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PubMed1998

Assessing the value of a new pharmaceutical. A feasibility study of contingent valuation in managed care.

OBJECTIVES: The authors assessed the feasibility and construct validity of the contingent valuation method for measuring the monetary value to healthy enrollees in a health maintenance organization of a new drug, filgrastim, as prophylaxis against febrile neutropenia after chemotherapy treatment for cancer. METHODS: A random sample of 220 enrollees from a closed-panel staff-model health maintenance organization who did not have cancer were interviewed. Chemotherapy, febrile neutropenia and filgrastim were described by video and decision board. Questions were asked in two different scenarios: (1) User-based: Assuming they were at the point of consumption and about to receive chemotherapy, what is the maximum they would be willing to pay to receive filgrastim? and (2) Insurance-based: Given they were at risk of cancer in the future, what is the maximum they would be willing to pay in additional monthly insurance premiums to add filgrastim to the plan? In a second insurance scenario where respondents were told that filgrastim was covered, what is the minimum reduction in premium that persons were willing to accept to relinquish coverage of the drug? A 2 x 2 factorial design was used to contrast two bidding algorithms to test for starting point bias and two 5-yearly prior risks of cancer, 1/200 versus 1/100. Main effects were tested by ANCOVA controlling for age, sex, health, and income. RESULTS: Demographics of experimental cells were similar. No evidence was found of significant starting point bias. For user-based questions, as expected, willingness-to-pay increases with febrile neutropenia risk reduction, but at a declining marginal rate. Despite careful presentation of information to respondents, willingness-to-pay for insurance was higher in the lower prior risk group. Consistent with previous contingent valuation studies, the authors of the present study found evidence that willingness-to-accept exceeds willingness-to-pay for coverage of the same benefit. CONCLUSIONS: An insurance-based contingent valuation study is feasible in a health maintenance organization. Construct validation evidence was encouraging, with the exception of the test for prior risk of cancer; however, this was a between-person contrast and may have been confounded by other factors.

Adult↗
PubMed1993

More than loose change: household health spending in the United States and Canada.

A key point of comparison between U.S. and Canadian health spending is what amount citizens spend for health coverage, given their respective health systems. A comparison of household spending surveys in the two countries shows that Canadian households pay about half of what American households pay for health coverage, but their personal tax burden is almost twice that of Americans. Net personal consumption thus is quite similar between the two countries. Total household health spending in the United States amounted to $215.6 billion in 1989--one-third of the total spent on health that year.

Adult↗
PubMed2006

[The impact of co-payments on patient behavior: evidence from a natural experiment].

As part of the Statutory Health Insurance Modernization Act a co-payment of 10 Euros per quarter for the first contact at a physician's or a dentist's office has been introduced with effect of January 1, 2004. Apart from contributing to the financial consolidation of the Statutory Health Insurance the co-payment aimed at changing the patients' behavior toward more self-responsibility. This article shows that physician contacts declined in the year 2004 compared to 2003. However, the share of those patients who had at least one physician contact in both years remained stable. Two Logit models point out that necessary physician contacts still take place, e. g., in case of disabled persons and persons with poor health. In addition, no discrimination of persons of low social status could be observed. The results are also approved by other studies. Therefore, it seems plausible, that the introduction of this co-payment has contributed to a reduction of unnecessary and redundant physician visits.

Adult↗
PubMedDate not supplied

[The demand for homes in old age].

A study is reported of the utilization of non-clinical institutional care (geriatric and old people's homes) by the elderly inhabitants of Mannheim (pop. 306,000). The aim of the research was to establish the probability of admission to institutional care of an elderly person from this population, and to examine the influence of socio-demographic features. Under the West German health insurance system, most of the long-stay care of the elderly is provided not in hospitals but in nursing and geriatric homes. Data were collected on age at admission, place of residence before admission, duration of stay, age at death and place of death, as well as on the financial basis of care. The data were gathered retrospectively, the sample consisting of all inhabitants of Mannheim over 65 years old who died in the year 1982 (N = 2,585). At any given time only about four per cent of the elderly population will be in institutional care. In this respect, Mannheim is typical for the Federal Republic of Germany. However, the research findings demonstrate that approximately one elderly person in five will spend the last period of his life in this type of care. Seen in this light, the geriatric and old people's homes acquire a much greater social significance than is revealed by the number of institutional places alone.

