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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

December 2012: 

Preventive Health Activities: 

Available Information on Federal Spending, Cost Savings, and 
International Comparisons Has Limitations: 

GAO-13-49: 

GAO Highlights: 

Highlights of GAO-13-49, a report to congressional requesters. 

Why GAO Did This Study: 

Preventive health activities have received attention for their 
potential to improve health outcomes or lower health care 
expenditures. While there is no widespread agreement on what 
constitutes preventive health activities, in this report they include 
clinical preventive services, such as immunizations provided in 
clinical settings, and community-oriented preventive health 
activities, such as health education media campaigns. A preventive 
health activity is considered cost saving if the activity costs less 
than the costs averted by it; an activity is cost-effective if it 
achieves benefits in a less costly way than alternatives. HHS, VA, and 
DOD administer programs that include preventive health activities. 

GAO was asked to report on preventive health activities. This report 
provides available information and discusses the limitations of this 
information regarding (1) preventive health activities in programs 
administered by HHS, VA, and DOD and the departments’ spending on such 
activities; (2) reported cost savings from and cost effectiveness of 
preventive health activities; and (3) U.S. spending on preventive 
health activities compared to that of other countries. 

GAO reviewed documents from HHS, VA, and DOD; interviewed officials 
from those departments and researchers; conducted a literature review; 
and reviewed OECD data on national health spending. 

HHS and VA provided technical comments on a draft of this report, 
which were incorporated as appropriate. 

What GAO Found: 

The Departments of Health and Human Services (HHS), Veterans Affairs 
(VA), and Defense (DOD) administer programs that include preventive 
health activities such as health screenings and education campaigns, 
but the departments reported that they do not track department-wide 
spending on these activities. Departments reported that determining 
such spending is challenging because these activities can be 
integrated with other health activities. For fiscal year 2011, the 
departments provided to GAO a mix of information related to spending 
for preventive health activities, and noted limitations. These 
limitations included incomplete estimates, estimates that included 
activities that were prevention-related but not specifically for 
clinical preventive services or community-oriented preventive health 
activities, and estimates that represented funding—-not spending--
information. Funding estimates represent amounts available to the 
departments at a particular time, but not necessarily actual spending. 
For fiscal year 2011, HHS combined estimates of spending for 
prevention for one agency with estimates of funding for nine other HHS 
agencies for a total of about $24 billion; however, the estimate did 
not include the Centers for Medicare & Medicaid Services, which 
oversees health coverage programs for over 100 million individuals. VA 
and DOD estimated that, for example, fiscal year 2011 spending for 
clinical preventive services was about $576 million and $1 billion, 
respectively. 

Researchers, reports, and articles have indicated that some preventive 
health activities may result in cost savings—-that is, the costs 
averted, such as medical costs to treat a disease or condition, exceed 
the cost of implementing it—and a number of preventive health 
activities, while not necessarily cost saving, may be cost-effective-—
that is, the activity provides good value at low cost relative to 
alternative activities. For example, according to one report that 
synthesized the results of three reviews, two clinical preventive 
services-—counseling on the use of low-dose aspirin to reduce coronary 
heart disease and childhood immunizations-—were considered to be cost 
saving. Researchers noted, however, that estimates of cost savings or 
cost-effectiveness are affected by multiple factors, such as how an 
activity is targeted. In addition, Centers for Disease Control and 
Prevention officials and others reported that a lack of key data may 
affect estimates of cost savings or cost-effectiveness and reported 
taking steps toward improving available information. 

Data for international comparisons of countries’ spending specifically 
for preventive health activities are not available. Instead, data 
available from the Organization for Economic Co-operation and 
Development (OECD) combine spending on certain preventive health 
activities—including community-oriented preventive health activities, 
such as vaccination programs—with spending on other public health 
activities, such as disease surveillance. On the basis of these data, 
the United States ranked 8th among 23 OECD member countries in the 
percentage of total health care spending reported for prevention and 
public health services. However, these data have limitations. For 
example, they do not include U.S. spending for preventive services 
provided in physicians’ offices or hospitals in the public and private 
sectors. 

View [hyperlink, http://www.gao.gov/products/GAO-13-49]. For more 
information, contact Katherine Iritani at (202) 512-7114 or 
iritanik@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

HHS, VA, and DOD Programs Include Preventive Health Activities, but 
Department-wide Spending on These Activities Is Not Specifically 
Tracked: 

Some Preventive Health Activities May Be Cost Saving or Cost-
Effective, but Multiple Factors Affect Estimates, and Key Data May Be 
Lacking: 

International Data on Preventive Health Activities Are Not Available, 
but United States Ranks Eighth in OECD Category That Combines Spending 
on Prevention and Public Health Services: 

Concluding Observations: 

Agency Comments: 

Appendix I: Requirements Related to Preventive Health Activities in 
the Duncan Hunter National Defense Authorization Act: 

Appendix II: Department of Health and Human Services Estimates of 
Spending and Funding for Preventive Health Activities: 

Appendix III: Department of Veterans Affairs Estimates of Spending and 
Funding for Preventive Health Activities: 

Appendix IV: Department of Defense Estimates of Spending for 
Preventive Health Activities: 

Appendix V: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Selected HHS Agencies and Their Functions: 

Table 2: Types of Preventive Health Activities Included in Programs 
Administered by HHS Agencies: 

Table 3: Effect of Targeting on Cost-Effectiveness Ratio for Selected 
Preventive Health Activities: 

Table 4: DOD Estimates of Spending for Providing Clinical Preventive 
Services in DOD's Direct Care and Purchased Care Systems, Fiscal Years 
2010 and 2011: 

Figures: 

Figure 1: Total Health Care Spending per Capita, by OECD Member 
Country, 2010: 

Figure 2: Spending for Prevention and Public Health Services as a 
Percentage of Total Health Spending, by OECD Member Country, 2010: 

Figure 3: Spending for Prevention and Public Health Services as a 
Percentage of Gross Domestic Product, by OECD Member Country, 2010: 

Figure 4: Spending for Prevention and Public Health Services per 
Capita, by OECD Member Country, 2010: 

Abbreviations: 

ACF: Administration for Children and Families: 

ACL: Administration for Community Living: 

ACIP: Advisory Committee on Immunization Practices: 

AHRQ: Agency for Healthcare Research and Quality: 

AOA: Administration on Aging: 

ASFR: Office of the Assistant Secretary for Financial Resources: 

CDC: Centers for Disease Control and Prevention: 

CMS: Centers for Medicare & Medicaid Services: 

DOD: Department of Defense: 

FDA: Food and Drug Administration: 

HHS: Department of Health and Human Services: 

HIV: human immunodeficiency virus: 

HPV: human papilloma virus: 

HRSA: Health Resources and Services Administration: 

IHS: Indian Health Service: 

LDL: low-density lipoprotein: 

NIH: National Institutes of Health: 

NHLBI: National Heart, Lung, and Blood Institute: 

OASH: Office of the Assistant Secretary for Health: 

OECD: Organization for Economic Co-operation and Development: 

QALY: quality-adjusted life-year: 

SAMHSA: Substance Abuse and Mental Health Services Administration: 

USPSTF: U.S. Preventive Services Task Force: 

VA: Department of Veterans Affairs: 

VHA: Veterans Health Administration: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

December 6, 2012: 

The Honorable Max Baucus: 
Chairman: 
Committee on Finance: 
United States Senate: 

The Honorable Tom Harkin: 
Chairman: 
Committee on Health, Education, Labor, and Pensions: 
United States Senate: 

The Honorable Carl Levin: 
Chairman: 
Committee on Armed Services: 
United States Senate: 

In recent years, preventive health activities have received attention 
for their potential to improve health outcomes or lower health care 
expenditures. Preventive health activities can prevent health 
conditions from occurring, or screen for or diagnose existing health 
conditions. For example, vaccinations can prevent infectious diseases, 
and mammograms are used to screen for breast cancer. Preventive health 
activities can also manage diagnosed health conditions and prevent 
certain conditions from worsening--for example, weight-reduction 
counseling to help manage diabetes. While there is no widespread 
agreement on what constitutes preventive health activities, in this 
report preventive health activities include clinical preventive 
services and community-oriented preventive health activities. Clinical 
preventive services are services that are provided to individuals in 
clinical settings such as immunizations, screenings, and counseling, 
and community-oriented preventive health activities are activities to 
improve the health of people in a community such as health education 
media campaigns and health screenings at community health fairs. 

The Department of Health and Human Services (HHS), the Department of 
Veterans Affairs (VA), and the Department of Defense (DOD) administer 
programs that provide preventive health activities and other health 
services to millions of Americans. For example, HHS's Medicare and 
Medicaid programs provide coverage for clinical preventive services 
for seniors and low-income adults and children,[Footnote 1] VA 
provides clinical preventive services and community-oriented 
preventive health activities for veterans and other eligible 
beneficiaries, and DOD provides clinical preventive services and 
community-oriented preventive health activities for active duty 
personnel and other beneficiaries. According to the National 
Prevention Strategy prepared by the National Prevention Council--a 
council that includes the heads of these three departments--the 
federal government will support preventive health activities to 
promote health and wellness by taking new or continuing actions such 
as promoting and expanding research efforts to identify high-priority 
preventive health activities.[Footnote 2] State and local governments, 
nonprofit organizations, companies in the private sector, as well as 
governments in other countries, also administer programs that include 
preventive health activities. 

Preventive health activities may have impacts on health care costs and 
improve health outcomes. Preventive health activities are considered 
to be cost saving when the cost of implementing the activity is less 
than costs--such as future medical costs to treat a disease or 
condition--that could be averted by the preventive health activity. 
Preventive health activities that may improve health outcomes are 
considered cost-effective if the activity generates benefits, such as 
improved health outcomes, in a less costly way than alternatives--that 
is, they provide good value at relatively low cost. 

You asked us to provide information on preventive health activities, 
including spending on these activities by HHS, VA, and DOD and 
limitations in this information. This report provides available 
information and discusses the limitations of this information 
regarding (1) preventive health activities included in programs 
administered by HHS, VA, and DOD and the departments' spending 
information on such activities; (2) reported cost savings from and 
cost-effectiveness of preventive health activities; and (3) U.S. 
spending on preventive health activities compared to that of other 
countries. 

To provide information and discuss the limitations of this information 
regarding preventive health activities included in programs 
administered by HHS, VA, and DOD and the departments' spending 
information on such activities, we reviewed documents and interviewed 
officials from HHS, VA, and DOD. We asked officials from each of these 
departments to describe completed or ongoing efforts, if any, to 
identify and track spending on clinical preventive services and 
community-oriented preventive heath activities included in programs 
administered by their respective departments, and we reviewed the 
related documents they provided.[Footnote 3] We asked the departments 
to provide readily available information from their data systems or 
existing documents. As a result, the information provided by the 
departments may not be based on a uniform definition of preventive 
health activities or comparable estimates of spending. We did not 
independently verify the information provided by the departments nor 
did we assess the rationale for including or excluding particular 
preventive health activities in the information that the departments 
provided. 

* For HHS, we reviewed documents provided by HHS's Office of the 
Assistant Secretary for Financial Resources (ASFR) (the office that 
provides guidance to HHS's Office of the Secretary on all aspects of 
HHS's budget) that include estimates of spending and other 
information, reviewed documents from HHS agencies that identified 
preventive health activities included in programs administered by the 
agencies, and interviewed ASFR and HHS agency officials.[Footnote 4] 

* For VA, we reviewed documents describing estimates of spending 
developed by VA's Veterans Health Administration (VHA), which 
administers VA's health care system, and we interviewed VHA officials. 
Specifically, we reviewed documents identifying selected clinical 
preventive services provided in VA medical facilities and describing 
spending estimates developed by VHA's Allocation Resource Center for 
these services.[Footnote 5] In addition to estimates of spending for 
clinical preventive services, we reviewed VA documents identifying 
community-oriented preventive health activities included in programs 
administered by VA's National Center for Health Promotion and Disease 
Prevention and VA's Clinical Public Health Group. We also interviewed 
officials who provided these documents. 

