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PubMed1995

Trends in state agency oral health and public health expenditures, 1984 through 1989.

This paper documents oral health and public health expenditures for fiscal years 1984, 1986, 1988, and 1989, as reported by state health agencies. During this period, reported national expenditures for public and oral health increased 68% and 46%, respectively; between successive fiscal years, fewer states (73%, 67%, 57%) reported increased oral health expenditures, while increasingly more states reported no categorical oral health expenditures. Block grant expenditures for oral health increased overall but decreased as a percentage of total oral health expenditures; 16 states reported no block grant expenditures for oral health in fiscal year 1989, perhaps reflecting either substantial state support, or marginal to nonexistent oral health programs in these states.

Data Collection↗
PubMed1999

Managing pharmaceutical expenditure while increasing access. The pharmaceutical management agency (PHARMAC) experience.

The role of the Pharmaceutical Management Agency (PHARMAC) is to manage pharmaceutical subsidy expenditure in New Zealand. PHARMAC has adopted a proactive approach. It selects the drugs that are to be subsidized and declines to subsidize others. It has established reference pricing across many drug groups, has entered into a range of innovative commercial contracts with pharmaceutical companies, and has encouraged greater price competition among pharmaceutical companies in order to lower prices and control expenditure risk. These initiatives have all been part of an overarching strategy to improve the value of the government's expenditure on pharmaceuticals. PHARMAC has also developed techniques of cost-utility analysis to assess the value of expenditure. PHARMAC has slowed pharmaceutical expenditure growth, culminating in a fall in expenditure in the 1998/1999 year. At the same time, patient access has continued to expand, with more prescriptions being written and new drugs being subsidized. Therefore, PHARMAC has made dramatic strides to improve the value of the government's expenditure on pharmaceutical subsidies and its actions have meant that more funds have been available for investment in other health services, than would have occurred if previous policies had remained unchanged.

Angiotensin-Converting Enzyme Inhibitors↗
PubMedDate not supplied

The relationship between modifiable health risks and group-level health care expenditures. Health Enhancement Research Organization (HERO) Research Committee.

PURPOSE: To assess the relationship between modifiable health risks and total health care expenditures for a large employee group. DESIGN: Risk data were collected through voluntary participation in health risk assessment (HRA) and worksite biometric screenings and were linked at the individual level to health care plan enrollment and expenditure data from employers' fee-for-service plans over the 6-year study period. SETTING: The setting was worksite health promotion programs sponsored by six large private-sector and public-sector employers. SUBJECTS: Of the 50% of employees who completed the HRA, 46,026 (74.7%) met all inclusion criteria for the analysis. MEASURES: Eleven risk factors (exercise, alcohol use, eating, current and former tobacco use, depression, stress, blood pressure, cholesterol, weight, and blood glucose) were dichotomized into high-risk and lower-risk levels. The association between risks and expenditures was estimated using a two-part regression model, controlling for demographics and other confounders. Risk prevalence data were used to estimate group-level impact of risks on expenditures. RESULTS: Risk factors were associated with 25% of total expenditures. Stress was the most costly factor, with tobacco use, overweight, and lack of exercise also being linked to substantial expenditures. CONCLUSIONS: Modifiable risk factors contribute substantially to overall health care expenditures. Health promotion programs that reduce these risks may be beneficial for employers in controlling health care costs.

Adult↗
PubMed2002

A guide to comparing health care expenditures in the 1996 MEPS to the 1987 NMES.

Substantial changes in the organization, delivery, and financing of health care over the last decade, combined with data collection and methodological improvements in the 1996 Medical Expenditure Panel Survey (MEPS), pose special challenges in comparing expenditure estimates in MEPS with those in the 1987 National Medical Expenditure Survey (NMES). The 1987 NMES used charges as its fundamental expenditure concept, whereas the 1996 MEPS used actual payments as its expenditure measure. In spite of these differences, researchers and policymakers will want to be able to analyze trends in health care expenditures using these two surveys. We discuss these issues in detail and present a simple, straightforward adjustment method that can be applied to the 1987 NMES public use expenditure data to improve comparability to the MEPS. We base this adjustment method on an analysis of provider-reported payment data collected in NMES. We present several examples of the application of this method that illustrate the importance of the adjustments for analyses of trends in health care spending.

