oversight

Preventive Health Activities: Available Information on Federal Spending, Cost Savings, and International Comparisons Has Limitations

Published by the Government Accountability Office on 2012-12-06.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                             United States Government Accountability Office

GAO                          Report to Congressional Requesters




                             PREVENTIVE
December 2012



                             HEALTH ACTIVITIES

                             Available Information
                             on Federal Spending,
                             Cost Savings, and
                             International
                             Comparisons Has
                             Limitations


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GAO-13-49
                                                 December 2012

                                                 PREVENTIVE HEALTH ACTIVITIES
                                                 Available Information on Federal Spending, Cost
                                                 Savings, and International Comparisons Has
                                                 Limitations
Highlights of GAO-13-49, a report to
congressional requesters




Why GAO Did This Study                           What GAO Found
Preventive health activities have                The Departments of Health and Human Services (HHS), Veterans Affairs (VA),
received attention for their potential to        and Defense (DOD) administer programs that include preventive health activities
improve health outcomes or lower                 such as health screenings and education campaigns, but the departments
health care expenditures. While there            reported that they do not track department-wide spending on these activities.
is no widespread agreement on what               Departments reported that determining such spending is challenging because
constitutes preventive health activities,        these activities can be integrated with other health activities. For fiscal year 2011,
in this report they include clinical             the departments provided to GAO a mix of information related to spending for
preventive services, such as                     preventive health activities, and noted limitations. These limitations included
immunizations provided in clinical
                                                 incomplete estimates, estimates that included activities that were prevention-
settings, and community-oriented
                                                 related but not specifically for clinical preventive services or community-oriented
preventive health activities, such as
health education media campaigns. A
                                                 preventive health activities, and estimates that represented funding—not
preventive health activity is considered         spending—information. Funding estimates represent amounts available to the
cost saving if the activity costs less           departments at a particular time, but not necessarily actual spending. For fiscal
than the costs averted by it; an activity        year 2011, HHS combined estimates of spending for prevention for one agency
is cost-effective if it achieves benefits        with estimates of funding for nine other HHS agencies for a total of about
in a less costly way than alternatives.          $24 billion; however, the estimate did not include the Centers for Medicare &
HHS, VA, and DOD administer                      Medicaid Services, which oversees health coverage programs for over
programs that include preventive                 100 million individuals. VA and DOD estimated that, for example, fiscal year 2011
health activities.                               spending for clinical preventive services was about $576 million and $1 billion,
                                                 respectively.
GAO was asked to report on
preventive health activities. This report        Researchers, reports, and articles have indicated that some preventive health
provides available information and               activities may result in cost savings—that is, the costs averted, such as medical
discusses the limitations of this                costs to treat a disease or condition, exceed the cost of implementing it—and a
information regarding (1) preventive             number of preventive health activities, while not necessarily cost saving, may be
health activities in programs                    cost-effective—that is, the activity provides good value at low cost relative to
administered by HHS, VA, and DOD                 alternative activities. For example, according to one report that synthesized the
and the departments’ spending on                 results of three reviews, two clinical preventive services—counseling on the use
such activities; (2) reported cost
                                                 of low-dose aspirin to reduce coronary heart disease and childhood
savings from and cost effectiveness of
                                                 immunizations—were considered to be cost saving. Researchers noted,
preventive health activities; and
(3) U.S. spending on preventive health           however, that estimates of cost savings or cost-effectiveness are affected by
activities compared to that of other             multiple factors, such as how an activity is targeted. In addition, Centers for
countries.                                       Disease Control and Prevention officials and others reported that a lack of key
                                                 data may affect estimates of cost savings or cost-effectiveness and reported
GAO reviewed documents from HHS,                 taking steps toward improving available information.
VA, and DOD; interviewed officials
from those departments and                       Data for international comparisons of countries’ spending specifically for
researchers; conducted a literature              preventive health activities are not available. Instead, data available from the
review; and reviewed OECD data on                Organization for Economic Co-operation and Development (OECD) combine
national health spending.                        spending on certain preventive health activities—including community-oriented
                                                 preventive health activities, such as vaccination programs—with spending on
HHS and VA provided technical
comments on a draft of this report,
                                                 other public health activities, such as disease surveillance. On the basis of these
which were incorporated as                       data, the United States ranked 8th among 23 OECD member countries in the
appropriate.                                     percentage of total health care spending reported for prevention and public
                                                 health services. However, these data have limitations. For example, they do not
                                                 include U.S. spending for preventive services provided in physicians’ offices or
View GAO-13-49. For more information,
contact Katherine Iritani at (202) 512-7114 or   hospitals in the public and private sectors.
iritanik@gao.gov.

                                                                                           United States Government Accountability Office
Contents


Letter                                                                                      1
               Background                                                                   7
               HHS, VA, and DOD Programs Include Preventive Health Activities,
                  but Department-wide Spending on These Activities Is Not
                  Specifically Tracked                                                     14
               Some Preventive Health Activities May Be Cost Saving or Cost-
                  Effective, but Multiple Factors Affect Estimates, and Key Data
                  May Be Lacking                                                           21
               International Data on Preventive Health Activities Are Not
                  Available, but United States Ranks Eighth in OECD Category
                  That Combines Spending on Prevention and Public Health
                  Services                                                                 28
               Concluding Observations                                                     32
               Agency Comments                                                             33

Appendix I     Requirements Related to Preventive Health Activities in
               the Duncan Hunter National Defense Authorization Act                        34



Appendix II    Department of Health and Human Services Estimates
               of Spending and Funding for Preventive Health Activities                    36



Appendix III   Department of Veterans Affairs Estimates of Spending
               and Funding for Preventive Health Activities                                40



Appendix IV    Department of Defense Estimates of Spending for
               Preventive Health Activities                                                42



Appendix V     GAO Contact and Staff Acknowledgments                                       44



Tables
               Table 1: Selected HHS Agencies and Their Functions                           8




               Page i                                    GAO-13-49 Preventive Health Activities
          Table 2: Types of Preventive Health Activities Included in
                   Programs Administered by HHS Agencies                              15
          Table 3: Effect of Targeting on Cost-Effectiveness Ratio for
                   Selected Preventive Health Activities                              25
          Table 4: DOD Estimates of Spending for Providing Clinical
                   Preventive Services in DOD’s Direct Care and Purchased
                   Care Systems, Fiscal Years 2010 and 2011                           42


Figures
          Figure 1: Total Health Care Spending per Capita, by OECD Member
                   Country, 2010                                                      13
          Figure 2: Spending for Prevention and Public Health Services as a
                   Percentage of Total Health Spending, by OECD Member
                   Country, 2010                                                      29
          Figure 3: Spending for Prevention and Public Health Services as a
                   Percentage of Gross Domestic Product, by OECD Member
                   Country, 2010                                                      30
          Figure 4: Spending for Prevention and Public Health Services per
                   Capita, by OECD Member Country, 2010                               31




          Page ii                                   GAO-13-49 Preventive Health Activities
Abbreviations

ACF               Administration for Children and Families
ACL               Administration for Community Living
ACIP              Advisory Committee on Immunization Practices
AHRQ              Agency for Healthcare Research and Quality
AOA               Administration on Aging
ASFR              Office of the Assistant Secretary for Financial Resources
CDC               Centers for Disease Control and Prevention
CMS               Centers for Medicare & Medicaid Services
DOD               Department of Defense
FDA               Food and Drug Administration
HHS               Department of Health and Human Services
HIV               human immunodeficiency virus
HPV               human papillomavirus
HRSA              Health Resources and Services Administration
IHS               Indian Health Service
LDL               low-density lipoprotein
NIH               National Institutes of Health
NHLBI             National Heart, Lung, and Blood Institute
OASH              Office of the Assistant Secretary for Health
OECD              Organization for Economic Co-operation and Development
QALY              quality-adjusted life-year
SAMHSA            Substance Abuse and Mental Health Services
                    Administration
USPSTF            U.S. Preventive Services Task Force
VA                Department of Veterans Affairs
VHA               Veterans Health Administration



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Page iii                                             GAO-13-49 Preventive Health Activities
United States Government Accountability Office
Washington, DC 20548




                                   December 6, 2012

                                   The Honorable Max Baucus
                                   Chairman
                                   Committee on Finance
                                   United States Senate

                                   The Honorable Tom Harkin
                                   Chairman
                                   Committee on Health, Education, Labor, and Pensions
                                   United States Senate

                                   The Honorable Carl Levin
                                   Chairman
                                   Committee on Armed Services
                                   United States Senate

                                   In recent years, preventive health activities have received attention for
                                   their potential to improve health outcomes or lower health care
                                   expenditures. Preventive health activities can prevent health conditions
                                   from occurring, or screen for or diagnose existing health conditions. For
                                   example, vaccinations can prevent infectious diseases, and
                                   mammograms are used to screen for breast cancer. Preventive health
                                   activities can also manage diagnosed health conditions and prevent
                                   certain conditions from worsening—for example, weight-reduction
                                   counseling to help manage diabetes. While there is no widespread
                                   agreement on what constitutes preventive health activities, in this report
                                   preventive health activities include clinical preventive services and
                                   community-oriented preventive health activities. Clinical preventive
                                   services are services that are provided to individuals in clinical settings
                                   such as immunizations, screenings, and counseling, and community-
                                   oriented preventive health activities are activities to improve the health of
                                   people in a community such as health education media campaigns and
                                   health screenings at community health fairs.

                                   The Department of Health and Human Services (HHS), the Department of
                                   Veterans Affairs (VA), and the Department of Defense (DOD) administer
                                   programs that provide preventive health activities and other health
                                   services to millions of Americans. For example, HHS’s Medicare and




                                   Page 1                                       GAO-13-49 Preventive Health Activities
Medicaid programs provide coverage for clinical preventive services for
seniors and low-income adults and children, 1 VA provides clinical
preventive services and community-oriented preventive health activities
for veterans and other eligible beneficiaries, and DOD provides clinical
preventive services and community-oriented preventive health activities
for active duty personnel and other beneficiaries. According to the
National Prevention Strategy prepared by the National Prevention
Council—a council that includes the heads of these three departments—
the federal government will support preventive health activities to promote
health and wellness by taking new or continuing actions such as
promoting and expanding research efforts to identify high-priority
preventive health activities. 2 State and local governments, nonprofit
organizations, companies in the private sector, as well as governments in
other countries, also administer programs that include preventive health
activities.

Preventive health activities may have impacts on health care costs and
improve health outcomes. Preventive health activities are considered to
be cost saving when the cost of implementing the activity is less than
costs—such as future medical costs to treat a disease or condition—that
could be averted by the preventive health activity. Preventive health
activities that may improve health outcomes are considered cost-effective
if the activity generates benefits, such as improved health outcomes, in a
less costly way than alternatives—that is, they provide good value at
relatively low cost.

You asked us to provide information on preventive health activities,
including spending on these activities by HHS, VA, and DOD and
limitations in this information. This report provides available information


1
 Medicare is the federal health insurance program for people age 65 or older, individuals
under age 65 with certain disabilities, and individuals diagnosed with end-stage renal
disease. Medicaid is a joint federal and state program that finances health care coverage
for certain low-income individuals and families.
2
 See National Prevention Council, National Prevention Strategy (Washington, D.C.: U.S.
Department of Health and Human Services, Office of the Surgeon General, 2011). The
National Prevention, Health Promotion and Public Health Council (referred to as the
National Prevention Council) was established under the Patient Protection and Affordable
Care Act (Pub. L. No. 111-148, § 4001, 124 Stat. 119, 538 (2010)) and is composed of the
heads of 17 federal agencies and chaired by the Surgeon General. Information about the
National Prevention Council and its National Prevention Strategy is available at
http://www.healthcare.gov/prevention/nphpphc (accessed Aug. 30, 2012).




