Changes in Hospitalisation Rates and Costs in New South Wales, 1996–97 and 2000–01

Changes in hospital admission rates and costs in New South Wales (NSW) between 1996‐97 and 2000–01 were examined by age, hospital type and socioeconomic status. A novel method led to a more accurate assessment of hospital patients' socio‐economic status than was previously possible. Use of unit record hospitals data and full population Census data allowed very high levels of disaggregation. Considerable increases in the baby boomer and frail aged populations led to higher hospital admission rates over the period. This was driven by the private sector, which saw its admission rates increase by 20 per cent (with the public sector rate declining by 6per cent). Public hospital admission rates by age were found to be up to 40 per cent greater for the poorest 20 per cent of the population than for the richest 20 per cent‐with a reversal of the pattern for private hospitals (up to 45 per cent greater for the richest 20 per cent than for the poorest 20 per cent). In a period when total NSW hospital expenditures increased by 21 per cent, we found that ‘per admission costs’ in the inpatient non‐psychiatric sub‐sector changed little.     

Investigating productivity change and hospital size: a nonparametric frontier approach

The study obtains measures of the productive efficiency of ‘larger’ and ‘smaller’ Northern Ireland hospitals during the 1986–92 pre-Trust period. The measures provide insights into how these hospitals were responding to the pressures for increased efficiency prior to Trust status. They also constitute a useful benchmark for evaluating productivity change under the post-1992 Trust status environment. A nonparametric frontier approach is used to measure productivity change and to decompose this into technical change (or shifts in the best practice frontier) and efficiency change (or change in how far a hospital is from the frontier). The latter change in efficiency is also decomposed into changes in scale efficiency, pure technical efficiency and input congestion. The findings indicate that smaller hospitals, starting from a less efficient base, achieved greater productivity gains than larger hospitals over 1986–92. For smaller hospitals, this was due to progressive shifts in the best practice frontier outweighing a substantial decline in efficiency. This decline was found to be due to a deterioration in scale efficiency over the period. The results overall support the current policy view that larger hospitals are more efficient than smaller hospitals in providing health care services.     

Ambiguity and spurious precision in the modern microeconomic cost framework

The MMCF stresses ‘variable’ and ‘fixed’ costs; homogenizes the firm's output; and limits itself to a single period to gain insight into the way markets do and/or should behave. Simplifying thus, it confounds expenditures and costs; fixed facilities and fixed costs; time-incremental and output-incremental costs; fixed capital and sunk costs; and ‘drawing board time’ and chronological time. The apparent precision of conclusions following therefrom is of little use in classifying a firm's expenditures even in simple one-site activities, such as a power plant or a cinema; and as is apparent through four econometric studies, MMCF provides little guidance for cost or price policy in network activities, since variable and short-run marginal costs may be defined arbitrarily.     

Contribution of intangible costs to the economic burden of multiple sclerosis

Abstract

Background:

Multiple sclerosis (MS) is associated with a substantial economic burden resulting from direct medical costs associated with health and disability-related resource utilization and indirect costs relating to reduced productivity. However, reduced health-related quality of life (HR-QOL) may be associated with additional costs, often termed ‘intangible costs,’ that should be considered as part of the economic burden from the societal or patient perspectives.

Objectives:

To review the contribution of intangible costs to the overall economic burden of MS.

Methods:

Medline was searched through March 2010 for relevant articles that included the terms ‘multiple sclerosis’ in combination with ‘intangible costs,’ ‘QALY,’ ‘quality-adjusted life year,’ ‘willingness-to-pay,’ and ‘WTP.’ Other than the restriction that the articles were published in English, there were no other exclusionary criteria for the search. Identified references were hand-searched to determine if intangible costs were estimated.

Results:

Thirteen studies across ten countries were identified that estimated intangible costs based on the number of quality-adjusted life-years (QALYs) lost due to a reduction in HR-QOL multiplied by accepted willingness-to-pay (WTP) thresholds. Although absolute costs varied depending on thresholds used and year of evaluation, the intangible costs accounted for 17.5–47.8% of total costs of MS. Furthermore, evidence suggested intangible costs are positively correlated with worsening disability. The largest increase in intangible costs occurred at the transition between mild and moderate disability. However, since no value has been established as being acceptable to pay for a QALY, a limitation of these studies was their dependence on the definition of the WTP threshold.

Conclusions:

Intangible costs substantially add to the economic burden of MS. There is not only a need to further characterize these costs and incorporate them into economic studies, but also to determine how these costs can be reduced through appropriate management strategies.     

