3

Informing Investment in Health

Public health leaders have sufficient information to take action in important sectors of population health. However, the public health system at all levels of government requires better information about the level of resources expended and how they are being used, what system characteristics are most closely linked with achieving desired outcomes, and what methods are most effective and efficient in improving population health. In this chapter, the committee first discusses the administrative changes needed to support the uniform collection and reporting of public health financial information (revenues and expenditures). Better information will help government officials to make evidence-based management decisions to generate and allocate resources for public health activities that maximize population health gains and minimize the costs of treating preventable diseases and injuries. And improved information will allow leaders of public health agencies to make better management decisions about organizing, staffing, and implementing public health activities that maximize the efficiency, reach, and effects of their operations. Research is also needed to generate objective information about the costs and outcomes of public health activities—information that would facilitate assessments of the comparative effectiveness of public health and social interventions and medical approaches, and allow decision makers in government and the private sector to identify better ways of allocating limited resources across the spectrum of health-related investment (Teutsch and Fielding, 2011b).



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3 Informing Investment in Health Public health leaders have sufficient information to take action in im- portant sectors of population health. However, the public health system at all levels of government requires better information about the level of resources expended and how they are being used, what system character- istics are most closely linked with achieving desired outcomes, and what methods are most effective and efficient in improving population health. In this chapter, the committee first discusses the administrative changes needed to support the uniform collection and reporting of public health financial information (revenues and expenditures). Better information will help gov- ernment officials to make evidence-based management decisions to generate and allocate resources for public health activities that maximize population health gains and minimize the costs of treating preventable diseases and injuries. And improved information will allow leaders of public health agen- cies to make better management decisions about organizing, staffing, and implementing public health activities that maximize the efficiency, reach, and effects of their operations. Research is also needed to generate objec- tive information about the costs and outcomes of public health activities— information that would facilitate assessments of the comparative effective- ness of public health and social interventions and medical approaches, and allow decision makers in government and the private sector to identify better ways of allocating limited resources across the spectrum of health-related investment (Teutsch and Fielding, 2011b). 75

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76 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE A NEED FOR FINANCIAL ANALYSIS AND RESEARCH As mentioned in Chapter 1 and discussed in more detail in Chapter 4, the information available about public health funding has considerable limitations. Many governmental public health programs were established in response to specific health threats or as results of new interventions, such as the creation of a specific vaccine or the implementation of new smoking in- terventions to reduce cancer deaths. The collection of public health program activities has become what a governmental public health department does. But in many locales, public health departments have not been allowed the “luxury” of organizing activities into a coherent whole in which essential capabilities exist to support all programs or in which funding from one program is leveraged in a systematic manner to benefit other programs. The combination of that historical circumstance in funding, a lack of national standards in recording and reporting funding and expenditure data, and variations in the definitions of public health challenges any attempt to obtain accurate expenditure estimates. Because financial information on public health is difficult to obtain at all levels of government, there is considerable uncertainty about current invest- ment in public health activities in the United States and about the sources of revenue for this investment and the relative contributions of federal, state, local, and private bodies. It is also unclear what those sources purchase in terms of the spectrum of public health activities and infrastructure, how resources are allocated among different geographic areas and population groups, and, perhaps most important, how investment compares with the outcomes of public health activities. Poor financial information systems can breed poor performance because a lack of data and measurement makes it more difficult to evaluate, manage, and improve (Kaplan and Porter, 2011). Without better financial information, policymakers cannot assess the value realized from public health spending, nor can they clearly identify the health and economic consequences of underinvestment. Public health managers are unable to link cost data to their organizational structures, staffing pat- terns, and service delivery models. This limits their ability to enhance the productivity and efficiency of their operations. Because of a lack of adequate financial information, effective and efficient public health departments go unrewarded, and inefficient agencies face few incentives to improve (Honoré and Costich, 2009; Honoré et al., 2007). In the United States, the Centers for Medicare and Medicaid Services Office of the Actuary develops the annual National Health Expenditure Accounts (NHEA) on the basis of data from federal and state governments and international standards. Some limitations of the NHEA, including definitional and methodological issues (Sensenig, 2011), are discussed in Chapter 4. Ballinger (2007) and Sensenig (2007, 2011) have shown that NHEA in Canada and the United States, respectively, do not usefully re- flect the level of spending on public health, because there are no uniform,