Age Factors↗
PubMed1986

Factors affecting residents' decisions to moonlight.

Moonlighting by residents has been a major concern of residency program administrators, since extensive moonlighting by residents in addition to their already demanding residency work schedule might jeopardize patient care. In this paper, the authors examine the influence of several factors on residents' decisions to moonlight. The results indicate that the main motivating factor behind their moonlighting is economic and that residents moonlight more frequently when they have the opportunity to do so. In addition, the residents with higher levels of medical school indebtedness were significantly more likely to moonlight than residents with less indebtedness. Personal characteristics of the residents and their specialties also influenced moonlighting but had a smaller impact than amounts of stipends and indebtedness and the number of off-duty hours. The results also suggest that residency administrators can influence their residents' decisions to moonlight.

Employment↗
PubMed2004

Meaning of housework and other unpaid responsibilities among older women.

This study explores the meaning and conditions of housework and other unpaid responsibilities for older women. Taped, in-person interviews were conducted with 53 ethnically and economically diverse women, 55-84 years old. The interview guide contained open-ended questions regarding the process of taking on housework and other unpaid responsibilities and the centrality to personal identity. Participants reported shifts in perceptions of housework as work, decreased importance of housework with age, the attitude of care recipients affecting the experience and meaning of unpaid responsibilities, and the impact of historical racist events on viewing unpaid responsibilities as opportunity.

Aged↗
PubMed2006

Changes in financial burdens for health care: national estimates for the population younger than 65 years, 1996 to 2003.

CONTEXT: Policymakers as well as physicians need to understand how rapidly rising health care costs are affecting specific groups of patients. OBJECTIVE: To estimate the number and characteristics of individuals in the United States faced with very high financial burdens for health care. DESIGN, SETTING, AND POPULATION: Data from a nationally representative sample of civilian, noninstitutionalized US individuals younger than 65 years from the Medical Expenditure Panel Surveys were used to calculate 2 measures of financial burden as a function of tax-adjusted family income. Total burden included all out-of-pocket expenditures for health care services, including premiums. Health care services burden excluded premiums and, when applied to the insured population, was used to identify the underinsured. We defined the underinsured as insured persons with health care service burdens in excess of 10% of tax-adjusted family income. MAIN OUTCOME MEASURES: Total and health care services burdens exceeding 10% and 20% of family income in 1996 and 2003. RESULTS: In 2003, there were 48.8 million individuals (19.2%) living in families spending more than 10% of family income on health care, an increase of 11.7 million persons since 1996. Of these individuals, about 18.7 million (7.3%) were spending more than 20% of family income. In 2003, individuals with higher-than-average risk of incurring high total burdens included poor and low-income persons and those with nongroup coverage, aged 55 to 64 years, living in a non-metropolitan statistical area, in fair or poor health, having any type of limitation, or having a chronic medical condition. Applying our definition of underinsured to the insured population, an estimated 17.1 million persons younger than 65 years were underinsured in 2003, including 9.3 million persons with private employment-related insurance, 1.3 million persons with private nongroup policies, and 6.6 million persons with public coverage. CONCLUSIONS: Our analysis identifies patients at greatest risk of health-related financial burdens that may adversely affect their access and adherence to recommended treatments. Our study also highlights the high costs associated with nongroup health insurance policies.

Adult↗
PubMedDate not supplied

Helping families mobilize their personal resources.

With changes in delivery of and payment for health care, hospital stays may be shorter and children may be going home sooner and sicker. Therefore, more care may be required at home. Even with access to a variety of services and resources in the community, families of medically fragile or chronically ill children can be overwhelmed and stressed. Relief can be provided to some degree if families creatively mobilize their own personal resources. However, for a variety of reasons, families may find it difficult to do this. While nurses and other health care professionals are accustomed to helping families find professional services and resources in the community, they can also be invaluable before discharge by assisting families with their personal resources--from giving encouragement and motivation to outlining practical planning steps. Pediatric nurses can use guidelines and a checklist to assist families with mobilizing their resources to ease the transition from hospital to home for the whole family.

