Accounting for Health and Health Care Approaches to Measuring the Sources and Costs of Their Improvement (2010) / Chapter Skim
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6 Linking Population Health to the Array of Health Inputs
6 Linking Population Health to the Array of Health Inputs
Pages 143-186
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From page 143... ...
In Chapters 2 and 3, we describe how satellite health accounts might be structured and identify the first steps in their construction -- defining the units of measurement for medical care and estimating economy-wide expenditures on those units. These are tasks that the Bureau of Economic Analysis (BEA)
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From page 144... ...
. It would not only identify, quantify, and value the flow of nonmedical health inputs, such as behavior trends (e.g., diet, risk taking, smoking, consumption of alcohol)
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While data on high blood pressure and other personal risk factors should be collected and presented, attribution is very difficult for a number of reasons -- perhaps one can say that lower hypertension will lead to fewer deaths, but overall mortality is based on many things that occur in the past, present, and future. The problem is most severe when the objective is to attribute outcomes to services or causes; in many cases, the medical linkages are not known or well understood.
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From page 146... ...
, consumption trends, other risk factors, behavioral trends, the environment, etc. Even before these data are inte grated into a health account, such a data clearinghouse would give researchers attempting to link cause and effect a starting place.
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The HUI3 has also been used by the agency to estimate trends in the health impact of various diseases. At the same time, the Canadian Institute for Health Information maintains the National Health Expenditure data base, which tracks annual medical spending in the country (Canadian Institute for Health Information, 2006)
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. However, if the impact on health status is limited, little social value is obtained from these outputs.
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, environmental exposures, and public health measures that transpire outside the medical care setting. While health policy gives some attention to public health issues, it deals little with the social context of life, which can exert profound influences on health (Woolf, 2009)
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6.3.1. Valuing Informal Care and Other Time Costs As emphasized above, a comprehensive health account requires tracking the full range of factors that affect health, even if they do not entail market transactions.
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Indeed, the same study states (Recommendation 6.3) that, ideally, estimates of the value of nonmarket medical care inputs, including time use, ought to be included in national health accounts.
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3 6.3.2. More Boundary Issues for a Health Account When considering the nonmarket and nonmedical contributions to population health, boundary issues (and interaction with market accounts related to other areas of economic activity)
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One con ceptual approach, identified earlier, is to begin with health inputs that are closest to the medical care system, specifically with treatment of diseases, and gradually move outward to the proximate determinants of disease, such as obesity, pollu tion, smoking and tobacco, illegal drugs, and possibly their determinants, such as eating and exercise.
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From page 154... ...
A full accounting is a long way off at this point because only scant data exist that would allow modeling the joint distribution of environmental and other factors. Nonetheless, the goal should be to develop detailed disease models that relate health inputs to outputs and that will allow researchers to infer the value of medical care at the disease level so that, when aggregated, it may be possible to estimate the productivity of medi cal care as a whole (Rosen and Cutler, 2007)
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A potential drawback to the episode-of-care approach is that it may inadvertently make primary care appear inefficient. For example, chronic diseases such as congestive heart failure and diabetes tend to be lifelong, requiring long-term therapy for patients.
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and an episodeof-care output measure will not capture these benefits. The function of the health account will be to make these distinctions -- to determine what aspects of care are leading to improved (or degraded)
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One needs an aggregate framework to account for such global impacts. The development of multidisease policy models is complex, however, and often requires several years of work.
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are attempting to do. Recommendation 6.1: A useful next step in the development of disease modeling for use in national health accounts would be to commission methodologi cal research that develops a common language and frame of reference from which to start.
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6.4.3. Integrated Modeling Efforts Outside the United States For policy purposes, the ultimate goal is to develop an integrated simulation and forecasting model that predicts multiple attributes of health and health care costs for a population based on risk factors, multiple diseases, uptake of medical therapies, and program interventions.
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POHEM has been building and incrementally adding disease-specific microsimulation models to a macro model of pensions and the life cycle. The first microsimulation model was of acute myocardial infarction.
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Continuous risk factors can be of various distributions (normal, lognormal, Weibull) and have risk functions asso
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The microsimulation model accounts for individual and family-level demo graphic, socioeconomic, and health risk factors; progression of health sta tus; chronic diseases; health-related expenditures; and quality of life. It will provide 20-year projections of disease-specific incidences, prevalences, and progression with treatment costs of chronic diseases and comorbidities.
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6.5. TYPES OF HEALTH DATA AND STATISTICS AND CHALLENGES TO THEIR IMPROVEMENT Although significant conceptual work remains to be done in the construction of a framework on which to build national health accounts, the single biggest challenge is to create the data infrastructure -- through new data collection and, perhaps more importantly, coordination of existing sources -- required to support the effort.
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We must develop, articulate, and implement a 21st century vision for health statistics. 7The discussion of data needs in this section is broad; it applies to a general integrated data system and is not specific to analyses of causal relationships between health inputs and health.
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, the National Center for Health Statistics (NCHS) , and others in developing a coordinated health data system.
