Beyond Health Insurance: Public Policy to Improve Health: Volume 19

Kevin Fiscella notes that, to date, progress in eliminating racial disparities has been slow. He calls for a comprehensive approach that goes beyond the narrow focus of current policy. Given the association between education and health, he advocates greater investments in early childhood education. In light of its broad geographic and demographic reach and role in preventing or delaying the onset of chronic disease, he also proposes to strengthen the delivery of primary care through the network of Federally Qualified Community Health Centers (FQHCs).

Purpose: We estimate national health expenditures on prevention using precise definitions, a transparent methodology, and a subdivision of the estimates into components to aid researchers in applying their own concepts of prevention activities.

Methodology/Approach: We supplemented the National Health Expenditure Accounts (NHEA) with additional data to identify national spending on primary and secondary prevention for each year from 1996 to 2004 across eight spending categories.

Findings: We estimate that NHEA expenditures devoted to prevention grew from $83.2 billion in 1996 to $159.8 billion in 2004, in current dollars. As a share of NHEA, this represents an increase from 7.8 percent in 1996 to 8.6 percent in 2004. This share peaked at 9 percent in 2002 and then declined due to reductions in public health spending as a percent of NHEA between 2002 and 2004. Primary prevention represents about half the expenditures, consisting largely of public health expenditures – the largest prevention element.

Originality/Value of Paper: Our 2004 estimate that 8.6 percent of NHEA goes to prevention is nearly three times as large as the commonly cited figure of 3 percent, but depends on the definitions used: our estimate falls to 8.1 percent when the research component is excluded, 5.1 percent when consideration is limited to primary prevention plus screening, 4.2 percent for primary prevention alone, and 2.8 percent if we count only public health expenditures. These findings should contribute to a more informed discussion of our nation's allocation of health care resources to prevention.

The second national goal for Healthy People 2010 is the elimination of health disparities related to social disadvantage in the United States. Unfortunately, progress to date has been limited. Our national strategy to achieve this goal has been too narrowly focused on public health. Success will require a broader strategy including alignment of existing national policies in non-health areas that affect the health of the socially disadvantaged such as education, health care, labor, welfare, housing, criminal justice, the environment, and taxation if it is to succeed. Key criteria are needed to begin to prioritize areas for federal investment to achieve this goal. These include the impact of the targeted condition on disparities, evidence base for the intervention, potential impact of the policy on disparities, economic impact, and federal politics. Two “big ideas” offer promise including federal investment in early child education and enhanced primary care within federally qualified community health centers. The proposed criteria are applied to each proposed policy.

We investigate whether information technology (IT) can help physicians more efficiently acquire new knowledge in a clinical environment characterized by information overload. We combine analysis of data from a randomized trial with a theoretical model of the influence that IT has on the acquisition of new medical knowledge. Although the theoretical framework we develop is conventionally microeconomic, the model highlights the non-market and non-pecuniary influence activities that have been emphasized in the sociological literature on technology diffusion. We report three findings. First, empirical evidence and theoretical reasoning suggests that computer-based decision support will speed the diffusion of new medical knowledge when physicians are coping with information overload. Second, spillover effects will likely lead to “underinvestment” in this decision support technology. Third, alternative financing strategies common to new IT, such as the use of marketing dollars to pay for the decision support systems, may lead to undesirable outcomes if physician information overload is sufficiently severe and if there is significant ambiguity in how best to respond to the clinical issues identified by the computer. This is the first paper to analyze empirically and theoretically how computer-based decision support influences the acquisition of new knowledge by physicians.

Health information drives crucial consumer health decisions and plays a central role in healthcare markets. Consumers who are better-informed about smoking, diet, and physical activity make healthier choices outside the healthcare sector (Kenkel, 1991; Ippolito & Mathios, 1990, 1995; Meara, 2001). Better-informed consumers also interact differently with physicians and other healthcare providers (e.g., Cutler, Landrum, & Stewart, 2006). In addition to the immediate consequences for individual consumers, health economists have long recognized that information also has broader implications for principal–agent relationships and the functioning of healthcare markets.¹ More recent lines of research in health economics and medical sociology emphasize the potential role of consumer information in explaining health disparities associated with socioeconomic status (Deaton, 2002; Goldman & Lakdawalla, 2001; Glied & Lleras-Muney, 2003; Link & Phelan, 1995). Both health economists and medical sociologists stress that because of disparities in consumer information, rapid medical progress tends to be accompanied by increased disparities in medical treatment and health outcomes.