* For DOD, we reviewed documents describing estimates of spending 
developed by the department and interviewed DOD officials about the 
department's preventive health activities. For example, to learn about 
DOD's clinical preventive services provided through TRICARE--DOD's 
program that provides health care to active duty personnel and other 
beneficiaries, including retired servicemembers--we reviewed documents 
describing spending estimates provided by DOD's TRICARE Management 
Activity (the DOD component that oversees TRICARE) and interviewed 
officials from the TRICARE Management Activity.[Footnote 6] 

For all the departments, we reviewed documents describing limitations 
of the information or discussed limitations with HHS, VA, and DOD 
officials. We did not independently verify the accuracy of the 
information. We determined the information to be sufficiently reliable 
for providing information on preventive health activities in programs 
administered by HHS, VA, and DOD and on the departments' estimates of 
spending on such activities, and limitations of this information. 
Where we identified limitations, we report them. 

To provide information about the reported cost savings from and cost-
effectiveness of preventive health activities, we conducted a 
literature review and interviewed researchers and government 
officials.[Footnote 7] For our literature review, we searched four 
databases--EMBASE, MEDLINE, SciSearch, and ProQuest--and identified 23 
articles that met our inclusion criteria--that is, each of the 23 
articles reviewed multiple research studies; clearly described a 
methodology; was published in a peer-reviewed journal between January 
2007 and March 2012; and identified U.S. based services that were cost 
saving or cost-effective, or factors that affect whether a preventive 
health activity is cost saving or cost-effective. In addition to 
conducting a literature review of articles published in peer-reviewed 
publications, we reviewed government and independent reports, 
including reports published by nonprofit organizations that were 
referenced in articles in our literature review or were suggested to 
us by the federal officials and researchers we interviewed. We 
interviewed officials from the following HHS agencies that provide 
research support to organizations that work on issues related to 
preventive health activities: the Agency for Healthcare Research and 
Quality (AHRQ)--specifically, we spoke to officials who provide 
research support to the U.S. Preventive Services Task Force (USPSTF); 
and the Centers for Disease Control and Prevention (CDC)--
specifically, we spoke to officials in the National Center for Chronic 
Disease Prevention and Health Promotion and the National Center for 
Immunization and Respiratory Diseases who provide support to the 
Community Preventive Services Task Force and the Advisory Committee on 
Immunization Practices (ACIP), respectively. We also interviewed 
members of ACIP, including the ACIP Chair. 

To provide information on U.S. spending on preventive health 
activities compared to that of other countries, we reviewed data 
collected by the Organization for Economic Co-operation and 
Development (OECD) on national health spending for the United States 
and other OECD member countries.[Footnote 8] OECD is an organization 
that, among other things, collects data on health spending from member 
countries. We reported relevant 2010 spending statistics for OECD 
member countries using data available on OECD's website.[Footnote 9] 
We also identified trends for the United States over time by comparing 
rankings for 2010 spending statistics with similar rankings for 2001 
through 2009. We reviewed documents published by OECD and interviewed 
experts--including officials from the Centers for Medicare & Medicaid 
Services' (CMS) Office of the Actuary (the office that submits the 
U.S. health care spending data to OECD) as well as researchers--to 
learn about guidelines established by OECD and the data submitted by 
OECD member countries. While there are limitations to using OECD data, 
the researchers we interviewed reported that the OECD data are the 
best available data for making international comparisons on health 
spending. We did not independently verify the accuracy of the data. We 
assessed the reliability of the data and determined that the data were 
sufficiently reliable for purposes of presenting available data 
comparing U.S. spending with that of other countries, noting 
limitations associated with these data. 

We conducted our work from December 2011 through December 2012 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform our work to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our research objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our research objectives. 

Background: 

HHS, VA, and DOD Health Care: 

HHS is the federal government's principal department for protecting 
the health of all Americans and providing essential human services, 
especially for vulnerable populations. For fiscal year 2011, HHS's 
department-wide expenditures totaled about $891 billion. HHS agencies 
that administer programs that include preventive health activities 
have missions and key functions that vary. For example, CMS 
administers the Medicare and Medicaid programs and the Children's 
Health Insurance Program, which provide health care insurance for more 
than 100 million adults and children. Three other agencies--the Indian 
Health Service (IHS), the Health Resources and Services Administration 
(HRSA), and the Substance Abuse and Mental Health Services 
Administration (SAMHSA)--provide health care services or support 
systems that provide these services. Two agencies--the National 
Institutes of Health (NIH) and AHRQ--are primarily research agencies. 
CDC develops and supports public health prevention programs and 
systems, such as disease surveillance and provider education programs. 
(See table 1 for more information about these HHS agencies.) 

Table 1: Selected HHS Agencies and Their Functions: 

HHS agency: Administration for Children and Families (ACF); 
Agency functions: Administers programs to promote the economic and 
social well-being of children, youth, families, and communities, 
focusing particular attention on vulnerable populations, such as 
children in low-income families, refugees, Native Americans, and 
children in foster care. 

HHS agency: Agency for Healthcare Research and Quality (AHRQ); 
Agency functions: Supports research that examines how people get 
access to health care, how much health care costs, and what happens to 
patients as a result of the health care they receive. 

HHS agency: Administration for Community Living (ACL)[A]; 
Agency functions: Administers programs to advance the concerns and 
interests of older Americans, people with disabilities, and their 
families through national networks of service, system change efforts, 
and protections to promote optimal life outcomes. 

HHS agency: Centers for Disease Control and Prevention (CDC); 
Agency functions: Administers programs to prevent significant health 
conditions and their risk factors, including infectious diseases, 
chronic diseases, birth defects and developmental disabilities, 
intentional and unintentional injury, and health conditions from 
environmental exposures. 

HHS agency: Centers for Medicare & Medicaid Services (CMS); 
Agency functions: Oversees the financing of health care services for 
the 43 million beneficiaries covered through Medicare and the nearly 
60 million low-income individuals (including adults and children) 
covered through Medicaid and the Children's Health Insurance Program. 

HHS agency: Health Resources and Services Administration (HRSA); 
Agency functions: Administers programs to improve access to health 
care services for people who are uninsured, isolated, or medically 
vulnerable. 

HHS agency: Indian Health Service (IHS); 
Agency functions: Provides health care to approximately 2.2 million 
American Indians and Alaska Natives through a network of 650 
hospitals, clinics, and health stations. 

HHS agency: National Institutes of Health (NIH); 
Agency functions: Supports medical research in the United States. It 
conducts and funds research about, for example, the causes, diagnosis, 
prevention, and cure of human diseases. 

HHS agency: Office of the Assistant Secretary for Health (OASH); 
Agency functions: Coordinates population-based public health and 
science activities across HHS agencies. 

HHS agency: Substance Abuse and Mental Health Services Administration 
(SAMHSA); 
Agency functions: Administers programs to promote emotional health and 
reduce the likelihood of mental illness, substance abuse, and suicide. 

Source: GAO summary of HHS information. 

[A] In April 2012, HHS created the ACL by combining the Administration 
on Aging (AOA), the Office on Disability, and the Administration on 
Intellectual and Developmental Disabilities. 

[End of table] 

VA also provides health care services that include preventive health 
activities. VA operates one of the largest health care delivery 
systems in the nation. VA provides a range of health care services to 
eligible veterans and certain eligible dependents or survivors of 
veterans. These services include primary care, inpatient and 
outpatient surgery, prosthetics, mental health services, prescription 
drugs, nursing home care, and preventive health activities. To provide 
this care, VA operates about 150 hospitals, 130 nursing homes, and 800 
outpatient clinics, as well as other facilities. In fiscal year 2011, 
VA spent about $51 billion on health care services and provided health 
care services to about 6.2 million patients. 

DOD operates a large, complex health system that in fiscal year 2011 
provided health insurance coverage for about 9.6 million active duty 
personnel and other beneficiaries, including eligible family members 
and retired servicemembers. DOD's health system consists of the Office 
of the Assistant Secretary for Health Affairs, the medical departments 
of the Army, Navy, and Air Force; the Joint Chiefs of Staff; the 
Combatant Command surgeons; and the TRICARE network of health care 
providers. DOD delivers health care services--including diagnostic, 
therapeutic, inpatient, and outpatient care--through the military 
services' medical departments at 59 military treatment facilities, 365 
ambulatory care clinics, and 281 dental clinics, which make up what is 
known as the direct care system. DOD also delivers similar services to 
TRICARE beneficiaries through its purchased care system, which 
consists of network and nonnetwork private-sector civilian primary and 
specialty care providers, hospitals, pharmacies, and suppliers. In 
fiscal year 2011, spending in DOD's health system totaled about $52 
billion. 

Estimating Cost Savings and Cost-Effectiveness of Preventive Health 
Activities: 

Preventive health activities may result in cost savings and may be 
cost-effective. An activity may be cost saving if the costs averted by 
the activity, such as future medical costs to treat a disease or 
condition, exceed the cost of implementing the preventive health 
activity. An activity may be considered cost-effective if it generates 
benefits, such as improved health outcomes, in a less costly way than 
alternatives. Cost-effectiveness analysis can help to evaluate whether 
the improvement in health care outcomes justifies the expenditures 
relative to other choices. 

Cost-effectiveness analyses typically compare the costs and health 
outcomes between two activities or compare an activity with no 
intervention. Estimates of cost-effectiveness are typically presented 
as a ratio of the net costs to the net outcomes of utilizing one 
preventive health activity over another. In presenting outcomes of 
cost-effectiveness analyses, researchers often use a measure called 
the quality-adjusted life-year (QALY), which takes into account both 
the number and quality of years added by an intervention. A year in 
perfect health is worth 1 QALY, and a year with less than perfect 
health--for example, with an adverse health condition--is generally 
worth between 0 and 1 QALY. The preventive health activity with the 
lower cost-effectiveness ratio is preferred because it costs less to 
achieve the desired health outcome. While there is no agreement on the 
specific threshold for determining that an activity is cost-effective, 
researchers have used a threshold of $50,000 per QALY or $100,000 per 
QALY to consider a preventive health activity to be cost-effective. 
[Footnote 10] 

In the United States, three federally supported organizations--USPSTF, 
ACIP, and the Community Preventive Services Task Force--assess 
information about preventive health activities and make 
recommendations to providers and policymakers based on an activity's 
effectiveness--that is, how well the activity produces a desired 
health outcome. 

* USPSTF is an independent panel of nonfederal experts in prevention 
and evidence-based medicine that makes recommendations to primary care 
clinicians on clinical preventive services.[Footnote 11] USPSTF 
reviews evidence from randomized control trials and other studies 
documenting the effectiveness of clinical preventive services. 
[Footnote 12] It then issues recommendations for providers and may 
include guidance on the sex and age groups most likely to benefit from 
the service, as well as the interval of the service. The USPSTF is 
convened by AHRQ, and AHRQ also provides it with administrative, 
research, technical, and dissemination support. 

* ACIP--a federal advisory committee of 15 experts selected by the 
Secretary of Health and Human Services--makes recommendations for 
vaccination administration, including a schedule of recommended 
vaccines for adults and children.[Footnote 13] As part of its 
recommendation process, ACIP reviews information on the cost or 
economic impact of the vaccinations it evaluates. CDC provides ACIP 
with management and support services. 

* The Community Preventive Services Task Force--an independent, 
nonfederal panel of 15 members appointed by the CDC Director--conducts 
systematic reviews of community-oriented preventive services, 
programs, and policies and issues recommendations and findings to help 
inform decision making about policy, practice, and research. The task 
force examines the evidence, produces findings and recommendations 
about effective and ineffective programs, services, and policies, and 
identifies research gaps that need to be filled. While the Community 
Preventive Services Task Force does not consider economic information, 
such as whether a preventive health service is cost saving or cost-
effective, as part of its recommendation process, it makes publicly 
available the economic information for the preventive health 
activities it recommends.[Footnote 14] The task force reviews 
research, including cost-effectiveness research, funded and conducted 
by CDC's Epidemiology and Analysis Program Office. CDC staff support 
the Community Preventive Services Task Force by conducting the 
systematic reviews with oversight from the task force, and by 
disseminating task force recommendations and findings. 