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77 INFORMING INVESTMENT IN HEALTH universally accepted definitions of public health activity across levels of government (or internationally). The Association of State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO) attempt to bridge that gap by conducting peri- odic surveys and other kinds of data collection to measure and understand public health department revenues and expenditures at the state and local levels, respectively (see, for example, ASTHO and NACCHO 2011 profiles of state and local public health departments). The value of the data on state and local governmental public health revenues is greatly limited by the lack of a uniform chart of accounts used among health departments, which makes it impossible for health department personnel around the United States to report data on expenditures consistently (Gans et al., 2007). In addition, the variation in scope of work among public health agencies and the fragmented and idiosyncratic1 nature of public health funding make it infeasible for the national associations to collect granular data on program- specific revenues and expenditures. Although knowing the level of funding by funding sources is a key to understanding the outcomes of investments in governmental public health programs, NACCHO found that “collecting these data nationally seems unrealistic given the difficulty of some [local health departments] in providing accurate data even on total revenues and expenditures” (NACCHO, 2011, p. 91). Charts of Accounts Honoré and colleagues observed that “[p]ublic health lacks an opera- tional framework for basic levels of financial analysis and research” (2007, p. 121). The key element of such a framework is a standardized chart of accounts to enable public health to gather uniform data and conduct com- parisons between jurisdictions. Charts of accounts are accounting records that organizations—including nonprofit organizations, health care entities, and universities—use to track expenditures and revenue (Honoré et al., 2007; see also University of Minnesota, 2010; Urban Institute National Center for Charitable Statistics, 2009). Charts of accounts generally match the financial structure of an organization and use categories or classifications for each type of expenditure. The information on a chart of accounts gives an organization an overview of financial activities and can be used for such purposes as fund accounting, reporting or demonstrating accountability to funders and stakeholders, development of financial reports, management, comparative analysis, and benchmarking. The lack of a uniform chart of accounts is a crucial gap for public health services research, in which a clear 1One reason for this is that there has never been a consistent federal funding stream for public health infrastructure as there has been for hospital infrastructure (the Hill–Burton Act of 1946 aimed to strengthen the nation’s hospitals and to reach a specific ratio of hospital beds per population) and for the National Institutes of Health biomedical research enterprise.

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78 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE understanding of the effectiveness and efficiency of investment in programs, personnel, and interventions is a necessity. The adoption of a uniform chart of accounts would enable public health departments at all levels to better ensure accountability for resources and outcomes. Accountability would be facilitated through uniform reporting of revenue and expenditures, and ultimately through establishing how financial inputs and outputs are associ- ated with long-term outcomes. The financial accounting systems used by public health agencies are highly idiosyncratic, varying from one jurisdiction to another, and they are generally fashioned on a local or state government’s template rather than being customized to meet the needs of public health departments.2 They are designed for budget management and fund accounting rather than for over- all financial and program management, that is, understanding the linkages between resources, processes, outputs, and outcomes (see Figure 3-1, a logic model first introduced in the committee’s report For the Public’s Health: The Role of Measurement in Action and Accountability and outlining the steps to population health improvement from inputs to outcomes3). Thus, there 2Several states have undertaken efforts to develop charts of accounts. Florida has a compre- hensive public health dataset and has begun to develop a chart of accounts (Honoré, 2011). It has begun to tackle the difficult issues of definitions (What is core public health? What are clinical care services “alone”?) and has developed a financial information reporting system. The system can be used to compare staffing, workload, population, budget, and full-time employees and can provide revenues and expenditures by program. It can measure revenue per capita, expenditure per capita, and the ratio of revenue to expenditures. This program is still in its testing phase but aims to be used at the state and local levels (Dillion, 2010). Ac- cording to a state health official, objectives include enabling comparisons among jurisdictions and informing “sound business decisions relative to public health.” Georgia has also begun to develop local charts of accounts for its local governments that include some aspects of public health (categories include maternal and child health services, adult health services, health centers, and general clinics). However, each jurisdiction can adapt the template to its needs, and it is not a comprehensive uniform chart of accounts for public health. Other states have begun comprehensive cost analyses as part of a broader process of thinking about revenues, expenditures, and outcomes (Honoré, 2011). 3In its first report on population health measurement, “the committee adapted a simple structure–process–outcome logic model (Donabedian, 1988) to illustrate both the sequence of steps between inputs and outputs in population health and the multiple categories for measurement” (IOM, 2011, pp. 50-51). The figure was originally provided to help in thinking about the types of data and indicators available and needed at each step in the process. The figure ranges from resources and capabilities to intermediate outcomes and indicators and distal outcomes. The “determinants of health” box in the figure “is intended to refer largely to determinants that can be modified by the actions of various agencies and organizations in the health system” (IOM, 2011, p. 51). “Arrows between the determinants of health and many of the boxes represent the feedback loops between determinants and system inputs or outputs. For example, broader societal values and priorities influence the availability of resources for population health activities. Population health interventions, such as policy changes, are often designed to influence particular determinants of health. After evaluation and research to assess the effectiveness of an intervention on a given determinant, the intervention may be modified or replaced” (IOM, 2011, p. 51).