The purpose of this paper is to examine the impact of pharmaceutical innovation on the longevity of Australians. The approach utilized involves estimation of difference-in-differences models using longitudinal, disease-level data during the period 1995–2003 to determine whether the diseases that had above-average increases in mean vintage (FDA approval year) of drugs had above-average reductions in mortality. Our findings are that the mean age at death increased more for diseases with larger increases in mean drug vintage. A 5-year increase in mean drug vintage is estimated to increase mean age at death by almost 11 months. The number of years of potential life lost before the ages of 65 and 70 (but not before age 75) was reduced by use of newer drugs. During the period 1995–2003, mean age at death increased by about 2.0 years, from 74.4 to 76.4. The estimates imply that, in the absence of any increase in drug vintage, mean age at death would have increased by only 0.7 years. The increase in drug vintage accounts for about 65% of the total increase in mean age at death. Estimated cost per life-year gained from using newer drugs is $10,585. An estimate by previous investigators of the value of a statistical Australian life-year ($70,618) is 6.7 times as large. We acknowledge potential limitations of this study by discussing several reasons why our estimate of the cost per life-year gained from using newer drugs could be too high or low. The value of this paper's evidence is primarily due to the government's Pharmaceutical Benefits Scheme: Australia has much better data on drug utilization than most other countries.

Several high-profile prescription drugs have been withdrawn from the U.S. market in the last decade, yet there is no direct evidence of how a prescription drug withdrawal affects consumers’ use of remaining drugs within the same therapeutic class. In theory, remaining drugs in the therapeutic class could enjoy competitive benefits or suffer negative spillovers from the withdrawal of a competing drug. Using the Medical Expenditure Panel Survey, we test for spillovers following prescription drug withdrawals in six therapeutic classes between 1997 and 2001. Results vary, but we find stronger evidence of negative spillovers than competitive benefits. We conclude with a discussion of the characteristics of drugs and classes that may influence how remaining drugs are affected by a withdrawal in the class.

The purpose of this paper is to explore consumer thinking about nutrition decisions and how firms can use consumers’ awareness of the links between nutrients and health generated by public health messages to market products, including ones, which have little nutritional value. We approach this issue by tracking the development of public health messages based on scientific research, dissemination of those messages in the popular press, and use of nutrition claims in food advertisements to assess whether firms are timing the use of nutrition claims to take advantage of heuristic-based decision-making. Our findings suggest that the timing of the development of nutrition information, its dissemination in the press, and use in advertising accords well with a heuristic processing model in which firms take advantage of associations between nutrient information and health in their advertisements. However, the demonstrated relationships may not be causal. Further research will be needed to provide stronger and more comprehensive evidence regarding the proposed message hijacking process. If the message hijacking framework is borne out: (1) simple overall health rating scales could significantly improve consumer decision-making, (2) the impact of misleading advertisements could be mitigated by encouraging a multidimensional view of nutrition, and (3) more intensive regulation of product labeling could limit the impact of hijacked messages.

Overall, this paper considers a novel hypothesis about the impact of public health messages on nutrition and health.

Report cards, performance evaluations, and quality assessments continue to penetrate the lexicon of the healthcare sector. The value of report cards is typically couched as enhancing consumerism among patients, increasing accountability among healthcare providers, and more broadly increasing the transparency of healthcare information. This paper discusses the potential benefits and pitfalls of these performance assessments.

This paper briefly reviews empirical evidence regarding the impact of report cards for healthcare providers and synthesizes the role and limitations of these performance measures into distinct evaluation criteria. The rapid proliferation of report cards for healthcare providers suggests a growing need to develop mechanisms and tools to evaluate their impact. The risks associated with utilizing report cards for provider oversight include the deleterious impact on vulnerable populations and a failure to accurately measure quality of care. The capacity to create report cards should not be the sole criterion to develop and utilize report cards to evaluate healthcare providers. Rather, careful consideration of the benefits and risks should accompany the implementation and utilization of report cards into regulatory processes. This report proposes an evaluation checklist by which to assess the role of report cards in a given healthcare context.

An important current trend in health care is the move toward personalized medicine. Personalized medicine includes diagnostic and therapeutic interventions, with risk defined through genetics. The key paradigm shift brought about by the advent of personalized medicine is the increased use of in vitro genomic diagnostics. These tests offer the potential of being able to predict which patients are likely to respond to a particular drug, or which patients are likely to develop adverse reactions to a drug. The focus of this paper is the use of genomic diagnostics, and how the increasing development and translation into clinical practice of diagnostic – drug combination products will be adopted into health care delivery. The meaning of value and how to measure it is considered from different perspectives. A novel framework for evaluating the value of genomic diagnostics is proposed. Finally, the implications for regulatory approval and policy are discussed using an illustrative case study.