Page 2                                              GAO-13-49 Preventive Health Activities
and discusses the limitations of this information regarding (1) preventive
health activities included in programs administered by HHS, VA, and
DOD and the departments’ spending information on such activities;
(2) reported cost savings from and cost-effectiveness of preventive health
activities; and (3) U.S. spending on preventive health activities compared
to that of other countries.

To provide information and discuss the limitations of this information
regarding preventive health activities included in programs administered
by HHS, VA, and DOD and the departments’ spending information on
such activities, we reviewed documents and interviewed officials from
HHS, VA, and DOD. We asked officials from each of these departments
to describe completed or ongoing efforts, if any, to identify and track
spending on clinical preventive services and community-oriented
preventive heath activities included in programs administered by their
respective departments, and we reviewed the related documents they
provided. 3 We asked the departments to provide readily available
information from their data systems or existing documents. As a result,
the information provided by the departments may not be based on a
uniform definition of preventive health activities or comparable estimates
of spending. We did not independently verify the information provided by
the departments nor did we assess the rationale for including or excluding
particular preventive health activities in the information that the
departments provided.

•   For HHS, we reviewed documents provided by HHS’s Office of the
    Assistant Secretary for Financial Resources (ASFR) (the office that
    provides guidance to HHS’s Office of the Secretary on all aspects of
    HHS’s budget) that include estimates of spending and other
    information, reviewed documents from HHS agencies that identified




3
 We did not contact the Department of the Treasury to review federal tax expenditures,
which are not within the scope of our work. Tax expenditures are preferential provisions in
the tax code, such as exemptions and exclusions from taxation, deductions, credits,
deferral of tax liability, and preferential tax rates that result in forgone revenue for the
federal government. The revenue that the government forgoes is viewed by many analysts
as spending channeled through the tax system. According to the Office of Management
and Budget, in fiscal year 2011, for example, the tax exclusion for employer-provided
health care alone totaled about $267.8 billion in forgone federal revenue. See Office of
Management and Budget, Analytical Perspectives, Budget of the United States
Government, Fiscal Year 2013 (Washington, D.C.: 2012).




Page 3                                               GAO-13-49 Preventive Health Activities
    preventive health activities included in programs administered by the
    agencies, and interviewed ASFR and HHS agency officials. 4

•   For VA, we reviewed documents describing estimates of spending
    developed by VA’s Veterans Health Administration (VHA), which
    administers VA’s health care system, and we interviewed VHA
    officials. Specifically, we reviewed documents identifying selected
    clinical preventive services provided in VA medical facilities and
    describing spending estimates developed by VHA’s Allocation
    Resource Center for these services. 5 In addition to estimates of
    spending for clinical preventive services, we reviewed VA documents
    identifying community-oriented preventive health activities included in
    programs administered by VA’s National Center for Health Promotion
    and Disease Prevention and VA’s Clinical Public Health Group. We
    also interviewed officials who provided these documents.

•   For DOD, we reviewed documents describing estimates of spending
    developed by the department and interviewed DOD officials about the
    department’s preventive health activities. For example, to learn about
    DOD’s clinical preventive services provided through TRICARE—
    DOD’s program that provides health care to active duty personnel and
    other beneficiaries, including retired servicemembers—we reviewed
    documents describing spending estimates provided by DOD’s
    TRICARE Management Activity (the DOD component that oversees
    TRICARE) and interviewed officials from the TRICARE Management
    Activity. 6

For all the departments, we reviewed documents describing limitations of
the information or discussed limitations with HHS, VA, and DOD officials.
We did not independently verify the accuracy of the information. We
determined the information to be sufficiently reliable for providing
information on preventive health activities in programs administered by



4
 In this report we use the term agency to refer to HHS agencies, as well as the Office of
the Assistant Secretary for Health.
5
 VHA’s Allocation Resource Center is responsible for developing, implementing, and
maintaining management information systems that provide data for VHA’s budget
process.
6
 We also reviewed documents, including DOD reports to Congress, related to preventive
health provisions in the Duncan Hunter National Defense Authorization Act for Fiscal Year
2009. Pub. L. No. 110-417, §§ 711- 714, 122 Stat. 4536, 4500-04 (2008).




Page 4                                               GAO-13-49 Preventive Health Activities
HHS, VA, and DOD and on the departments’ estimates of spending on
such activities, and limitations of this information. Where we identified
limitations, we report them.

To provide information about the reported cost savings from and cost-
effectiveness of preventive health activities, we conducted a literature
review and interviewed researchers and government officials. 7 For our
literature review, we searched four databases—EMBASE, MEDLINE,
SciSearch, and ProQuest—and identified 23 articles that met our
inclusion criteria—that is, each of the 23 articles reviewed multiple
research studies; clearly described a methodology; was published in a
peer-reviewed journal between January 2007 and March 2012; and
identified U.S. based services that were cost saving or cost-effective, or
factors that affect whether a preventive health activity is cost saving or
cost-effective. In addition to conducting a literature review of articles
published in peer-reviewed publications, we reviewed government and
independent reports, including reports published by nonprofit
organizations that were referenced in articles in our literature review or
were suggested to us by the federal officials and researchers we
interviewed. We interviewed officials from the following HHS agencies
that provide research support to organizations that work on issues related
to preventive health activities: the Agency for Healthcare Research and
Quality (AHRQ)—specifically, we spoke to officials who provide research
support to the U.S. Preventive Services Task Force (USPSTF); and the
Centers for Disease Control and Prevention (CDC)—specifically, we
spoke to officials in the National Center for Chronic Disease Prevention
and Health Promotion and the National Center for Immunization and
Respiratory Diseases who provide support to the Community Preventive
Services Task Force and the Advisory Committee on Immunization
Practices (ACIP), respectively. We also interviewed members of ACIP,
including the ACIP Chair.

To provide information on U.S. spending on preventive health activities
compared to that of other countries, we reviewed data collected by the
Organization for Economic Co-operation and Development (OECD) on



7
 We interviewed researchers at two nonprofit organizations that focus on preventive
health activities and two academic institutions. These researchers were referred to us by
federal officials or published articles in peer-reviewed publications or reports on the topic
of the cost savings or cost-effectiveness of preventive health activities, including articles or
reports cited by HHS.




Page 5                                                 GAO-13-49 Preventive Health Activities
national health spending for the United States and other OECD member
countries. 8 OECD is an organization that, among other things, collects
data on health spending from member countries. We reported relevant
2010 spending statistics for OECD member countries using data available
on OECD’s website. 9 We also identified trends for the United States over
time by comparing rankings for 2010 spending statistics with similar
rankings for 2001 through 2009. We reviewed documents published by
OECD and interviewed experts—including officials from the Centers for
Medicare & Medicaid Services’ (CMS) Office of the Actuary (the office
that submits the U.S. health care spending data to OECD) as well as
researchers—to learn about guidelines established by OECD and the
data submitted by OECD member countries. While there are limitations to
using OECD data, the researchers we interviewed reported that the
OECD data are the best available data for making international
comparisons on health spending. We did not independently verify the
accuracy of the data. We assessed the reliability of the data and
determined that the data were sufficiently reliable for purposes of
presenting available data comparing U.S. spending with that of other
countries, noting limitations associated with these data.

We conducted our work from December 2011 through December 2012 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform our work to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our research objectives. We believe




8
 As of August 2012, OECD had 34 member countries. According to OECD, its member
countries include many of the world’s most advanced economies but also emerging
economies like Mexico, Chile, and Turkey. OECD lists the member countries on its
website:
http://www.oecd.org/document/58/0,3746,en_2649_201185_1889402_1_1_1_1,00.html
(accessed Aug. 8, 2012). OECD also reports data on health outcomes. OECD health data
are used by researchers and others to compare health spending and outcomes in the
United States with that of other countries.
9
 We used 2010 spending data because it was the most recent data available for most
member countries at the time of our review. As of July 2012, OECD had posted 2010
health spending data from 28 of its 34 member countries, and posted data on prevention
and public health services from 23 of these countries. Data from these 23 countries were
used for this report. To identify the rankings for relevant 2010 spending statistics, we used
the OECD.Stat database available on OECD’s website
(http://www.oecd.org/document/30/0,3746,en_2649_37407_12968734_1_1_1_37407,00.h
tml, accessed July 11, 2012).




Page 6                                                GAO-13-49 Preventive Health Activities
                          that the evidence obtained provides a reasonable basis for our findings
                          and conclusions based on our research objectives.

Background
HHS, VA, and DOD Health   HHS is the federal government’s principal department for protecting the
Care                      health of all Americans and providing essential human services,
                          especially for vulnerable populations. For fiscal year 2011, HHS’s
                          department-wide expenditures totaled about $891 billion. HHS agencies
                          that administer programs that include preventive health activities have
                          missions and key functions that vary. For example, CMS administers the
                          Medicare and Medicaid programs and the Children’s Health Insurance
                          Program, which provide health care insurance for more than 100 million
                          adults and children. Three other agencies—the Indian Health Service
                          (IHS), the Health Resources and Services Administration (HRSA), and
                          the Substance Abuse and Mental Health Services Administration
                          (SAMHSA)—provide health care services or support systems that provide
                          these services. Two agencies—the National Institutes of Health (NIH) and
                          AHRQ—are primarily research agencies. CDC develops and supports
                          public health prevention programs and systems, such as disease
                          surveillance and provider education programs. (See table 1 for more
                          information about these HHS agencies.)




                          Page 7                                     GAO-13-49 Preventive Health Activities
Table 1: Selected HHS Agencies and Their Functions

HHS agency                                         Agency functions
Administration for Children and Families           Administers programs to promote the economic and social well-being of children, youth,
(ACF)                                              families, and communities, focusing particular attention on vulnerable populations, such
                                                   as children in low-income families, refugees, Native Americans, and children in foster
                                                   care.
Agency for Healthcare Research and Quality Supports research that examines how people get access to health care, how much
(AHRQ)                                     health care costs, and what happens to patients as a result of the health care they
                                           receive.
                                           a
Administration for Community Living (ACL)          Administers programs to advance the concerns and interests of older Americans,
                                                   people with disabilities, and their families through national networks of service, system
                                                   change efforts, and protections to promote optimal life outcomes.
Centers for Disease Control and Prevention         Administers programs to prevent significant health conditions and their risk factors,
(CDC)                                              including infectious diseases, chronic diseases, birth defects and developmental
                                                   disabilities, intentional and unintentional injury, and health conditions from
                                                   environmental exposures.
Centers for Medicare & Medicaid Services           Oversees the financing of health care services for the 43 million beneficiaries covered
(CMS)                                              through Medicare and the nearly 60 million low-income individuals (including adults and
                                                   children) covered through Medicaid and the Children’s Health Insurance Program.
Health Resources and Services                      Administers programs to improve access to health care services for people who are
Administration (HRSA)                              uninsured, isolated, or medically vulnerable.
Indian Health Service (IHS)                        Provides health care to approximately 2.2 million American Indians and Alaska Natives
                                                   through a network of 650 hospitals, clinics, and health stations.
National Institutes of Health (NIH)                Supports medical research in the United States. It conducts and funds research about,
                                                   for example, the causes, diagnosis, prevention, and cure of human diseases.
Office of the Assistant Secretary for Health       Coordinates population-based public health and science activities across HHS
(OASH)                                             agencies.
Substance Abuse and Mental Health                  Administers programs to promote emotional health and reduce the likelihood of mental
Services Administration (SAMHSA)                   illness, substance abuse, and suicide.
                                               Source: GAO summary of HHS information.
                                               a
                                               In April 2012, HHS created the ACL by combining the Administration on Aging (AOA), the Office on
                                               Disability, and the Administration on Intellectual and Developmental Disabilities.


