Costs, Collective Actions and Crowd-Out in Public Health: New Evidence from ARM

AcademyHealth’s Annual Research Meeting (ARM) convened in San Diego this week to unleash the latest findings from a host of new health services research studies, many with a strong orientation toward economics and public health. I cannot begin to summarize all the great work from this meeting in a single post, so for now I will take a random thought-walk through a couple of the studies I found most striking. (Note: I will update this post in a few days with links to meeting slides once they are posted online).

Front of mind for me is the fascinating pragmatic randomized trial conducted in local health department settings by Allison Saville and her colleagues at the University of Colorado, Colorado Children’s Hospital and Colorado’s state health department. This trial tested the cost-effectiveness of a novel strategy for boosting child vaccination rates using a reminder and recall (R&R) intervention delivered centrally by local health departments in collaboration with community-based primary care practices. The study found that the collaborative, health department-delivered R&R model outperformed a standard physician practice-based R&R model both in terms of vaccination rates and in terms of costs, clearly showing the value of collective action involving public health agencies and primary care practices.

Another elegant study of vaccination practices was presented by LA County Health Department’s Ricardo Basurto-Davila and colleagues, focusing on the health and economic effects of school-based vaccination programs used during the 2009 H1N1 influenza outbreak. The researchers find that school-based strategies produced significantly higher child vaccination coverage rates than did traditional community-based and clinic-based vaccination programs. These higher rates of child coverage, however, came at the expense of coverage among adults 65 years of age and older. In fact, the cost reductions achieved by school-based vaccination programs were attributable mostly to the lower vaccination rates they produced among seniors, rather than to lower disease transmission rates among children. The findings suggest that public health agencies must carefully consider the characteristics of the outbreak and the population groups most at risk when choosing to use mass vaccination strategies for influenza.

Other economically interesting studies focused on food and diet-related public health risks. The University of Washington’s Betty Bekemeier linked financial data on local expenditures for food safety and sanitation with county-level surveillance data on the incidence of food-borne and water-borne diseases in two states over 8 years, finding that some of these diseases are less common in higher-spending communities. A very different study presented by Washington’s Davine Wright used a Markov model to estimate the cost-effectiveness of a school-based screening program designed to detect eating disorders in children, finding an attractive cost per QALY gained of about $57,000.

Penn’s famed behavioral economist and physician Kevin Volpp presented findings from two new trials that explored whether financial incentives tied to weight loss tend to crowd-out the intrinsic motivations people have to achieve a healthier weight. He finds that voluntary participants in randomized weight loss trials tend to have high levels of intrinsic motivation for weight loss at baseline, and that randomly assigned financial incentives do not erode these motivations significantly during the course of a trial. Money does not appear to crowd-out other forms of motivation in these studies.

The new study I presented at ARM this year examined financial crowd-out at a higher scale of operation − one that is particularly relevant now that 26 states are in the midst of implementing the ACA’s Medicaid expansions. Specifically, we asked: does growth in state Medicaid spending crowd out the ability of state governments to invest in other types of beneficial public health programs? And if so, what are the health consequences of such crowd-out? Using almost 20 years of data from 1993-2011, we find evidence of significant crowd-out, consistent with the federal matching formula that rewards states for Medicaid spending but does not provide commensurate incentives for other types of public health outlays. We project that, over time, this crowd-out phenomenon is large enough to result in elevated rates of preventable mortality, offsetting the mortality gains produced by expanded Medicaid coverage. (We were flattered for this work to receive designation as one of the “Best of ARM” studies and as such to receive critiques from noted health economists Steve Parente and Jack Needleman during the meeting).

And speaking of the best, UC-Berkeley’s Tim Brown received the AcademyHealth Article of the Year Award in Public Health Systems Research for his research examining the health effects attributable to public health spending by California’s local agencies. In a pair of recent analyses using careful panel data methods and instrumental-variables techniques, Tim finds sizable reductions in all-cause mortality and notable gains in self-reported health status among California counties that experience growth in per-capita local health department spending during 2001-2008. These studies add to a growing evidence base regarding the health and economic value of public health activities.

Equally importantly, these studies and the larger ARM meeting (including the Public Health Systems Research Interest Group meeting) showcase the value of investing in rigorous research designs and analytic methodologies to answer important questions about public health policy and practice. These studies show that creativity, persistence, and a deep commitment to inquiry and analysis can produce valuable public health knowledge, even when time, money and data are constrained.

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2 thoughts on “Costs, Collective Actions and Crowd-Out in Public Health: New Evidence from ARM

  1. Pingback: The Comparative Effectiveness of Preparedness | Public Health Economics

  2. Pingback: Expanding Experiments in Public Health Delivery Systems | Public Health Economics

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