Congressional Budget Office

1. Congressional Budget Office Presentation to the National Center for Health Statistics Peter Orszag Director August 11, 2008

2. Federal Spending Under CBO’s AlternativeFiscal Scenario Percentage of Gross Domestic Product

3. 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)

4. Sources of Growth in Projected Federal Spending on Medicare and Medicaid Percentage of GDP

5. Before we all get too depressed… Embedded in the nation’s central long-term fiscal challenge appears to be a substantial opportunity: Can we reduce health care costs without impairing health outcomes?

6. Medicare Spending per Beneficiary in the United States, by Hospital Referral Region, 2005

7. Variations Among Academic Medical Centers 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.

8. What Additional Services Are Provided in High-Spending Regions? Source: Elliot Fisher, Dartmouth Medical School.

9. 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

10. 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)

11. 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

12. CBO’s Wish List for Data • Richer Mortality and Longitudinal Data • Data on Social Environment • Development of a Single National Health Indicator

13. 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

14. Increase in Life Expectancy, and Increase in Difference in Life Expectancy by Economic Status Years Source: Data from Singh and Siahpush (2006) and CDC.

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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