Cost-utility analysis of the rehabilitation of patients with musculoskeletal problems

The objective of this study is to discuss the rehabilitation of patients in primary health care with problems in the musculoskeletal system from a socioeconomic perspective. A trial with coordinated rehabilitation in primary health care is compared with traditional rehabilitation. This trial, performed in Sweden in 1994, was a two-year prospective and comparative study of consecutively included patients with long-term illnesses due musculoskeletal problems (810 observations). A cost-utility analysis shows that the new rehabilitation program in primary health care is a cost-minimization program for society. There is no significant difference in the quality of life between the trial and control groups. The total cost is lower for rehabilitation in primary health care than for traditional rehabilitation (6 percent). The indirect costs are higher than the direct health care costs (60 percent), and payments from social insurance increased by 8 percent. The health economic results support rehabilitation in primary health care but also points out that this type of rehabilitation can be further improved.     

Occupational health nurses and case management

Employers, providers, consumers, regulators, and society are demanding a systematic method to determine quality and cost efficiency in the provision of health care services in a multidisciplinary continuum of care within a reasonable time limit. Societal and legislative pressure on employers to incorporate and accommodate workers with disabilities or limitations and rising health insurance costs have urged organizations to set up effective strategies. An overview of the historical evolution of case management, trends in engaging workers in a successful return to work process, and a case study are presented.     

Tax subsidies,the rational demand for insurance and the health care crisis

An individual's optimal insurance coverage depends on balancing his gain through avoiding risk against his loss through the distortion of demand. The U.S. tax system subsidizes the purchase of excessive health insurance by excluding employer premium payments from employees' taxable incomes and by permitting the deduction of a portion of individual premiums. The current operational model of demand for health insurance shows that the tax subsidy does substantially increase insurance coverage. Since much of the rise in health care costs can be attributed to the growth of insurance, the tax subsidy is responsible for much of what is widely perceived as a health care crisis.     

Efficiency of health care delivery systems: effects of health insurance coverage

Health insurance expansions may increase the demand for care-creating incentives for health systems to increase input consumption. The possibility remains that added capacity and personnel will have little effect on health outcomes, decreasing the technical efficiency of health care delivery systems. We estimate that a 1 percentage point increase in health insurance coverage decreases the technical efficiency of health care delivery by 1.3 percentage points, translating into approximately 50 billion dollars in additional health expenditures. This finding uncovers a previously unexplored consequence of changes in health insurance on the supply side of health care markets suggesting one avenue through which health care costs growth may occur.     

The fiscal consequences of public health investments in disease-modifying therapies for the treatment of multiple sclerosis in Sweden

Abstract

Background and aims: The economic consequences of multiple sclerosis (MS) are broader than those observed within the health system. The progressive nature suggests that people will not be able to live a normal productive life and will gradually require public benefits to maintain living standards. This study investigates the public economic impact of MS and how investments in disease-modifying therapies (DMTs) influence the lifetime costs to government attributed to changes in lifetime tax revenue and disability benefits based on improved health status linked to delayed disease progression.

Methods: Disease progression rates from previous MS Markov cohort models were applied to interferon beta-1a, peginterferon beta-1a, dimethyl fumarate, and natalizumab using a public economic framework. The established relationship between expanded disability status scale and work-force participation, annual earnings, and disability rates for each DMT were applied. Subsequently, we assessed the effect of DMTs on discounted governmental costs consisting of health service costs, social insurance and disability costs, and changes in lifetime tax revenues.

Results: Fiscal benefits attributed to informal care and community services savings for interferon beta-1a, peginterferon beta-1a, dimethyl fumarate, and natalizumab were SEK340,387, SEK486,837, SEK257,330, and SEK958,852 compared to placebo, respectively. Tax revenue gains linked to changes in lifetime productivity for interferon beta-1a, peginterferon beta-1a, dimethyl fumarate, and natalizumab were estimated to be SEK27,474, SEK39,659, SEK21,661, and SEK75,809, with combined fiscal benefits of cost savings and tax revenue increases of SEK410,039, SEK596,592, SEK326,939, and SEK1,208,023, respectively.

Conclusion: The analysis described here illustrates the broader public economic benefits for government attributed to changes in disease status. The lifetime social insurance transfer costs were highest in non-treated patients, and lower social insurance costs were demonstrated with DMTs. These findings suggest that focusing cost-effectiveness analysis only on health costs will likely underestimate the value of DMTs.     