OECD: 

OECD is an international economic organization in which its member 
countries discuss, develop, and analyze economic and social policy. 
OECD collects data on total health spending and spending on specific 
health categories such as medical goods, inpatient care, and 
outpatient care, from its member countries, including the United 
States. For the United States, CMS's Office of the Actuary reports 
national health spending data to OECD. To make the data collected from 
member countries as comparable as possible, OECD establishes 
guidelines for the types of spending that should be included in 
various spending categories.[Footnote 15] For example, OECD's 
guidelines for total health spending in 2010 included spending in both 
the public and private sectors on health services conducted in 
hospitals and other facilities or settings such as long-term nursing 
care centers and physicians' offices. The guidelines also included 
total spending on pharmaceuticals, health administration, and public 
health. In 2010, the United States ranked first among OECD countries 
in total health care spending (about $2.5 trillion). The United States 
also ranked first among OECD countries in total health care spending 
as a percentage of the country's gross domestic product (about 18 
percent) and in total health care spending per capita$8,233 per person 
(see figure 1). 

Figure 1: Total Health Care Spending per Capita, by OECD Member 
Country, 2010: 

[Refer to PDF for image: horizontal bar graph] 

Country: United States; 
Total health spending, per capita (U.S. dollars): $8,232.88. 

Country: Norway; 
Total health spending, per capita (U.S. dollars): $5,387.59. 

Country: Switzerland; 
Total health spending, per capita (U.S. dollars): $5,269.64. 

Country: Netherlands; 
Total health spending, per capita (U.S. dollars): $5,056.24. 

Country: Denmark; 
Total health spending, per capita (U.S. dollars): $4,463.92. 

Country: Canada; 
Total health spending, per capita (U.S. dollars): $4,444.86. 

Country: Austria; 
Total health spending, per capita (U.S. dollars): $4,394.76. 

Country: Germany; 
Total health spending, per capita (U.S. dollars): $4,338.43. 

Country: France; 
Total health spending, per capita (U.S. dollars): $3,974. 

Country: Belgium; 
Total health spending, per capita (U.S. dollars): $3,968.84. 

Country: Sweden; 
Total health spending, per capita (U.S. dollars): $3,757.70. 

Country: Ireland; 
Total health spending, per capita (U.S. dollars): $3,718.22. 

Country: United Kingdom; 
Total health spending, per capita (U.S. dollars): $3,433.25. 

Country: Iceland; 
Total health spending, per capita (U.S. dollars): $3,309.34. 

Country: Finland; 
Total health spending, per capita (U.S. dollars): $3,250.91. 

Country: New Zealand; 
Total health spending, per capita (U.S. dollars): $3,022.14. 

Country: Italy; 
Total health spending, per capita (U.S. dollars): $2,963.66. 

Country: Greece; 
Total health spending, per capita (U.S. dollars): $2,913.72. 

Country: Portugal; 
Total health spending, per capita (U.S. dollars): $2,727.71. 

Country: Slovenia; 
Total health spending, per capita (U.S. dollars): $2,428.49. 

Country: Slovak Republic; 
Total health spending, per capita (U.S. dollars): $2,095.47. 

Country: Korea; 
Total health spending, per capita (U.S. dollars): $2,035.40. 

Country: Czech Republic; 
Total health spending, per capita (U.S. dollars): $1,883.55. 

Country: Hungary; 
Total health spending, per capita (U.S. dollars): $1,600.50. 

Country: Poland; 
Total health spending, per capita (U.S. dollars): $1,388.69. 

Country: Estonia; 
Total health spending, per capita (U.S. dollars): $1,293.80. 

Country: Chile; 
Total health spending, per capita (U.S. dollars): $1,202.15. 

Country: Mexico; 
Total health spending, per capita (U.S. dollars): $915.73. 

Source: GAO analysis of data from the Organization for Economic Co-
operation and Development (OECD). 

Note: This figure presents a summary of 2010 data on total health care 
spending per capita for 28 OECD member countries. OECD adjusted 
spending per capita for purchasing power parity. 

[End of figure] 

HHS, VA, and DOD Programs Include Preventive Health Activities, but 
Department-wide Spending on These Activities Is Not Specifically 
Tracked: 

HHS, VA, and DOD Identified Preventive Health Activities Included in 
the Programs They Administer: 

HHS agencies identified preventive health activities--specifically, 
clinical preventive services and community-oriented preventive health 
activities--included in programs that they administer, with different 
programs targeting different populations. (See table 2 for types of 
preventive health activities included in programs that HHS agencies 
administer and examples of such activities.) For example, CMS's 
Medicare and Medicaid programs provide coverage for clinical 
preventive services for Medicare and Medicaid beneficiaries, while 
IHS's programs provide preventive health activities for American 
Indians and Alaska Natives. CDC administers programs that include 
community-oriented preventive health activities such as the National 
Tobacco Control Program, which provides access to quit lines and ad 
campaigns to reduce smoking. 

Table 2: Types of Preventive Health Activities Included in Programs 
Administered by HHS Agencies: 

HHS agency: Administration for Children and Families (ACF); 
Type of preventive health activities included: Clinical preventive 
services: [Check]; 
Type of preventive health activities included: Community-oriented 
preventive health activities: [Empty]; 
Example: ACF awards discretionary grants to states through its Office 
of Refugee Resettlement Preventive Health Services program to 
coordinate and promote access to clinical preventive services that 
include health screenings for refugees. 

HHS agency: Agency for Healthcare Research and Quality (AHRQ); 
Type of preventive health activities included: Clinical preventive 
services: [Check]; 
Type of preventive health activities included: Community-oriented 
preventive health activities: [Empty]; 
Example: AHRQ convenes the U.S. Preventive Services Task Force 
(USPSTF)--a panel of experts that makes recommendations on clinical 
preventive services--and provides administrative, research, technical, 
and dissemination support for the USPSTF. 

HHS agency: Administration for Community Living (ACL)[A]; 
Type of preventive health activities included: Clinical preventive 
services: [Empty]; 
Type of preventive health activities included: Community-oriented 
preventive health activities: [Check]; 
Example: ACL administers programs that promote opportunity, healthy 
lifestyles, and healthy behaviors for older Americans, people with 
disabilities, and their families through education, research and 
service across diverse networks of state and local programs. 

HHS agency: Centers for Disease Control and Prevention (CDC); 
Type of preventive health activities included: Clinical preventive 
services: [Check]; 
Type of preventive health activities included: Community-oriented 
preventive health activities: [Check]; 
Example: CDC administers programs that include community-oriented 
preventive health activities such as the National Tobacco Control 
Program, which provides access to quit lines and ad campaigns to 
reduce smoking. CDC also supports the Community Preventive Services 
Task Force, which conducts reviews on the effectiveness of community-
oriented preventive health activities. CDC's Vaccines for Children 
program and Section 317 Immunization Program fund the purchasing and 
delivery of vaccines to vulnerable populations. 

HHS agency: Centers for Medicare & Medicaid Services (CMS); 
Type of preventive health activities included: Clinical preventive 
services: [Check]; 
Type of preventive health activities included: Community-oriented 
preventive health activities: [Check]; 
Example: CMS's Medicare and Medicaid programs provide coverage for 
many clinical preventive services such as wellness examinations, 
screenings, vaccinations, and counseling for Medicare and Medicaid 
beneficiaries. CMS's Everyone with Diabetes Counts program includes 
community-oriented preventive health activities that seek to educate 
Medicare beneficiaries with diabetes in vulnerable populations and 
increase their health literacy. 

HHS agency: Health Resources and Services Administration (HRSA); 
Type of preventive health activities included: Clinical preventive 
services: [Check]; 
Type of preventive health activities included: Community-oriented 
preventive health activities: [Check]; 
Example: HRSA's National Health Service Corps supports the provision 
of clinical preventive health activities and community-oriented 
preventive health activities by offering assistance to underserved 
communities in every state to recruit and retain primary care 
providers. 

HHS agency: Indian Health Service (IHS); 
Type of preventive health activities included: Clinical preventive 
services: [Check]; 
Type of preventive health activities included: Community-oriented 
preventive health activities: [Check]; 
Example: IHS provides clinical preventive services to American Indians 
and Alaska Natives through its network of hospitals and clinics. IHS's 
Community Health Representative program supports community-oriented 
preventive health activities by, for example, providing health 
education in patients' homes and schools and facilitating screening at 
health fairs. 

HHS agency: National Institutes of Health (NIH); 
Type of preventive health activities included: Clinical preventive 
services: [Check]; 
Type of preventive health activities included: Community-oriented 
preventive health activities: [Check]; 
Example: NIH supports research designed to yield results directly 
applicable to identifying and assessing risk, and to develop 
interventions for preventing or ameliorating high-risk behaviors, the 
occurrence of disease, disorder, injury, or progression of detectable 
but asymptomatic disease. Research projects support clinical 
preventive services and community-oriented preventive health 
activities. 

HHS agency: Office of the Assistant Secretary for Health (OASH); 
Type of preventive health activities included: Clinical preventive 
services: [Check]; 
Type of preventive health activities included: Community-oriented 
preventive health activities: [Check]; 
Example: OASH leads the President's Council on Physical Fitness, 
Sports, and Nutrition in efforts to increase physical activity in the 
United States. The council advises the President through the Secretary 
of Health and Human Services about physical activity, fitness, sports, 
and good nutrition. In addition, OASH provides funding support for 
Title X family planning clinics which provide clinical preventive 
services to millions of individuals. 

HHS agency: Substance Abuse and Mental Health Services Administration 
(SAMHSA); 
Type of preventive health activities included: Clinical preventive 
services: [Check]; 
Type of preventive health activities included: Community-oriented 
preventive health activities: [Check]; 
Example: SAMHSA's Safe Schools/Healthy Students Initiative includes 
both clinical preventive services and community-oriented preventive 
health activities. It provides funding to local law enforcement, 
juvenile justice agencies, social services, mental health agencies, 
and other community organizations to plan and implement comprehensive 
and coordinated programs, policies, and service delivery systems that 
promote mental, emotional, and behavioral well-being and prevent 
violence and drug abuse among children and youth. 

Source: GAO summary of HHS information. 

[A] In April 2012, HHS created the ACL by combining the Administration 
on Aging (AOA), the Office on Disability, and the Administration on 
Intellectual and Developmental Disabilities. 

[End of table] 

VA also identified clinical preventive services and community-oriented 
preventive health activities in the programs it administers for 
veterans and other beneficiaries in VA facilities. Examples of the 
clinical preventive services that VA provides to beneficiaries who are 
eligible for such services include immunizations; dental cleanings; 
depression screenings; post-traumatic stress screenings; diabetes 
screenings; hypertension screenings; tobacco use screenings and 
counseling; and screenings for breast cancer, cervical cancer, and 
colorectal cancer. VA provides these services to beneficiaries in VA 
medical centers, community-based outpatient clinics, and other VA 
facilities.[Footnote 16] In addition, VA's National Center for Health 
Promotion and Disease Prevention provides support for clinical staff 
in VA medical facilities and coordinates VA's community-oriented 
preventive health activities. For example, the center leads the 
department's efforts to provide guidance to clinicians and veterans on 
a range of clinical preventive services, and administers the 
department's MOVE! Weight Management Program. VA's Clinical Public 
Health Group--an office that addresses public health concerns through, 
among other things, education and outreach, policy development, and 
research--also administers community-oriented preventive health 
activities, including prevention education for tobacco use, human 
immunodeficiency virus (HIV), and influenza. 

In addition, DOD identified clinical preventive services and community-
oriented preventive health activities included in programs 
administered through the department's direct care and purchased care 
systems for active duty personnel and other beneficiaries, including 
retired servicemembers. Examples of services include immunizations; 
depression screenings; dental screenings; diabetes screenings; obesity 
screenings; vision screenings; and screenings for breast cancer, 
cervical cancer, and colorectal cancer. DOD's direct care system also 
includes community-oriented preventive health activities such as 
tobacco cessation and obesity and alcohol abuse prevention programs. 
For example, DOD's TRICARE Management Activity coordinates the Quit 
Tobacco--Make Everyone Proud program, which is a tobacco cessation 
marketing and education campaign to increase awareness of the negative 
effects of tobacco use and decrease its use and acceptance in the 
military work environment. DOD also reported that the Duncan Hunter 
National Defense Authorization Act for Fiscal Year 2009 required DOD 
to reduce beneficiary cost sharing and undertake certain preventive 
health activities.[Footnote 17] (For more information on these 
provisions, see appendix I.) 

