National Health Accounts

Faced with precipitous increases in health care costs, policy-makers are increasingly seeking ways to control medical spending. But what if efforts at cost-control discourage cost effective medical interventions? How can policymakers ensure that their efforts focus on the least valuable types of spending? These concerns are at the heart of a new effort designed by Faculty of Arts and Sciences economist David Cutler and funded by PHSI, NBER, the Lasker Foundation, and the National Institute on Aging. Over the next three years, Cutler and his associate, Dr. Allison Rosen of the University of Michigan, will produce the first set of "National Health Accounts", detailed statistics tracking the impact of medical spending on health and life expectancy. The Federal government currently tracks medical spending, but not the health benefits of this spending. Dr. Cutler contends that such accounts provide a troubling picture of medical expenditures.

"When all we measure is spending, we are tempted to just minimize costs. That is a destructive policy; it means we do not make many investments with very high returns," said Cutler in an interview earlier this month. "By balancing the costs with the benefits, my belief is that we will make sounder decisions about what reforms we should take."

Cutler's current work builds on an earlier prototype project (also funded by PHSI) which focused on developing a summary measure of U.S. adult population health. The new effort is not without its challenges. To have a meaningful impact, National Health Accounts must not simply track health benefits and costs, but must connect specific costs to specific benefits over time. National Health Accounts are most useful when they can show not simply that increases in spending led to improvements in health, but that specific medical interventions in a particular disease yielded a specific health benefit within that disease population. The benefits of various medical interventions can then be compared to identify the most and least cost-effective spending. The process of connecting spending to health benefits is time consuming, and is a topic of heated debate within the medical community.

"The difficult issue is to determine how important medical care has been in improved health relative to other factors: smoking, drinking, diet, exercise, social factors, etc.," said Cutler. "Doctors will always argue over what is most important, but we can try to be as accurate as possible."

Ultimately, Cutler hopes that National Health Accounts will become a permanent statistical product of the Federal government. The shift from academic research to government production would not be without precedent - the Commerce Department's National Income and Product Accounts, the statistics on which calculations of Gross Domestic Product are based, were initially produced through the efforts of a single scholar. Even on its own, Cutler's work on National Health Accounts will prove highly valuable to health policy. Already, his work in heart disease has suggested that concerns over costs of medical care mask the importance of high-cost therapeutic innovations in increasing life expectancy. Among a variety of diseases, the mortality and morbidity benefits of medical advances may be significantly greater than the costs.

PHSI Project Results in Book on Uninsurance

Uninsured in America: Life and Death in the Land of Opportunity a book project supported by PHSI, was recently published by the University of California Press. Authored by Susan Sered & Rushika Fernandopulle, Uninsured in America represents the culmination of a multi-year research effort aimed at articulating the individual, social, and cultural impact of health care uninsurance through the personal stories of uninsured Americans. Sered and Fernandopulle hoped that producing a book that addressed the uninsurance problem using a more anthropological approach and that told the personal stories of ordinary Americans would be more effective than the traditional tools of health policy in changing public misconceptions of uninsurance. To research the book, Sered (a medical anthropologist and Director of Harvard's Religion, Health, and Healing Initiative) and Fernandopulle (a practicing physician and former PHSI Executive Director) traveled around the country interviewing more than 120 uninsured Americans, as well as the health care professionals with whom they interact. The interviewees chosen were representative of many of the major causes of uninsurance, including self-employment, under-employment, and divorce. The finished product is of interest not only to its intended public audience but also to health care policy scholars and students. Sered and Fernandopulle advance several provocative analytical points, including their extensive characterization of the "death spiral" caused by uninsurance, their analysis of the connection between health care and the cultural meanings of failure, and their assertion that uninsured Americans are slowly taking on a social status similar to India's caste of the untouchables. By telling the stories of just 120 of the 46 million uninsured Americans, Uninsured in America manages to provide lay readers with a more engaging and accessible account of America's uninsurance problem than any number of statistics might hope to do.