Adult↗
PubMed2005

Future outlook and financial strain: testing the personal agency and latent deprivation models of unemployment and well-being.

A sample (N=239) of unemployed adults completed scales measuring well-being, financial strain, future outlook, and the latent benefits of employment. The study tested (a) the relative contributions of the latent deprivation and agency restriction models in predicting well-being and (b) whether financial strain interacted with future outlook to predict well-being or whether financial strain was mediated by future outlook. The authors found support for agency restriction over the latent deprivation model and concluded that examining internal personal agency processes is required to explain the decline in well-being. No interaction effects were identified for financial strain and future outlook, but future outlook did mediate the influence of financial strain. Age and length of unemployment were also associated with well-being.

Adolescent↗
PubMed1995

Lifetime patterns of payment for nursing home care.

Although much is known about who pays the annual aggregate nursing home bill, relatively little is known about payment-source patterns of individuals during their lifetimes. In this article, lifetime payment-source patterns are analyzed for elderly nursing home users, particularly the extent to which they spend down assets to become eligible for Medicaid. During their lifetimes, 44% of persons who use nursing homes after 65 years of age start and end as private payers, 27% start and end as recipients of Medicaid benefits, and 14% spend down assets to become eligible for Medicaid benefits. Although still a relatively small proportion, the asset spend-down estimate based on lifetime data is 2.5 times previous national estimates based on data for single nursing home stays. The projected risk of spending down assets in nursing homes for all persons who turn 65 years of age in 1995, including users and nonusers of nursing homes, is slightly more than 6%. Equally or more important for policy is that 17% of all persons who turn 65 years of age can expect to end up using a nursing home and receiving Medicaid reimbursement. Of those, more than 3 in 5 will have entered the nursing home already eligible for Medicaid benefits.

Black or African American↗
PubMed2002

Trends in mental health insurance benefits and out-of-pocket spending.

BACKGROUND: Insurance benefits can have a large effect on whether one is able to access health care services. Mental health and substance abuse (MHSA) insurance coverage has typically been less generous than that of general health services. AIMS OF THE STUDY: This paper examines trends in the generosity of private insurance benefits for mental health (MH) services in the United States from 1987 to 1996. The paper estimates the benefit-induced change in insurance payments for MH services that would have been made by typical health plans between 1987 and 1996 holding constant utilization of individuals at the 1987 level so that the changes in effective benefits could be isolated. METHODS: Trends in mental health benefits were measured using two nationally representative household surveys of the U.S. civilian non-institutionalized population, the 1987 National Medical Expenditure Survey (NMES) and the 1996 Medical Expenditure Panel Survey (MEPS). Data on utilization and expenditures from the NMES/MEPS were used to simulate what the average person would have paid out-of-pocket under typical insurance plans in 1987 and in 1996. RESULTS: The study finds that limits on MH coverage, such as limits on reimbursed days of care, became more prevalent from 1987 to 1996, but that consumer cost-sharing rates declined. The simulations indicate that private insurance would have paid for a lower proportion of total spending in 1996 (60.1 percent) as compared to 1987 (65.8 percent). DISCUSSION: Despite the fact that limits on mental health services became more prevalent over the time-period evaluated, out-of-pocket expenditures did not increase as significantly because there was a corresponding increase in coinsurance covered by health plans. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Trends in plan design negatively affected those with high costs who are likely to surpass their limits and positively affected coverage for those with minimal use due to lower cost-sharing. These trends also indicate that persons in the most need, those with high utilization, particularly of inpatient care, experienced a decline in coverage while those with less intensive needs may have experienced a slight increase. IMPLICATIONS FOR HEALTH POLICIES: Out-of-pocket spending in both years of the study was substantial suggesting that improved health care coverage, such as that mandated in parity legislation, could improve access to care for persons needing mental health treatment. IMPLICATION FOR FURTHER RESEARCH: Additional research is needed to understand how trends in out-of-pocket spending and insurance benefits have influenced access to care.

Adolescent↗
PubMed2003

Financial, occupational, and personal consequences of disability in patients with chronic fatigue syndrome and fibromyalgia compared to other fatiguing conditions.