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79 INFORMING INVESTMENT IN HEALTH In the context of the social and environmental determinants of health Processes, Processes/ Needs Intermediate Health Planning and interventions, interventions/ Resources Capacities assessment outcomes outcomes priority setting policies Across different geographic levels and including public health agencies and stakeholders, and with attention to equity and disparities among population groups FIGURE 3-1 Logic model: from inputs to outputs and outcomes. SOURCE: IOM, 2011. Figure 3-1 from old pub, with modifications is a dearth of comprehensive and consistent financial data on the nation’s health departments. A standard chart of accounts would ensure that expen- ditures were recorded consistently among jurisdictions and would support management, permit comparisons between jurisdictions, and allow more ac- curate estimates of public health spending by states, regions, and the nation. A uniform chart of accounts would also provide a reliable basis for studying how variability in use of resources leads to differences in processes and in- terventions and how they lead to differences in outputs. It would help local health departments to make more informed decisions on allocating their resources. The minimum package of public health services introduced in Chapter 2 to ensure a standard level of capacity in all jurisdictions could also serve as a framework for developing a chart of accounts, that is, preparing sets of accounts for each domain of foundational capabilities and each basic program. Steps toward creating a unified chart of accounts would include • S tudying the accounting structures now in place. • B uilding a model chart of accounts. • C omparing the model with existing accounting practices used by local and state agencies. • E xamining how well accounting structures accommodate funding flows. Once it were developed and endorsed, the Department of Health and Hu- man Services (HHS) could require use of a chart of accounts for reporting as a condition of receipt of federal funds, as is the case with the Medicare Cost Report that all health care providers must submit.4 4See, for example, Hospital Cost Report (CMS, 2012).

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80 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE The characteristics of a useful chart of accounts include • A mutually exclusive set of expense accounts to ensure that pro- gram expenses are not double-counted. • A uniform record that captures all work activity that creates expenses. • S ufficient detail to link resources to specific processes that affect intermediate and final outcomes. • T he management information needed to enable improvement of performance of public health systems on a local, statewide, and national basis. A chart of accounts also needs to support management accounting of a specified set of items, beginning with the minimum package of services consisting of foundational capability domains and required programs; fund accounting; and financial reporting. And a process will be needed to ensure that the public health chart of accounts is not static but evolves to suit the financial reporting and management needs of the field. Uniform charts of accounts have been used successfully in other sectors, including medical care and education. Examples in the medical care sector include those used by the Healthcare Financial Management Association (HFMA) and charts of accounts for hospitals (Nowicki and Berger, 2006). In the education sector, the National Center for Education Statistics Common Core of Data surveys administered to school districts and schools leads to the publication of an annual report on school revenues and expenditures. Financial reporting standards and frameworks also guide colleges and uni- versities (Honoré et al., 2007). Charts of accounts are linked with what Honoré and colleagues describe as “exemplary practices” used in the clinical care and educational sectors (2007). These practices include (1) uniform classifications for expenses and revenues, (2) infrastructures for electronic data reporting, (3) standardized system-wide financial analysis practices, (4) extensive reporting of financial results, and (5) professional associations for the accounting workforce. Implementation of these practices in some fields has been driven by private sector market forces that demand accountability, whereas in other fields it has evolved as a result of statutory mandates and stakeholder demands for information (Honoré et al., 2007, p. 125). Over the last several years, NACCHO and the University of Southern Mississippi have partnered to develop a Web-based Public Health Uniform Data System for local health departments (a project funded by the Robert Wood Johnson Foundation). The system, projected to be available in 2012, is expected to have the capacity to collect data and provide immediate feedback to health departments on financial and operational performance,

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81 INFORMING INVESTMENT IN HEALTH benchmarking, program sustainability, and other measures. Its purpose is to make available a uniform set of account definitions to promote the collec- tion and analysis of valid, reliable, and uniform public health data. It will be the closest thing yet to a uniform chart of public health accounts.5 The committee views the HHS and NACCHO effort as a step in the right direc- tion. However, the committee notes that the type of classification described in the draft template appears to be based on the array of expense categories that are typically seen in health departments and does not appear to create mutually exclusive expense accounts as typical charts of accounts do. Ad- ditional work is needed to develop charts of accounts that fully meet the needs of public health departments. Adopting a uniform chart of accounts in all public health departments will not be easy or rapid. An ideal chart of accounts would assign expen- diture codes to a hierarchic cascade of activities that begins with the broad functions and the minimum package of public health services. Each broad category would divide into more granular categories, which would even- tually lead to codes that describe discrete tasks associated with the broad category. Several barriers potentially stand in the way of adoption of a uniform chart of accounts. For example, the committee acknowledges that it will be difficult to assign a uniform accounting code structure that all health depart- ments would be required to adopt. However, if agreement can be reached on the highest levels of accounting aggregation, health departments could reshape their existing charts of accounts to align with the highest levels of definitions. In time, health departments could progressively refine their sub- codes to comport with the national model chart of accounts. In the interval before an agency reaches complete compliance with the model chart of ac- counts, it could submit data to a nationally operated information utility that would translate local codes into nationally compliant codes. For example, a purpose of health information exchange organizations is to take health care encounter data encoded in a hospital or provider office idiosyncratically and translate them to nationally standardized codes that can be interpreted and used by other health care organizations. A similar translation process could serve as a transitional step for public health accounting data and lead to the development of a structure to which each public health department would “map,” for example, its way of coding. The cost of adoption of a chart of accounts is another barrier. It includes investment needed to familiarize health department personnel with new systems and the cost of implementing a new infrastructure, which could be substantial. As an example of how sets of accounts are developed, all immunization- 5Personal Communication, Peggy Honoré, December 1, 2011. For more information, see http://publichealthfinance.org/research-and-analysis/2292.