HHS, VA, and DOD Do Not Track Department-wide Spending for Preventive 
Health Activities, but Provided a Mix of Information Related to 
Spending for Preventive Health Activities: 

HHS, VA, and DOD reported that they do not specifically track 
department-wide spending[Footnote 18] on preventive health activities 
and that determining total spending on preventive health activities is 
challenging because such activities are often integrated with other 
activities. According to HHS, VA, and DOD officials, spending for 
preventive health activities is not easily distinguished in their data 
from spending on other health activities. For example, VA and DOD 
officials reported that it can be challenging to identify the portion 
of spending linked to a clinical preventive service and identify the 
portion that is for treatment when both types of services are provided 
in a single patient visit. The departments noted that they are not 
required to specifically track department-wide spending on all the 
preventive health activities included in the programs they administer. 

HHS, VA, and DOD provided us with a mix of information related to 
spending for preventive health activities, and noted limitations 
associated with the information. For example, some spending for 
preventive health activities was not included, or prevention-related 
spending was included but was not for preventive health activities. In 
addition, in some cases, information provided by HHS and VA did not 
present estimated spending for these activities, but rather funding, 
which represents an amount available at a particular time, but does 
not necessarily reflect actual spending that occurred.[Footnote 19] 
Funding estimates provided by HHS and VA suggest that there was 
spending on preventive health activities, but the funding estimates 
may not represent the amounts that were spent on the activities. For 
example, a department may not have spent all of its available funding 
for a preventive health activity.[Footnote 20] 

HHS: 

The most readily available information related to preventive health 
activities compiled by HHS is found in its annual crosscut briefing 
documents--documents that are used by HHS's Office of the Secretary to 
make budget-related decisions and to answer questions from Congress 
and others related to the President's annual budget request. ASFR 
compiles the information for these documents, but in its requests for 
information from the agencies for the documents, it has not provided 
agencies with a specific definition of activities to include in their 
prevention estimates nor specified a method for calculating an 
estimate. These annual crosscut briefing documents on prevention 
provide a mix of spending and funding estimates for prevention-related 
activities that include, but are not limited to, preventive health 
activities, and in recent years did not include estimates for CMS, 
which oversees health coverage programs for over 100 million 
individuals. In particular: 

* The most recent annual crosscut briefing document on prevention 
available at the time of our review included estimates of spending for 
one HHS agency and funding for nine HHS agencies for fiscal year 2011. 
[Footnote 21] 

* The document did not include an estimate of spending for fiscal year 
2011 for CMS--that is, it did not include estimated spending for 
preventive health activities in Medicare, Medicaid, and the Children's 
Health Insurance Program.[Footnote 22] 

* The document included estimates for prevention-related activities 
that include, but are not limited to, clinical preventive services and 
community-oriented preventive health activities. That is, the document 
included estimates of other prevention-related funding or spending 
such as emergency preparedness, environmental health, and occupational 
safety. For example, HHS's prevention estimates included funding for 
the Food and Drug Administration's (FDA) oversight of food safety, 
tobacco products, and medical products.[Footnote 23] 

The most recent HHS annual crosscut briefing document included in our 
review reported that for one agency (NIH), estimated spending on 
prevention for fiscal year 2011 was about $6 billion, and that 
estimated funding for prevention for nine agencies--ACF, AHRQ, AOA, 
CDC, FDA, HRSA, IHS, OASH, and SAMHSA--was about $18 billion that 
year. The annual crosscut briefing document did not include any 
estimated spending for fiscal year 2011 for CMS. (See appendix II for 
more information on HHS's prevention estimates.) 

VA: 

VA estimated spending of about $576 million for providing selected 
clinical preventive services in its VA medical facilities, including 
VA medical centers, outpatient clinics, and other facilities. VA's 
estimated spending included UPSTSF-recommended services and other 
clinical preventive services that VA provided to its beneficiaries in 
outpatient settings in fiscal year 2011. The estimate also included 
estimated related spending for salaries and benefits for providers, 
administrative activities, and maintenance of facilities. VA did not 
include estimated spending for pharmaceutical drugs, services provided 
through VA's purchased care program (which covers health care services 
provided to eligible veterans outside of VA when a VA facility is not 
available) or services provided in an inpatient setting. VA also 
provided its estimates of funding (totaling over $5 million) for its 
National Center for Health Promotion and Disease Prevention, which is 
responsible for developing the resources that support VA medical 
centers in providing community-oriented preventive health activities, 
and its Clinical Public Health Group's community-oriented preventive 
health activities for fiscal year 2011. VA officials told us that 
individual VA medical facilities may have conducted additional 
community-oriented preventive health activities, such as taking 
measures to increase testing for HIV, that are not included in VA's 
estimates. (See appendix III for more information on VA's estimates of 
spending and funding.) 

DOD: 

DOD estimated spending about $1 billion to provide selected clinical 
preventive services, including (but not limited to) services 
recommended by the USPSTF, through its direct care and purchased care 
systems to active duty personnel, retired servicemembers, and other 
beneficiaries for fiscal year 2011. DOD also estimated spending about 
$407 million on some of its community-oriented preventive health 
activities and other activities (such as epidemiology) in DOD's direct 
care system for fiscal year 2011. DOD's spending estimates also have 
limitations. For example, because DOD's estimates were limited to a 
review of purchased care claims and direct care data records, spending 
for some clinical preventive services--such as counseling about 
smoking cessation provided during a visit in which the patient 
received services for hypertension--is not included in the estimates. 
Also, while DOD's estimates of spending include amounts for some 
community-oriented preventive health activities, they also include 
estimated spending on other activities (such as those related to 
drinking water safety and food and facility sanitation); DOD noted 
that it cannot separately identify spending specifically for the 
community-oriented preventive health activities. (See appendix IV for 
more information on DOD's estimates of spending.) 

Some Preventive Health Activities May Be Cost Saving or Cost-
Effective, but Multiple Factors Affect Estimates, and Key Data May Be 
Lacking: 

Some Preventive Health Activities May Result in Cost Savings or May Be 
Cost-Effective: 

Articles in peer-reviewed publications and government and independent 
reports we reviewed identified some preventive health activities that 
may result in cost savings and reported that a larger number may be 
cost-effective. The articles and reports we reviewed identified 
preventive health activities, such as childhood immunizations, 
workplace wellness programs, and disease screenings, that have been 
found in certain circumstances to be cost saving--that is, the costs 
averted by the activity, such as future medical costs to treat a 
disease or condition, exceed the cost of implementing it.[Footnote 24] 
For example, according to one report that synthesized the results of 
three reviews of a number of clinical preventive services (the 
synthesis report), several clinical preventive services were estimated 
to be cost-saving by one or more of the three reviews.[Footnote 25] 
The report found that two preventive services--counseling on the use 
of low-dose aspirin to reduce coronary heart disease and childhood 
immunizations--were estimated to be cost-saving by all three reviews. 
The National Prevention Council's National Prevention Strategy also 
reported that preventive health activities such as certain diabetes 
and tobacco interventions can result in cost savings.[Footnote 26] The 
articles and reports we reviewed, including the synthesis report, also 
identified a number of preventive health activities that, while not 
found to be cost saving, were estimated to be cost-effective--that is, 
they provided good value at low cost relative to alternative 
activities.[Footnote 27] The synthesis report identified several 
preventive health activities that were estimated by at least one of 
the reviews to be cost-effective, including counseling women to use 
calcium supplements, colorectal cancer screening, and hepatitis B 
screening in pregnant women. Colorectal cancer screening in adults 50 
years old and older was found to be cost-effective by all three 
reviews.[Footnote 28] 

Articles and reports we reviewed noted that there are important 
limitations associated with estimates of cost savings and cost-
effectiveness. For example, some of the articles noted that preventive 
health activities that are found not to be cost saving or cost-
effective may be less likely to be published in peer-reviewed 
journals.[Footnote 29] In addition, the synthesis report noted that 
there is no evidence that the findings included in the three reviews 
it examined are representative of the available literature on 
preventive health activities as a whole. 

Multiple Factors Affect Cost Savings and Cost-Effectiveness Estimates, 
and Key Data May Be Lacking: 

According to articles in peer-review publications and government and 
independent reports we reviewed, as well as researchers and federal 
officials we interviewed, each cost savings and cost-effectiveness 
estimate is affected by multiple factors. These include how an 
activity is targeted, the assumptions used in calculating cost savings 
and cost-effectiveness estimates, and a lack of key data. 

The targeting of a preventive health activity is an important factor 
affecting estimates of the cost savings or cost-effectiveness of that 
activity. Articles in peer-reviewed publications and reports, 
researchers we interviewed, and CDC officials reported that if a 
preventive health activity is targeted to a population at a higher 
risk of developing a specific disease, instead of being provided to 
the entire population regardless of their risk to develop the disease, 
the intervention will more likely result in cost savings or be cost-
effective.[Footnote 30] For example, CDC officials told us that 
childhood vaccinations are often estimated to be cost saving and cost-
effective because the vaccines target a very specific, easy to 
identify, and high-risk population at relatively low financial costs. 
In addition, a CDC official noted that because the majority of 
children are at risk for developing the diseases targeted by the 
vaccinations, the vaccinations prevent a large number of diseases and 
thus avert the costs associated with the treatment of those diseases. 
[Footnote 31] As another example, a review of smoking cessation 
programs found that programs targeted to specific groups of smokers, 
such as pregnant women, were more cost-effective than those targeted 
at the general population of smokers. See table 3 for an illustration 
of how targeting can affect estimates of a preventive health 
activity's cost-effectiveness--for example, targeting smokers on the 
basis of their levels of low-density lipoprotein (LDL) cholesterol and 
risk factors of developing heart disease.[Footnote 32] However, it can 
be difficult for physicians, for example, to know beforehand which 
patients are at a higher risk of developing a disease, in order to 
target a specific preventive health activity, as the Congressional 
Budget Office has reported.[Footnote 33] As a result, some preventive 
health activities may be provided to many patients, even those who 
will most likely not develop the disease, and costs can accumulate as 
the number of patients utilizing the preventive health activity 
increases. 

Table 3: Effect of Targeting on Cost-Effectiveness Ratio for Selected 
Preventive Health Activities: 

Preventive health activity: Using a statin to prevent heart disease; 
Compared to: Diet-based prevention; 
Target population: Male smokers with very high low-density lipoprotein 
(LDL) cholesterol,[B] high blood pressure, age 35-44 years; 
Cost-effectiveness ratio (dollars)[A]: $54,000/QALY. 

Preventive health activity: Using a statin to prevent heart disease; 
Compared to: Diet-based prevention; 
Target population: Male smokers with high LDL cholesterol,[B] high 
blood pressure, age 35-44 years; 
Cost-effectiveness ratio (dollars)[A]: 100,000/QALY. 

Preventive health activity: Using alendronate to prevent fragility 
fractures; 
Compared to: No intervention; 
Target population: Postmenopausal women with bone marrow density 2.4 
standard deviations below normal, no vertebral abnormalities, age 60; 
Cost-effectiveness ratio (dollars)[A]: 37,482/QALY. 

Preventive health activity: Using alendronate to prevent fragility 
fractures; 
Compared to: No intervention; 
Target population: Postmenopausal women with bone marrow density 1.0 
standard deviation below normal, no vertebral abnormalities, age 80; 
Cost-effectiveness ratio (dollars)[A]: 166,219/QALY. 

Source: GAO summary of information from published research. 

Notes: Data are from L. A. Prosser et al., "Cost-Effectiveness of 
Cholesterol-Lowering Therapies According to Selected Patient 
Characteristics," Annals of Internal Medicine, vol. 132, no. 10 (2000) 
and R. L. Fleurence, C. P. Iglesias, and J. M. Johnson, "The Cost 
Effectiveness of Bisphophonates for the Prevention and Treatment of 
Osteoporosis," Pharamcoeconomics, vol. 25, no. 11 (2007). 