                                               VA also provides health care services that include preventive health
                                               activities. VA operates one of the largest health care delivery systems in
                                               the nation. VA provides a range of health care services to eligible
                                               veterans and certain eligible dependents or survivors of veterans. These
                                               services include primary care, inpatient and outpatient surgery,
                                               prosthetics, mental health services, prescription drugs, nursing home
                                               care, and preventive health activities. To provide this care, VA operates
                                               about 150 hospitals, 130 nursing homes, and 800 outpatient clinics, as
                                               well as other facilities. In fiscal year 2011, VA spent about $51 billion on
                                               health care services and provided health care services to about
                                               6.2 million patients.




                                               Page 8                                                  GAO-13-49 Preventive Health Activities
                            DOD operates a large, complex health system that in fiscal year 2011
                            provided health insurance coverage for about 9.6 million active duty
                            personnel and other beneficiaries, including eligible family members and
                            retired servicemembers. DOD’s health system consists of the Office of
                            the Assistant Secretary for Health Affairs, the medical departments of the
                            Army, Navy, and Air Force; the Joint Chiefs of Staff; the Combatant
                            Command surgeons; and the TRICARE network of health care providers.
                            DOD delivers health care services—including diagnostic, therapeutic,
                            inpatient, and outpatient care—through the military services’ medical
                            departments at 59 military treatment facilities, 365 ambulatory care
                            clinics, and 281 dental clinics, which make up what is known as the direct
                            care system. DOD also delivers similar services to TRICARE
                            beneficiaries through its purchased care system, which consists of
                            network and nonnetwork private-sector civilian primary and specialty care
                            providers, hospitals, pharmacies, and suppliers. In fiscal year 2011,
                            spending in DOD’s health system totaled about $52 billion.


Estimating Cost Savings     Preventive health activities may result in cost savings and may be cost-
and Cost-Effectiveness of   effective. An activity may be cost saving if the costs averted by the
Preventive Health           activity, such as future medical costs to treat a disease or condition,
                            exceed the cost of implementing the preventive health activity. An activity
Activities                  may be considered cost-effective if it generates benefits, such as
                            improved health outcomes, in a less costly way than alternatives. Cost-
                            effectiveness analysis can help to evaluate whether the improvement in
                            health care outcomes justifies the expenditures relative to other choices.

                            Cost-effectiveness analyses typically compare the costs and health
                            outcomes between two activities or compare an activity with no
                            intervention. Estimates of cost-effectiveness are typically presented as a
                            ratio of the net costs to the net outcomes of utilizing one preventive health
                            activity over another. In presenting outcomes of cost-effectiveness
                            analyses, researchers often use a measure called the quality-adjusted
                            life-year (QALY), which takes into account both the number and quality of
                            years added by an intervention. A year in perfect health is worth 1 QALY,
                            and a year with less than perfect health—for example, with an adverse
                            health condition—is generally worth between 0 and 1 QALY. The
                            preventive health activity with the lower cost-effectiveness ratio is
                            preferred because it costs less to achieve the desired health outcome.
                            While there is no agreement on the specific threshold for determining that




                            Page 9                                      GAO-13-49 Preventive Health Activities
an activity is cost-effective, researchers have used a threshold of $50,000
per QALY or $100,000 per QALY to consider a preventive health activity
to be cost-effective. 10

In the United States, three federally supported organizations—USPSTF,
ACIP, and the Community Preventive Services Task Force—assess
information about preventive health activities and make recommendations
to providers and policymakers based on an activity’s effectiveness—that
is, how well the activity produces a desired health outcome.

•    USPSTF is an independent panel of nonfederal experts in prevention
     and evidence-based medicine that makes recommendations to
     primary care clinicians on clinical preventive services. 11 USPSTF
     reviews evidence from randomized control trials and other studies
     documenting the effectiveness of clinical preventive services. 12 It then
     issues recommendations for providers and may include guidance on
     the sex and age groups most likely to benefit from the service, as well
     as the interval of the service. The USPSTF is convened by AHRQ,
     and AHRQ also provides it with administrative, research, technical,
     and dissemination support.

•    ACIP—a federal advisory committee of 15 experts selected by the
     Secretary of Health and Human Services—makes recommendations
     for vaccination administration, including a schedule of recommended
     vaccines for adults and children. 13 As part of its recommendation
     process, ACIP reviews information on the cost or economic impact of


10
  Because there is no commonly accepted cost-effectiveness ratio threshold that
determines whether a preventive health activity is cost-effective, the thresholds
researchers apply may vary. Given such variations, a preventive health activity may be
found to be cost-effective in one research study that uses a particular threshold, but not in
another study that applies a different threshold. For example, a preventive health activity
may be considered cost-effective when using a threshold cost-effectiveness ratio of
$100,000 per QALY, but when a lower cost-effectiveness threshold is used, such as
$50,000 per QALY, the same activity might not be considered cost-effective.
11
  USPTSF is made up of 16 volunteer members who are primary care providers (such as
internists, pediatricians, family physicians, obstetricians/gynecologists, nurses, and
behavioral health specialists).
12
  The USPSTF does not consider economic information, such as whether a preventive
health service is cost saving or cost-effective, as part of its recommendation process.
13
  ACIP recommendations are not considered official until they are approved by the CDC
Director and published in CDC’s Morbidity and Mortality Weekly Report.




Page 10                                               GAO-13-49 Preventive Health Activities
            the vaccinations it evaluates. CDC provides ACIP with management
            and support services.

       •    The Community Preventive Services Task Force—an independent,
            nonfederal panel of 15 members appointed by the CDC Director—
            conducts systematic reviews of community-oriented preventive
            services, programs, and policies and issues recommendations and
            findings to help inform decision making about policy, practice, and
            research. The task force examines the evidence, produces findings
            and recommendations about effective and ineffective programs,
            services, and policies, and identifies research gaps that need to be
            filled. While the Community Preventive Services Task Force does not
            consider economic information, such as whether a preventive health
            service is cost saving or cost-effective, as part of its recommendation
            process, it makes publicly available the economic information for the
            preventive health activities it recommends. 14 The task force reviews
            research, including cost-effectiveness research, funded and
            conducted by CDC’s Epidemiology and Analysis Program Office. CDC
            staff support the Community Preventive Services Task Force by
            conducting the systematic reviews with oversight from the task force,
            and by disseminating task force recommendations and findings.

OECD   OECD is an international economic organization in which its member
       countries discuss, develop, and analyze economic and social policy.
       OECD collects data on total health spending and spending on specific
       health categories such as medical goods, inpatient care, and outpatient
       care, from its member countries, including the United States. For the
       United States, CMS’s Office of the Actuary reports national health
       spending data to OECD. To make the data collected from member
       countries as comparable as possible, OECD establishes guidelines for
       the types of spending that should be included in various spending




       14
         The Community Preventive Services Task Force reviews published information related
       to the cost savings or cost-effectiveness of the preventive health activities it recommends
       and posts this information online. For example, the task force finding and rationale
       statement on interventions for children and adolescents with asthma included information
       from studies that considered costs and benefits of the interventions—see
       http://www.thecommunityguide.org/asthma/rrchildren.html (accessed Aug. 17, 2012).




       Page 11                                              GAO-13-49 Preventive Health Activities
categories. 15 For example, OECD’s guidelines for total health spending in
2010 included spending in both the public and private sectors on health
services conducted in hospitals and other facilities or settings such as
long-term nursing care centers and physicians’ offices. The guidelines
also included total spending on pharmaceuticals, health administration,
and public health. In 2010, the United States ranked first among OECD
countries in total health care spending (about $2.5 trillion). The United
States also ranked first among OECD countries in total health care
spending as a percentage of the country’s gross domestic product (about
18 percent) and in total health care spending per capita ─$8,233 per
person (see fig. 1).




15
  OECD disseminates its guidelines in a published manual called A System of Health
Accounts. The manual containing guidelines for OECD’s 2010 data—the data used for this
report—was released by OECD in 2000. A revised version of the manual was released in
November 2011.




Page 12                                           GAO-13-49 Preventive Health Activities
Figure 1: Total Health Care Spending per Capita, by OECD Member Country, 2010




                                       Note: This figure presents a summary of 2010 data on total health care spending per capita for 28
                                       OECD member countries. OECD adjusted spending per capita for purchasing power parity.




                                       Page 13                                                   GAO-13-49 Preventive Health Activities
HHS, VA, and DOD
Programs Include
Preventive Health
Activities, but
Department-wide
Spending on These
Activities Is Not
Specifically Tracked
HHS, VA, and DOD             HHS agencies identified preventive health activities—specifically, clinical
Identified Preventive        preventive services and community-oriented preventive health activities—
Health Activities Included   included in programs that they administer, with different programs
                             targeting different populations. (See table 2 for types of preventive health
in the Programs They         activities included in programs that HHS agencies administer and
Administer                   examples of such activities.) For example, CMS’s Medicare and Medicaid
                             programs provide coverage for clinical preventive services for Medicare
                             and Medicaid beneficiaries, while IHS’s programs provide preventive
                             health activities for American Indians and Alaska Natives. CDC
                             administers programs that include community-oriented preventive health
                             activities such as the National Tobacco Control Program, which provides
                             access to quit lines and ad campaigns to reduce smoking.




                             Page 14                                     GAO-13-49 Preventive Health Activities
Table 2: Types of Preventive Health Activities Included in Programs Administered by HHS Agencies

                         Type of preventive health activities included
                                                   Community-oriented
                        Clinical preventive         preventive health
HHS agency                   services                   activities       Example
Administration for              x                                        ACF awards discretionary grants to states through its
Children and Families                                                    Office of Refugee Resettlement Preventive Health
(ACF)                                                                    Services program to coordinate and promote access
                                                                         to clinical preventive services that include health
                                                                         screenings for refugees.
Agency for                      x                                        AHRQ convenes the U.S. Preventive Services Task
Healthcare Research                                                      Force (USPSTF)—a panel of experts that makes
and Quality (AHRQ)                                                       recommendations on clinical preventive services—
                                                                         and provides administrative, research, technical, and
                                                                         dissemination support for the USPSTF.
Administration for                                         x             ACL administers programs that promote opportunity,
Community Living                                                         healthy lifestyles, and healthy behaviors for older
      a
(ACL)                                                                    Americans, people with disabilities, and their families
                                                                         through education, research and service across
                                                                         diverse networks of state and local programs.
Centers for Disease             x                          x             CDC administers programs that include community-
Control and                                                              oriented preventive health activities such as the
Prevention (CDC)                                                         National Tobacco Control Program, which provides
                                                                         access to quit lines and ad campaigns to reduce
                                                                         smoking. CDC also supports the Community
                                                                         Preventive Services Task Force, which conducts
                                                                         reviews on the effectiveness of community-oriented
                                                                         preventive health activities. CDC’s Vaccines for
                                                                         Children program and Section 317 Immunization
                                                                         Program fund the purchasing and delivery of vaccines
                                                                         to vulnerable populations.
Centers for Medicare            x                          x             CMS’s Medicare and Medicaid programs provide
& Medicaid Services                                                      coverage for many clinical preventive services such
(CMS)                                                                    as wellness examinations, screenings, vaccinations,
                                                                         and counseling for Medicare and Medicaid
                                                                         beneficiaries. CMS’s Everyone with Diabetes Counts
                                                                         program includes community-oriented preventive
                                                                         health activities that seek to educate Medicare
                                                                         beneficiaries with diabetes in vulnerable populations
                                                                         and increase their health literacy.
Health Resources                x                          x             HRSA’s National Health Service Corps supports the
and Services                                                             provision of clinical preventive health activities and
Administration                                                           community-oriented preventive health activities by
(HRSA)                                                                   offering assistance to underserved communities in
                                                                         every state to recruit and retain primary care
                                                                         providers.