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82 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE related activities would be grouped in a set of immunization accounts. The generic “immunization” can be separated into codes for “routine vaccine clinic administration,” “routine vaccine supply management,” “emergency mass immunization clinic,” and so on. During an influenza pandemic or oth- er emergency mass immunization event, the codes for those activities would be linked to the “emergency preparedness” set of accounts. Staff conduct- ing immunization activities would recognize the work as vaccination clinic work, and administrators may also need to define it as a component of a specific emergency response. A thorough chart of accounts would categorize program expenses to show actual expenditures involved in doing the work and offer the flexibility of associating expenses to lines of revenue (such as insurance or Medicaid reimbursement for vaccinations administered or funding from Section 317 of the Public Health Services Act, which provides support for vaccines and vaccination infrastructure). Once standard defini- tions and a uniform chart of accounts have been adopted, it will be pos- sible to capture reliable specific data on public health spending patterns in existing federal surveys, such as the U.S. Census Bureau’s periodic Census of Governments, which is the primary source of data used in NHEA. That survey currently asks state and local governments to report their public health expenditures in one large lump-sum category that is poorly defined. The Census Bureau could ask governments for much more detailed report- ing on public health expenditures if it were assured that governments would provide this information in a consistent format. Table 3-1 shows a sample portion of a hypothetical and highly simplified chart of accounts. Recommendation 5: The committee recommends that a technical expert panel be established through collaboration among govern- ment agencies and organizations6 that have pertinent expertise to develop a model chart of accounts for use by public health agencies at all levels to enable better tracking of funding related to program- matic outputs and outcomes across agencies. The adoption of a uniform chart of accounts could be made a Public Health Accreditation Board (PHAB) requirement in addition to being made a pre- requisite for federal and state funding. The process of developing a chart of accounts needs to take place with consideration of the broader management needs of public health departments and the more difficult work of measuring and accounting for nonclinical services. 6Agencies and organizations would include HHS, public health departments, ASTHO, NAC- CHO, PHAB, and the National Association of State Budget Officers.

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83 INFORMING INVESTMENT IN HEALTH TABLE 3-1 Excerpt of a Hypothetical, Highly Simplified Public Health Chart of Accounts Account Category Account (Programs) Code Account Title Definition/Linked to Immunization All funds spent on immunizations 3000 Routine vaccine clinic administration 3010 Routine vaccine supply management 3020 Emergency mass immunization Linked to preparedness clinic category 3030 Communication on immunization Environmental Health 6000 Healthy Homes and Lead Hazard Linked to prevention Prevention Program programs category 6000.1 Public service announcements 6000.2 Staff training 6010 Compliance and enforcement, Air 6010.1 Outreach and education 6010.2 Permits 6020 Compliance and enforcement, Water Chronic Disease 9000 Asthma Linked to environmental health Obesity Linked to chronic disease Prevention and category Control 9010.1 Data collection, obesity (all ages) Linked to data collection category 9010.2 Program evaluation, obesity Linked to research and data collection categories 9010.3 Mass media campaigns and social Linked to communication marketing 9010.4 Nutrition education and counseling Linked to general education and counseling continued

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84 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE TABLE 3-1 Continued Account Category Account (Programs) Code Account Title Definition/Linked to 9010.5 Physical education and counseling Linked to general education and counseling 9010.6 Restaurant menu labeling inspection and enforcement 9010.7 Planning 9010.8 Policy development Asthma 9020.1 Data collection, asthma (all ages) 9020.2 Program evaluation, asthma Account Category (Administrative) Workforce 1000 Total salaries 1010 Total liability days for unused vacation 1020 Total fringe benefits 1030 Professional development Infrastructure 2000 Utilities 2010 Computers 2010.1 Information technology support DATA AND INFORMATION TO SUPPORT PRACTICE This section discusses the research and evaluation needed to inform and support evidence-based and best practices in the funding of public health. Research, for example prevention-effectiveness and comparative- effectiveness research, and evaluation are relevant to funding because they inform the continuum of public health practice, including decisions about what population-based interventions are funded, and the field’s knowledge about what works best in public health financing, administration, and or- ganization (PHSSR, 2012). The committee outlines below the thin evidence base that supports many areas of public health practice, the funding imbal- ances and the siloed nature of health research and development, and some specific needs.