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Project Updates

Lessons from the Harvard Forums on Health
PHSI and the Harvard School of Public Health recently completed a year-long series of events known as the Harvard Forums on Health. Held in communities across the country, these events were aimed at identifying and analyzing local innovations in health care reform to provide insight into possible national reform strategies. Now, two years after initiating this innovative project, PHSI is preparing to release the final product of the Forums: a report and policy agenda for national health care reform. The document will be based on both the five topical Forums held between June 2003 and May 2004, and on the proceedings of a final summative Forum held in the fall of 2004. In that forum, Lessons from the Harvard Forums on Health, leaders from the health care industry, government, nonprofits, academia, and clinical practice - as well as former Forum speakers - convened at Harvard Medical School for an intensive, day-long meeting to discuss the implications of the Forums' findings. The outcome of the Forums, as envisioned by the final forum participants, will be a roadmap for incremental reform that is based on the practical considerations of current and expected future political landscapes. The final document is still being completed; an executive summary is currently available on the PHSI website.

Using IT to Transform Clinical Care
In response to the success of its initial clinical IT conference in July 2004, PHSI recently worked with the Department of Defense and the Department of Veterans Affairs to bring together a select group of leaders from the public sector, the health care industry, and the academy to participate in two roundtable-style conferences on selected challenges and opportunities in clinical IT. The first of these symposia, held in March 2005, focused on personal health records (PHRs) and featured a discussion by Dr. David Brailer on the his office's evolving understanding of the challenges facing PHR adoption, including concerns over data security and the industry-wide ramifications of data sharing practices and standards. The most recent conference, held in June 2005 and attended by many of the same leaders as the March symposium, addressed the potential for information technology to transform clinical care in large health care organizations - from improving overall quality and efficiency to changing the dynamics of individual patient-physician encounters. The goals of the symposia were to generate a set of lessons that might help other organizations tackle clinical IT challenges and might help inform national and industry-wide clinical IT initiatives, and to help participating organizations learn from each other as they face the challenges of implementing and sustaining the value of clinical IT initiatives. Several symposium participants have continued their discussions offline and are now leveraging each others' expertise to improve their organizations' clinical IT initiatives. The symposia were moderated by Dr. David Blumenthal and included faculty participants Jonathan Teich from HMS, Ashish Jha from HSPH and Andrew McAfee from HBS. A draft manuscript outlining the lessons learned from the adoption of complex IT systems in large organizations is nearly complete and will soon be submitted to a peer-reviewed journal Symposium participants are also currently working on a second manuscript that identifies the challenges to PHR implementation and potential solutions.

Footsteps: Profiles of Forty Remarkable Health Care Leaders
One of PHSI's earliest efforts focused on improving future health care leadership by providing guidance on the academic and career paths taken by today's top health care policy leaders. Dubbed the Project on Emerging Health Care Leadership, this effort consisted primarily of in-depth interviews with health care leaders - especially those who had taken somewhat unusual or non-traditional educational or career paths. The results of these interviews were for several years circulated internally at Harvard in a small wire-bound volume known as the Guide to Health Careers. Now, in an effort to expand access to this information, an edited version of the Guide is being published by Pilgrim Press as Footsteps: Profiles of Forty Remarkable Health Care Leaders. In its new form, the Guide can be of use not just within Harvard but to other career offices, institutions, and even individuals interested in a guide to health careers that focuses on the paths taken by today's top health care leaders. Footsteps will be distributed to career offices at the various Harvard faculties and will also be available for purchase online.

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News & Events

PHSI Website Redesign
The PHSI website is currently in the midst of a multi-stage redesign effort. As more projects are completed and new projects are initiated, the website will play an ever larger role in providing access to papers, presentations, transcripts, and other documentation from PHSI events and projects, and PHSI is taking steps to ensure that the organization and design of the site keep up with this growth. The first stage of the redesign effort - improvements in design & usability, and changes in the way projects and documents are displayed - was recently completed. Visit the updated PHSI website.

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For more information on the projects and events described in this newsletter, or to unsubscribe, please contact us at phsi@harvard.edu.