                                         Page 15                                          GAO-13-49 Preventive Health Activities
                           Type of preventive health activities included
                                                      Community-oriented
                          Clinical preventive          preventive health
HHS agency                     services                    activities                Example
Indian Health Service             x                                 x                IHS provides clinical preventive services to American
(IHS)                                                                                Indians and Alaska Natives through its network of
                                                                                     hospitals and clinics. IHS’s Community Health
                                                                                     Representative program supports community-
                                                                                     oriented preventive health activities by, for example,
                                                                                     providing health education in patients’ homes and
                                                                                     schools and facilitating screening at health fairs.
National Institutes of            x                                 x                NIH supports research designed to yield results
Health (NIH)                                                                         directly applicable to identifying and assessing risk,
                                                                                     and to develop interventions for preventing or
                                                                                     ameliorating high-risk behaviors, the occurrence of
                                                                                     disease, disorder, injury, or progression of detectable
                                                                                     but asymptomatic disease. Research projects support
                                                                                     clinical preventive services and community-oriented
                                                                                     preventive health activities.
Office of the Assistant           x                                 x                OASH leads the President’s Council on Physical
Secretary for Health                                                                 Fitness, Sports, and Nutrition in efforts to increase
(OASH)                                                                               physical activity in the United States. The council
                                                                                     advises the President through the Secretary of Health
                                                                                     and Human Services about physical activity, fitness,
                                                                                     sports, and good nutrition. In addition, OASH
                                                                                     provides funding support for Title X family planning
                                                                                     clinics which provide clinical preventive services to
                                                                                     millions of individuals.
Substance Abuse and               x                                 x                SAMHSA’s Safe Schools/Healthy Students Initiative
Mental Health                                                                        includes both clinical preventive services and
Services                                                                             community-oriented preventive health activities. It
Administration                                                                       provides funding to local law enforcement, juvenile
(SAMHSA)                                                                             justice agencies, social services, mental health
                                                                                     agencies, and other community organizations to plan
                                                                                     and implement comprehensive and coordinated
                                                                                     programs, policies, and service delivery systems that
                                                                                     promote mental, emotional, and behavioral well-being
                                                                                     and prevent violence and drug abuse among children
                                                                                     and youth.
                                           Source: GAO summary of HHS information.
                                           a
                                           In April 2012, HHS created the ACL by combining the Administration on Aging (AOA), the Office on
                                           Disability, and the Administration on Intellectual and Developmental Disabilities.


                                           VA also identified clinical preventive services and community-oriented
                                           preventive health activities in the programs it administers for veterans and
                                           other beneficiaries in VA facilities. Examples of the clinical preventive
                                           services that VA provides to beneficiaries who are eligible for such
                                           services include immunizations; dental cleanings; depression screenings;
                                           post-traumatic stress screenings; diabetes screenings; hypertension
                                           screenings; tobacco use screenings and counseling; and screenings for



                                           Page 16                                                    GAO-13-49 Preventive Health Activities
breast cancer, cervical cancer, and colorectal cancer. VA provides these
services to beneficiaries in VA medical centers, community-based
outpatient clinics, and other VA facilities. 16 In addition, VA’s National
Center for Health Promotion and Disease Prevention provides support for
clinical staff in VA medical facilities and coordinates VA’s community-
oriented preventive health activities. For example, the center leads the
department’s efforts to provide guidance to clinicians and veterans on a
range of clinical preventive services, and administers the department’s
MOVE! Weight Management Program. VA’s Clinical Public Health
Group—an office that addresses public health concerns through, among
other things, education and outreach, policy development, and
research—also administers community-oriented preventive health
activities, including prevention education for tobacco use, human
immunodeficiency virus (HIV), and influenza.

In addition, DOD identified clinical preventive services and community-
oriented preventive health activities included in programs administered
through the department’s direct care and purchased care systems for
active duty personnel and other beneficiaries, including retired
servicemembers. Examples of services include immunizations;
depression screenings; dental screenings; diabetes screenings; obesity
screenings; vision screenings; and screenings for breast cancer, cervical
cancer, and colorectal cancer. DOD’s direct care system also includes
community-oriented preventive health activities such as tobacco
cessation and obesity and alcohol abuse prevention programs. For
example, DOD’s TRICARE Management Activity coordinates the Quit
Tobacco—Make Everyone Proud program, which is a tobacco cessation
marketing and education campaign to increase awareness of the negative
effects of tobacco use and decrease its use and acceptance in the
military work environment. DOD also reported that the Duncan Hunter
National Defense Authorization Act for Fiscal Year 2009 required DOD to
reduce beneficiary cost sharing and undertake certain preventive health
activities. 17 (For more information on these provisions, see app. I.)



16
  In addition to services it provides directly, VA also operates a fee-based purchased care
program that covers health care services—including dental services, outpatient care,
inpatient care, emergency care, and medical transportation—provided to eligible veterans
outside of the VA when a VA facility is not available. Total annual fee payments under this
program were about $3.8 billion in fiscal year 2009. VA did not identify clinical preventive
services provided through its fee-based purchased care program.
17
 Pub. L. No 110-417, §§711-714, 122 Stat. 4356, 4500-04 (2008).




Page 17                                              GAO-13-49 Preventive Health Activities
HHS, VA, and DOD Do Not   HHS, VA, and DOD reported that they do not specifically track
Track Department-wide     department-wide spending 18 on preventive health activities and that
Spending for Preventive   determining total spending on preventive health activities is challenging
                          because such activities are often integrated with other activities.
Health Activities, but    According to HHS, VA, and DOD officials, spending for preventive health
Provided a Mix of         activities is not easily distinguished in their data from spending on other
Information Related to    health activities. For example, VA and DOD officials reported that it can
Spending for Preventive   be challenging to identify the portion of spending linked to a clinical
                          preventive service and identify the portion that is for treatment when both
Health Activities         types of services are provided in a single patient visit. The departments
                          noted that they are not required to specifically track department-wide
                          spending on all the preventive health activities included in the programs
                          they administer.

                          HHS, VA, and DOD provided us with a mix of information related to
                          spending for preventive health activities, and noted limitations associated
                          with the information. For example, some spending for preventive health
                          activities was not included, or prevention-related spending was included
                          but was not for preventive health activities. In addition, in some cases,
                          information provided by HHS and VA did not present estimated spending
                          for these activities, but rather funding, which represents an amount
                          available at a particular time, but does not necessarily reflect actual
                          spending that occurred. 19 Funding estimates provided by HHS and VA
                          suggest that there was spending on preventive health activities, but the
                          funding estimates may not represent the amounts that were spent on the




                          18
                            Spending means obligations, including those for which expenditures have been made.
                          The term obligation refers to a definite commitment by a federal agency that creates a
                          legal liability to make payments immediately or in the future. Agencies incur obligations,
                          for example, when they award grants or contracts to private entities. An expenditure is the
                          actual spending of money by the issuance of checks, disbursement of cash, or electronic
                          transfer of funds made to liquidate a federal obligation. See GAO, A Glossary of Terms
                          Used in the Federal Budget Process, GAO-05-734SP (Washington, D.C.: September
                          2005).
                          19
                            When spending estimates were not readily available, HHS and VA provided available
                          information for funding for those activities. Funding means budget authority, which is the
                          authority provided by federal law to enter into financial obligations that will result in
                          immediate or future outlays involving federal government funds.




                          Page 18                                              GAO-13-49 Preventive Health Activities
      activities. For example, a department may not have spent all of its
      available funding for a preventive health activity. 20

HHS   The most readily available information related to preventive health
      activities compiled by HHS is found in its annual crosscut briefing
      documents—documents that are used by HHS’s Office of the Secretary to
      make budget-related decisions and to answer questions from Congress
      and others related to the President’s annual budget request. ASFR
      compiles the information for these documents, but in its requests for
      information from the agencies for the documents, it has not provided
      agencies with a specific definition of activities to include in their
      prevention estimates nor specified a method for calculating an estimate.
      These annual crosscut briefing documents on prevention provide a mix of
      spending and funding estimates for prevention-related activities that
      include, but are not limited to, preventive health activities, and in recent
      years did not include estimates for CMS, which oversees health coverage
      programs for over 100 million individuals. In particular:

      •    The most recent annual crosscut briefing document on prevention
           available at the time of our review included estimates of spending for
           one HHS agency and funding for nine HHS agencies for fiscal year
           2011. 21

      •    The document did not include an estimate of spending for fiscal year
           2011 for CMS—that is, it did not include estimated spending for
           preventive health activities in Medicare, Medicaid, and the Children’s
           Health Insurance Program. 22


      20
        Funding represents an amount available at a particular time for spending (obligation and
      expenditure) for what may potentially be a range of activities including but not limited to
      preventive health activities. Funding amounts may not actually have been spent for the
      activities expected at the time the amounts were made available (for example, within
      applicable authority, amounts may have been subsequently transferred to other accounts
      or reprogrammed within an existing account in a departmental budget) and, even if spent
      for those activities, it may not be clear whether they were preventive in nature.
      21
        The most recent crosscut briefing document on prevention in our review included the
      estimated amount of requested funding related to the President’s budget request for fiscal
      year 2012 and estimated spending on or funding for prevention for fiscal year 2011.
      22
        The most recent estimate for CMS that was included in an HHS annual crosscut briefing
      document on prevention we reviewed was for fiscal year 2008. CMS’s estimated spending
      for prevention reported for that year was about $39 billion, but CMS noted that this
      estimate did not include preventive services covered by Medicare or Medicaid through
      managed care and included substantial amounts for treatment services provided.




      Page 19                                              GAO-13-49 Preventive Health Activities
     •    The document included estimates for prevention-related activities that
          include, but are not limited to, clinical preventive services and
          community-oriented preventive health activities. That is, the document
          included estimates of other prevention-related funding or spending
          such as emergency preparedness, environmental health, and
          occupational safety. For example, HHS’s prevention estimates
          included funding for the Food and Drug Administration’s (FDA)
          oversight of food safety, tobacco products, and medical products. 23

     The most recent HHS annual crosscut briefing document included in our
     review reported that for one agency (NIH), estimated spending on
     prevention for fiscal year 2011 was about $6 billion, and that estimated
     funding for prevention for nine agencies—ACF, AHRQ, AOA, CDC, FDA,
     HRSA, IHS, OASH, and SAMHSA—was about $18 billion that year. The
     annual crosscut briefing document did not include any estimated
     spending for fiscal year 2011 for CMS. (See app. II for more information
     on HHS’s prevention estimates.)

