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Congressional Budget Office
Presentation to the National Center for Health Statistics
Peter OrszagDirector
August 11, 2008
Federal Spending Under CBO’s AlternativeFiscal Scenario
Percentage of Gross Domestic Product
1962 1972 1982 1992 2002 2012 2022 2032 2042 2052 2062 2072 2082
0
10
20
30
40
Medicare and Medicaid
Actual Projected
Social Security
Other Spending (Excluding debt service)
Misdiagnosing the Problem
Most discussions in media:
aging and demographics
Most of the fiscal problem:
rising cost per beneficiary
(not number or type of beneficiaries)
Sources of Growth in Projected Federal Spending on Medicare and Medicaid
Percentage of GDP
2007 2022 2037 2052 2067 2082
0
5
10
15
20
Effect of Aging Alone
Interaction
Effect of Excess CostGrowth Alone
Before we all get too depressed…
Embedded in the nation’s centrallong-term fiscal challenge appears to be a substantial opportunity:
Can we reduce health carecosts without impairing healthoutcomes?
Variations Among Academic Medical Centers
UCLA Medical Center
Massachusetts General Hospital
Mayo Clinic(St. Mary’s Hospital)
Biologically Targeted Interventions: Acute Inpatient Care
CMS composite quality score 81.5 85.9 90.4
Care Delivery―and Spending―Among Medicare Patients in Last Six Months of Life
Total Medicare spending 50,522 40,181 26,330
Hospital days 19.2 17.7 12.9
Physician visits 52.1 42.2 23.9
Ratio, medical specialist / primary care 2.9 1.0 1.1
Use of Biologically Targeted Interventions and Care-Delivery Methods Among Three of U.S. News and World Report’s “Honor Roll” AMCs
Source: Elliot Fisher, Dartmouth Medical School.
What Additional Services Are Provided in High-Spending Regions?
Source: Elliot Fisher, Dartmouth Medical School.
CBO’s Activities in Analyzing Health Care
New Hires and Expanded Staffing– New deputy assistant director (Keith Fontenot) in the Budget
Analysis Division– Increase in health staff agency-wide from 30 FTEs to
50 FTEs – FY 2009 plans
Reports and Analysis in 2008– Critical Topics in Health Reform– Health Options
Examples of CBO’s Uses of NCHS Data Sets
Comparisons of measured BMI and self-reported BMI (NHANES)
Estimates of Medicaid long term care costs (National Nursing Home Survey)
Analysis of the impact of increases in certain chronic conditions on the receipt of SSDI (NHIS)
Current CBO Projects Using NCHS Data Sets Linked to Administrative Data
Estimating the effects of current and past obesity on Medicare spending– NHANES I Epidemiologic Follow-up Study (20-year follow-
up) linked to Medicare claims data
Comparing Medicare spending for individuals with and without health insurance prior to becoming eligible for Medicare– NHIS data linked to Medicare claims data
CBO’s Wish List for Data
Richer Mortality and Longitudinal Data Data on Social Environment Development of a Single National
Health Indicator
Mortality: A Key Health Outcome
Used to measure national health trends Used to measure disparities by race, ethnic origin Used to assess differences in quality across
providers Trend toward looking for value and efficiency in
health care is generating interest in more refined measures of health outcomes, but mortality will always be key indicator
Increase in Life Expectancy, and Increase in Difference in Life Expectancy by Economic Status
Source: Data from Singh and Siahpush (2006) and CDC.
Years
At Birth At Age 65
0
1
2
3
4
Increase in Average Life Expectancy, 1980–2000
Increase in Difference in Average Life ExpectancyBetween Lowest and Highest Decile, 1980–2000
Mortality Data
Richer data sought linking comorbidities, educational attainment, other demographic considerations
– Periodic efforts to quantify the level of known problems via vehicles like the National Mortality Follow Back survey would be very useful
– Including/improving SES information in mortality data would be valuable
– Opportunities to include and/or improve information on nation of origin and duration of domestic residence would enrich the data
Longitudinal Data
Cross-sectional data are insufficient when the lag between treatment and outcome is long
Collection of longitudinal data with a sufficient sample size to analyze multiple interventions/outcomes is costly
Opportunities to enhance utility of cross-sectional data (following subsamples, linking with administrative data) offer an alternative approach– For example, tracking NHANES subpopulations with similar
conditions, but different medical interventions
Social Environment and Impact on Disease
The importance of social integration is well known– Better mental health– Lower heart disease, mortality risk
Social environment affects health behaviors– Diet, physical activity, smoking
Social environment affects perceptions of health– Before unification, low self-reported back pain in East
Germany– After unification, reports of back pain increased in East
Germany, possibly because of exposure to West German media reports on the topic
Existing Data on Social Environment
NHANES– Sources of social and financial support– Church attendance– Number of friends
Hispanic Community Health Survey– Acculturation
Framingham Heart Study– Participants listed friends/family contacts for follow-up– Overlap between participant and contacts allowed
researchers to analyze impact of social v. geographic closeness on changes in obesity, smoking status
Future Data on Social Environment
National Longitudinal Study of Adolescent Health– Includes questionnaires for parents, siblings, peers, and
school administrators and interviews with romantic partners
Proposed Community HANES– Similar to NHANES, but focused in a few small areas– Would include data on physical environment; could include
data on social network
Single National Health Quality Indicator
Mortality/life expectancy is often used as a proxy for average health of the population
Single indicator is convenient for tracking progress over time, but mortality may not be the best single measure
A new national indicator could incorporate a more comprehensive range of health measures