[A] The cost-effectiveness ratio represents the cost per quality-
adjusted life-year (QALY) that would be added by the activity. A year 
in perfect health is worth 1 QALY, and a year in less than perfect 
health--that is, with any adverse condition--is generally worth 
between 0 and 1 QALY. The preventive health activity with the lower 
cost-effectiveness ratio is preferred because it costs less to achieve 
the health outcome. For example, if the cost-effectiveness ratio of 
one preventive health activity is $80,000/QALY and that of another 
activity is $20,000/QALY, the activity with the $20,000/QALY cost-
effectiveness ratio would be preferred. 

[B] The National Heart, Lung, and Blood Institute (NHLBI) categorizes 
LDL cholesterol between 160 to189 milligrams per deciliter as high. 
Very high LDL cholesterol is 190 milligrams per deciliter or higher. 
NHLBI categorizes high blood pressure as a diastolic blood pressure of 
95 millimeters of mercury or higher. The target population also has 
low levels of "good" cholesterol, or high-density lipoproteins. 

[End of table] 

Also affecting an estimate of a preventive health activity's cost 
savings or cost-effectiveness are the assumptions used in calculating 
the estimate, such as those regarding the effectiveness of the 
activity, perspective of the study, and accounting for future medical 
technology. For example, in modeling the cost-effectiveness of a 
vaccine, a researcher might assume that the vaccine is 90 percent 
effective at preventing a disease in the model, but the actual 
effectiveness of the vaccine may not be known. 

* Assumptions about the effectiveness of the activity. Assumptions 
about the effectiveness of an activity can affect estimates of cost 
savings or cost-effectiveness. For example, researchers reviewed 
multiple estimates of the cost-effectiveness of vaccination against 
human papilloma virus (HPV) and found that varying the assumptions for 
the vaccine's effectiveness, the number of years the vaccine would 
provide protection against HPV, or the years of costs for additional 
screening and testing for HPV produced estimates of the vaccine's cost-
effectiveness ranging from $20,600 per QALY to more than $3.5 million 
per QALY.[Footnote 34] 

* The perspective of a study. The perspective of a study--that is, who 
is receiving the benefit or bearing the cost--can affect an estimate 
of the extent to which a preventive health activity is cost saving or 
cost-effective. Many studies are conducted from the perspective of the 
entity providing the preventive health activity, such as an employer 
or hospital system, so the costs and benefits of an activity to an 
individual consumer or others may not be considered. For example, a 
review of multiple estimates of the cost-effectiveness of HIV 
screenings noted that a study conducted from the perspective of the 
entity funding the activity may not incorporate certain costs, such as 
treatment costs, or long-term benefits, such as extension of life 
expectancy. As a result, the study may not reflect all possible costs 
and savings that could result from a preventive health activity. 

* Assumptions about technology. Assumptions about future medical 
technology may also affect a cost saving and cost-effectiveness 
estimate about a preventive health activity. A CDC official told us 
that in projecting the costs and benefits of an activity, the typical 
assumption is that medical technology will be and cost the same years 
into the future, even though technology, which can alter the costs and 
benefits of an activity, can change rapidly over time. 

Difficulties in estimating cost savings and cost-effectiveness for a 
preventive health activity, including the need to make assumptions, 
can arise from a lack of key data. For example, ACIP officials said a 
challenge in determining the cost savings or cost-effectiveness of 
vaccines is that data needed for the analysis, such as the actual 
price of a new vaccine, are not available at the time they make a 
recommendation. Similarly, data on outcomes resulting from a 
preventive health activity are not available for many diseases. A CDC 
official stated that when a community-oriented preventive health 
activity has not been found to be cost-effective, this is often due to 
a lack of sufficient data needed to conduct cost-effectiveness 
analysis rather than evidence that the activity is not cost-effective. 
In some cases, the outcome measures used to study the effects of a 
preventive health activity make determining cost-effectiveness 
difficult. For example, instead of using an outcome measure such as 
the cost per QALY, a study evaluating efforts to increase vaccination 
may measure the cost per child immunized. Additional economic modeling 
would have to occur, and assumptions be made, in order to convert the 
data to cost per QALY. Researchers also noted that some studies that 
focus on the effectiveness of preventive health activities do not 
report costs of the preventive health activity. A research article 
that reviewed studies that estimated cost savings resulting from 
workplace wellness programs reported that nearly one-third of the 
studies in its review did not report program costs.[Footnote 35] 
According to CDC officials, CDC is taking steps to collect data for 
cost-effectiveness analyses for programs related to preventive health 
activities for which relevant data have been lacking. In addition, the 
Institute of Medicine conducted a study to develop a framework for 
assessing community-oriented preventive health activities. This 
framework considers, among other things, the sources of data that are 
available and needed for analysis.[Footnote 36] 

International Data on Preventive Health Activities Are Not Available, 
but United States Ranks Eighth in OECD Category That Combines Spending 
on Prevention and Public Health Services: 

Data for international comparisons of countries' spending specifically 
for preventive health activities are not available. Instead, the most 
readily available data is a category of OECD health data called 
"prevention and public health services,"[Footnote 37] which combines 
spending on certain clinical preventive services and community-
oriented preventive health activities, such as vaccination programs, 
and public health activities, such as disease surveillance and blood 
banks.[Footnote 38] On the basis of these data, the United States 
ranked 8th among 23 OECD member countries in the percentage of total 
health care spending reported for prevention and public health 
services (see figure 2). In 2010, U.S. spending on prevention and 
public health services was about $88.4 billion, or 3.5 percent of 
total U.S. health care spending of $2.5 trillion--a rate that has 
remained relatively steady since 2001.[Footnote 39] 

Figure 2: Spending for Prevention and Public Health Services as a 
Percentage of Total Health Spending, by OECD Member Country, 2010: 

[Refer to PDF for image: horizontal bar graph] 

Country: New Zealand; 
Percentage of total health spending: 6.985%. 

Country: Canada; 
Percentage of total health spending: 6.564%. 

Country: Finland; 
Percentage of total health spending: 5.179%. 

Country: Slovak Republic; 
Percentage of total health spending: 5.042%. 

Country: Netherlands; 
Percentage of total health spending: 4.482%. 

Country: Hungary; 
Percentage of total health spending: 4.349%. 

Country: Slovenia; 
Percentage of total health spending: 3.643%. 

Country: United States; 
Percentage of total health spending: 3.475%. 

Country: Sweden; 
Percentage of total health spending: 3.41%. 

Country: Germany; 
Percentage of total health spending: 3.132%. 

Country: Korea; 
Percentage of total health spending: 3.092%. 

Country: Estonia; 
Percentage of total health spending: 2.715%. 

Country: Norway; 
Percentage of total health spending: 2.418%. 

Country: Czech Republic; 
Percentage of total health spending: 2.408%. 

Country: Switzerland; 
Percentage of total health spending: 2.365%. 

Country: Denmark; 
Percentage of total health spending: 2.224%. 

Country: France; 
Percentage of total health spending: 2.05%. 

Country: Portugal; 
Percentage of total health spending: 2.022%. 

Country: Belgium; 
Percentage of total health spending: 1.967%. 

Country: Poland; 
Percentage of total health spending: 1.928%. 

Country: Austria; 
Percentage of total health spending: 1.693%. 

Country: Iceland; 
Percentage of total health spending: 1.483%. 

Country: Italy; 
Percentage of total health spending: 0.438%. 

Source: GAO analysis of data from the Organization for Economic Co-
operation and Development (OECD). 

Note: This figure presents a summary of 2010 data on health care 
spending, including spending for the 23 OECD member countries that 
submitted data to OECD on the category of prevention and public health 
services. 

[End of figure] 

U.S. spending in the OECD category of prevention and public health 
services also ranked third highest as a percentage of gross domestic 
product among the 23 countries reporting 2010 data to OECD. 
Specifically, total U.S. spending on prevention and public health 
services was 0.6 percent of U.S. gross domestic product (about $88.4 
billion for prevention and public health spending out of a total gross 
domestic product of about $14.4 trillion). Canada and New Zealand 
spent a higher percentage of gross domestic product on prevention and 
public health services (see figure 3). U.S. rankings in OECD's 
international comparisons of spending on prevention and public health 
services as a percentage of gross domestic product have been generally 
constant since 2001. 

Figure 3: Spending for Prevention and Public Health Services as a 
Percentage of Gross Domestic Product, by OECD Member Country, 2010: 

[Refer to PDF for image: horizontal bar graph] 

Country: Canada; 
Percentage of gross domestic product: 0.747%. 

Country: New Zealand; 
Percentage of gross domestic product: 0.704%. 

Country: United States; 
Percentage of gross domestic product: 0.612%. 

Country: Netherlands; 
Percentage of gross domestic product: 0.538%. 

Country: Finland; 
Percentage of gross domestic product: 0.462%. 

Country: Slovak Republic; 
Percentage of gross domestic product: 0.454%. 

Country: Germany; 
Percentage of gross domestic product: 0.363%. 

Country: Hungary; 
Percentage of gross domestic product: 0.339%. 

Country: Slovenia; 
Percentage of gross domestic product: 0.329%. 

Country: Sweden; 
Percentage of gross domestic product: 0.326%. 

Country: Switzerland; 
Percentage of gross domestic product: 0.269%. 

Country: Denmark; 
Percentage of gross domestic product: 0.247%. 

Country: France; 
Percentage of gross domestic product: 0.239%. 

Country: Norway; 
Percentage of gross domestic product: 0.228%. 

Country: Korea; 
Percentage of gross domestic product: 0.219%. 

Country: Portugal; 
Percentage of gross domestic product: 0.217%. 

Country: Belgium; 
Percentage of gross domestic product: 0.208%. 

Country: Austria; 
Percentage of gross domestic product: 0.186%. 

Country: Czech Republic; 
Percentage of gross domestic product: 0.18%. 

Country: Estonia; 
Percentage of gross domestic product: 0.172%. 

Country: Iceland; 
Percentage of gross domestic product: 0.138%. 

Country: Poland; 
Percentage of gross domestic product: 0.135%. 

Country: Italy; 
Percentage of gross domestic product: 0.041%. 

Source: GAO analysis of data from the Organization for Economic Co-
operation and Development (OECD). 

Note: This figure presents a summary of 2010 data on health care 
spending, including spending for the 23 OECD member countries that 
submitted data to OECD on the category of prevention and public health 
services. 

[End of figure] 

U.S. spending per capita on prevention and public health services was 
$286.11, second highest, behind Canada (see figure 4). U.S. rankings 
in OECD's international comparisons of spending on prevention and 
public health services per capita have also been fairly constant since 
2001. 

Figure 4: Spending for Prevention and Public Health Services per 
Capita, by OECD Member Country, 2010: 

[Refer to PDF for image: horizontal bar graph] 

Country: Canada; 
Spending per capita (U.S. dollars): $291.75. 

Country: United States; 
Spending per capita (U.S. dollars): $286.11. 

Country: Netherlands; 
Spending per capita (U.S. dollars): $226.63. 

Country: New Zealand; 
Spending per capita (U.S. dollars): $211.09. 

Country: Finland; 
Spending per capita (U.S. dollars): $168.36. 

Country: Germany; 
Spending per capita (U.S. dollars): $135.86. 

Country: Norway; 
Spending per capita (U.S. dollars): $130.25. 

Country: Sweden; 
Spending per capita (U.S. dollars): $128.13. 

Country: Switzerland; 
Spending per capita (U.S. dollars): $124.63. 

Country: Slovak Republic; 
Spending per capita (U.S. dollars): $105.65. 

Country: Denmark; 
Spending per capita (U.S. dollars): $99.28. 

Country: Slovenia; 
Spending per capita (U.S. dollars): $88.47. 

Country: France; 
Spending per capita (U.S. dollars): $81.48. 

Country: Belgium; 
Spending per capita (U.S. dollars): $78.09. 

Country: Austria; 
Spending per capita (U.S. dollars): $74.41. 

Country: Hungary; 
Spending per capita (U.S. dollars): $69.60. 

Country: Korea; 
Spending per capita (U.S. dollars): $62.92. 

Country: Portugal; 
Spending per capita (U.S. dollars): $55.15. 

Country: Iceland; 
Spending per capita (U.S. dollars): $49.09. 

Country: Czech Republic; 
Spending per capita (U.S. dollars): $45.36. 

Country: Estonia; 
Spending per capita (U.S. dollars): $35.13. 

Country: Poland; 
Spending per capita (U.S. dollars): $26.78. 