OBJECTIVE: To examine the nature and degree of self-reported disability in patients with chronic fatigue syndrome (CFS) and its associated conditions, fibromyalgia (FM) and subsyndromal fatigue (CF), compared with a chronically fatiguing but unrelated medical condition (MED). METHODS: Six hundred and thirty patients evaluated at the University of Washington Chronic Fatigue Clinic were sent questionnaires asking them to identify the financial, occupational, and personal consequences of their fatiguing illness. Thorough medical evaluations had previously applied accepted criteria for defining CFS, FM, and CF. RESULTS: The FM groups (those with and without CFS) were among the least employed. Likewise, the FM and CFS groups, more frequently than the other groups, endorsed loss of material possessions (such as car), loss of job, and loss of support by friends and family, as well as recreational activities as a result of their fatiguing illness. There were no reliable differences between groups in use of disability benefits. CONCLUSION: There is substantial illness-related disability among those evaluated at a specialized chronic fatigue clinic. Those reporting the most pervasive disability met criteria for FM either alone or in conjunction with CFS. Employers and personal relations of patients with chronic fatigue should make a greater effort to accommodate the illness-related limitations of these conditions, especially for those with FM and CFS.

Adult↗
PubMed1975

Equal treatment and unequal benefits: the Medicare program.

This paper analyzes the distribution of Medicare benefits among elderly persons on the basis of income, race, and geographical location. It first presents available statistical evidence from Medicare on the distribution of benefits and the magnitude of differentials among these elderly. It then sorts out the contribution to differentials arising from differences in the availability of medical resources. prices of medical services, and other demographic factors. The importance of various Medicare program features on remaining differentials--such as the cost-sharing provisions of Medicare, reimbursement policies, and nondiscrimination enforcement procedures--are then investigated. The effect of health status on utilization of medical services by the elderly is also analyzed, and the distribution of Medicare benefits by income for elderly persons of similar health status is presented. The paper concludes with recommendations for reducing differentials in Medicare benefits and indicates those policy changes which would result in a distribution of benefits more closely related to health care needs of the elderly.

Aged↗
PubMedDate not supplied

Costs to the patient for seeking malaria care in Myanmar.

This study investigates the costs incurred by patients diagnosed with uncomplicated malaria at a formal rural health facility in Myanmar. A cross-sectional survey of 410 patients indicated that the majority of patients were male (89.3%), married (84.6%) and the head of their family (80.2%); this spectrum reflected the deliberate selection of persons for whom relatively accurate costing was feasible. The average total costs incurred for an episode of malaria was kyats 173.58 (95% CI = 166.13-181.02). with the highest cost contribution being the loss of earnings due to absence from work (mean = kyats 135.05; 95% CI = 128.14-141.96). Total costs to the patient per episode were, on the average, equivalent to 4.2 days of per capita economic output indicating that malaria imposes a significant financial burden on the patient even though medical services and treatment are provided free of charge. Variables significantly positively associated with patient cost included the duration of illness (P < 0.001), income of the patient (P < 0.001), presence of accompanying person at the health facility (P < 0.001) and being a farmer (P = 0.026). The results of this study highlight the importance of using confirmatory diagnosis in rural settings to minimize the financial burden of malaria to the patient and family.

Adult↗
PubMed1995

Change in expenditure patterns of retirees: 1972-1973 and 1986-1987.

This study presents a comparative analysis of changes over time in expenditure patterns of retirees. Tobit regressions reveal significant differences in expenditure patterns in health care, leisure, necessities, and philanthropy. Over the past two decades, health care became more of a necessity, and its budget share increased. The marginal propensity to consume (MPC) leisure activities more than doubled. Retirees allocated lesser budget shares to the necessity areas of food and apparel, but single females had increased housing shares. The budget share and MPC for charitable contributions declined. Over time, the average propensity to consume (APC) increased greatly from 94 to 103 percent, a potential problem if elderly persons dissave at unsustainable rates. The spending of older retirees now differs substantially from younger retirees, with the APC declining with age, an apparent contradiction of the life cycle hypothesis. Apparently, the retired are more cautious about spending in the latter stages of the life cycle.

