Public Health Impact Analysis: Summary
The public health impact analyses capture the potential value of a proposed health benefit mandate—what health outcomes are improved at what cost. The analyses focus on the health outcomes of Californians with health insurance that may be subject to a health benefit mandate law passed at the state level. This summary describes the methodology and assumptions that the California Health Benefits Review Program (CHBRP) developed to conduct public health impact analyses of proposed health benefit mandates, as required by the program's authorizing statute. CHBRP's authorizing statute requires a public health impact analysis that includes but is not limited to the following:
The impact on the health of the community, including the reduction of communicable disease and the benefits of prevention such as those provided by childhood immunizations and prenatal care.
The impact on the health of the community, including diseases and conditions where gender and racial disparities in outcomes are established in peer-reviewed scientific and medical literature.
The extent to which the proposed service reduces premature death and the economic loss associated with disease.
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 health benefit 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. Also, when possible, CHBRP presents an assessment of potential harms and financial burden related to the mandate. For each defined health outcome, baseline data on the incidence, prevalence, and health services utilization rates of associated conditions are collected. The public health team uses a five-tiered hierarchy of evidence to prioritize sources of incidence and prevalence data:
- Tier 1. Registries with California-specific census counts
- Tier 2. Surveys with California-specific estimates
- Tier 3. Surveys with national estimates only, peer-reviewed literature, or grey literature
- Tier 4. Actuarial contractor database
- Tier 5. Content experts
The public health team conducts primary and secondary research and prefers California data before regional or national data. Examples of data sets used to conduct the public health impact analysis include the California Cancer Registry (Tier 1), the California Health Interview Survey (CHIS) (Tier 2), and California agency reports (Tier 3). More details on these data sources can be found in Public Health Impacts Analysis: Research Approach. Baseline data on prevalence/incidence for the disease/condition and relevant outcomes are presented in each report. This provides context for analyses in the medical effectiveness, cost and utilization, and public health sections.
Impact on Public Health
The data elements needed to estimate the public health impact on the overall health of Californians with health insurance that may be subject to a health benefit mandate law passed at the state level include:
- Baseline incidence and health outcomes of the relevant condition(s);
- The medical effectiveness of the mandated health benefit; and
- The impact on coverage and utilization due to the mandate.
First, using registry- or survey-based datasets and/or literature, the public health team estimates baseline health status relevant to the health benefit mandate. This includes but is not limited to rates of morbidity (disease), mortality, premature death, disability, health behaviors, and other risk factors stratified by age, gender, race, and ethnicity. Second, the public health impacts section uses findings from the literature review in the medical effectiveness analysis. The literature review commonly includes meta-analyses and randomized controlled trials, which provide information on the effectiveness of the proposed benefit or service on specific health outcomes. Third, the public health impacts section uses estimated changes in benefit coverage and/or utilization of treatments or services relevant to the proposed legislation from the cost impact analysis section. Estimated changes in benefit coverage include 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. The cost section also estimates changes in utilization rates for insured Californians who are presently covered for the proposed benefit and for those who will be newly covered for the benefit, postmandate. Using these data elements, estimates are made regarding 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 results are compiled by the public health team to produce an overall mean estimate that can be used to calculate the predicted short-term (one year) health effects of the benefit mandate.
Impact on Disparities (e.g., Gender and Racial/Ethnic Disparities) and Social Determinants of Health
When possible, CHBRP reports detail differences in disease prevalence, health services utilization, and health outcomes by gender and race/ethnicity, preferably in the insured population. Four steps are used to assess whether disparities exist and whether the proposed mandate will have an impact on gender and/or racial disparities:
- Conduct a literature review;
- Review data sources for prevalence, utilization, and outcome data by race/ethnicity and gender;
- Determine whether a mandate will impact disparities; and
- Determine whether a change in disparities can be quantified.
Impact on Premature Death and Economic Loss
In addition, the public health team estimates the extent to which the proposed benefit would reduce premature death and the economic loss associated with disease. In order to calculate an expected impact on premature death, mortality must be a relevant health outcome; the treatment or service must be medically effective at reducing mortality; and the mandate must increase coverage or utilization of the benefit. Where premature death is a relevant outcome, the public health team conducts a literature review to determine if societal costs of illness (indirect costs) have been established and uses the evidence to support one of four conclusions: disease/condition is not relevant to economic loss; impact of mandate on economic loss is unknown; mandate is not estimated to affect economic loss; or mandate is estimated to increase economic loss.
When the expected benefits may not be realized within the one-year timeframe used in the cost and utilization analyses, the public health team also projects the long-term public health impacts (beyond 12 months) associated with a benefit mandate. In this case, the public health team generally relies on qualitative assessments based on longitudinal studies and other research about the long-term impacts of health care. This type of analysis is especially relevant for preventive care and disease management programs where the benefits accrue over many years. For more detailed information about CHBRP’s public health methodology, see Public Health Impact Analysis: Research Approach.