Country: Italy; 
Spending per capita (U.S. dollars): $12.98. 

Source: GAO analysis of data from the Organization for Economic Co-
operation and Development (OECD). 

Note: This figure presents a summary of 2010 data on health care 
spending, including spending for the 23 OECD member countries that 
submitted data to OECD on the category of prevention and public health 
services. OECD adjusted spending per capita for purchasing power 
parity. 

[End of figure] 

While OECD's data are frequently used to make international 
comparisons, there are limitations in using OECD's data to make 
international comparisons on spending included in the prevention and 
public health services category. For this category, OECD requested 
that countries submit data that include spending on certain types of 
preventive health and public health activities, such as maternal and 
child health activities and school health services. However, member 
countries do not always consistently report spending for this 
category. For example, the data submitted by the United States reflect 
federal, state, and local government spending for maternal and child 
health activities, school health services, and certain other 
preventive health and public health activities, but do not include 
government or private sector spending on clinical preventive services 
provided in physicians' offices or hospitals.[Footnote 40] In 
contrast, the data submitted by other OECD countries may include 
amounts spent on preventive health activities by the private sector in 
physicians' offices or hospitals. While there are known limitations to 
using OECD data, experts we interviewed reported that the OECD data 
are the best available data for comparing U.S. spending on prevention 
and public health services with that of other countries, and the data 
have been frequently used to make international comparisons.[Footnote 
41] An OECD official told us that OECD is taking steps to improve the 
comparability of the data in the future by, for example, providing 
clarity about the criteria that should be used by member countries to 
report prevention-related data. The official noted that it will be a 
couple of years before these data are available. 

Concluding Observations: 

Preventive health activities have received attention over the past 
several years for their potential impact on health care spending or 
health outcomes. However, HHS, VA, and DOD do not track department-
wide spending on preventive health activities, and identifying 
spending on such activities is challenging because they are often 
integrated with other activities. Further, estimating cost savings and 
cost-effectiveness of preventive health activities is difficult 
because of the multiple factors that can affect these estimates, 
including the need to make assumptions and a lack of key data. These 
methodological challenges, as well as a lack of widespread agreement 
on what constitutes a preventive health activity, are important 
considerations that affect the completeness and precision of available 
information on preventive health activities. 

Agency Comments: 

HHS, VA, and DOD reviewed a draft of this report. DOD concurred with 
the draft report. HHS and VA provided technical comments, which we 
incorporated as appropriate. 

As agreed with your offices, unless you publicly announce its contents 
earlier, we plan no further distribution of this report until 30 days 
from the report date. At that time, we will send copies of this report 
to the Secretary of Health and Human Services, Secretary of Veterans 
Affairs, Secretary of Defense, and interested congressional 
committees. In addition, the report will be available at no charge on 
the GAO website at [hyperlink, http://www.gao.gov]. 

If you or your staff have any questions regarding this report, please 
contact me at (202) 512-7114 or iritanik@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made key contributions 
to this report are listed in appendix V. 

Signed by: 

Katherine Iritani: 
Director, Health Care: 

[End of section] 

Appendix I: Requirements Related to Preventive Health Activities in 
the Duncan Hunter National Defense Authorization Act: 

The Duncan Hunter National Defense Authorization Act for Fiscal Year 
2009 requires DOD to reduce beneficiary cost sharing for preventive 
health activities and undertake certain preventive health activities, 
[Footnote 42] as follows: 

* Section 711: Waiver of Copayments for Preventive Services for 
Certain TRICARE Beneficiaries. Requires the Secretary of Defense to 
promulgate rules eliminating beneficiary cost-sharing previously 
associated with certain preventive services (such as colorectal cancer 
screening, breast cancer screening, cervical cancer screening, 
prostate cancer screening, annual physical exams, and vaccinations) 
for beneficiaries enrolled in TRICARE's fee-for-service program who 
are not eligible for Medicare. Beneficiaries enrolled in TRICARE's 
managed care option already received these services with a zero cost 
share. In December 2011, DOD issued a final rule implementing this 
provision by eliminating beneficiary cost sharing for certain 
preventive services provided on or after October 14, 2008.[Footnote 43] 

* Section 712: Military Health Risk Management Demonstration Project. 
Requires the Secretary of Defense to conduct a demonstration project 
designed to evaluate the efficacy of providing incentives to encourage 
healthy behaviors on the part of non-Medicare-eligible retired 
beneficiaries, including their dependents, enrolled in TRICARE's 
managed care option. Authorizes the Secretary to offer incentives to 
encourage participation in the demonstration project; accordingly, 
beneficiaries were offered a monetary incentive award for full 
compliance with the demonstration's requirements. Single participants 
would receive $115, and participants with family members would receive 
$230. In its interim report submitted to Congress in August 2011, DOD 
reported that it began implementing the demonstration project in 
October 2010, and that it was monitoring patients for compliance from 
January 2011 through December 2011. According to DOD, incentive 
payments were disbursed in June 2012. DOD also reported that the 
department had been collecting data to estimate costs avoided as a 
result of decreased health risk conditions and that results would be 
included in a final report to Congress, which DOD anticipates 
submitting by December 2012. 

* Section 713: Smoking Cessation Program under TRICARE. Requires the 
Secretary of Defense to establish a smoking cessation program to be 
available to TRICARE beneficiaries who are not eligible for Medicare. 
Requirements for the program include providing no-cost, smoking 
cessation pharmaceuticals; counseling; access to a toll-free 24/7 quit 
line with counseling; and access to printed and Internet-based tobacco 
cessation material. According to DOD, program implementation planning 
has been ongoing. DOD issued a proposed rule in September 2011. 
[Footnote 44] As of July 2012, a final rule had not been published. 
DOD also reported that access to printed materials and web-based 
information on smoking cessation has been available to TRICARE 
beneficiaries, and that a final status report to Congress will be 
submitted following full implementation of the Smoking Cessation 
Program under TRICARE. 

* Section 714: Preventive Health Allowance. Requires the Secretary of 
Defense to conduct a demonstration project to evaluate whether 
providing an annual allowance (called a preventive health services 
allowance) would increase the use of preventive health services by 
members of the Armed Forces and their family members. Preventive 
services under this section included colorectal, breast, cervical, and 
prostate cancer screening; an annual physical exam; an annual dental 
exam; weight and body mass screening, and vaccinations. The 
demonstration, which began on December 1, 2009, was limited to 1,500 
members from each of the Army, Navy, Air Force, and Marine Corps. The 
amount of the allowance for compliance with the required preventive 
health services was set at $500 for single participants, and $1,000 
for those enrolled with dependents, and the demonstration ended 
December 31, 2011. Although the final report was due no later than 
March 31, 2012, the department anticipates submitting the final report 
to Congress by December 2012 to allow for complete collection, review, 
and analysis of the data. 

[End of section] 

Appendix II: Department of Health and Human Services Estimates of 
Spending and Funding for Preventive Health Activities: 

The Department of Health and Human Services (HHS) does not track 
department-wide spending on preventive health activities, but the 
department provided us with a mix of information related to spending 
for preventive health activities and noted limitations associated with 
the information. For nine HHS agencies, HHS provided agency-level 
estimates of funding for prevention-related activities, which include 
but are not limited to preventive heath activities (clinical 
preventive services or community-oriented preventive health 
activities).[Footnote 45] For the National Institutes of Health (NIH), 
HHS provided estimated spending on prevention-related activities. 

HHS's estimates of funding for most of its agencies and estimates of 
spending for NIH were prepared by the department as part of its annual 
crosscut briefing document on prevention.[Footnote 46] HHS's Office of 
the Secretary uses this document to make budget-related decisions and 
answer questions from Congress and others related to the President's 
annual budget request.[Footnote 47] In its fiscal year 2012 crosscut 
briefing document (related to the President's budget request for 
fiscal year 2012), HHS combined its fiscal year 2011 funding estimates 
for prevention for nine HHS agencies with NIH's spending 
(specifically, obligations) estimate for prevention and reported a 
total of about $24 billion. However, this 2011 estimate excluded the 
Centers for Medicare & Medicaid Service's (CMS) Medicare and Medicaid 
programs and the Children's Health Insurance Program.[Footnote 48] The 
fiscal year 2011 estimate that included funding for programs 
administered by nine HHS agencies and spending for programs 
administered by NIH included clinical preventive services and 
community-oriented preventive health activities, as well as other 
prevention-related activities that HHS agencies did not identify as 
clinical preventive services or community-oriented preventive health 
activities. For example, HHS included in its prevention estimates 
funding for Food and Drug Administration (FDA) oversight of drugs and 
medical devices. 

The HHS annual crosscut briefing documents on prevention are limited 
in multiple ways. First, HHS officials told us that each HHS agency 
used its own criteria to identify prevention funding--that is, HHS 
agencies did not use a uniform definition of prevention. As a result, 
activities that are similar in nature may have been included in one 
but not in another agency's estimate. Second, the agency estimates do 
not always represent the same kind of information. For example, 
funding estimates for most agencies represent budget authority, but 
estimates as reported for CDC represent budget authority, transfers, 
and user fees that the agency had authority to obligate as separate 
categories. Third, criteria used by an agency to identify the 
activities to include in its prevention estimate may not have always 
been consistently applied by that agency. The annual crosscut briefing 
document included the following estimates for fiscal year 2011 for 10 
HHS agencies: 

* Administration for Children and Families (ACF). The document 
included estimated funding of $330 million for prevention. 

* Agency for Healthcare Research and Quality (AHRQ). The document 
included estimated funding of $28 million for prevention. 

* Administration on Aging (AOA).[Footnote 49] The document included 
estimated funding of $24 million for prevention. 

* Centers for Disease Control and Prevention (CDC). The document 
included estimated funding of $11.4 billion for prevention. The $11.4 
billion estimate includes budget authority, transfers, and user fees 
that the agency had authority to obligate as separate categories. 
[Footnote 50] 

* FDA. The document included estimated funding of $3 billion for 
prevention. The estimate represents user fees that the agency had 
authority to obligate and other budget authority as separate 
categories and, according to FDA officials, excludes infrastructure 
funding such as funding for facilities and rent-related activities. 
According to FDA, the agency's activities included in its estimate do 
not include clinical preventive services or community-oriented 
preventive health activities. 

* Health Resources and Services Administration (HRSA). The document 
included estimated funding of $1.3 billion for prevention. Although 
HRSA's estimate included multiple programs administered by the agency, 
the estimate did not include all of the agency's funding for 
prevention. According to HRSA officials, HRSA's estimate included 
funding for a program (the National Health Service Corps) that places 
primary care providers in underserved areas, but did not include any 
of the funding for its Health Center Program, which also provides 
primary care services in underserved areas. According to HRSA 
officials, the Health Center Program will be included in the 
prevention estimates in the future. 

* Indian Health Service (IHS). The document included estimated funding 
of $953 million for prevention. 

* NIH. Instead of estimated funding, the document included estimated 
spending--specifically, obligations--for prevention of $6 billion. 
[Footnote 51] 

* Office of the Assistant Secretary for Health (OASH). The document 
included estimated funding of $255 million for prevention. 

* Substance Abuse and Mental Health Services Administration (SAMHSA). 
The document included estimated funding of $719 million for prevention. 

[End of section] 

Appendix III: Department of Veterans Affairs Estimates of Spending and 
Funding for Preventive Health Activities: 

The Department of Veterans Affairs (VA) does not specifically track 
department-wide spending on preventive health activities, but it 
provided estimates of spending and funding. VA estimated its spending 
on certain clinical preventive services for VA beneficiaries, and 
estimated its funding for certain community-oriented preventive health 
activities. 

VA estimated that its spending--specifically, its obligations--for 
providing certain clinical preventive services to eligible veterans 
and nonveterans in an outpatient setting in fiscal year 2011 totaled 
about $576 million.[Footnote 52] VA's fiscal year 2011 estimate 
includes estimated obligations for providing clinical preventive 
services in all VA medical facilities, including VA medical centers, 
outpatient clinics, and other facilities.[Footnote 53] Examples of the 
clinical preventive services included in the estimate are dental 
cleaning; depression screening; post-traumatic stress screening; 
immunizations; diabetes screening; hypertension screening; tobacco use 
screening and counseling; and screenings for breast cancer, cervical 
cancer, and colorectal cancer. The Veterans Health Administration's 
(VHA) Allocation Resource Center[Footnote 54] reported that the 
clinical preventive services included in the analysis were identified 
by VA's National Center for Health Promotion and Disease Prevention. 
The services included (but were not limited to) those recommended by 
the U.S. Preventive Services Task Force (USPSTF). 