VA   VA estimated spending of about $576 million for providing selected
     clinical preventive services in its VA medical facilities, including VA
     medical centers, outpatient clinics, and other facilities. VA’s estimated
     spending included UPSTSF-recommended services and other clinical
     preventive services that VA provided to its beneficiaries in outpatient
     settings in fiscal year 2011. The estimate also included estimated related
     spending for salaries and benefits for providers, administrative activities,
     and maintenance of facilities. VA did not include estimated spending for
     pharmaceutical drugs, services provided through VA’s purchased care
     program (which covers health care services provided to eligible veterans
     outside of VA when a VA facility is not available) or services provided in
     an inpatient setting. VA also provided its estimates of funding (totaling
     over $5 million) for its National Center for Health Promotion and Disease
     Prevention, which is responsible for developing the resources that
     support VA medical centers in providing community-oriented preventive
     health activities, and its Clinical Public Health Group’s community-
     oriented preventive health activities for fiscal year 2011. VA officials told
     us that individual VA medical facilities may have conducted additional
     community-oriented preventive health activities, such as taking measures



     23
       According to FDA, FDA activities are related to prevention, but do not include clinical
     preventive health activities or community-oriented preventive health activities.




     Page 20                                               GAO-13-49 Preventive Health Activities
                           to increase testing for HIV, that are not included in VA’s estimates. (See
                           app. III for more information on VA’s estimates of spending and funding.)

DOD                        DOD estimated spending about $1 billion to provide selected clinical
                           preventive services, including (but not limited to) services recommended
                           by the USPSTF, through its direct care and purchased care systems to
                           active duty personnel, retired servicemembers, and other beneficiaries for
                           fiscal year 2011. DOD also estimated spending about $407 million on
                           some of its community-oriented preventive health activities and other
                           activities (such as epidemiology) in DOD’s direct care system for fiscal
                           year 2011. DOD’s spending estimates also have limitations. For example,
                           because DOD’s estimates were limited to a review of purchased care
                           claims and direct care data records, spending for some clinical preventive
                           services—such as counseling about smoking cessation provided during a
                           visit in which the patient received services for hypertension—is not
                           included in the estimates. Also, while DOD’s estimates of spending
                           include amounts for some community-oriented preventive health
                           activities, they also include estimated spending on other activities (such
                           as those related to drinking water safety and food and facility sanitation);
                           DOD noted that it cannot separately identify spending specifically for the
                           community-oriented preventive health activities. (See app. IV for more
                           information on DOD’s estimates of spending.)



Some Preventive
Health Activities May
Be Cost Saving or
Cost-Effective, but
Multiple Factors
Affect Estimates, and
Key Data May Be
Lacking
Some Preventive Health     Articles in peer-reviewed publications and government and independent
Activities May Result in   reports we reviewed identified some preventive health activities that may
Cost Savings or May Be     result in cost savings and reported that a larger number may be cost-
                           effective. The articles and reports we reviewed identified preventive
Cost-Effective             health activities, such as childhood immunizations, workplace wellness
                           programs, and disease screenings, that have been found in certain


                           Page 21                                     GAO-13-49 Preventive Health Activities
circumstances to be cost saving—that is, the costs averted by the activity,
such as future medical costs to treat a disease or condition, exceed the
cost of implementing it. 24 For example, according to one report that
synthesized the results of three reviews of a number of clinical preventive
services (the synthesis report), several clinical preventive services were
estimated to be cost-saving by one or more of the three reviews. 25 The
report found that two preventive services—counseling on the use of low-
dose aspirin to reduce coronary heart disease and childhood
immunizations—were estimated to be cost-saving by all three reviews.
The National Prevention Council’s National Prevention Strategy also
reported that preventive health activities such as certain diabetes and
tobacco interventions can result in cost savings. 26 The articles and reports
we reviewed, including the synthesis report, also identified a number of
preventive health activities that, while not found to be cost saving, were
estimated to be cost-effective—that is, they provided good value at low
cost relative to alternative activities. 27 The synthesis report identified
several preventive health activities that were estimated by at least one of
the reviews to be cost-effective, including counseling women to use
calcium supplements, colorectal cancer screening, and hepatitis B
screening in pregnant women. Colorectal cancer screening in adults



24
  See, for example, J. T. Cohen, P. J. Neumann, and M. C. Weinstein, “Does Preventive
Care Save Money? Health Economics and the Presidential Candidates,” New England
Journal of Medicine, vol. 358, no. 7 (2008); K. Baicker, D. Cutler, and Z. Song, “Workplace
Wellness Programs Can Generate Savings,” Health Affairs, vol. 29, no. 2 (2010); and
R. S. Braithwaite and S. M. Mentor, “Identifying Favorable-Value Cardiovascular Health
Services,” American Journal of Managed Care, vol. 17, no. 6 (2011).
25
  The report synthesized the findings of work by the National Commission on Prevention
Priorities, the National Business Group on Health, and an academic researcher. According
to the report, these three reviews were included because they all evaluated intervention
costs and health benefits, quantified benefits (for example, in terms of QALYs gained),
and were not limited to a particular intervention or to interventions for a particular
subpopulation. J. T. Cohen and P. J. Neumann, The Cost Savings and Cost-Effectiveness
of Clinical Preventive Care, Research Synthesis Report No. 18 (Princeton, NJ: Robert
Wood Johnson Foundation, September 2009).
26
 National Prevention Council, National Prevention Strategy (Washington, D.C.: U.S.
Department of Health and Human Services, Office of the Surgeon General, 2011).
27
  See, for example, J. W. Kahende et al., “A Review of Economic Evaluations of Tobacco
Control Programs,” International Journal of Environmental Research and Public Health,
vol. 6 (2009) and R. L. Fleurence, C. P. Iglesias, and J. M. Johnson, “The Cost
Effectiveness of Bisphophonates for the Prevention and Treatment of Osteoporosis,”
Pharmacoeconomics, vol. 25, no. 11 (2007).




Page 22                                              GAO-13-49 Preventive Health Activities
                           50 years old and older was found to be cost-effective by all three
                           reviews. 28

                           Articles and reports we reviewed noted that there are important limitations
                           associated with estimates of cost savings and cost-effectiveness. For
                           example, some of the articles noted that preventive health activities that
                           are found not to be cost saving or cost-effective may be less likely to be
                           published in peer-reviewed journals. 29 In addition, the synthesis report
                           noted that there is no evidence that the findings included in the three
                           reviews it examined are representative of the available literature on
                           preventive health activities as a whole.


Multiple Factors Affect    According to articles in peer-review publications and government and
Cost Savings and Cost-     independent reports we reviewed, as well as researchers and federal
Effectiveness Estimates,   officials we interviewed, each cost savings and cost-effectiveness
                           estimate is affected by multiple factors. These include how an activity is
and Key Data May Be        targeted, the assumptions used in calculating cost savings and cost-
Lacking                    effectiveness estimates, and a lack of key data.

                           The targeting of a preventive health activity is an important factor
                           affecting estimates of the cost savings or cost-effectiveness of that
                           activity. Articles in peer-reviewed publications and reports, researchers
                           we interviewed, and CDC officials reported that if a preventive health
                           activity is targeted to a population at a higher risk of developing a specific
                           disease, instead of being provided to the entire population regardless of
                           their risk to develop the disease, the intervention will more likely result in
                           cost savings or be cost-effective. 30 For example, CDC officials told us that


                           28
                             Articles in peer-reviewed publications and reports we reviewed also identified some
                           preventive health activities that have been found not to be cost-effective. For example,
                           one article estimated that screening for type 2 diabetes in all U.S. residents aged 45 years
                           and older who have no other health factors, such as hypertension, was not cost-effective.
                           See R. Li et al., “Cost-Effectiveness of Interventions to Prevent and Control Diabetes
                           Mellitus: A Systematic Review,” Diabetes Care, vol. 33, no. 8 (2010).
                           29
                             See, for example, R. Braithwaite, and S. Mentor. “Identifying Favorable-Value
                           Cadiovacular Health Services,” American Journal of Managed Care, vol. 17, no. 6 (2011)
                           and K. Baicker, D. Cutler, and Z. Song, “Workplace Wellness Programs Can Generate
                           Savings,” Health Affairs, vol. 29, no. 2 (2010).
                           30
                             In some cases, successful targeting can lead to additional costs. For example, if
                           someone is screened for and has high blood pressure, the person may need to take
                           medication or have additional tests for the rest of his or her life, which is an added cost.




                           Page 23                                                GAO-13-49 Preventive Health Activities
childhood vaccinations are often estimated to be cost saving and cost-
effective because the vaccines target a very specific, easy to identify, and
high-risk population at relatively low financial costs. In addition, a CDC
official noted that because the majority of children are at risk for
developing the diseases targeted by the vaccinations, the vaccinations
prevent a large number of diseases and thus avert the costs associated
with the treatment of those diseases. 31 As another example, a review of
smoking cessation programs found that programs targeted to specific
groups of smokers, such as pregnant women, were more cost-effective
than those targeted at the general population of smokers. See table 3 for
an illustration of how targeting can affect estimates of a preventive health
activity’s cost-effectiveness—for example, targeting smokers on the basis
of their levels of low-density lipoprotein (LDL) cholesterol and risk factors
of developing heart disease. 32 However, it can be difficult for physicians,
for example, to know beforehand which patients are at a higher risk of
developing a disease, in order to target a specific preventive health
activity, as the Congressional Budget Office has reported. 33 As a result,
some preventive health activities may be provided to many patients, even
those who will most likely not develop the disease, and costs can
accumulate as the number of patients utilizing the preventive health
activity increases.




31
  According to HHS officials, preventive health activities directed specifically to high-risk
populations, such as children with developmental disabilities and special health care
needs, may realize even greater cost savings and benefit.
32
  Estimates of cost-effectiveness are typically presented as a ratio of the net costs to the
net outcomes of utilizing one preventive health activity over another.
33
  D. Elmendorf, Director, Congressional Budget Office, letter to the Honorable Nathan
Deal, (Washington, D.C.: Aug. 7, 2009). This letter is available online at
https://www.cbo.gov/publication/20967. This letter responds to a question concerning the
Congressional Budget Office’s analysis of the budgetary effects of proposals to expand
governmental support for preventive medical care and wellness services. In making its
estimates of the budgetary effects of expanded governmental support for preventive care,
CBO takes into account any estimated savings accruing within specified time frames that
would result from greater use of such care as well as the estimated costs of that additional
care. CBO’s estimates take into account that preventive care may reduce spending for an
individual and that, to avert one case of acute illness, it is often necessary to provide
preventive care to many patients, most of whom would not have suffered the illness
anyway.




Page 24                                                GAO-13-49 Preventive Health Activities
Table 3: Effect of Targeting on Cost-Effectiveness Ratio for Selected Preventive Health Activities

                                                                                                                     Cost-effectiveness ratio
                                                                                                                                             a
Preventive health activity       Compared to                      Target population                                                 (dollars)
Using a statin to prevent        Diet-based prevention            Male smokers with very high low-density                        $54,000/QALY
                                                                                                b
heart disease                                                     lipoprotein (LDL) cholesterol, high blood
                                                                  pressure, age 35-44 years
                                                                                                                b
Using a statin to prevent        Diet-based prevention            Male smokers with high LDL cholesterol,                        100,000/QALY
heart disease                                                     high blood pressure, age 35-44 years
Using alendronate to prevent     No intervention                  Postmenopausal women with bone marrow                            37,482/QALY
fragility fractures                                               density 2.4 standard deviations below
                                                                  normal, no vertebral abnormalities, age 60
Using alendronate to prevent     No intervention                  Postmenopausal women with bone marrow                          166,219/QALY
fragility fractures                                               density 1.0 standard deviation below
                                                                  normal, no vertebral abnormalities, age 80
                                          Source: GAO summary of information from published research.