Whatever Inconsistencies and Effects? Explaining the Resilience of the Policy Reforms Applied to Developing Countries

Why is ‘neoliberalism’ still a predominant framework within economics and policy-making? This paper considers the mix of theoretical assumptions, causalities and policies known as the ‘Washington consensus’, focusing on developing countries. First, it analyses their main elements, resilience and effects (the ‘lost decades in spite of policy reform’). Second, it examines the reasons of this resilience and argues that a reason is their adaptive capacity via constant exchanges between facts and conceptual assumptions, because this mix is constituted of heterogeneous elements (from neoclassical theory, ad hoc models or empirics-based policy-making): inconsistency is a core feature and as such its correction is irrelevant. These ‘adaptive inconsistencies’ are consolidated by the simultaneous theoretical/policy dimension of the mix. Its cognitive resilience is reinforced by the irrefutability of causations and the cause/effect time lag (‘after current costs, there will be gains’, e.g. growth), and is not challenged by the social costs of policies.     

The brain drain, ‘educated unemployment’, human capital formation,and economic betterment1

Extending both the ‘harmful brain drain’ literature and the ‘beneficial brain gain’ literature, this paper analyzes both the negative and the positive impact of migration by skilled individuals in a unified framework. The paper extends the received literature on the ‘harmful brain drain’ by showing that in the short run, international migration can result in ‘educated unemployment’ and overeducation in developing countries, as well as a brain drain from these countries. A simulation suggests that the costs of ‘educated unemployment’ and overeducation can amount to significant losses for the individuals concerned, who may constitute a substantial proportion of the educated individuals. Adopting a dynamic framework, it is then shown that due to the positive externality effect of the prevailing, economy‐wide endowment of human capital on the formation of human capital, a relaxation in migration policy in both the current period and the preceding period can facilitate ‘take‐off’ of a developing country in the current period. Thus, it is suggested that while the migration of some educated individuals may reduce the social welfare of those who stay behind in the short run, it improves it in the long run.     

Competing for Good Immigrants

I analyze the competition among different countries for ‘desirable’ and ‘undesirable’ potential immigrants, using both an immigration quota and a level of (imperfect) ‘scrutiny’ that would‐be immigrants face. Scrutiny imposes costs on immigrants and therefore makes it less attractive to immigrate. The number of applying undesirable immigrants increases in immigration quota and decreases in the level of scrutiny. In contrast, the number of desirable applicants can go in either direction as scrutiny increases and is independent of the immigration quota, because an increase in the immigration quota is completely crowded out by more applications by undesirable immigrants.     

George Shackle and uncertainty: a revolution still awaited

It is argued that Keynes consciously sought incomes policy, first, in 1925, and, secondly, during the second world war. The first occasion concerned the need to keep costs down in the wake of the revaluation of sterling. The second instance concerned the difficulties of financing the war effort that would arise from a chronic excess demand for labour leading to greatly increased wages. Keynes came to recognize that cost push wage inflation was a serious potential threat to the maintenance of full employment. However despite his specific proposals then it is uncertain what he would have advocated for contemporary circumstances, as he increasingly came to view this as a ‘political’ rather than an ‘economic’ problem.     

Family ownership,altruism and agency costs in Australian small- and medium-sized enterprises

Given the continuing uncertainty about whether family firms enjoy lower agency costs, this article hypothesizes that a combination of the effects of family ownership, altruism and self-control is instead at play. To begin with, family ownership can indeed reduce agency costs through better aligning the interests of owners and managers. This is a ‘determining’ effect in that it independently mitigates one source of agency problems. However, altruism combined with self-control problems arising from the highly concentrated ownership often found in family firms can also increase agency costs. This is an ‘embedding’ effect as it is rooted in the personal relationships within the family firm. Using the Business Longitudinal Database compiled by the Australian Bureau of Statistics on small- and medium-sized enterprises (SMEs), we find that for larger SMEs (those with 20–200 employees), the gains in lower agency costs arising from family ownership are almost completely offset by the losses from altruism and the lack of self-control.     

Efficiency of hospitals in Germany: a DEA-bootstrap approach

Various attempts to assess the performance of German hospitals have generated a wide range of estimates regarding their efficiency. These attempts were based on different, often rather small data sets consisting of heterogeneous hospitals; the techniques applied range from simple benchmarking approaches to studies which employ Data Envelopment Analysis (DEA). Some studies report ‘dramatic differences in efficiency’ and propose savings potentials of 50%; others find an average efficiency in excess of 95% and characterize almost 75% of their observations as fully efficient. This study presents results for two datasets representative of two segments of the German hospital system. These segments comprise all hospitals that have one internal medicine and one surgery department; the hospitals are located in the old federal states of Germany. None of the hospitals provides tertiary care. DEA can be applied because all hospitals offer a comparable quality and range of services. The results were estimated with a DEA-bootstrapping procedure and suggest an average bias–corrected efficiency of around 80%.     