VA reported limitations associated with its estimated obligations for 
providing clinical preventive services in its facilities. VA reported 
that it cannot determine when certain services included in the 
estimate, such as colonoscopies, were provided for preventive purposes 
or for treatment purposes. In addition, VA could not identify the 
provision of certain clinical preventive services, such as sexually 
transmitted infections counseling for adults at increased risk, and 
therefore these services were not included in the estimates. 

VA also reported that fiscal year 2011 funding for its National Center 
for Health Promotion and Disease Prevention--which is responsible for 
developing the resources that support VA medical centers in providing 
community-oriented preventive health activities--totaled about $4 
million (out of its fiscal year 2011 total budget authority for health 
care of about $50.7 billion). The funding amount includes all of the 
center's activities, such as the MOVE! Weight Management Program. VA 
also reported that funding for its Clinical Public Health Group's 
community-oriented preventive health activities in fiscal year 2011 
totaled about $1.4 million. Examples of the Clinical Public Health 
Group's activities include the HIV Prevention Handbook, the VA Flu 
Manual, VA's Infection: Don't Pass It On campaign, and developing and 
printing tobacco cessation educational materials. VA officials told us 
that individual VA medical facilities may have conducted additional 
community-oriented preventive health activities, such as measures to 
increase testing for HIV, that are not included in VA's estimates. 

[End of section] 

Appendix IV: Department of Defense Estimates of Spending for 
Preventive Health Activities: 

The Department of Defense (DOD) does not specifically track department-
wide spending on preventive health activities, but it estimated its 
spending for providing certain clinical preventive services through 
its direct care and purchased care systems. In addition, DOD estimated 
its spending on some of the community-oriented preventive health 
activities and other activities such as epidemiology provided in its 
direct care system. 

DOD estimated that its spending for providing selected clinical 
preventive services, including but not limited to services recommended 
by the U.S. Preventive Services Task Force (USPSTF), through its 
direct care and purchased care systems totaled about $1 billion in 
fiscal year 2011 and about $969 million in fiscal year 2010.[Footnote 
55] Examples of clinical preventive services included in the estimates 
are vision and dental screenings; immunizations; hypertension 
screening; cardiovascular disease screening; and screenings for breast 
cancer, cervical cancer, and colorectal cancers. In each year, more 
than three-fourths of DOD's estimated spending for clinical preventive 
services was spent in its direct care system. (See table 4.) 

Table 4: DOD Estimates of Spending for Providing Clinical Preventive 
Services in DOD's Direct Care and Purchased Care Systems, Fiscal Years 
2010 and 2011: 

DOD system: Direct care; 
2010: $751,943,686; 
2011: $816,160,851; 
Total: $1,568,104,537. 

DOD system: Purchased care; 
2010: 217,512,837; 
2011: 266,147,691; 
Total: $483,660,527. 

DOD system: Total; 
2010: $969,456,522; 
2011: $1,082,308,542; 
Total: $2,051,765,064. 

Source: GAO summary of DOD estimates. 

Note: Pharmacy costs, laboratory costs, and facility costs are not 
included in the purchased care estimates of spending. Rows and columns 
may not total due to rounding. 

[End of table] 

DOD reported limitations associated with its estimated spending for 
providing clinical preventive services through its direct care and 
purchased care systems.[Footnote 56] Because its estimates were 
limited to a review of purchased care claims and direct care data 
records, the costs for some clinical preventive services are not 
included in the spending estimates. For example, a patient who 
receives services for hypertension may also receive counseling about 
smoking cessation from the provider during a visit. The counseling 
would not be captured in the data used for DOD's estimates. Also, 
pharmacy costs, laboratory costs, and facility costs in the military 
treatment facilities are included in the direct care spending 
estimates but not in the purchased care spending estimates. 

DOD also estimated its spending--specifically, obligations--on some of 
its community-oriented preventive health activities and other 
activities such as epidemiology provided in its direct care system. 
DOD's estimated obligations for these activities totaled about $326 
million in fiscal year 2009, about $379 million in fiscal year 2010, 
and about $407 million in fiscal year 2011. DOD included some 
community-oriented preventive health activities coordinated by DOD's 
TRICARE Management Activity in these estimates. Specifically, the 
estimates included DOD's "That Guy" alcohol education campaign and the 
Quit Tobacco--Make Everyone Proud program (a tobacco cessation 
marketing and education campaign), as well as other activities such as 
drinking water safety, and food and facility sanitation. DOD noted 
that it cannot separately identify spending specifically for the 
community-oriented preventive health activities. 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Katherine Iritani, (202) 512-7114 or iritanik@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Kim Yamane, Assistant 
Director; George Bogart; Hernan Bozzolo; Cathy Hamann; and Toni 
Harrison made key contributions to this report. 

[End of section] 

Footnotes: 

[1] Medicare is the federal health insurance program for people age 65 
or older, individuals under age 65 with certain disabilities, and 
individuals diagnosed with end-stage renal disease. Medicaid is a 
joint federal and state program that finances health care coverage for 
certain low-income individuals and families. 

[2] See National Prevention Council, National Prevention Strategy 
(Washington, D.C.: U.S. Department of Health and Human Services, 
Office of the Surgeon General, 2011). The National Prevention, Health 
Promotion and Public Health Council (referred to as the National 
Prevention Council) was established under the Patient Protection and 
Affordable Care Act (Pub. L. No. 111-148, § 4001, 124 Stat. 119, 538 
(2010)) and is composed of the heads of 17 federal agencies and 
chaired by the Surgeon General. Information about the National 
Prevention Council and its National Prevention Strategy is available 
at [hyperlink, http://www.healthcare.gov/prevention/nphpphc] (accessed 
Aug. 30, 2012). 

[3] We did not contact the Department of the Treasury to review 
federal tax expenditures, which are not within the scope of our work. 
Tax expenditures are preferential provisions in the tax code, such as 
exemptions and exclusions from taxation, deductions, credits, deferral 
of tax liability, and preferential tax rates that result in forgone 
revenue for the federal government. The revenue that the government 
forgoes is viewed by many analysts as spending channeled through the 
tax system. According to the Office of Management and Budget, in 
fiscal year 2011, for example, the tax exclusion for employer-provided 
health care alone totaled about $267.8 billion in forgone federal 
revenue. See Office of Management and Budget, Analytical Perspectives, 
Budget of the United States Government, Fiscal Year 2013 (Washington, 
D.C.: 2012). 

[4] In this report we use the term agency to refer to HHS agencies, as 
well as the Office of the Assistant Secretary for Health. 

[5] VHA's Allocation Resource Center is responsible for developing, 
implementing, and maintaining management information systems that 
provide data for VHA's budget process. 

[6] We also reviewed documents, including DOD reports to Congress, 
related to preventive health provisions in the Duncan Hunter National 
Defense Authorization Act for Fiscal Year 2009. Pub. L. No. 110-417, 
§§ 711-714, 122 Stat. 4536, 4500-04 (2008). 

[7] We interviewed researchers at two nonprofit organizations that 
focus on preventive health activities and two academic institutions. 
These researchers were referred to us by federal officials or 
published articles in peer-reviewed publications or reports on the 
topic of the cost savings or cost-effectiveness of preventive health 
activities, including articles or reports cited by HHS. 

[8] As of August 2012, OECD had 34 member countries. According to 
OECD, its member countries include many of the world's most advanced 
economies but also emerging economies like Mexico, Chile, and Turkey. 
OECD lists the member countries on its website: [hyperlink, 
http://www.oecd.org/document/58/0,3746,en_2649_201185_1889402_1_1_1_1,00
.html] (accessed Aug. 8, 2012). OECD also reports data on health 
outcomes. OECD health data are used by researchers and others to 
compare health spending and outcomes in the United States with that of 
other countries. 

[9] We used 2010 spending data because it was the most recent data 
available for most member countries at the time of our review. As of 
July 2012, OECD had posted 2010 health spending data from 28 of its 34 
member countries, and posted data on prevention and public health 
services from 23 of these countries. Data from these 23 countries were 
used for this report. To identify the rankings for relevant 2010 
spending statistics, we used the OECD.Stat database available on 
OECD's website [hyperlink, 
(http://www.oecd.org/document/30/0,3746,en_2649_37407_12968734_1_1_1_374
07,00.html], accessed July 11, 2012). 

[10] Because there is no commonly accepted cost-effectiveness ratio 
threshold that determines whether a preventive health activity is cost-
effective, the thresholds researchers apply may vary. Given such 
variations, a preventive health activity may be found to be cost-
effective in one research study that uses a particular threshold, but 
not in another study that applies a different threshold. For example, 
a preventive health activity may be considered cost-effective when 
using a threshold cost-effectiveness ratio of $100,000 per QALY, but 
when a lower cost-effectiveness threshold is used, such as $50,000 per 
QALY, the same activity might not be considered cost-effective. 

[11] USPTSF is made up of 16 volunteer members who are primary care 
providers (such as internists, pediatricians, family physicians, 
obstetricians/gynecologists, nurses, and behavioral health 
specialists). 

[12] The USPSTF does not consider economic information, such as 
whether a preventive health service is cost saving or cost-effective, 
as part of its recommendation process. 

[13] ACIP recommendations are not considered official until they are 
approved by the CDC Director and published in CDC's Morbidity and 
Mortality Weekly Report. 

[14] The Community Preventive Services Task Force reviews published 
information related to the cost savings or cost-effectiveness of the 
preventive health activities it recommends and posts this information 
online. For example, the task force finding and rationale statement on 
interventions for children and adolescents with asthma included 
information from studies that considered costs and benefits of the 
interventions--see [hyperlink, 
http://www.thecommunityguide.org/asthma/rrchildren.html] (accessed 
Aug. 17, 2012). 

[15] OECD disseminates its guidelines in a published manual called A 
System of Health Accounts. The manual containing guidelines for OECD's 
2010 data--the data used for this report--was released by OECD in 
2000. A revised version of the manual was released in November 2011. 

[16] In addition to services it provides directly, VA also operates a 
fee-based purchased care program that covers health care services--
including dental services, outpatient care, inpatient care, emergency 
care, and medical transportation--provided to eligible veterans 
outside of the VA when a VA facility is not available. Total annual 
fee payments under this program were about $3.8 billion in fiscal year 
2009. VA did not identify clinical preventive services provided 
through its fee-based purchased care program. 

[17] Pub. L. No 110-417, §§711-714, 122 Stat. 4356, 4500-04 (2008). 

[18] Spending means obligations, including those for which 
expenditures have been made. The term obligation refers to a definite 
commitment by a federal agency that creates a legal liability to make 
payments immediately or in the future. Agencies incur obligations, for 
example, when they award grants or contracts to private entities. An 
expenditure is the actual spending of money by the issuance of checks, 
disbursement of cash, or electronic transfer of funds made to 
liquidate a federal obligation. See GAO, A Glossary of Terms Used in 
the Federal Budget Process, [hyperlink, 
http://www.gao.gov/products/GAO-05-734SP] (Washington, D.C.: September 
2005). 

[19] When spending estimates were not readily available, HHS and VA 
provided available information for funding for those activities. 
Funding means budget authority, which is the authority provided by 
federal law to enter into financial obligations that will result in 
immediate or future outlays involving federal government funds. 

[20] Funding represents an amount available at a particular time for 
spending (obligation and expenditure) for what may potentially be a 
range of activities including but not limited to preventive health 
activities. Funding amounts may not actually have been spent for the 
activities expected at the time the amounts were made available (for 
example, within applicable authority, amounts may have been 
subsequently transferred to other accounts or reprogrammed within an 
existing account in a departmental budget) and, even if spent for 
those activities, it may not be clear whether they were preventive in 
nature. 

[21] The most recent crosscut briefing document on prevention in our 
review included the estimated amount of requested funding related to 
the President's budget request for fiscal year 2012 and estimated 
spending on or funding for prevention for fiscal year 2011. 

