Historical Application Of Statistics In Health Care Field
The organization, delivery, and financing of health care services in the United States is complex, comprising an interdependence of the private and government sectors of the economy. This pluralistic health care economy, with its pragmatic mix of public and private organizations, has produced a wide range of databases that enable us to monitor the health of the nation.
Health care expenditures have been rising rapidly in the United States and claiming a larger share of national resources during the past three decades. In 1965, $41.1 billion was spent for health care, comprising 5.7 percent of the gross domestic product (National Center for Health Statistics, 1999). In 1998, health care expenditures in the United States totaled $1.1 trillion, an average of $4,094 per person, comprising 13.5 percent of the nations gross domestic product (Levit et al., 2000). Almost 11.5 million civilians were employed in the health services industry in 1998, comprising 8.8 percent of employed civilians (National Center for Health Statistics, 1999).
The growth of the health care industry in the United States has been accompanied by significant achievements in public health, including advances in prevention and significant declines since 1950 in death rates for diseases of the heart (56 percent), and stroke (70 percent) (Morbidity and Mortality Weekly Report, 1999). We have been successful in monitoring these and other morbidity and mortality trends through the growth and development of our health data systems.
Health care is a pressing social, political, and economic issue in the United States. The American pluralistic health care economy presents special problems for data collection, analysis, and dissemination. Health statistics systems have grown rapidly with the growth of the industry and the expansion of private health insurance coverage and public health care programs.
There is general agreement that data are needed to monitor the health of the nation; to plan and develop better health services; to deliver those services in an effective, efficient, and equitable manner; to measure their effectiveness; to make decisions on resource allocation; and to conduct research. Data also are needed to facilitate effective policy making, planning, management, and evaluation. Private organizations of health professionals, health service providers, health insurance, and many others have important interests in the collection and use of health data. The federal government needs a variety of data to support its major role in improving health and medical care delivery systems throughout the nation. State and local government agencies also have key roles in disease prevention, delivery of health services, and health planning and evaluation that require timely and reliable health statistics.
This paper presents a brief historical review of how the health statistics system has evolved to its present configuration and the lessons to be learned that might guide the future evolution of the system. This review will focus on the changes during the past 35 years in the types and uses of health statistics, the constituencies, and changes in technologies supporting the health statistics system. Gaps in health statistics, as well as several cross-cutting issues, will be discussed. Special focus will be on the federal health statistical system, especially as it relates to the production, use, and need for health data at the federal, state, and local levels. The paper concludes with challenges for the future in producing a health statistics system for the twenty-first century.
The statistical needs of the American pluralistic health care economy have grown enormously in the past 35 years since the enactment of the Medicare and Medicaid programs in 1965, the rapid growth of private health insurance, the expansion of the health care industry, and the concomitant public health, medical, and technological advances to meet the needs of a growing population. The rapid aging of the population, the emergence of chronic illnesses to replace infectious diseases as the leading causes of morbidity and mortality, and the growing heath care needs of subpopulation groups (i.e., minorities, uninsured, immigrants, and persons with disabilities and low incomes) are current phenomena that require close monitoring in the future.
Health statistics often are obtained via sample surveys conducted through telephone, mail, or in-person interviews of individuals and/or households. Health surveys go back to the Hagerstown morbidity studies conducted by the Public Health Service in the early 1920s. However, sample surveys did not become dominant until the rise of probability sampling in the 1930s (Frankel and Stock, 1969). The Public Health Service conducted the first National Health Survey in 1935–1936, funded by the Works Projects Administration (Duncan and Shelton, 1978). In 1953 the National Opinion Research Center began a series of surveys separated by five-year intervals on the consumers use of medical care, the degree of health insurance protection, and expenditures for care (Andersen and Anderson, 1967).
In October 1953, a subcommittee of the U.S. National Committee on Vital and Health Statistics (NCVHS) recommended that a national health survey be established on a permanent basis. The passage of the National Health Survey Act of 1956 called for a continuing survey and special studies on the nations health. It also provided for studying methods and survey techniques for obtaining this statistical information and for disseminating results of these surveys and studies. The National Health Survey, later renamed the National Health Interview Survey (NHIS), began in 1957. In 1960, the National Center for Health Statistics (NCHS) was created by combining the National Health Survey and the National Office of Vital Statistics. Responsibility for vital statistics had been transferred to the Public Health Service from the Bureau of the Census.
NCHS is the federal government’s principal health statistics agency (National Research Council, 1992; Office of Management and Budget, 1998). The NCHS congressional mandate addresses the full spectrum of concerns in the health field from birth to death, including overall health status, environmental, social and other health hazards, the onset and diagnosis of illness and disability, health resources, and the use, cost, and financing of health care. NCHS also has the mandated responsibility for assisting the states and local health agencies in meeting their costs of data collection.
Although NCHS is considered the main health statistics agency, many other federal agencies also have significant responsibilities for health data collection. For example, included in the NIH statistical budget are activities that support the design and implementation of epidemiologic studies, clinical trials, biomedical research, and laboratory investigations conducted by the various institutes. Other DHHS components, such as the Centers for Disease Control and Prevention (CDC), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Office of the Assistant Secretary for Planning and Evaluation (OASPE), the Agency for Health Care Policy and Research (AHCPR), the Health Care Financing Administration (HCFA), and the Health Resources Services Administration (HRSA) also actively collect health data. The Office of Management and Budget (OMB), which reviews agencies’ budgets and tracks the amount allocated toward “statistical activities” reports that 13 agencies of DHHS had direct statistical budgets amounting to $804 million in fiscal year 1999; of this total, NCHS’s budget comprised only 10.7 percent (Office of Management and Budget, 1998). By comparison, the statistical budget for the National Institutes of Health (NIH) comprised more than two-fifths of the total DHHS budget—$347.7 million, or 43.2 percent.