Aged↗
PubMed1990

Spend-down of assets before Medicaid eligibility among elderly nursing-home recipients in Michigan.

Many elderly persons enter nursing homes as private pay clients, spend their available life savings, and then apply for medical assistance under Medicaid after their assets are depleted. However, reliable data on the size and characteristics of this "spend-down" population have been lacking. This study used Medicaid claims and enrollment data to identify the proportion of elderly Medicaid nursing-home users who originally entered nursing homes as private pay clients versus those eligible for Medicaid before or concurrent with, their nursing-home admission. The study population consisted of all elderly nursing-home users receiving Medicaid in Michigan in 1984, a total of 36,898 unduplicated recipients. Findings indicated that "spend-downers" comprised 27.2% of all elderly users. Once on Medicaid, spend downers exhibited similar nursing-home utilization patterns as other groups, but incurred lower Medicaid claims because they contributed more to the cost of their nursing-home care. In aggregate, the State of Michigan Medicaid program spent $75.4 million on nursing-home services in 1984 for elderly persons who spent down to eligibility in a nursing home. These data are relevant to state policy initiatives to reduce Medicaid spending for nursing-home care by encouraging potential spend downers to purchase long-term care insurance.

Aged↗
PubMed1976

Exercise rehabilitation in coronary heart disease: community group programs.

This paper outlines a suggested protocol for community exercise programs for the rehabilitation of patients with coronary heart disease. Information presented is based on more than seven years of experience gained by the Cardio-Pulmonary Research Institute through programs in Seattle, Mercer Island, and Yakima, WA, and in Portland, OR. Participants, referred by their personal physicians, meet three times weekly for individually prescribed group walking-jogging-calisthenic sessions lasting 45 minutes each. More than 900 individuals have participated in the program, which has been shown to be feasible, economical and safe.

Community Health Services↗
PubMed2005

Using willingness to pay to measure family members' preferences in mental health.

BACKGROUND: Willingness to pay is a valuation technique that has rarely been applied in mental health economics. First used in environmental economics to measure the intangible value of environmental improvements, WTP has increasingly been used in health care economics. The technique may be useful in mental health policy research where it can be critical to include the intangible impact of mental health treatment on individuals other than the person with illness, such as family members, in cost-benefit analyses. AIMS OF THE STUDY: The goal of the study was to test the application of WTP in a sample of individuals who have family members with serious mental illness. This paper describes the survey development process and the feasibility analysis that was conducted as part of the study. METHODS: A mail survey was designed by the author in two phases and utilized cognitive pretests and focus group pretests in the process of development. Qualitative analysis of this process resulted in a revised survey instrument that was then distributed to a random sample of 2000 individuals who have family members with mental illness. Feasibility was evaluated based upon the study response rate, the willingness to pay item response rate and an outlier response analysis. RESULTS: Qualitative analysis during the survey development process found that it was critical to consider two areas of concern in the application of WTP with this population in the mental health field. Some respondents experienced a highly emotional response to the initial versions of the survey, and complex probabilities were difficult for the respondents to answer. These findings resulted in significant modifications in the survey design. The analysis of response rate, WTP item non-response rate, and outlier responses found no significant concerns regarding overall feasibility of WTP with this population. DISCUSSION: Based upon the results from this study, WTP is a potentially useful tool for further research in the mental health policy and economics field. However, significant accommodations must be made in survey design to account for a possibility of a high level of emotional distress for those dealing with the illness of a family member. Some of these modifications may be in contrast to the recommendations currently being followed in health care economics. Face-to-face surveys may be preferred in some cases, such as with elderly respondents. Limitations of this study include the lack of targeted follow-up due to the anonymous study design and the fact that there are so few models for WTP studies in mental health. IMPLICATIONS FOR MENTAL HEALTH POLICY: Given that effective mental health programs can be matched with additional expenditures, it is important to explore comprehensive measures of value for treatment in cost-benefit analysis. The values of persons whose family members have serious mental illness are important to consider in setting policy. The success of this study suggests that WTP could be used in other settings, e.g., to understand community preferences for mental health treatment programs, to understand differences in preferences across multiple stakeholder groups.

Consumer Behavior↗