                                          Notes: Data are from L. A. Prosser et al., “Cost-Effectiveness of Cholesterol-Lowering Therapies
                                          According to Selected Patient Characteristics,” Annals of Internal Medicine, vol. 132, no. 10 (2000)
                                          and R. L. Fleurence, C. P. Iglesias, and J. M. Johnson, “The Cost Effectiveness of Bisphophonates
                                          for the Prevention and Treatment of Osteoporosis,” Pharamcoeconomics, vol. 25, no. 11 (2007).
                                          a
                                           The cost-effectiveness ratio represents the cost per quality-adjusted life-year (QALY) that would be
                                          added by the activity. A year in perfect health is worth 1 QALY, and a year in less than perfect
                                          health—that is, with any adverse condition—is generally worth between 0 and 1 QALY. The
                                          preventive health activity with the lower cost-effectiveness ratio is preferred because it costs less to
                                          achieve the health outcome. For example, if the cost-effectiveness ratio of one preventive health
                                          activity is $80,000/QALY and that of another activity is $20,000/QALY, the activity with the
                                          $20,000/QALY cost-effectiveness ratio would be preferred.
                                          b
                                            The National Heart, Lung, and Blood Institute (NHLBI) categorizes LDL cholesterol between 160
                                          to189 milligrams per deciliter as high. Very high LDL cholesterol is 190 milligrams per deciliter or
                                          higher. NHLBI categorizes high blood pressure as a diastolic blood pressure of 95 millimeters of
                                          mercury or higher. The target population also has low levels of “good” cholesterol, or high-density
                                          lipoproteins.


                                          Also affecting an estimate of a preventive health activity’s cost savings or
                                          cost-effectiveness are the assumptions used in calculating the estimate,
                                          such as those regarding the effectiveness of the activity, perspective of
                                          the study, and accounting for future medical technology. For example, in
                                          modeling the cost-effectiveness of a vaccine, a researcher might assume
                                          that the vaccine is 90 percent effective at preventing a disease in the
                                          model, but the actual effectiveness of the vaccine may not be known.

                                          •     Assumptions about the effectiveness of the activity. Assumptions
                                                about the effectiveness of an activity can affect estimates of cost
                                                savings or cost-effectiveness. For example, researchers reviewed
                                                multiple estimates of the cost-effectiveness of vaccination against
                                                human papillomavirus (HPV) and found that varying the assumptions
                                                for the vaccine’s effectiveness, the number of years the vaccine would
                                                provide protection against HPV, or the years of costs for additional



                                          Page 25                                                       GAO-13-49 Preventive Health Activities
     screening and testing for HPV produced estimates of the vaccine’s
     cost-effectiveness ranging from $20,600 per QALY to more than
     $3.5 million per QALY. 34

•    The perspective of a study. The perspective of a study—that is, who is
     receiving the benefit or bearing the cost—can affect an estimate of the
     extent to which a preventive health activity is cost saving or cost-
     effective. Many studies are conducted from the perspective of the
     entity providing the preventive health activity, such as an employer or
     hospital system, so the costs and benefits of an activity to an
     individual consumer or others may not be considered. For example, a
     review of multiple estimates of the cost-effectiveness of HIV
     screenings noted that a study conducted from the perspective of the
     entity funding the activity may not incorporate certain costs, such as
     treatment costs, or long-term benefits, such as extension of life
     expectancy. As a result, the study may not reflect all possible costs
     and savings that could result from a preventive health activity.

•    Assumptions about technology. Assumptions about future medical
     technology may also affect a cost saving and cost-effectiveness
     estimate about a preventive health activity. A CDC official told us that
     in projecting the costs and benefits of an activity, the typical
     assumption is that medical technology will be and cost the same
     years into the future, even though technology, which can alter the
     costs and benefits of an activity, can change rapidly over time.

Difficulties in estimating cost savings and cost-effectiveness for a
preventive health activity, including the need to make assumptions, can
arise from a lack of key data. For example, ACIP officials said a challenge
in determining the cost savings or cost-effectiveness of vaccines is that
data needed for the analysis, such as the actual price of a new vaccine,
are not available at the time they make a recommendation. Similarly, data
on outcomes resulting from a preventive health activity are not available


34
  In a study of HPV vaccine, when the researcher assumed the vaccine was 90 percent
effective and provided lifetime protection at a cost of $377 per 3-shot series, it produced a
cost-effectiveness ratio of $24,300 per QALY. When the assumptions were changed to
assume 100 percent effectiveness, the cost-effectiveness improved to $20,600 per QALY.
When researchers used a model with other assumptions for the HPV vaccination strategy
such as vaccination at age 12 years and preventive screenings—annual cervical
screening and liquid-based cytology testing starting at age 18—and compared it to the
next-best strategy, which was similar to this strategy but did not include liquid-based
cytology, cost-effectiveness worsened to more than $3.5 million per QALY.




Page 26                                               GAO-13-49 Preventive Health Activities
for many diseases. A CDC official stated that when a community-oriented
preventive health activity has not been found to be cost-effective, this is
often due to a lack of sufficient data needed to conduct cost-effectiveness
analysis rather than evidence that the activity is not cost-effective. In
some cases, the outcome measures used to study the effects of a
preventive health activity make determining cost-effectiveness difficult.
For example, instead of using an outcome measure such as the cost per
QALY, a study evaluating efforts to increase vaccination may measure
the cost per child immunized. Additional economic modeling would have
to occur, and assumptions be made, in order to convert the data to cost
per QALY. Researchers also noted that some studies that focus on the
effectiveness of preventive health activities do not report costs of the
preventive health activity. A research article that reviewed studies that
estimated cost savings resulting from workplace wellness programs
reported that nearly one-third of the studies in its review did not report
program costs. 35 According to CDC officials, CDC is taking steps to
collect data for cost-effectiveness analyses for programs related to
preventive health activities for which relevant data have been lacking. In
addition, the Institute of Medicine conducted a study to develop a
framework for assessing community-oriented preventive health activities.
This framework considers, among other things, the sources of data that
are available and needed for analysis. 36




35
 K. Baicker, D. Cutler, and Z. Song, “Workplace Wellness Programs Can Generate
Savings,” Health Affairs, vol. 29, no. 2 (2010).
36
  For the report on this study, see the Institute of Medicine website
(http://www.iom.edu/Activities/PublicHealth/CommunityPrevention.aspx, accessed
Nov. 14, 2012).




Page 27                                           GAO-13-49 Preventive Health Activities
                        Data for international comparisons of countries’ spending specifically for
International Data on   preventive health activities are not available. Instead, the most readily
Preventive Health       available data is a category of OECD health data called “prevention and
                        public health services,” 37 which combines spending on certain clinical
Activities Are Not      preventive services and community-oriented preventive health activities,
Available, but United   such as vaccination programs, and public health activities, such as
                        disease surveillance and blood banks. 38 On the basis of these data, the
States Ranks Eighth     United States ranked 8th among 23 OECD member countries in the
in OECD Category        percentage of total health care spending reported for prevention and
That Combines           public health services (see fig. 2). In 2010, U.S. spending on prevention
                        and public health services was about $88.4 billion, or 3.5 percent of total
Spending on             U.S. health care spending of $2.5 trillion—a rate that has remained
Prevention and Public   relatively steady since 2001. 39

Health Services




                        37
                          OECD defines prevention and public health services as services designed to enhance
                        the health status of the population, as opposed to curative services, which repair health
                        dysfunction.
                        38
                          These data are not comparable to the spending and funding estimates provided by
                        HHS, VA and DOD. For example, OECD’s data pertaining to the United States do not
                        capture spending for certain clinical preventive services provided by HHS, VA, and DOD,
                        and combine federal spending with state and local spending.
                        39
                          As of July 2012, OECD posted 2010 health spending data from 28 of its member
                        countries, and posted data for the OECD category of prevention and public health
                        services from 23 of these countries. For the most recent data, see the OECD.Stat
                        database available on OECD’s website
                        (http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT#, accessed July 12,
                        2012). In order to compare spending, OECD converts countries’ health expenditures to a
                        common currency (e.g., U.S. dollars) and makes adjustments to take account of the
                        different purchasing power of the national currencies.




                        Page 28                                              GAO-13-49 Preventive Health Activities
Figure 2: Spending for Prevention and Public Health Services as a Percentage of Total Health Spending, by OECD Member
Country, 2010




                                        Note: This figure presents a summary of 2010 data on health care spending, including spending for
                                        the 23 OECD member countries that submitted data to OECD on the category of prevention and
                                        public health services.


                                        U.S. spending in the OECD category of prevention and public health
                                        services also ranked third highest as a percentage of gross domestic
                                        product among the 23 countries reporting 2010 data to OECD.
                                        Specifically, total U.S. spending on prevention and public health services
                                        was 0.6 percent of U.S. gross domestic product (about $88.4 billion for
                                        prevention and public health spending out of a total gross domestic
                                        product of about $14.4 trillion). Canada and New Zealand spent a higher
                                        percentage of gross domestic product on prevention and public health
                                        services (see fig. 3). U.S. rankings in OECD’s international comparisons
                                        of spending on prevention and public health services as a percentage of
                                        gross domestic product have been generally constant since 2001.



                                        Page 29                                                  GAO-13-49 Preventive Health Activities
Figure 3: Spending for Prevention and Public Health Services as a Percentage of Gross Domestic Product, by OECD Member
Country, 2010




                                       Note: This figure presents a summary of 2010 data on health care spending, including spending for
                                       the 23 OECD member countries that submitted data to OECD on the category of prevention and
                                       public health services.


                                       U.S. spending per capita on prevention and public health services was
                                       $286.11, second highest, behind Canada (see fig. 4). U.S. rankings in
                                       OECD’s international comparisons of spending on prevention and public
                                       health services per capita have also been fairly constant since 2001.




                                       Page 30                                                  GAO-13-49 Preventive Health Activities
Figure 4: Spending for Prevention and Public Health Services per Capita, by OECD Member Country, 2010




                                        Note: This figure presents a summary of 2010 data on health care spending, including spending for
                                        the 23 OECD member countries that submitted data to OECD on the category of prevention and
                                        public health services. OECD adjusted spending per capita for purchasing power parity.


                                        While OECD’s data are frequently used to make international
                                        comparisons, there are limitations in using OECD’s data to make
                                        international comparisons on spending included in the prevention and
                                        public health services category. For this category, OECD requested that
                                        countries submit data that include spending on certain types of preventive
                                        health and public health activities, such as maternal and child health
                                        activities and school health services. However, member countries do not
                                        always consistently report spending for this category. For example, the
                                        data submitted by the United States reflect federal, state, and local
                                        government spending for maternal and child health activities, school
                                        health services, and certain other preventive health and public health
                                        activities, but do not include government or private sector spending on



                                        Page 31                                                  GAO-13-49 Preventive Health Activities
               clinical preventive services provided in physicians’ offices or hospitals. 40
               In contrast, the data submitted by other OECD countries may include
               amounts spent on preventive health activities by the private sector in
               physicians’ offices or hospitals. While there are known limitations to using
               OECD data, experts we interviewed reported that the OECD data are the
               best available data for comparing U.S. spending on prevention and public
               health services with that of other countries, and the data have been
               frequently used to make international comparisons. 41 An OECD official
               told us that OECD is taking steps to improve the comparability of the data
               in the future by, for example, providing clarity about the criteria that
               should be used by member countries to report prevention-related data.
               The official noted that it will be a couple of years before these data are
               available.