Actuarial Analysis↗
PubMed2004

Medicare program expenditures associated with hospice use.

BACKGROUND: Hospice providers contend that enrollment reduces the cost of the Medicare programs, but estimates of effects are dated, methodologically limited, and focused on persons with cancer. OBJECTIVE: To estimate the effects of hospice care on Medicare program payments during the last year of life from 1996 to 1999 within cohorts defined by age and diagnosis. DESIGN: Retrospective cohort. SETTING: Deceased Medicare enrollees. PARTICIPANTS: Elderly Medicare fee-for-service beneficiaries who received 36 months of continuous Part A and B coverage before death during 1996 to 1999 (n = 245 326). Age- and condition-specific (cancer or noncancer and principal condition) cohorts were defined. MEASUREMENTS: Medicare expenditures in the last year of life, as a total figure and by service type. The cost effects of hospice were estimated by using linear regression within the cohorts for hospice enrollees compared with nonenrollees after adjustment for propensity to use hospice, gender, race, enrollment in Medicaid, urban setting, duration of illness, comorbid conditions, low use of Medicare, nursing home residence, and year of death. RESULTS: Adjusted mean expenditures were 4.0% higher overall among hospice enrollees than among nonenrollees. Adjusted mean expenditures were 1% lower for hospice enrollees with cancer than for patients with cancer who did not use hospice. Savings were highest (7% to 17%) among enrollees with lung cancer and other very aggressive types of cancer diagnosed in the last year of life. Expenditures for hospice enrollees without cancer were 11% higher than for nonenrollees, ranging from 20% to 44% for patients with dementia and 0% to 16% for those with chronic heart failure or failure of most other organ systems. Hospice-related savings decreased and relative costs increased with age. CONCLUSION: Hospice enrollment correlates with reduced Medicare expenditures among younger decedents with cancer but increased expenditures among decedents without cancer and those older than 84 years of age. Future studies should assess the effects of hospice on quality and on expenditures from all payment sources.

Aged↗
PubMed1987

Total family expenditures for health care: United States, 1980.

Information on total family expenditures for health care in 1980 is presented in this report. Total expenditures are the total amounts billed (either actual or imputed) to families whether these amounts are paid out-of-pocket by the family, paid by private health insurance or a public health care coverage program, or remain unpaid. The data discussed here were gathered in the national household sample of the National Medical Care Utilization and Expenditure Survey (NMCUES). In this sample, information was collected on health problems, health care received, expenditures for care, health insurance, and related topics throughout calendar year 1980 from approximately 6,800 families in the civilian noninstitutionalized population of the United States. The survey excluded all individuals who were in institutions or in the military. This report also entirely excludes families with military heads, even if they had some civilian members. For this report, a family was initially defined as (1) two or more persons living together who were related by either blood, marriage, adoption, or a formal foster care relationship or (2) a single person living outside such relationships. Because data on these families were collected across an entire year, the important concept of "longitudinal family" was developed. This concept was necessary to deal with the fact that the composition of a family could change over time and that families could come into existence and go out of existence over time. As the data are based on this dynamic concept of families, all measures of expenditures for care are calculated in annual rates. Family data are important for understanding the health care system because decisions to seek and use health care are usually family decisions, health care is usually paid for out of family resources, and family distributions for health-related variables differ from the distributions found for individuals. This report deals with total expenditures for health care as reported by a sample of consumers of health care. These types of data are limited by the knowledge the respondent has as to the amount of the total bill. For various reasons, which are discussed in detail in the text, the respondent often doesn't know the amount of the total bill. Therefore, the statistics in this report should be regarded as having more limitations than the statistics in two previous family reports: "Family Use of Health Care: United States, 1980" (Dicker and Sunshine, 1987) and "Family Out-of-Pocket Expenditures for Health Care: United States, 1980" (Sunshine and Dicker, 1987).

