoking and Health, August 1999.
64
  Ehlinger E. Tobacco Use Among College Students (citing Core Alcohol and Drug
Survey findings). Healthy Generations. Maternal and Child Health, Division of
Epidemiology, School of Public Health, University of Minnesota. 1(1): 2000.
65
 Ehlinger E. Tobacco Use Among College Students. Healthy Generations. Maternal and
Child Health, Division of Epidemiology, School of Public Health, University of
Minnesota. 1(1): 2000.

Section 3. Investment in Prevention: Heart Disease
66
   National Institutes of Health. Consensus Development Panel on Physical Activity and
Cardiovascular Health. Physical Activity and Cardiovascular Health. Journal of the
American Medical Association. 266:3 (1996): 241-246.
67
 Krauss NA, Machlin S, Kass BL. Use of Healthcare Services, 1996. Rockville (MD):
Agency for Healthcare Policy and Research: 1999. MEPS Research Findings No. 7.
AHCPR Pub. No. 99-0018.
68
 National Institutes of Health, National Heart Lung and Blood Institute, National
Cholesterol Education Program. Third Report of the Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults.
69
  Centers for Disease Control and Prevention. National Center for Chronic Disease
Prevention and Health Promotion. Division of Physical Activity and Nutrition. Kids Walk
to School. A Guide to Promote Walking to School. 2000.
70
 Minnesota Department of Health. Eliminating Health Disparities: Cardiovascular
Disease (fact sheet). March 2001.
71
     Ibid.
72
     Ornish D, Scherwitz LW, Intensive Lifestyle Changes for Reversal of Coronary Heart


Blue Cross and Blue Shield of Minnesota                                                     60
November 8, 2001                                               Investment in Prevention



Disease. Journal of the American Medical Association. 280:23 (1998): 2001-7.
73
  Robertson, RM. Women and Cardiovascular Disease: The Risks of Misperception and
the Need for Action. Circulation 103(2001):2318-2320.
74
 Bauman AE, Bellew B, et al. Impact of an Australian Mass Media Campaign Targeting
Physical Activity in 1998. American Journal of Preventive Medicine 21(1) (2001):41-7.
75
 Foerster SB, Kizer KW, et al. California's "5 A Day — For Better Health!" Campaign:
An Innovative Population-Based Effort to Effect Large-Scale Dietary Change. American
Journal of Preventive Medicine 11(2),(1995): 124-31.
76
 National Institutes of Health. The Sixth Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National
Heart, Lung, and Blood Institutes. National High Blood Pressure Education Program.
NIH Publication No. 98-4080. November 1997.

Section 4. Investment in Prevention: Cancer
77
   Minnesota Department of Health. Cancer in Minnesota: Racial and Ethnic Disparities.
A Report on Cancers for Which Prevention or Early Detection Can Make a Difference.
October 2001.
78
  Minnesota Department of Health. Cancer Control Section. Programs and Projects of
the Cancer Control Section (fact sheet). 2001.
79
 World Cancer Research Fund and the American Institute for Cancer Research. Food,
Nutrition and the Prevention of Cancer: A Global Perspective. Washington, DC:
American Institute for Cancer Research; 1997.
80
 McClelland JW, Demark-Wahnefried W, et al. Fruit and Vegetable Consumption of
Rural African Americans: Baseline Survey Results of the Black Churches United for
Better Health 5 A Day Project. Nutrition and Cancer 30:2 (1998):148-57.
81
 Sorensen G, Stoddard A, et al. Increasing Fruit and Vegetable Consumption Through
Worksites and Families in the Treatwell 5-a-Day Study. American Journal of Public
Health. 89 (1999):54-60.
82
 Centers for Disease Control and Prevention. National Skin Cancer Prevention
Education Program (fact sheet). 2001.
83
     Ibid.
84
  Minnesota Department of Health. Cancer in Minnesota: Racial and Ethnic Disparities.
A Report on Cancers for Which Prevention or Early Detection Can Make a Difference.
October 2001.



Blue Cross and Blue Shield of Minnesota                                                   61

				
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