Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

This study addresses a perceived need for the US health care system to transition from a culture of reactive treatment of disease to one of proactive disease prevention and health promotion (henceforth "prevention"). As a first step, we need metrics and methods to measure spending on prevention as a basis for understanding the current distribution of funds between prevention and treatment and to promote discussion regarding both the amount that should be spent on prevention and how that amount would best be distributed among various prevention activities.

It is commonly asserted that about 3 percent of national health expenditures are for prevention as opposed to treatment. However, this figure is based upon a study that is nearly 20 years old and that is no longer available except in executive summary. It is impossible to determine from existing documentation exactly how this figure was estimated or even how prevention was defined. One of the objectives of our study has been to develop annual estimates of national health expenditures on prevention using precise definitions, an open description of the methods, and a subdivision of the estimates into components so that individual researchers can apply their own concepts of what classes of activities should be viewed as prevention.

Our characterization of prevention activities employs the standard categories of primary prevention and secondary prevention and the expenditure breakout of the National Health Expenditure Accounts (NHEA), including the categories of personal health care (with subcategories of clinical services and dental services), public health activity, and research. Because the NHEA do not identify expenditures for prevention, we use information from supplementary national data sources, literature, and expert judgment to estimate the portion of each NHEA category that is associated with primary prevention and with secondary prevention.

These expenditure estimates should improve the precision of discussions of the share of national health expenditures going to prevention. However, the more important issues are whether that share is appropriate and whether the allocation across different preventive activities could be improved. The second phase of this study will take some initial steps toward capturing what is currently known on these issues. There is a huge body of literature containing estimates of the cost-effectiveness of a wide variety of specific preventive and medical treatment interventions. Fortunately, there have been some thorough and well-documented meta-analyses of this literature that can serve as a starting point for our efforts. We will compare our estimates of what is being spent on various categories of prevention to what the literature suggests is most valuable. We will analyze these findings, incorporating the opinions of experts who remain skeptical of much of the literature, and summarize our conclusions.