Age Factors↗
PubMed2000

[National Health Insurance expenditures in 1994 for thirty long-term illness].

OBJECTIVE: The health insurance system carried out a survey in 1994 on the illnesses included in the regulations on the thirty long-term illnesses (ALD 30) exempt from patients' contributions to the costs of medical treatment. One of the objectives of this study was to provide the average amount, per patient with these illnesses, of the total expenditures of payments in kind reimbursed by the health insurance system and their distribution by principal expenditure post and by illness. METHODOLOGY: A sample of 67,828 patients was randomly selected at the rate of 2% of the total patients under ALD 30 in November 1994. The expenditures reimbursed over the course of June through November 1994 were collected from a computerized petition on the Health Insurance Information System. RESULTS: The average annual cost per patient within the regulation is estimated at 35,991 FF (+/- 692). Close to half of these expenditures correspond to public hospital stays. The annual expenditures extrapolated from the total ALD 30 is estimated at 143.7 billion FF, or 35% of the total expenditures of payments in kid reimbursed by the health insurance system. "Mental illnesses" represent the largest portion of these expenditures given to ALD 30 (23%). CONCLUSIONS: The survey allows for an evaluation of the average cost per patient covered 100% by the health insurance system under ALD 30. For the majority of these illnesses, these evaluations are the only benchmarks currently available.

Chronic Disease↗
PubMed2001

Medical care expenditures under gatekeeper and point-of-service arrangements.

OBJECTIVE: To compare expenditures for medical care in a closed-panel gatekeeper HMO and an open-panel point-of-service (POS) plan that share the same provider network. DATA SOURCE/STUDY SETTING: The two study HMOs are distinct product lines of a single managed care organization; both plans are commercial products. We used administrative data files from the study plans for 1994-95 to assess differences in total medical care expenditures and spending for five categories of services: physician services, inpatient hospital services, outpatient hospital services, prescription drugs, and other services. STUDY DESIGN: Multivariate analyses were based on the two-part model of the demand for medical care. The dependent variables in these models were expenditures in each of the five categories of services, and the independent variables were indicator variables for plan type and visit copayments, prescription drug copayment, distance to the nearest primary care physician (PCP), demographic characteristics, chronic conditions, area characteristics, and entry/exit indicator variables. PRINCIPAL FINDINGS: Total expenditures for medical care ranged from equal in both plans to 7 percent higher in the gatekeeper HMO (p < .10), depending on the copayments for physician visits. Expenditures were not higher in the POS plan for any of the five categories of services. These findings were robust to a wide range of sensitivity analyses. CONCLUSIONS: Direct patient access to specialists in POS plans does not necessarily result in higher medical care expenditures. When POS enrollees are required to choose PCPs, patient cost sharing, physician financial incentives, and utilization review may control expenditures without constraining direct patient access to providers.

Adolescent↗
PubMedDate not supplied

Out-of-pocket expenditure on healthcare in a north Indian village.

BACKGROUND: Information on healthcare expenditure at the family or household level is important for the planning and management of health services. It is particularly relevant for health insurance agencies to estimate the amount of premium for initiating a universal health insurance system. METHODS: Of 800 families in a village, 160 were selected by systematic random sampling. Of these, 156 families were followed up for a period of 12 months (September 1998 to August 1999) by making monthly visits. Responses from each family, as given by the head of the family, were recorded with the help of an interview schedule administered in the local language. The interview schedule covered any morbidity among the family members in the past one month and the out-of-pocket expenditure incurred on the same. RESULTS: The private health sector was utilized in 59.4% of total episodes. Utilization of the private sector was directly associated with a higher socioeconomic status (p = 0.002). Of the total expenditure on non-hospitalized cases, 83.6% was incurred in the private sector. The mean per capita annual out-of-pocket expenditure on health was Rs 131. The median expenditure per episode was Rs 15. CONCLUSION: Our study shows that out-of-pocket expenditure is more than the government expenditure on health. There is a need for systems such as health insurance to protect the poor from high medical costs.