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85 INFORMING INVESTMENT IN HEALTH The Evidence Base The committee has noted before that the evidence base on the effective- ness of health interventions is growing, but it remains particularly sparse with respect to population-based interventions. The work of the Centers for Disease Control and Prevention Task Force on Community Preventive Services has led the way in establishing the effectiveness of interventions, but there are areas where much remains to be done to show what is ef- fective.7 Health systems research, including public health services and sys- tems research, is an expanding field (AcademyHealth, 2012; RWJF, 2012). However, efforts to improve population health are hampered by the many uncertainties and evidence gaps concerning how to promote health and prevent disease and disability on a populationwide basis. The nation’s local, state, and federal public health agencies—with their peers and partners in the private and public sectors—constitute a vast but diffuse delivery system charged, to greater or smaller degrees, with imple- menting public health and prevention strategies (Teutsch and Fielding, 2011a). But evidence on the most effective and efficient ways of organiz- ing, financing, and deploying the strategies through the delivery system is inadequate (Coffman, 2003/2004; IOM, 2011). Public health leaders have few research-tested guidelines, protocols, and decision supports to inform their choices about funding, staffing, and managing public health activi- ties. Similarly, policy leaders have relatively little empirical guidance on the most effective ways to exercise taxing, spending, and regulatory authorities for the public’s health. The dearth of evidence promotes wide variation in public health practices among communities, creating missed opportunities for improving population health, waste and inefficiencies in resource use, and inequities in health protection (Culyer and Lomas, 2006). The scientific fields of prevention research and, more recently, public health services and systems research (PHSSR) have mobilized to address those information needs and build the evidence needed for improved decisionmaking in pub- lic health practice. Thacker and colleagues (2005, p. 227) found that “[i]n addition to the relatively young state of the field, there is little funding for population-based effectiveness research in public health compared with basic and patient-oriented clinical research. This situation might reflect the analytic challenges of this kind of research or the absence of societal com- mitment to invest resources in such research.” Expanded investments in the applied fields of research are needed to produce information with which policy officials and public health professionals can drive improvements in 7The Cochrane Collaboration, the Campbell Collaboration, and others are building the evidence base of systematic reviews of population-based interventions (Sweet and Moynihan, 2007).

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90 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE lation health information system, conducts some of the nation’s primary surveys on population health, including the Health Interview Survey and the National Health and Nutrition Examination Survey. However, the agency’s role has been seriously limited by funding constraints, and the committee believes that NCHS can play a broader leadership role in the population health information system by expanding its analytic capabili- ties, its research activities, its ability to collaborate with those who use its data, and its ability to help to modernize and integrate the system. Doing so would increase the usefulness of NCHS data and facilitate and guide the “translation” of data into information and knowledge that decisionmakers and communities can use. Public health organizations receive inadequate research support to address the leading causes of premature death and disease in American communities. Considerable uncertainty remains in the policy and practice domains about the array of public health services that every community should offer, the level of investment required to provide those services, and the health and economic benefits that can be expected from the investment over various timeframes—including the potential for downstream offsets in medical care spending. The nation’s current public health knowledge and capabilities are inadequate to address some of the most pressing threats to population health, such as those related to obesity and social determinants of health. Where evidence-based strategies are lacking, the development of new knowledge and efficacious public health strategies is imperative. It takes a strong research infrastructure to produce the evidence needed for optimizing the nation’s portfolio of investment in public health and the na- tion’s health expenditures on health in general, but, as noted by an earlier Institute of Medicine (IOM) committee (IOM, 2003), there is still little infrastructure and support for this type of research. The Guide to Community Preventive Services provides evidence-based recommendations and identifies important gaps in knowledge regarding the effectiveness of interventions and thus contributes to a research agenda (TFCPS et al., 2005). On the service delivery side, a research agenda for public health services research has recently been developed (PHSSR, 2011). More and better evidence is needed to inform policy and managerial deci- sions about resource allocation in public health and to ensure accountability for current and future investment in the public health system. Types of Research Needed The discovery of new and better prevention strategies and delivery system approaches requires a continuum of research activities, including

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91 INFORMING INVESTMENT IN HEALTH • escriptive research to understand the distribution of population D health measures at national, state, and community levels; to detect variation in health measures among communities; and to detect changes in health measures. • pidemiologic and etiologic research to identify causal mechanisms E and pathways that determine population health and explain why health varies among communities and why it changes. • fficacy trials and effectiveness studies to identify the prevention E strategies (programs, policies, and interventions) that improve population health. • conomic studies to determine the cost, efficiency, cost effective- E ness, and economic impact of prevention strategies (such as those for obesity) and thus to inform the decisions of policymakers, com- munities, and individuals. • issemination and implementation research to determine the best D ways to organize, finance, and deliver effective prevention strategies to population groups that can benefit. • omparative effectiveness research and priority-setting studies to C determine which prevention strategies work best in which commu- nity and institutional settings and in which population groups. In addition to those traditional scientific approaches to learning what works, the public health field needs to seek knowledge from newly emerg- ing avenues of inquiry, including the application of behavioral economics principles and complex systems analysis to study how environmental, social, and economic conditions and patterns of interaction combine to influence population health (see Box 3-2 for an example). Research in public health also needs to embrace “realistic” methods of inquiry that rely on cumula- tive, rapid-cycle learning from experience and that are designed to elucidate how complex, multicomponent public health strategies and prevention interventions interact with different social, environmental, and institu - tional contexts to produce community-level outcomes. The nontraditional approaches, termed realistic evaluation by Pawlson and Tilley in the social research literature and called the science of improvement by Berwick in the clinical research literature, offer methods that “are not compromises in learning how to improve; they are superior” (Berwick, 2008, p. 1183; Pawson and Tilley, 1997). A strong infrastructure is needed to support each part of the research continuum described above. Specific needs include • R obust data collection at state and community levels. • M ethods for constructing meaningful indicator sets—valid, reliable, sensitive, specific, and actionable.

