SUMMARY

Public Health Impact Analysis

Introduction
This summary describes the methodology and assumptions that the California Health Benefits Review Program (CHBRP) developed to conduct the public health impact analysis of proposed mandated health benefits, as required by SB 1704 (and originally authorized by AB 1996 in 2002).

SB 1704 (California Health and Safety Code Section 127660 et seq.) requires a public health impact analysis that includes, but that is not limited to, the following:

Health Outcomes and Data Sources
Prior to collection of baseline public health data, the CHBRP public health team meets to determine and define the relevant health outcomes related to the proposed mandate. These determinations are made in consultation with a content expert and the medical effectiveness team. Examples of health outcomes include reductions in morbidity, mortality, disability, days of hospitalization and emergency department visits, changes in self-reported health status, improvements in physiological measures of health such as blood pressure, cholesterol, weight and forced expiratory volume, changes in health behaviors such as increased physical activity or quitting smoking, and improvements in the quality of life. For each defined health outcome, baseline data on the incidence, prevalence, and health services utilization rates of associated conditions are collected.

Four primary data sets are used to conduct the public health impact analysis: the California Health Interview Survey (CHIS), the California Behavioral Risk Factor Survey (BRFS), the CDC WONDER database, and the claims database maintained by Milliman.

Data Elements and Analysis
Four types of data are needed to conduct the public health impact analysis.

First, estimates of baseline health status and health care utilization rates of relevant services are collected. Baseline health status data include, but are not limited to, rates of morbidity (disease), mortality, premature death, disability, health behaviors, and other risk factors stratified by age, gender, race, and ethnicity. Measures of relevant baseline health care utilization in the affected population are obtained and may include rates of physician visits, emergency department visits, inpatient admissions, and length of stay, and prescription drug use stratified by age, gender, condition, and type of health insurance. The specific services for which utilization rates are needed vary by benefit mandate.

Second, the change in coverage suggested by the proposed legislation is estimated. This includes estimates of the number of insured Californians who are presently covered for the proposed benefit and the number who would be newly covered if the mandate were enacted. Coverage rates are derived from surveys of employers and health plans regarding current coverage for the specific mandated benefits. The affected population will vary by mandate and may be defined by gender, age, condition, and type of health insurance coverage.

Third, measures of utilization impacts are estimated for insured Californians who are presently covered for the proposed benefit and those who will be newly covered for the benefit, post-mandate. For persons newly covered by the mandate, an assumption is made about their utilization of the new benefit based on current use of those with existing coverage, as well as use of similar kinds of services for the affected population. Expert opinion and a literature review guide the assumptions regarding expected changes in utilization for people who are currently covered. In some cases, increased utilization is assumed for those currently covered, based on the expected increased awareness of coverage of the benefit by both patients and providers following enactment of the mandate.

Finally, based on the findings from the literature review on medical effectiveness, estimates are made on the impact of new utilization of the mandated benefit on specific health outcomes in the affected population (e.g. the effect of asthma self-management training on the reduction of hospitalizations for asthma). The literature review includes meta-analyses and randomized controlled trials providing information on the effectiveness of the proposed benefit or service on specific health outcomes. When data is available, as given by the Medical Effectiveness Analysis Research Approach, changes in coverage, utilization, and public health outcomes are quantified. The results are compiled by the public health team to produce an overall mean estimate that can be used to calculate the predicted health effects of the benefit mandate. This final step in the analysis assesses the overall change in health outcomes in the affected population using the estimates of changes in utilization resulting from the mandate combined with the rates of effectiveness of utilization derived from the medical impact literature review. For each specific health outcome reviewed in the literature for which there is baseline health outcomes data available, the estimated impact on each health outcome is applied to the affected population to determine the overall change in outcomes resulting from the mandate.

In addition, the public health team estimates the extent to which the proposed benefit or service reduces premature death and the economic loss associated with disease and includes expected effects by gender and race/ethnicity whenever data are available. When the expected benefits may not be realized within the one year used for quantitative estimates of effects, the public health team also projects the longer term public health impacts associated with a benefit mandate, relying more on a qualitative assessments based on longitudinal studies and other research about the long-term impacts of health care. This type analysis is especially relevant for preventive care and disease management programs where the benefits accrue over many years.