Investigating household choice for health and life insurance

The objective of this article is to investigate the joint determination of household choice for health and life insurance. Using the 2008–2009 Consumer Expenditure Survey data, we model household choice for health and life insurance assuming households consider purchasing them to manage financial risks in their life, after accounting for household characteristics, insurance characteristics, health status, and disability status. The model allows assessing the impact of health insurance choice on the choice of life insurance and the correlation between these two choices. The result suggests that health insurance choice positively affects the choice of life insurance and these two choices are positively correlated indicating complementary nature of these insurances in the basket of households’ risk minimising goods.     

State Variations in Hospital Expenditures: An Ecological Approach

Hospital expenditures vary across states both in terms of the levels and growth rates. Economic status, insurance coverage (or lack thereof), health risk factors, and demographic factors are used to explain these differences. Interestingly, the prevalence of poverty rates across states does not seem to be a good predictor of differences in hospital expenditures but the percent without health insurance does relate to higher hospital expenditures, when the factors listed above are all considered. Policy discussions about universal health insurance may be missing a point if better health care coverage resulted in lower hospital costs.

Cost of health care and quality outcomes of patients at nurse-managed clinics

Lack of health insurance is a critical factor in access to appropriate health services and is directly associated with poor functioning, increased morbidity and mortality, lack of continuity of care, and rising health care costs. Nurse-managed clinics (NMCs) can serve as an important safety net in the health care delivery system by offering needed health services to the poor and underinsured populations. Indicators of quality of care at NMCs include removing barriers to care, improving health care access, and developing therapeutic relationships with nurse practitioners. Much evidence also exists that nurse-managed clinics improve the use of preventative services, aid in the promotion of health, compliance of treatment and patient satisfaction, and reduce emergency room visits and rehospitalizations. One of the consistent themes in this review is the need for patient volume enhancement and the importance of reimbursement through Medicaid and third-party payers if nurse-managed clinics are to remain viable.     

Complex home care: Part I--Utilization and costs to families for health care services each year

As many as 120 persons per million people in the United States are dependent on the lifelong, complex, technology-based care of home parenteral nutrition (HPN) infusions. However, data for costs paid by families for HPN-related health care services and for non-reimbursed expenditures are rarely tabulated and most often underestimated. The goals of this study were to describe health care services used by families to manage HPN, report the frequency of each service used annually, and estimate the average annual non-reimbursed costs to families for these health services. The numerous and varied types of services reported and the time required to coordinate and access HPN services illustrates the challenges faced by patients and their family caregivers. The lack of a coordinated and efficient system for delivering complex chronic care results in poorer outcomes for HPN patients and their families on-reimbursed costs and the extensive amount of time required to coordinate multi-professional services negatively impacts the clinical outcomes and quality of life of complex chronic home care.     

Complex home care: Part 2- family annual income, insurance premium, and out-of-pocket expenses

Annual costs paid by families for intravenous infusion of home parenteral nutrition (HPN) health insurance premiums, deductibles, co-payments for health services, and the wide range of out-of-pocket home health care expenses are significant. The costs of managing complex chronic care at home cannot be completely understood until all out-of-pocket costs have been defined, described, and tabulated. Non-reimbursed and out-of-pocket costs paid by families over years for complex chronic care negatively impact the financial stability of families. National health care reform must take into account the long-term financial burdens of families caring for those with complex home care. Any changes that may increase the out-of-pocket costs or health insurance costs to these families can also have a negative long-term impact on society when greater numbers of patients declare bankruptcy or qualify for medical disability.     

Exploring the variability of patient costs in disease management programs: a hierarchical modelling approach

Disease management programs include a wide variation of patients with different chronic diseases and different health care utilization. The aim of this article was to identify factors on patient-level and organizational-level that explain the variability in costs of patients with different chronic diseases enrolled in a DMP by employing a rigorous analytical model. A generalized linear mixed model (GLMM) was specified to perform a multi-level analysis of cross-sectional hierarchical data from 16 DMPs in the Netherlands. Multiple imputation, sub-group analysis per disease and analysis from both the health care and the societal perspectives were also performed. Our model showed that age, the presence of cardiovascular disease, multi-morbidity and payments on top of the payment for the usual care had positive relation with costs, while better quality of life was associated with lower health care costs. In the COPD sample, physical activity and employment were associated with health care costs. Our study showed that there is great variability in health care costs among patients included in DMPs and identified patient and organizational explanatory factors. The findings are relevant to the design of future DMPs and their payment schemes.     