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92 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE • I nfrastructure for accessing and linking with new and diverse sources of data relevant to population health, including electronic health data, place-based data sources (such as the food environment and the physical environment), and commercial data on purchas- ing, consumption, travel, work, and recreational behavior (also discussed in IOM, 2011). • R esearch on analytic methods and a variety of techniques, includ- ing complex system modeling, structural equation modeling, and qualitative methods to shed light on causal mechanisms and the effectiveness of interventions. • T raining and development for the public health research workforce. According to a social scientist (Coffman, 2003/2004, p. 7), evaluation and research can be contrasted as follows: Evaluation “determines the merit, worth, or value of things” through a process that “identifies relevant val- ues or standards that apply to what is being evaluated, performs empirical investigation using techniques from the social sciences, and then integrates conclusions with the standards into an overall evaluation or set of evalu- ations.” Research does not seek to formulate evaluative conclusions but rather “is restricted to empirical (rather than evaluative) research, and bases BOX 3-2 Obesity and Information Needs In the case of obesity, little is known about the types of population-based inter- ventions that can stem the tide of obesity that is leading to diabetes and other costly health conditions. As discussed in Chapter 1, complex adaptive systems are involved in causing obesity, and action on multiple levels is needed to solve this serious public health problem (Bar-Yam, 2006; Leischow and Milstein, 2006; Leischow et al., 2008). There are many gaps in public health knowledge about obesity. For example, although it is understood that obesity is in part the result of preventable risky behavior, such as inactivity and poor nutrition, there is not enough knowledge to guide the selection of interventions or combinations thereof. Is adding a supermarket a key requirement? What types of school-based interven- tions work? What about increasing the walkability of neighborhoods, and what elements of the built environment make the most difference? What combination of sidewalks, traffic lights, crosswalks, and bicycle and walking paths is needed? Little is known about how to select the best metrics to show improvement or to define what combination of individual-based and population-based interventions would make a difference. Food–environment data are becoming available, city planners are increasingly versed in public health, and several HHS agencies are targeting obesity, including through the study of policy interventions, but more research is needed, as is funding to support it.

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93 INFORMING INVESTMENT IN HEALTH BOX 3-3 Examples of Where Research and Evaluation Can Help Considerable uncertainty remains in the policy and practice communities about the basic package of critical public health services that are needed in every com- munity, the level of investment that is required to support the availability of the package of services, and the health and economic benefits that can be expected from the investment and over what timeframe, including the potential for down- stream savings in medical care spending. More and better evidence is needed to inform policy and managerial decisions about resource allocation in public health and to ensure accountability for current and future investment in the public health system. Implementing a standard chart of accounts as recommended in this chapter is a prerequisite. The nation’s current public health knowledge and capabilities must be strength- ened to address some of the most pressing threats to population health, such as those related to obesity and the effects of the social determinants of health. Where evidence-based strategies are lacking, the discovery of new knowledge and ef- ficacious public health strategies is imperative. A robust research infrastructure is required to produce the evidence needed for optimizing the nation’s portfolio of investment in public health, but, as noted in the 2003 IOM report, there is still little infrastructure and support for this type of research. Research on public health services and systems is still in its adolescence (Scutchfield and Ingram, 2011). its conclusions only on factual results—that is, observed, measured, or cal- culated data” (Coffman, 2003/2004). In the field of public health, research has several different purposes: on a practice level,10 to demonstrate the ef- fectiveness and comparative effectiveness of population-based interventions; and on an administrative or management level, to inform the organization, administration, and financing of public health department activities. At each level, the committee has identified gaps in the knowledge available to inform decision making. That is pertinent to a report on funding both because of the need for research funding and because of the need for additional research on public health administration and financing (for example, research on the optimal size of a health department, discussed above; see also Box 3-3). Not enough is known about how health departments can become learn- ing organizations and acquire an adaptive systems perspective that would enable them to function productively in the self-organizing partnerships that 10Much public health research is not practice-oriented, such as etiologic research, behavioral science, and laboratory science; but little research is aimed at closing the gap between research and practice, for example, research useful to those in the field who need to implement the best intervention for a given issue (Glasgow and Emmons, 2007).