Patient selection in a mixed oligopoly market for health care: the role of the soft budget constraint

Competition in hospital care is often implemented through mixed markets where public and private hospitals compete for patients. The optimality of this market form has long been debated in the literature. In this paper, we investigate the role of soft budget constraint in affecting patient selection within a mixed market. Patient selection is the undesired effect of hospital competition when three conditions are met: asymmetry in hospitals’ objectives, presence of hospital’s private information and inability to enforce hard budget constraint. The paper shows that soft budget is a pre-condition for the existence of patient selection. Our paper adds an important dimension to the existing literature which considers asymmetry of information as the only cause for this market failure. The understanding of the mechanisms leading to patient selection makes it possible for the regulator to design measures to reduce such undesirable effect.     

A limited-dependent analysis of the choice of regular labour contract in seasonal agriculture

The paper examines both theoretically and empirically the factors determining the demand for regular labour in seasonal agriculture. In an implicit contract framework it is argued that there are ‘hoarding costs’ of regular labour in the slack period when there is not much work to be done. Consequently, the number of regular labour employed is constrained by the hoarding cost where larger employment-intensive farms tend to hire more regular labour. Evidence from the ICRISAT villages in India, too, show that though the marginal costs of regular labour are zero, there are significant hoarding costs of regular labour among small farms so that larger farmers are the major demanders of regular labour. Estimates of the double-hurdle model jointly determining the probability of hiring regular labour and demand for regular labour-hours (if a regular labour is hired) are shown to be an improvement over univariate tobit estimates of the demand for regular labour-hours only.     

The Hidden Costs of Wind Generation in a Thermal Power System: What Cost?

New renewable energy generation in Australia is unambiguously more expensive than thermal plant, at least when comparing direct costs. The federal government claims the 20 per cent renewable energy target will increase electricity tariffs by 4 per cent. Apart from the direct costs, critics of renewables cite additional ‘hidden costs’ arising from the intermittency of wind and the subsequent causation of ‘back‐up plant’ for system security. South Australia, where wind's market share now exceeds 17 per cent, provides a valuable case study to analyse ‘hidden costs’. The evidence is that hidden costs are trivial and the government's claim appears accurate.     

On the (in)efficiency of Swiss hospitals

The efficiency of hospitals is of interest to health insurers, government authorities and hospital management itself. However, econometric methods for determining (in)efficiency have severe drawbacks since hospitals are multiproduct firms and because the duality between production and cost functions cannot be assumed. In this work, non-parametric, deterministic data envelopment analysis (DEA) is used to measure the relative inefficiency of 89 Swiss hospitals covering the years 1993–1996 (310 observations). Special attention is given to the role of patient days in the production of health. The findings depend on whether patient days are viewed as an input of patient time or as an output, as in previous studies. While the probability of a unit being inefficient cannot be explained using the available data, the degree of overall inefficiency is shown to significantly depend on the financial incentives faced by management, in particular due to subsidization. Private hospitals do not seem to be less inefficient than public ones; however, this may be caused by their ‘overusing’ inputs that in fact are valued as amenities by patients. This consideration points to an important limitation in applying the purely quantitative criteria of DEA to hospitals.     

The effect of major adverse renal cardiovascular event (MARCE) incidence,procedure volume,and unit cost on the hospital savings resulting from contrast media use in inpatient angioplasty

Objective: To determine the net economic impact of switching from low-osmolar contrast media (LOCM) to iso-osmolar contrast media (IOCM; iodixanol) in patients undergoing inpatient coronary or peripheral angioplasty in the United States (US).

Methods: A budget impact model (BIM) was developed from a hospital perspective. Nationally representative procedural and contrast media prevalence rates, along with MARCE (major adverse renal cardiovascular event) incidence and episode-related cost data were derived from Premier Hospital Data (October 2014 to September 2015). A previously estimated relative risk reduction in MARCE associated with IOCM usage (9.3%) was applied. The higher cost of IOCM was included when calculating the net impact estimates at the aggregate, hospital type, and per hospital levels. One-way (±25%) and probabilistic sensitivity analyses identified the model’s most important inputs.