               Preventive health activities have received attention over the past several
Concluding     years for their potential impact on health care spending or health
Observations   outcomes. However, HHS, VA, and DOD do not track department-wide
               spending on preventive health activities, and identifying spending on such
               activities is challenging because they are often integrated with other
               activities. Further, estimating cost savings and cost-effectiveness of
               preventive health activities is difficult because of the multiple factors that
               can affect these estimates, including the need to make assumptions and
               a lack of key data. These methodological challenges, as well as a lack of
               widespread agreement on what constitutes a preventive health activity,
               are important considerations that affect the completeness and precision
               of available information on preventive health activities.




               40
                 U.S. spending for health care services provided in physicians’ offices and hospitals,
               including both treatment services and preventive health activities, are included in a
               different OECD spending category. Private sector spending in OECD’s prevention and
               public health services category includes privately funded occupational health care and
               prevention and public health services provided by charities, other nongovernmental
               organizations, and voluntary organizations.
               41
                 For example, the Institute of Medicine used OECD data to compare the United States to
               other nations in per capita health expenditures and health outcomes, such as infant
               mortality, for a recent report on public health financing. See Institute of Medicine, For the
               Public’s Health: Investing in a Healthier Future (Washington, D.C.: The National
               Academies Press, 2012).




               Page 32                                               GAO-13-49 Preventive Health Activities
                  HHS, VA, and DOD reviewed a draft of this report. DOD concurred with
Agency Comments   the draft report. HHS and VA provided technical comments, which we
                  incorporated as appropriate.


                  As agreed with your offices, unless you publicly announce its contents
                  earlier, we plan no further distribution of this report until 30 days from the
                  report date. At that time, we will send copies of this report to the
                  Secretary of Health and Human Services, Secretary of Veterans Affairs,
                  Secretary of Defense, and interested congressional committees. In
                  addition, the report will be available at no charge on the GAO website at
                  http://www.gao.gov.

                  If you or your staff have any questions regarding this report, please
                  contact me at (202) 512-7114 or iritanik@gao.gov. Contact points for our
                  Offices of Congressional Relations and Public Affairs may be found on
                  the last page of this report. GAO staff who made key contributions to this
                  report are listed in appendix V.




                  Katherine Iritani
                  Director, Health Care




                  Page 33                                       GAO-13-49 Preventive Health Activities
Appendix I: Requirements Related to
              Appendix I: Requirements Related to
              Preventive Health Activities in the Duncan
              Hunter National Defense Authorization Act


Preventive Health Activities in the Duncan
Hunter National Defense Authorization Act
              The Duncan Hunter National Defense Authorization Act for Fiscal Year
              2009 requires DOD to reduce beneficiary cost sharing for preventive
              health activities and undertake certain preventive health activities, 1 as
              follows:

              •   Section 711: Waiver of Copayments for Preventive Services for
                  Certain TRICARE Beneficiaries. Requires the Secretary of Defense to
                  promulgate rules eliminating beneficiary cost-sharing previously
                  associated with certain preventive services (such as colorectal cancer
                  screening, breast cancer screening, cervical cancer screening,
                  prostate cancer screening, annual physical exams, and vaccinations)
                  for beneficiaries enrolled in TRICARE’s fee-for-service program who
                  are not eligible for Medicare. Beneficiaries enrolled in TRICARE’s
                  managed care option already received these services with a zero cost
                  share. In December 2011, DOD issued a final rule implementing this
                  provision by eliminating beneficiary cost sharing for certain preventive
                  services provided on or after October 14, 2008. 2

              •   Section 712: Military Health Risk Management Demonstration Project.
                  Requires the Secretary of Defense to conduct a demonstration project
                  designed to evaluate the efficacy of providing incentives to encourage
                  healthy behaviors on the part of non-Medicare-eligible retired
                  beneficiaries, including their dependents, enrolled in TRICARE’s
                  managed care option. Authorizes the Secretary to offer incentives to
                  encourage participation in the demonstration project; accordingly,
                  beneficiaries were offered a monetary incentive award for full
                  compliance with the demonstration’s requirements. Single participants
                  would receive $115, and participants with family members would
                  receive $230. In its interim report submitted to Congress in August
                  2011, DOD reported that it began implementing the demonstration
                  project in October 2010, and that it was monitoring patients for
                  compliance from January 2011 through December 2011. According to
                  DOD, incentive payments were disbursed in June 2012. DOD also
                  reported that the department had been collecting data to estimate
                  costs avoided as a result of decreased health risk conditions and that
                  results would be included in a final report to Congress, which DOD
                  anticipates submitting by December 2012.



              1
               Pub. L. No. 110-417, §§ 711-714, 122 Stat. 4356, 4500-04 (2008).
              2
               76 Fed. Reg. 81368 (Dec. 28, 2011) (to be codified at 32 C.F.R. §§ 199.4 and 199.17).




              Page 34                                            GAO-13-49 Preventive Health Activities
Appendix I: Requirements Related to
Preventive Health Activities in the Duncan
Hunter National Defense Authorization Act




•   Section 713: Smoking Cessation Program under TRICARE. Requires
    the Secretary of Defense to establish a smoking cessation program to
    be available to TRICARE beneficiaries who are not eligible for
    Medicare. Requirements for the program include providing no-cost,
    smoking cessation pharmaceuticals; counseling; access to a toll-free
    24/7 quit line with counseling; and access to printed and Internet-
    based tobacco cessation material. According to DOD, program
    implementation planning has been ongoing. DOD issued a proposed
    rule in September 2011. 3 As of July 2012, a final rule had not been
    published. DOD also reported that access to printed materials and
    web-based information on smoking cessation has been available to
    TRICARE beneficiaries, and that a final status report to Congress will
    be submitted following full implementation of the Smoking Cessation
    Program under TRICARE.

•   Section 714: Preventive Health Allowance. Requires the Secretary of
    Defense to conduct a demonstration project to evaluate whether
    providing an annual allowance (called a preventive health services
    allowance) would increase the use of preventive health services by
    members of the Armed Forces and their family members. Preventive
    services under this section included colorectal, breast, cervical, and
    prostate cancer screening; an annual physical exam; an annual dental
    exam; weight and body mass screening, and vaccinations. The
    demonstration, which began on December 1, 2009, was limited to
    1,500 members from each of the Army, Navy, Air Force, and Marine
    Corps. The amount of the allowance for compliance with the required
    preventive health services was set at $500 for single participants, and
    $1,000 for those enrolled with dependents, and the demonstration
    ended December 31, 2011. Although the final report was due no later
    than March 31, 2012, the department anticipates submitting the final
    report to Congress by December 2012 to allow for complete
    collection, review, and analysis of the data.




3
76 Fed. Reg. 58199 (Sept. 20, 2011) (to be codified at 32 C.F.R. §§ 199.4 and 199.21).




Page 35                                           GAO-13-49 Preventive Health Activities
Appendix II: Department of Health and
              Appendix II: Department of Health and Human
              Services Estimates of Spending and Funding
              for Preventive Health Activities


Human Services Estimates of Spending and
Funding for Preventive Health Activities
              The Department of Health and Human Services (HHS) does not track
              department-wide spending on preventive health activities, but the
              department provided us with a mix of information related to spending for
              preventive health activities and noted limitations associated with the
              information. For nine HHS agencies, HHS provided agency-level
              estimates of funding for prevention-related activities, which include but
              are not limited to preventive heath activities (clinical preventive services
              or community-oriented preventive health activities). 1 For the National
              Institutes of Health (NIH), HHS provided estimated spending on
              prevention-related activities.

              HHS’s estimates of funding for most of its agencies and estimates of
              spending for NIH were prepared by the department as part of its annual
              crosscut briefing document on prevention. 2 HHS’s Office of the Secretary
              uses this document to make budget-related decisions and answer
              questions from Congress and others related to the President’s annual
              budget request. 3 In its fiscal year 2012 crosscut briefing document
              (related to the President’s budget request for fiscal year 2012), HHS



              1
               Funding means budget authority, which is the authority provided by federal law to enter
              into financial obligations that will result in immediate or future outlays involving federal
              government funds. See GAO, A Glossary of Terms Used in the Federal Budget Process,
              GAO-05-734SP (Washington, D.C.: September 2005). Funding represents an amount
              available at a particular time for spending (obligation and expenditure) for what may
              potentially be a range of activities including but not limited to preventive health activities.
              Funding amounts may not actually have been spent for the activities expected at the time
              the amounts were made available (for example, within applicable authority, amounts may
              have been subsequently transferred to other accounts or reprogrammed within an existing
              account in the department’s budget) and, even if spent for those activities, it may not be
              certain that they were preventive in nature. In some instances, HHS agencies reported
              budget authority, transfers, and user fees available for obligation separately. We report
              information as provided to us by HHS agencies.
              2
               HHS does not define prevention for the purposes of its annual crosscut briefing
              documents on prevention. In addition to preventive health activities (clinical preventive
              services and community-oriented preventive health activities), HHS may include in
              prevention activities such as emergency preparedness, environmental health, and
              occupational safety activities. HHS, VA, and DOD participate in the National Prevention
              Council, which consists of 17 departments, agencies, and offices across the federal
              government—representing sectors such as housing, transportation, education,
              environment, and defense—that promote prevention and wellness. Information about the
              council is available at http://www.healthcare.gov/prevention/nphpphc (accessed Aug. 30,
              2012).
              3
               HHS also prepares crosscut briefing documents that estimate department-wide funding
              for other health-related topics, such as behavioral health, patient safety, and tobacco.




              Page 36                                                GAO-13-49 Preventive Health Activities
Appendix II: Department of Health and Human
Services Estimates of Spending and Funding
for Preventive Health Activities




combined its fiscal year 2011 funding estimates for prevention for nine
HHS agencies with NIH’s spending (specifically, obligations) estimate for
prevention and reported a total of about $24 billion. However, this 2011
estimate excluded the Centers for Medicare & Medicaid Service’s (CMS)
Medicare and Medicaid programs and the Children’s Health Insurance
Program. 4 The fiscal year 2011 estimate that included funding for
programs administered by nine HHS agencies and spending for programs
administered by NIH included clinical preventive services and community-
oriented preventive health activities, as well as other prevention-related
activities that HHS agencies did not identify as clinical preventive services
or community-oriented preventive health activities. For example, HHS
included in its prevention estimates funding for Food and Drug
Administration (FDA) oversight of drugs and medical devices.

The HHS annual crosscut briefing documents on prevention are limited in
multiple ways. First, HHS officials told us that each HHS agency used its
own criteria to identify prevention funding—that is, HHS agencies did not
use a uniform definition of prevention. As a result, activities that are
similar in nature may have been included in one but not in another
agency’s estimate. Second, the agency estimates do not always
represent the same kind of information. For example, funding estimates
for most agencies represent budget authority, but estimates as reported
for CDC represent budget authority, transfers, and user fees that the
agency had authority to obligate as separate categories. Third, criteria
used by an agency to identify the activities to include in its prevention
estimate may not have always been consistently applied by that agency.
The annual crosscut briefing document included the following estimates
for fiscal year 2011 for 10 HHS agencies:

•   Administration for Children and Families (ACF). The document
    included estimated funding of $330 million for prevention.

•   Agency for Healthcare Research and Quality (AHRQ). The document
    included estimated funding of $28 million for prevention.