Income,health and health care utilization in the UK

The aim of this paper is to analyse the links between income, health and health care utilisation behaviour using longitudinal data from the British Household Panel Survey. The emphasis is to frame the analysis as a social phenomenon, so that the dynamics of individual health production in the social context can be understood. The study estimates the relationships between income, health and health care utilisation with lag effects. The empirical results support the hypothesis that these three variables influence each other with lag effects and that many social and economic factors influence an individual's probability of having a health problem or making use of health care facilities, even when such facilities are free at the point of use.     

Avoiding the mistreatment of bad risks in a democracy: Universal Health Insurance from a constitutional perspective

This paper examines the concept that social insurance for medical care may represent a kind of constitutional choice. The long-term stability of the U.S. Medicare program indicates that such programs are rarely altered. The primary reason postulated for treating subsidized medical insurance as a constitutional choice is to guard against a temporary majority of persons in good health or not at risk for a disease voting to deny benefits for the minority who are at higher risk. It is argued, however, that, although there needs to be constitutional status for social insurance, insurance need not and probably should not take the form of tax-financed equal coverage for all.     

Social Insurance Based on Personal Savings

Many countries have reformed, or plan to reform, their pension system. The trend is to move from an entitlement based system to a system in which contributions accumulate in some form of personal savings account. In recent years proposals have been made to apply a personal savings account also to other elements of social insurance, such as unemployment insurance, social assistance, health care costs and others. This paper presents a simple model and a simulation to compare the lifetime consequences of replacing a wide range of social insurance systems with savings account based social insurance. The results indicate that savings account based social insurance can be designed to provide the same economic security as offered by a generous welfare state, and yet lower marginal taxes considerably.     

Estimating a health production function for the US: some new evidence

This study reports some new evidence on the impact of medical care, socioeconomic, lifestyle and environmental factors on the health status of the population of the USA. The results show that additional medical care utilization is relatively ineffective in lowering mortality and increasing life expectancy. The most important factors that influence death rates are related to socioeconomic status and lifestyle. The results suggest that health care policy which focuses primarily on the provision of medical care services and ignores larger economic and social considerations may do little to benefit the nation's health.     

A dynamic analysis of the demand for health insurance and health care

We find that asymmetric information is important for the uptake of supplementary private health insurance and health care utilization. We use dynamic panel data models to investigate the sources of asymmetric information and distinguish short-run selection effects into insurance from long-run selection effects. Short-run selection effects (i.e. responses to shocks) are adverse, but small in size. Also long-run effects driven by differences in, for example, preferences and risk aversion, are small. But we find some evidence for multidimensional asymmetric information. For example, mental health causes advantageous selection. Estimates of health care utilization models suggest that moral hazard is not important.     

Do Competing Health Insurance Licensors Provide Pro-patient Effects?

This paper shows that competition among health insurance licensors has strong pro-patient effects, if inter-regulatory competition is allowed. The pro-patient effects of the competition among health insurance licensors do not depend on the need for the patients to form or exercise their political influence, such as, forming cooperatives or voting, as suggested by Backer's pressure group theory. When inter-jurisdictional transactions are allowed, endogenous policy making ensures that the health care licensors pursue public interests at no costs to patients.     

Out-of-pocket health care expenditure in Turkey: Analysis of the 2003–2008 Household Budget Surveys

This paper analyses the prevalence of ‘catastrophic’ out-of-pocket health expenditure in Turkey and identifies the factors which are associated with its risk using the Turkish Household Budget Surveys from 2003 to 2008. A sample selection approach based on Sartori (2003) is adopted to allow for the potential selection problem which may arise if poor households choose not to seek health care due to concerns regarding its affordability. The results suggest that poor households are less likely to seek health care as compared to non-poor households and that a negative relationship between poverty and experiencing catastrophic health expenditure remains even after allowing for such selection bias. Our findings, which may assist policy-makers concerned with health care system reforms, also highlight factors such as insurance coverage, which may protect households from the risk of incurring catastrophic health expenditure.     

Forecasting requirements for health care personnel

Accurate forecasting of requirements for health care personnel is an important part of avoiding significant imbalances that create costly inefficiencies in health care markets. Manpower shortages threaten access, quality, and costs of health care. This article reviews five general approaches previously used to determine manpower requirements. Suggestions are made for the analytic components of a comprehensive model for identifying significant imbalances in supply or demand for health care workers.