National Health Accounts Uninsured in America Harvard Forums on Health Clinical IT Health Care Leadership Website Redesign	Summer 2005 National Health Accounts Faced with precipitous increases in health care costs, policy-makers are increasingly seeking ways to control medical spending. But what if efforts at cost-control discourage cost effective medical interventions? How can policymakers ensure that their efforts focus on the least valuable types of spending? These concerns are at the heart of a new effort designed by Faculty of Arts and Sciences economist David Cutler and funded by PHSI, NBER, the Lasker Foundation, and the National Institute on Aging. Over the next three years, Cutler and his associate, Dr. Allison Rosen of the University of Michigan, will produce the first set of "National Health Accounts", detailed statistics tracking the impact of medical spending on health and life expectancy. The Federal government currently tracks medical spending, but not the health benefits of this spending. Dr. Cutler contends that such accounts provide a troubling picture of medical expenditures. "When all we measure is spending, we are tempted to just minimize costs. That is a destructive policy; it means we do not make many investments with very high returns," said Cutler in an interview earlier this month. "By balancing the costs with the benefits, my belief is that we will make sounder decisions about what reforms we should take." Cutler's current work builds on an earlier prototype project (also funded by PHSI) which focused on developing a summary measure of U.S. adult population health. The new effort is not without its challenges. To have a meaningful impact, National Health Accounts must not simply track health benefits and costs, but must connect specific costs to specific benefits over time. National Health Accounts are most useful when they can show not simply that increases in spending led to improvements in health, but that specific medical interventions in a particular disease yielded a specific health benefit within that disease population. The benefits of various medical interventions can then be compared to identify the most and least cost-effective spending. The process of connecting spending to health benefits is time consuming, and is a topic of heated debate within the medical community. "The difficult issue is to determine how important medical care has been in improved health relative to other factors: smoking, drinking, diet, exercise, social factors, etc.," said Cutler. "Doctors will always argue over what is most important, but we can try to be as accurate as possible." Ultimately, Cutler hopes that National Health Accounts will become a permanent statistical product of the Federal government. The shift from academic research to government production would not be without precedent - the Commerce Department's National Income and Product Accounts, the statistics on which calculations of Gross Domestic Product are based, were initially produced through the efforts of a single scholar. Even on its own, Cutler's work on National Health Accounts will prove highly valuable to health policy. Already, his work in heart disease has suggested that concerns over costs of medical care mask the importance of high-cost therapeutic innovations in increasing life expectancy. Among a variety of diseases, the mortality and morbidity benefits of medical advances may be significantly greater than the costs. back to table of contents PHSI Project Results in Book on Uninsurance Uninsured in America: Life and Death in the Land of Opportunity a book project supported by PHSI, was recently published by the University of California Press. Authored by Susan Sered & Rushika Fernandopulle, Uninsured in America represents the culmination of a multi-year research effort aimed at articulating the individual, social, and cultural impact of health care uninsurance through the personal stories of uninsured Americans. Sered and Fernandopulle hoped that producing a book that addressed the uninsurance problem using a more anthropological approach and that told the personal stories of ordinary Americans would be more effective than the traditional tools of health policy in changing public misconceptions of uninsurance. To research the book, Sered (a medical anthropologist and Director of Harvard's Religion, Health, and Healing Initiative) and Fernandopulle (a practicing physician and former PHSI Executive Director) traveled around the country interviewing more than 120 uninsured Americans, as well as the health care professionals with whom they interact. The interviewees chosen were representative of many of the major causes of uninsurance, including self-employment, under-employment, and divorce. The finished product is of interest not only to its intended public audience but also to health care policy scholars and students. Sered and Fernandopulle advance several provocative analytical points, including their extensive characterization of the "death spiral" caused by uninsurance, their analysis of the connection between health care and the cultural meanings of failure, and their assertion that uninsured Americans are slowly taking on a social status similar to India's caste of the untouchables. By telling the stories of just 120 of the 46 million uninsured Americans, Uninsured in America manages to provide lay readers with a more engaging and accessible account of America's uninsurance problem than any number of statistics might hope to do. back