Results: Based on weighted analysis, 513,882?US inpatient angioplasties and 35,610 MARCE cases were estimated annually. Switching to an “IOCM only” strategy from a “LOCM only” strategy increases contrast media cost, but prevents 2,900 MARCE events. The annual budget impact was an estimated saving of $30.71 million, aggregated across all US hospitals, $6,316 per hospital, or $60 per procedure. Net savings were maintained across all univariate sensitivity analyses. While MARCE/event-free cost differential was the most important factor driving total net savings for hospitals in the Northeast and West, procedural volume was important in the Midwest and rural locations.

Conclusions: Switching to an “IOCM only” strategy from a “LOCM only” approach yields substantial net global savings to hospitals, both at the national level and within hospital sub-groups. Hospital administrators should maintain awareness of the factors that are likely to be more influential for their hospital and recognize that purchasing on the basis of lower contrast media cost may result in higher overall costs for patients undergoing inpatient angioplasty.     

Technological Expectations And The Diffusion Of ‘Intermediate’ Technologies

The concept of ‘technological expectations’ has established itself as a key one in the smdy of innovation adoption. The article suggests that it may help explaining not just the adopters' timing decisions, but also their decisions regarding the kind of innovation they adopt. Innova tions that set the technological frontier face the competitive diffusion of some ‘intemdiate’ technologies. These may be either old technologies or ‘midrange’ ones. which purposefully lag behind the frontier, in order to impose lower adoption costs to their users.

Taking into account midrange innovations casts new light on the supply side of the diffu sion process. in terms of technological variety and selection effects. Drawing examples from the electronic colour pre-press industry, we highlight the equipment suppliers' anxious quest for the successful midrange innovation, able to hit the right txade-off between proximity to the frontier and adoption costs.     

Market failure and the existence of the state: a restatement and critique

In this article the ‘market failure’ approach to the existence of the state in market economies is restated and generalized in terms of transaction costs economizing. This approach is then criticized in that it asserts the pre-existence of societal consensus regarding efficiency versus distribution. In the presence of ex-ante distributional inequalities I suggest that distribution is a more plausible determinant of the existence and functions of the capitalist state, both theoretically and empirically. The possibility has implications on the notion of state neutrality, and on viewing the market as the ‘natural’ means of allocating resources. It also questions the very need for the existence of the market.     

Medical economic impact of tracheotomy patients on a hospital system

Abstract

Background:

Tracheotomy patients are a small portion of hospitalizations, but account for disproportionately high risk and costs. There are many complex decisions that go into the care of these patients, and practice variation is expected to be compounded in a health system. This study sought to characterize the medical economic impact of tracheotomy patients on the hospital system.

Methods:

A retrospective review of the health system’s hospital billing software was performed for 2013, and pertinent outcomes measures were tabulated.

Results:

There were 829 tracheotomies performed in the health system of seven hospitals, with total costs of $128,883,865. Average length of stay was 36.74 days for principal procedures, and 43.36 days for tracheotomy as secondary procedures. Mortality was ～18% overall, and re-admissions were 10.93% for primary, and 14.36% for secondary procedures. A fairly wide variation in each category among the different hospitals was observed.

Conclusions:

There are potentially many factors that impact variations of care and outcomes in patients with tracheotomy. Due to their large economic impact and risks for morbidity and mortality, a formalized care pathway is warranted. Goals of the pathway should include understanding medical decisions surrounding these complex patients, monitoring pertinent outcomes, reducing practice variation, and improving the efficiency of compassionate care.     

Cost effectiveness of a medical vigilance system to reduce patient falls

Patient falls are a serious problem in hospitals, resulting in substantial morbidity, mortality, length of stay, and costs. The results of a small trial of a patient vigilance system in a post-neurosurgery unit of a large acute care hospital are reported. The system includes two components: (a) passive sensor array placed under the patient in a hospital bed, and (b) a bedside unit that connects to the nurse call system already in place at the hospital. This trial demonstrated the overall effectiveness of the vigilance system in reducing the rate of patient falls. The cost-effectiveness analysis found that use of this system was associated with somewhat higher measured costs. It is likely that the system was cost-saving, due to unmeasured costs.     

A Constitutional Interpretation of the GATT/WTO

Constitutional analysis is used to evaluate the role of the WTO. The following questions are addressed: - can the WTO define and implement its own decisions, rather than those of its members? - if so, does this make it an ‘organised player’, capable of having its own role? - what allows it to exist as an ‘organised player’? My main conclusion is that the WTO's legitimisation depends not only on its safeguarding of existing rules, but also on its long-term ability to maintain equity in the distribution of benefits and costs among member Countries.