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94 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE are becoming the norm, as opposed to the traditional management setting (Leischow et al., 2008). Translation of Research for Decisionmaking and Action Building the research infrastructure that the committee proposes will allow policymakers to make informed resource allocation decisions that are based on societal or community values and on estimated health and economic impacts of prevention and public health strategies (including use by the National Prevention, Health Promotion, and Public Health Coun- cil as recommended in Chapter 2). It will help to develop evidence-based implementation strategies, guidelines, protocols, and checklists for use by the public health practice community. The evidence can be used to establish and update accreditation standards and performance expectations for public health agencies as accreditation becomes more widely adopted by public health agencies. Finally, the information that is generated would be used to support rapid-cycle innovation, quality improvement, and learning by public health agency administrators. Cycle time in learning what works in public health needs to be reduced through research and development designed to “fail fast and often” to pro- duce a steady stream of innovative results that do work well. Policymakers and public health decision makers need to be able to learn what works in public health, for what population, in what contexts, and at what cost. Whereas “steady-state” industries devote 2-3 percent to research and de- velopment, pharmaceutical, biotechnology and medical technology, and software industries all spend about 15 percent of their budgets on these endeavors (Cutler, 2011). Public health is most similar to industries that face pressures to grow, adapt, and improve and that rely heavily on research and development investments to generate the innovations that sustain them. Yet, of every $100 in federal health research spending, less than $1 is devoted to research on how to deliver (and finance) interventions, and most of that small amount is spent on delivery system research focused on medical care and only a minuscule portion on public health systems and services research (Woolf, 2007, 2008). Public health has not been able to innovate, adapt, and respond quickly enough to contemporary health threats—particularly those associated with chronic disease. If it maintains a steady-state approach, public health and the larger health system will not be able to contain the rising health conse- quences and costs of chronic disease or address the changing needs of popu- lation health. With respect to large-scale chronic disease prevention, there are some good ideas but not a lot of evidence on whether and how they can be implemented effectively populationwide. Given the economic magnitude of the population health problem (75 percent of the nation’s $2.6 trillion

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95 INFORMING INVESTMENT IN HEALTH annual health care expenditures are due to chronic disease [CDC, 2011]), it seems prudent to invest in the research and development needed to learn how to avoid the preventable elements of that cost. For example, 15 percent of the current NHEA estimate of total federal public health spending ($11.5 billion) would be $1.7 billion. That amount, if devoted to public health research and development, would equal less than 0.1 percent of what the United States spends each year on health care for chronic disease treatment. If such an investment led to interventions that had only a modest impact on the growth of costs related to chronic disease, such as lowering the growth in cost by 1 percent as suggested by Roehrig and Rousseau (2011), it would yield a saving of more than $11 for every $1 invested—a highly favorable return on investment. The “value of information” associated with learning what works in public health seems to be very high according to its cost- saving potential. The field must find ways to reach more of the populations that are at great risk for preventable disease and injury and must seek out new and more effective prevention strategies. The committee believes that knowing what works in population health is critical for the future of our nation, and the rate of spending on research and development in public health needs to be similar to that in the industries mentioned above—perhaps up to 15 per- cent of total public health expenditures. Funding of research, development, and dissemination in public health must be seen as a critical investment in the nation’s economic growth and competitiveness. The ACA authorized a program of research related to many of the issues raised in this chapter (Section 4301, “Research on Optimizing the Delivery of Public Health Services”), but funding and infrastructure development for this program are not yet available. The committee recommends steps to achieve the needed research infrastructure. Recommendation 6: The committee recommends that Congress direct the Department of Health and Human Services to develop a robust research infrastructure for establishing the effectiveness and value of public health and prevention strategies, mechanisms for effective implementation of these strategies, the health and economic outcomes derived from this investment, and the compara- tive effectiveness and impact of this investment. The infrastructure should include • A dedicated stream of funding for research and evaluation. • A national research agenda. • Development of data systems and measures to capture research- quality information on key elements of public health delivery, including program implementation costs.

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96 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE • Development and validation of methodologies for comparing the benefits and costs of alternative strategies to improve population health. The recommended research infrastructure would be shared among three HHS agencies—the National Institutes of Health, the Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention— and a national research agenda needs to include a priority-ordered list of topics to be addressed by the research. Development of data systems and measures to capture research-quality information (and training of needed staff) is needed at the national, state, and community levels and would include information on expenditures, workforce size and composition, and the volume, intensity, and mix of activities produced.11 There are many data systems for studying medical care delivery, such as the Medical Expenditure Panel Survey, the Healthcare Cost and Utilization Project with its National Inpatient Sample, and the National Ambulatory Medical Care Survey. Analogous data systems for public health delivery are needed. The development and validation of methods to improve popula- tion health need to include strategies from outside the health sector. The current research paradigm—randomized clinical trials as the gold standard for intervention research—needs to be expanded to include other empirical study designs and the use of modeling and microsimulation for comparing treatment strategies with prevention strategies, including strategies aimed at underlying determinants of health and combinations of strategies. As discussed in the committee’s report on measurement, system dynamics and other types of modeling are useful in a context of great complexity, such as one in which health problems are caused by multiple, interacting factors and requiring action by multiple stakeholders on many dimensions (see, for example, Homer and Hirsch, 2006; Homer et al., 2007, 2010; Jones et al., 2006; Leischow and Milstein, 2006; Leischow et al., 2008; Milstein, 2008; Milstein et al., 2011). Enhancing the research capacity of public health departments is consistent with the idea of public health departments as knowledge organizations described in Chapter 2. On the basis of what is known about what public health agencies can and cannot afford to do and in light of the imbalance in national spending on clinical care and on population-based health services, the committee believes that the nation does not invest sufficiently in public health. The information available, however, does not allow the committee to determine with any precision what proportion of the nation’s health spending is needed to support population-based public health efforts. Improvements in the 11This research model should reflect a desire for real progress by using traditional and nontraditional methods.