to table of contents Project Updates Lessons from the Harvard Forums on Health PHSI and the Harvard School of Public Health recently completed a year-long series of events known as the Harvard Forums on Health. Held in communities across the country, these events were aimed at identifying and analyzing local innovations in health care reform to provide insight into possible national reform strategies. Now, two years after initiating this innovative project, PHSI is preparing to release the final product of the Forums: a report and policy agenda for national health care reform. The document will be based on both the five topical Forums held between June 2003 and May 2004, and on the proceedings of a final summative Forum held in the fall of 2004. In that forum, Lessons from the Harvard Forums on Health, leaders from the health care industry, government, nonprofits, academia, and clinical practice - as well as former Forum speakers - convened at Harvard Medical School for an intensive, day-long meeting to discuss the implications of the Forums' findings. The outcome of the Forums, as envisioned by the final forum participants, will be a roadmap for incremental reform that is based on the practical considerations of current and expected future political landscapes. The final document is still being completed; an executive summary is currently available on the PHSI website. Using IT to Transform Clinical Care In response to the success of its initial clinical IT conference in July 2004, PHSI recently worked with the Department of Defense and the Department of Veterans Affairs to bring together a select group of leaders from the public sector, the health care industry, and the academy to participate in two roundtable-style conferences on selected challenges and opportunities in clinical IT. The first of these symposia, held in March 2005, focused on personal health records (PHRs) and featured a discussion by Dr. David Brailer on the his office's evolving understanding of the challenges facing PHR adoption, including concerns over data security and the industry-wide ramifications of data sharing practices and standards. The most recent conference, held in June 2005 and attended by many of the same leaders as the March symposium, addressed the potential for information technology to transform clinical care in large health care organizations - from improving overall quality and efficiency to changing the dynamics of individual patient-physician encounters. The goals of the symposia were to generate a set of lessons that might help other organizations tackle clinical IT challenges and might help inform national and industry-wide clinical IT initiatives, and to help participating organizations learn from each other as they face the challenges of implementing and sustaining the value of clinical IT initiatives. Several symposium participants have continued their discussions offline and are now leveraging each others' expertise to improve their organizations' clinical IT initiatives. The symposia were moderated by Dr. David Blumenthal and included faculty participants Jonathan Teich from HMS, Ashish Jha from HSPH and Andrew McAfee from HBS. A draft manuscript outlining the lessons learned from the adoption of complex IT systems in large organizations is nearly complete and will soon be submitted to a peer-reviewed journal Symposium participants are also currently working on a second manuscript that identifies the challenges to PHR implementation and potential solutions. Footsteps: Profiles of Forty Remarkable Health Care Leaders One of PHSI's earliest efforts focused on improving future health care leadership by providing guidance on the academic and career paths taken by today's top health care policy leaders. Dubbed the Project on Emerging Health Care Leadership, this effort consisted primarily of in-depth interviews with health care leaders - especially those who had taken somewhat unusual or non-traditional educational or career paths. The results of these interviews were for several years circulated internally at Harvard in a small wire-bound volume known as the Guide to Health Careers. Now, in an effort to expand access to this information, an edited version of the Guide is being published by Pilgrim Press as Footsteps: Profiles of Forty Remarkable Health Care Leaders. In its new form, the Guide can be of use not just within Harvard but to other career offices, institutions, and even individuals interested in a guide to health careers that focuses on the paths taken by today's top health care leaders. Footsteps will be distributed to career offices at the various Harvard faculties and will also be available for purchase online. back to table of contents News & Events PHSI Website Redesign The PHSI website is currently in the midst of a multi-stage redesign effort. As more projects are completed and new projects are initiated, the website will play an ever larger role in providing access to papers, presentations, transcripts, and other documentation from PHSI events and projects, and PHSI is taking steps to ensure that the organization and design of the site keep up with this growth. The first stage of the redesign effort - improvements in design & usability, and changes in the way projects and documents are displayed - was recently completed. Visit the updated PHSI website. back to table of contents For more information on the projects and events described in this newsletter, or to unsubscribe, please contact us at phsi@harvard.edu.