[22] The most recent estimate for CMS that was included in an HHS 
annual crosscut briefing document on prevention we reviewed was for 
fiscal year 2008. CMS's estimated spending for prevention reported for 
that year was about $39 billion, but CMS noted that this estimate did 
not include preventive services covered by Medicare or Medicaid 
through managed care and included substantial amounts for treatment 
services provided. 

[23] According to FDA, FDA activities are related to prevention, but 
do not include clinical preventive health activities or community-
oriented preventive health activities. 

[24] See, for example, J. T. Cohen, P. J. Neumann, and M. C. 
Weinstein, "Does Preventive Care Save Money? Health Economics and the 
Presidential Candidates," New England Journal of Medicine, vol. 358, 
no. 7 (2008); K. Baicker, D. Cutler, and Z. Song, "Workplace Wellness 
Programs Can Generate Savings," Health Affairs, vol. 29, no. 2 (2010); 
and R. S. Braithwaite and S. M. Mentor, "Identifying Favorable-Value 
Cardiovascular Health Services," American Journal of Managed Care, 
vol. 17, no. 6 (2011). 

[25] The report synthesized the findings of work by the National 
Commission on Prevention Priorities, the National Business Group on 
Health, and an academic researcher. According to the report, these 
three reviews were included because they all evaluated intervention 
costs and health benefits, quantified benefits (for example, in terms 
of QALYs gained), and were not limited to a particular intervention or 
to interventions for a particular subpopulation. J. T. Cohen and P. J. 
Neumann, The Cost Savings and Cost-Effectiveness of Clinical 
Preventive Care, Research Synthesis Report No. 18 (Princeton, NJ: 
Robert Wood Johnson Foundation, September 2009). 

[26] National Prevention Council, National Prevention Strategy 
(Washington, D.C.: U.S. Department of Health and Human Services, 
Office of the Surgeon General, 2011). 

[27] See, for example, J. W. Kahende et al., "A Review of Economic 
Evaluations of Tobacco Control Programs," International Journal of 
Environmental Research and Public Health, vol. 6 (2009) and R. L. 
Fleurence, C. P. Iglesias, and J. M. Johnson, "The Cost Effectiveness 
of Bisphophonates for the Prevention and Treatment of Osteoporosis," 
Pharmacoeconomics, vol. 25, no. 11 (2007). 

[28] Articles in peer-reviewed publications and reports we reviewed 
also identified some preventive health activities that have been found 
not to be cost-effective. For example, one article estimated that 
screening for type 2 diabetes in all U.S. residents aged 45 years and 
older who have no other health factors, such as hypertension, was not 
cost-effective. See R. Li et al., "Cost-Effectiveness of Interventions 
to Prevent and Control Diabetes Mellitus: A Systematic Review," 
Diabetes Care, vol. 33, no. 8 (2010). 

[29] See, for example, R. Braithwaite, and S. Mentor. "Identifying 
Favorable-Value Cadiovacular Health Services," American Journal of 
Managed Care, vol. 17, no. 6 (2011) and K. Baicker, D. Cutler, and Z. 
Song, "Workplace Wellness Programs Can Generate Savings," Health 
Affairs, vol. 29, no. 2 (2010). 

[30] In some cases, successful targeting can lead to additional costs. 
For example, if someone is screened for and has high blood pressure, 
the person may need to take medication or have additional tests for 
the rest of his or her life, which is an added cost. 

[31] According to HHS officials, preventive health activities directed 
specifically to high-risk populations, such as children with 
developmental disabilities and special health care needs, may realize 
even greater cost savings and benefit. 

[32] Estimates of cost-effectiveness are typically presented as a 
ratio of the net costs to the net outcomes of utilizing one preventive 
health activity over another. 

[33] D. Elmendorf, Director, Congressional Budget Office, letter to 
the Honorable Nathan Deal, (Washington, D.C.: Aug. 7, 2009).This 
letter is available online at [hyperlink, 
https://www.cbo.gov/publication/20967]. This letter responds to a 
question concerning the Congressional Budget Office's analysis of the 
budgetary effects of proposals to expand governmental support for 
preventive medical care and wellness services. In making its estimates 
of the budgetary effects of expanded governmental support for 
preventive care, CBO takes into account any estimated savings accruing 
within specified time frames that would result from greater use of 
such care as well as the estimated costs of that additional care. 
CBO's estimates take into account that preventive care may reduce 
spending for an individual and that, to avert one case of acute 
illness, it is often necessary to provide preventive care to many 
patients, most of whom would not have suffered the illness anyway. 

[34] In a study of HPV vaccine, when the researcher assumed the 
vaccine was 90 percent effective and provided lifetime protection at a 
cost of $377 per 3-shot series, it produced a cost-effectiveness ratio 
of $24,300 per QALY. When the assumptions were changed to assume 100 
percent effectiveness, the cost-effectiveness improved to $20,600 per 
QALY. When researchers used a model with other assumptions for the HPV 
vaccination strategy such as vaccination at age 12 years and 
preventive screenings--annual cervical screening and liquid-based 
cytology testing starting at age 18--and compared it to the next-best 
strategy, which was similar to this strategy but did not include 
liquid-based cytology, cost-effectiveness worsened to more than $3.5 
million per QALY. 

[35] K. Baicker, D. Cutler, and Z. Song, "Workplace Wellness Programs 
Can Generate Savings," Health Affairs, vol. 29, no. 2 (2010). 

[36] For the report on this study, see the Institute of Medicine 
website [hyperlink, 
(http://www.iom.edu/Activities/PublicHealth/CommunityPrevention.aspx], 
accessed Nov. 14, 2012). 

[37] OECD defines prevention and public health services as services 
designed to enhance the health status of the population, as opposed to 
curative services, which repair health dysfunction. 

[38] These data are not comparable to the spending and funding 
estimates provided by HHS, VA and DOD. For example, OECD's data 
pertaining to the United States do not capture spending for certain 
clinical preventive services provided by HHS, VA, and DOD, and combine 
federal spending with state and local spending. 

[39] As of July 2012, OECD posted 2010 health spending data from 28 of 
its member countries, and posted data for the OECD category of 
prevention and public health services from 23 of these countries. For 
the most recent data, see the OECD.Stat database available on OECD's 
website [hyperlink, 
http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT#], accessed 
July 12, 2012. In order to compare spending, OECD converts countries' 
health expenditures to a common currency (e.g., U.S. dollars) and 
makes adjustments to take account of the different purchasing power of 
the national currencies. 

[40] U.S. spending for health care services provided in physicians' 
offices and hospitals, including both treatment services and 
preventive health activities, are included in a different OECD 
spending category. Private sector spending in OECD's prevention and 
public health services category includes privately funded occupational 
health care and prevention and public health services provided by 
charities, other nongovernmental organizations, and voluntary 
organizations. 

[41] For example, the Institute of Medicine used OECD data to compare 
the United States to other nations in per capita health expenditures 
and health outcomes, such as infant mortality, for a recent report on 
public health financing. See Institute of Medicine, For the Public's 
Health: Investing in a Healthier Future (Washington, D.C.: The 
National Academies Press, 2012). 

[42] Pub. L. No. 110-417, §§ 711-714, 122 Stat. 4356, 4500-04 (2008). 

[43] 76 Fed. Reg. 81368 (Dec. 28, 2011) (to be codified at 32 C.F.R. 
§§ 199.4 and 199.17). 

[44] 76 Fed. Reg. 58199 (Sept. 20, 2011) (to be codified at 32 C.F.R. 
§§ 199.4 and 199.21). 

[45] Funding means budget authority, which is the authority provided 
by federal law to enter into financial obligations that will result in 
immediate or future outlays involving federal government funds. See 
GAO, A Glossary of Terms Used in the Federal Budget Process, 
[hyperlink, http://www.gao.gov/products/GAO-05-734SP] (Washington, 
D.C.: September 2005). Funding represents an amount available at a 
particular time for spending (obligation and expenditure) for what may 
potentially be a range of activities including but not limited to 
preventive health activities. Funding amounts may not actually have 
been spent for the activities expected at the time the amounts were 
made available (for example, within applicable authority, amounts may 
have been subsequently transferred to other accounts or reprogrammed 
within an existing account in the department's budget) and, even if 
spent for those activities, it may not be certain that they were 
preventive in nature. In some instances, HHS agencies reported budget 
authority, transfers, and user fees available for obligation 
separately. We report information as provided to us by HHS agencies. 

[46] HHS does not define prevention for the purposes of its annual 
crosscut briefing documents on prevention. In addition to preventive 
health activities (clinical preventive services and community-oriented 
preventive health activities), HHS may include in prevention 
activities such as emergency preparedness, environmental health, and 
occupational safety activities. HHS, VA, and DOD participate in the 
National Prevention Council, which consists of 17 departments, 
agencies, and offices across the federal government--representing 
sectors such as housing, transportation, education, environment, and 
defense--that promote prevention and wellness. Information about the 
council is available at [hyperlink, 
http://www.healthcare.gov/prevention/nphpphc] (accessed Aug. 30, 2012). 

[47] HHS also prepares crosscut briefing documents that estimate 
department-wide funding for other health-related topics, such as 
behavioral health, patient safety, and tobacco. 

[48] The most recent estimate for CMS that was included in an HHS 
annual crosscut briefing document on prevention we reviewed was for 
fiscal year 2008. CMS's estimated spending for prevention reported for 
that year was about $39 billion, but CMS noted that this estimate did 
not include preventive services covered by Medicare or Medicaid 
through managed care and included substantial amounts for treatment, 
rather than prevention. 

[49] In April 2012, HHS created the Administration for Community 
Living (ACL) by combining AOA, the Office on Disability, and the 
Administration on Intellectual and Developmental Disabilities. 

[50] This estimate consisted of all of CDC's available funding for 
fiscal year 2011. However, at the time the estimate was compiled, the 
agency was operating under a series of continuing resolutions. CDC 
indicated that subsequent enactment of the fiscal year 2011 full-year 
continuing resolution resulted in a downward adjustment for CDC's 
funding for fiscal year 2011, to about $11.0 billion. 

[51] NIH publishes information on spending for prevention on its 
website [hyperlink, http://report.nih.gov/categorical_spending.aspx]. 

[52] According to VA, the estimates it provided are the department's 
estimated obligations, and the estimated amount is about 2.2 percent 
of the total obligations (about $26 billion) of providing outpatient 
clinical services through VA facilities in fiscal year 2011. 

[53] VA included in its estimate the estimated obligations associated 
with clinical preventive services provided in outpatient settings in 
VA facilities, including estimated obligations for salaries and 
benefits for providers, administrative activities, and maintenance of 
facilities. VA did not include estimated obligations for 
pharmaceutical drugs, services provided for purchased care (provided 
to eligible veterans outside of VA when a VA facility is not 
available) or services provided in an inpatient setting. To estimate 
obligations, VA used the Decision Support System, which is an activity-
based cost accounting system that generates estimates of the cost of 
individual VA hospital stays and health care encounters. If the first 
procedure or diagnosis in a VA beneficiary's encounter was a clinical 
preventive service, then VA estimated that 90 percent of the cost of 
the encounter was for preventive health activities. If the procedure 
or diagnosis was not listed first, then VA estimated that 25 percent 
of the cost of the encounter was for preventive health activities. 
According to VA, nearly two-thirds of the encounters used for the 
estimate had preventive services listed first. 

[54] VHA administers VA's health care system, and VHA's Allocation 
Resource Center is responsible for developing, implementing, and 
maintaining management information systems that provide data for VHA's 
budget process. 

[55] DOD estimated spending for providing selected clinical preventive 
services in its direct care system using encounter data from the 
Comprehensive Ambulatory/Professional Record dataset and in its 
purchased care system using encounter data from the TRICARE Encounter 
Data Non-Institutional Data dataset. Both datasets are contained in 
DOD's Military Health System Data Repository. DOD's spending estimates 
are based on estimated costs using a relative value unit that adjusted 
for quantity and provider specialties. 

[56] According to DOD, the total costs of providing clinical services 
to beneficiaries through its purchased care system in fiscal year 2011 
represented 48 percent of its total costs for providing clinical 
services. 

[End of section] 

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