4
 The most recent estimate for CMS that was included in an HHS annual crosscut briefing
document on prevention we reviewed was for fiscal year 2008. CMS’s estimated spending
for prevention reported for that year was about $39 billion, but CMS noted that this
estimate did not include preventive services covered by Medicare or Medicaid through
managed care and included substantial amounts for treatment, rather than prevention.




Page 37                                           GAO-13-49 Preventive Health Activities
Appendix II: Department of Health and Human
Services Estimates of Spending and Funding
for Preventive Health Activities




•   Administration on Aging (AOA). 5 The document included estimated
    funding of $24 million for prevention.

•   Centers for Disease Control and Prevention (CDC). The document
    included estimated funding of $11.4 billion for prevention. The
    $11.4 billion estimate includes budget authority, transfers, and user
    fees that the agency had authority to obligate as separate categories. 6

•   FDA. The document included estimated funding of $3 billion for
    prevention. The estimate represents user fees that the agency had
    authority to obligate and other budget authority as separate categories
    and, according to FDA officials, excludes infrastructure funding such
    as funding for facilities and rent-related activities. According to FDA,
    the agency’s activities included in its estimate do not include clinical
    preventive services or community-oriented preventive health activities.

•   Health Resources and Services Administration (HRSA). The
    document included estimated funding of $1.3 billion for prevention.
    Although HRSA’s estimate included multiple programs administered
    by the agency, the estimate did not include all of the agency’s funding
    for prevention. According to HRSA officials, HRSA’s estimate included
    funding for a program (the National Health Service Corps) that places
    primary care providers in underserved areas, but did not include any
    of the funding for its Health Center Program, which also provides
    primary care services in underserved areas. According to HRSA
    officials, the Health Center Program will be included in the prevention
    estimates in the future.

•   Indian Health Service (IHS). The document included estimated
    funding of $953 million for prevention.




5
 In April 2012, HHS created the Administration for Community Living (ACL) by combining
AOA, the Office on Disability, and the Administration on Intellectual and Developmental
Disabilities.
6
  This estimate consisted of all of CDC’s available funding for fiscal year 2011. However, at
the time the estimate was compiled, the agency was operating under a series of
continuing resolutions. CDC indicated that subsequent enactment of the fiscal year 2011
full-year continuing resolution resulted in a downward adjustment for CDC’s funding for
fiscal year 2011, to about $11.0 billion.




Page 38                                               GAO-13-49 Preventive Health Activities
Appendix II: Department of Health and Human
Services Estimates of Spending and Funding
for Preventive Health Activities




•   NIH. Instead of estimated funding, the document included estimated
    spending—specifically, obligations—for prevention of $6 billion. 7

•   Office of the Assistant Secretary for Health (OASH). The document
    included estimated funding of $255 million for prevention.

•   Substance Abuse and Mental Health Services Administration
    (SAMHSA). The document included estimated funding of $719 million
    for prevention.




7
 NIH publishes information on spending for prevention on its website
(http://report.nih.gov/categorical_spending.aspx).




Page 39                                             GAO-13-49 Preventive Health Activities
Appendix III: Department of Veterans Affairs
              Appendix III: Department of Veterans Affairs
              Estimates of Spending and Funding for
              Preventive Health Activities


Estimates of Spending and Funding for
Preventive Health Activities
              The Department of Veterans Affairs (VA) does not specifically track
              department-wide spending on preventive health activities, but it provided
              estimates of spending and funding. VA estimated its spending on certain
              clinical preventive services for VA beneficiaries, and estimated its funding
              for certain community-oriented preventive health activities.

              VA estimated that its spending—specifically, its obligations—for providing
              certain clinical preventive services to eligible veterans and nonveterans in
              an outpatient setting in fiscal year 2011 totaled about $576 million. 1 VA’s
              fiscal year 2011 estimate includes estimated obligations for providing
              clinical preventive services in all VA medical facilities, including VA
              medical centers, outpatient clinics, and other facilities. 2 Examples of the
              clinical preventive services included in the estimate are dental cleaning;
              depression screening; post-traumatic stress screening; immunizations;
              diabetes screening; hypertension screening; tobacco use screening and
              counseling; and screenings for breast cancer, cervical cancer, and
              colorectal cancer. The Veterans Health Administration’s (VHA) Allocation
              Resource Center 3 reported that the clinical preventive services included
              in the analysis were identified by VA’s National Center for Health
              Promotion and Disease Prevention. The services included (but were not
              limited to) those recommended by the U.S. Preventive Services Task
              Force (USPSTF).



              1
               According to VA, the estimates it provided are the department’s estimated obligations,
              and the estimated amount is about 2.2 percent of the total obligations (about $26 billion) of
              providing outpatient clinical services through VA facilities in fiscal year 2011.
              2
               VA included in its estimate the estimated obligations associated with clinical preventive
              services provided in outpatient settings in VA facilities, including estimated obligations for
              salaries and benefits for providers, administrative activities, and maintenance of facilities.
              VA did not include estimated obligations for pharmaceutical drugs, services provided for
              purchased care (provided to eligible veterans outside of VA when a VA facility is not
              available) or services provided in an inpatient setting. To estimate obligations, VA used
              the Decision Support System, which is an activity-based cost accounting system that
              generates estimates of the cost of individual VA hospital stays and health care
              encounters. If the first procedure or diagnosis in a VA beneficiary’s encounter was a
              clinical preventive service, then VA estimated that 90 percent of the cost of the encounter
              was for preventive health activities. If the procedure or diagnosis was not listed first, then
              VA estimated that 25 percent of the cost of the encounter was for preventive health
              activities. According to VA, nearly two-thirds of the encounters used for the estimate had
              preventive services listed first.
              3
               VHA administers VA’s health care system, and VHA’s Allocation Resource Center is
              responsible for developing, implementing, and maintaining management information
              systems that provide data for VHA’s budget process.




              Page 40                                                GAO-13-49 Preventive Health Activities
Appendix III: Department of Veterans Affairs
Estimates of Spending and Funding for
Preventive Health Activities




VA reported limitations associated with its estimated obligations for
providing clinical preventive services in its facilities. VA reported that it
cannot determine when certain services included in the estimate, such as
colonoscopies, were provided for preventive purposes or for treatment
purposes. In addition, VA could not identify the provision of certain clinical
preventive services, such as sexually transmitted infections counseling for
adults at increased risk, and therefore these services were not included in
the estimates.

VA also reported that fiscal year 2011 funding for its National Center for
Health Promotion and Disease Prevention—which is responsible for
developing the resources that support VA medical centers in providing
community-oriented preventive health activities—totaled about $4 million
(out of its fiscal year 2011 total budget authority for health care of about
$50.7 billion). The funding amount includes all of the center’s activities,
such as the MOVE! Weight Management Program. VA also reported that
funding for its Clinical Public Health Group’s community-oriented
preventive health activities in fiscal year 2011 totaled about $1.4 million.
Examples of the Clinical Public Health Group’s activities include the HIV
Prevention Handbook, the VA Flu Manual, VA’s Infection: Don’t Pass It
On campaign, and developing and printing tobacco cessation educational
materials. VA officials told us that individual VA medical facilities may
have conducted additional community-oriented preventive health
activities, such as measures to increase testing for HIV, that are not
included in VA’s estimates.




Page 41                                        GAO-13-49 Preventive Health Activities
Appendix IV: Department of Defense
              Appendix IV: Department of Defense Estimates
              of Spending for Preventive Health Activities



Estimates of Spending for Preventive Health
Activities
              The Department of Defense (DOD) does not specifically track
              department-wide spending on preventive health activities, but it estimated
              its spending for providing certain clinical preventive services through its
              direct care and purchased care systems. In addition, DOD estimated its
              spending on some of the community-oriented preventive health activities
              and other activities such as epidemiology provided in its direct care
              system.

              DOD estimated that its spending for providing selected clinical preventive
              services, including but not limited to services recommended by the U.S.
              Preventive Services Task Force (USPSTF), through its direct care and
              purchased care systems totaled about $1 billion in fiscal year 2011 and
              about $969 million in fiscal year 2010. 1 Examples of clinical preventive
              services included in the estimates are vision and dental screenings;
              immunizations; hypertension screening; cardiovascular disease
              screening; and screenings for breast cancer, cervical cancer, and
              colorectal cancers. In each year, more than three-fourths of DOD’s
              estimated spending for clinical preventive services was spent in its direct
              care system. (See table 4.)

              Table 4: DOD Estimates of Spending for Providing Clinical Preventive Services in
              DOD’s Direct Care and Purchased Care Systems, Fiscal Years 2010 and 2011

               DOD system                                    2010                  2011                      Total
               Direct care                            $751,943,686       $816,160,851             $1,568,104,537
               Purchased care                          217,512,837         266,147,691              $483,660,527
               Total                                  $969,456,522     $1,082,308,542             $2,051,765,064
              Source: GAO summary of DOD estimates.

              Note: Pharmacy costs, laboratory costs, and facility costs are not included in the purchased care
              estimates of spending. Rows and columns may not total due to rounding.




              1
               DOD estimated spending for providing selected clinical preventive services in its direct
              care system using encounter data from the Comprehensive Ambulatory/Professional
              Record dataset and in its purchased care system using encounter data from the TRICARE
              Encounter Data Non-Institutional Data dataset. Both datasets are contained in DOD’s
              Military Health System Data Repository. DOD’s spending estimates are based on
              estimated costs using a relative value unit that adjusted for quantity and provider
              specialties.




              Page 42                                                    GAO-13-49 Preventive Health Activities
Appendix IV: Department of Defense Estimates
of Spending for Preventive Health Activities




DOD reported limitations associated with its estimated spending for
providing clinical preventive services through its direct care and
purchased care systems. 2 Because its estimates were limited to a review
of purchased care claims and direct care data records, the costs for some
clinical preventive services are not included in the spending estimates.
For example, a patient who receives services for hypertension may also
receive counseling about smoking cessation from the provider during a
visit. The counseling would not be captured in the data used for DOD’s
estimates. Also, pharmacy costs, laboratory costs, and facility costs in the
military treatment facilities are included in the direct care spending
estimates but not in the purchased care spending estimates.

DOD also estimated its spending—specifically, obligations—on some of
its community-oriented preventive health activities and other activities
such as epidemiology provided in its direct care system. DOD’s estimated
obligations for these activities totaled about $326 million in fiscal year
2009, about $379 million in fiscal year 2010, and about $407 million in
fiscal year 2011. DOD included some community-oriented preventive
health activities coordinated by DOD’s TRICARE Management Activity in
these estimates. Specifically, the estimates included DOD’s “That Guy”
alcohol education campaign and the Quit Tobacco—Make Everyone
Proud program (a tobacco cessation marketing and education campaign),
as well as other activities such as drinking water safety, and food and
facility sanitation. DOD noted that it cannot separately identify spending
specifically for the community-oriented preventive health activities.




2
 According to DOD, the total costs of providing clinical services to beneficiaries through its
purchased care system in fiscal year 2011 represented 48 percent of its total costs for
providing clinical services.




Page 43                                               GAO-13-49 Preventive Health Activities
Appendix V: GAO Contact and Staff
                  Appendix V: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Katherine Iritani, (202) 512-7114 or iritanik@gao.gov
GAO Contact
                  In addition to the contact named above, Kim Yamane, Assistant Director;
Staff             George Bogart; Hernan Bozzolo; Cathy Hamann; and Toni Harrison
Acknowledgments   made key contributions to this report.




(290979)
                  Page 44                                    GAO-13-49 Preventive Health Activities
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