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97 INFORMING INVESTMENT IN HEALTH tracking of revenues and expenditures in public health and the enhance- ments in research and evaluation described in this chapter would no doubt inform the determination of public health funding needs, but a national ef- fort is needed to begin to ascertain this and to make recommendations for an optimal balance. As the minimum package of public health services is established and the resources required to deliver them are ascertained, the public health field will gain a deeper understanding of the relative values of public health and clinical services. That understanding will inform invest- ment in the public health system and the appropriate allocation between clinical care and population health. Defining the minimum package of public health services will require the attention of a dedicated group that is knowledgeable about public health and population-based prevention, the economic impact of public health activities, and the value that could be realized by investment in clinical, nonclinical, and population-based efforts. Recommendation 7: Expert panels should be convened by the Na- tional Prevention, Health Promotion, and Public Health Council to determine • The components and cost of the minimum package of public health services at local and state and the cost of main federal functions. • The proportions of federal health spending that need to be in- vested in the medical care and public health systems. The information developed by the panels should be included in the council’s annual report to Congress. Public health is dynamic, and there are always new challenges and the need to maintain progress in meeting old challenges. The recommended expert panels would anticipate future needs and capacities and adapt to changing circumstances. CONCLUDING OBSERVATIONS This chapter has described two kinds of efforts needed to revitalize the public health infrastructure by clarifying how public health funding is used: standardizing financial information, which will require the development and adoption of a uniform chart of accounts, and expanding public health research to improve public health effectiveness and make the best use of resources. Earlier in this report, the committee described categories of public health knowledge that are adequate to inform action. Research and tools for disciplined management (given performance objectives and real world resource constraints) are needed to help public health professionals to do

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98 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE their work better and more efficiently and to identify effective strategies and appropriate interventions. At the national level, expert guidance will fulfill two purposes: describing the governmental public health services that every community needs and determining the magnitude of funding necessary to accomplish them. REFERENCES AcademyHealth. 2012. Public Health Services and Systems Research, 2003-2011. http://www. academyhealth.org/files/FileDownloads/HSRProjUpdate2012.pdf (December 12, 2011). Ballinger, G. 2007. Refining estimates of public health spending as measured in national health expenditure accounts: The Canadian experience. Journal of Public Health Management & Practice 13(2):115-120. Bar-Yam, Y. 2006. Improving the effectiveness of health care and public health: A multiscale complex systems analysis. American Journal of Public Health 96(3):459-466. Berwick, D. M. 2008. The science of improvement. Journal of the American Medical Associa- tion 299(10):1182-1184. CDC (Centers for Disease Control and Prevention). 2011. Rising Health Care Costs Are Un- sustainable. http://www.cdc.gov/workplacehealthpromotion/businesscase/reasons/rising. html (January 27, 2012). CHSR (Coalition for Health Services Research). 2009. Federal Funding for Health Services Research: Nominal Spending Increases Does Not Compensate for Years of Real Declines. Washington, DC: Academy Health. CMS (Centers for Medicare and Medicaid Services). 2012. Hospital Cost Report. Washington, DC: CMS. Coffman, J. 2003/2004. Michael Scriven on the differences between evaluation and social sci- ence research. Harvard Family Research Project 9(4):7. Cook-Deegen, R. 2011. Boosting health services research. Science 333:1384-1385. Crow, M. M. 2011. A radical restructure is the only way to solve the systemic problems of the world’s biggest funder of biomedical research. Nature 471:569-571. Culyer, A. J., and J. Lomas. 2006. Deliberative processes and evidence-informed decision mak- ing in healthcare: Do they work and how might we know? Evidence & Policy: A Journal of Research, Debate and Practice 2(3):357-371. Cutler, D. 2011 (March 3). Transcript, Eighth Meeting of the IOM Committee on Public Health Strategies to Improve Public Health. Washington, DC: IOM. Donabedian, A. 1988. The quality of care: How can it be assessed? Journal of the American Medical Association 260 (12):1743-1748. Dillion, A. 2010. Viewing Public Health Financial Information from a Different Perspec- tive: Financial Ratio Analysis in Florida County Health Departments. http://www. publichealthsystems.org/media/file/Dillon2D.pdf (December 12, 2011). Gans, D. N., N. F. Piland, and P. A. Honoré. 2007. Developing a chart of accounts: Histori- cal perspective of the medical group management association. Journal of Public Health Management & Practice 13(2):130-132. Garcia, R., and A. White. 2006. Healthy Parks, Schools, and Communities: Mapping Green Access and Equity for the Los Angeles Region. Los Angeles, CA: The City Project. Garcia, R., Z. Rawson, M. Yellott, and C. Zaldana. 2009. Economic Stimulus, Green Space, and Equal Justice: Policy Report. Los Angeles, CA: The City Project. Gaziano, T. A., G. Galea, and K. S. Reddy. 2007. Scaling up interventions for chronic disease prevention: The evidence. The Lancet 370:1939-1946.

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