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the data currently available that would be useful in the construction of national health accounts and for linking expenditures to health, (2) key data challenges to improving that data, (3)
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. In a separate section, information is requested on "other significant conditions contributing to death but not resulting in the underlying cause" (this might include disease risk factors such as smoking or hyperlipidemia)
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The known problems with cause-of-death data as currently collected in the United States are exacerbated when comorbidities are present. Furthermore, cause of death on death certificates is an inherently poor source of data for understanding the excess risk of death due to certain risk factors as many are fre quently underreported.
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Recommendation 6.3: The key data-producing agencies (National Center for Health Statistics, Centers for Medicare & Medicaid Services, and Agency for Healthcare Research and Quality, with coordination from the Bureau of Economic Analysis) should work together to identify gaps in the data coverage of U.S.
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The two agencies should be brought into the health accounts data collection conversations; this should be a relatively easy step as both are already required to provide comparable data for their two agencies. Better data are also needed to monitor progress toward eliminating dispari ties.
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Another option is to combine the power of claims databases (convenience samples) with the representativeness of household surveys (probability samples)
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Because underestimation of disease prevalence is largely an expenditure survey problem only for conditions that rely solely on utilization data for identi fication, the problem can be readily rectified. Recommendation 6.5: Once consensus has been reached on a disease clas sification system for use in the national health accounts and a minimum data set has been specified, existing population survey-based databases should add questions about these diseases in order to more accurately capture population-wide health and expenditure data for the core disease set.
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If claims forms included the "right" information, they would go a long way toward satisfying some health accounting data needs. A lot could be done with claims data for the insured population because of their enormous size and wide coverage.
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Overall, a reasonable strategy for constructing a core data set to underlie national health and medical care accounts would be to identify a currently avail able survey, or combination of surveys, such as MEPS, to serve as the backbone of the data infrastructure, then to use claims information in a supplemental role wherever population or disease coverage gaps appear. Claims data from Medicare and Medicaid would cover large portions of the population.
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Even though various projects are under way and making progress on this front, too few of the connections have been accurately quantified to make these results a focal point for a report on national health accounts. That said, there clearly needs to be a consis tent set of rules to serve as a blueprint for development of the data infrastructure designed for the purpose of, among other things, informing research on the causal factors that affect the population's health.
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From page 176... ...
6.6.1. The Need for a Computerized National Data Infrastructure The United States is a long way off from being able to satisfactorily model population health and health determinants in a systematic way, but a starting point is to begin keeping better track of risk factors, health indicators, and other related data.
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From page 177... ...
Recommendation 6.8: A study should be commissioned by a funding agency (National Institutes of Health or National Science Foundation) to take an inventory of other countries' population health statistics systems, the role played by microsimulation modeling, the implications for longitudinal 13 Currently, only about 17 percent of physicians in the United States use computerized patient records, even though some very large service providers, such as Kaiser Permanente and the Mayo Clinic, do so.
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. The authors estimate that interoperability and health information exchange could lead to $77 billion in savings.
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Budgetary pressures require that current data collection and dissemination procedures be constantly assessed. These trends imply that it is time for the statistical agencies to make stronger efforts to coordinate data collection efforts across surveys and agencies -- which may entail a cultural shift from within -- to invest in the 21st century vision for health statistics.
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From page 180... ...
For example, both Medicare claims data and NDI data can be linked to NHANES, however, access to these linked data sets is difficult, time consuming, and sometimes expensive to obtain. Furthermore, while some progress has been made linking data collected by different government agencies, linkages between private and public data have not yet been accomplished on any meaningful scale.
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From page 181... ...
Even the NHEAs have a 12-month lag until release, limiting their usefulness to policy makers. Furthermore, the lag increases substantially when NHEA-to-microdata linkages are required -- as in the development of the disease-based health accounts discussed in this report.
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6.6.5. Characteristics for a Minimum Data Set In moving forward on development of a national health account, it is essential to identify the ideal data needs to inform policy and then to specify a minimum data set, designed to collect information consistently across all relevant surveys to ensure broad representativeness.
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ICD diagnoses or top 20-30 diseasesd Core set of diseases linkable to utilization data Long-term care Palliative (end of life) care Hospice, Y/N, home/elsewhere Residential care (if included in the Assisted living, retirement homes domain of medical care)
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From page 184... ...
that may affect current and future health and health care spending, potential criteria for the selection of a set of key indicators include • the importance of what is being measured in terms of its impact on health status and health expenditures, the policy relevance, and the susceptibility of the problem to intervention; • the scientific soundness of the measure in terms of its validity, reliability, and evidence base; and • the feasibility and cost of obtaining nationally comparable data for the measure.
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From page 185... ...
That said, it is an achievable goal made all the more possible by the ongoing collaborative efforts of the national data agencies. It is the hope of the panel that our full set of recommendations provides a logical set of building blocks that -- together but implemented separately -- would contribute significantly to a more coherent and policy-responsive system of health statistics.
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From page 186... ...
The Institute of Medicine has proposed new rules that would make health research exempt from HIPAA privacy rules and emphasize data security, transparency, and accountability, regardless of the funding source. The proposed rules would add consistency in regulatory oversight and ensure protec tion of participants.
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