Family Characteristics↗
PubMed2003

[Structure of treatment expenditures for hemodialysis patients (data of Kaunas University of Medicine Hospital in the year 2001)].

Prevalence of the end-stage renal disease patients is rising every year. In Lithuania the cost of hemodialysis procedure is under regulation of the Minister of Health. The objective of our study was to evaluate expenditures for hospitalizations and medical ambulatory treatment using data of Kaunas University of Medicine Hospital dialysis center in the year 2001. We analyzed ambulatory case records of all 111 end-stage renal disease patients dialyzed in our clinic in November 2001. Retrospective data about hospitalizations, hospital beds, expenditures for hospitalizations and medicamental ambulatory treatment were collected. There were 123 hospitalizations in 75 patients, 1967 total hospital days. Admission rate was 1.34+/-1.5 per patient year, 19.82+/-25.96 hospital beds per patient year, the mean duration of each hospitalization - 16.26+/-11.57 days. Expenditures for hospitalizations were 1415 litas ($ 354) per patient year. In average, hemodialysis procedures were carried out 2.5 times a week per patient (or 130 times a year) and expenditures for hemodialysis procedure were 36400 litas ($ 9100) per patient year. The mean number of medications monthly prescribed to hemodialyzed patients was 6.83+/-2.21. Expenditures for these medications were 16240 Lt ($ 4060) per patient year including expenditures for erythropoietin 14976 Lt per patient year. All health insurance expenditures for hemodialyzed patients were 54055 litas ($ 13514) and this was 2-4 fold lower than reported in developed countries.

Adult↗
PubMedDate not supplied

Excess morbidity and expenditure on healthcare in families with smokers: a community study.

BACKGROUND: There is paucity of information on health-related expenditure attributed to smoking in India. This community study estimated the expenditure on healthcare and morbidity borne by families of smokers and compared these with those of families without smokers. It was hypothesized that families with smokers were likely to have a higher health expenditure than non-smoker families attributable to the increased probability of health problems associated with smoking. METHODS: The study population comprised 1000 urban and rural families divided into two groups. Group I consisted of 500 families with one or more smoker(s) while group II comprised 500 families without a smoker. Both groups had an equal representation from the urban and rural populations (250 each). The study team used a structured, generally close-ended questionnaire, pre-tested for its validity and reliability, to interview the families. Different components of health-related expenditure and other morbidity indices were studied. Each family was studied in two phases: (i) initially, for the retrospective assessment of expenditure and other losses during the preceding one year, and (ii) prospectively, for the following 10 months on repeated visits and estimations made every two months. The data collected retrospectively were mostly incomplete and could not be used for analyses. RESULTS: The number of family members reporting sick was significantly higher in group I than in group II among both urban and rural families (p < 0.001). There was an excess expenditure of Rs 730 and Rs 141, in addition to Rs 4209 and Rs 894 on smoking products in group I families in urban and rural areas, respectively. Univariate analysis showed that the odds ratio for having any health-related expenditure for a group I family was 3.346 (95% confidence interval 2.533-4.420), which was highly significant (p < 0.0001). The differences in loss of work on account of illness and loss of man-days among members of groups I and II were not significant. However, the number of lost school days among children of group I families, loss of efficiency of its members and change of jobs due to loss of efficiency were highly significant. CONCLUSION: The direct healthcare costs as well as the indirect fiscal losses are higher in families with one or more smoker(s).

Family Health↗
PubMed1991

A survey of Papua New Guinea's health sector financing and expenditure.

As a result of increasing economic constraints in the health sector of Papua New Guinea, the Department of Health embarked upon a major financial policy review program in 1986, which incorporated several studies in key areas. This paper presents the results of one component of the review, a health sector financing and expenditure study, which was undertaken for the 1986 financial year. The study found that: 1) 88% of health sector expenditure was provided by the public sector; 2) over 95% of expenditure was used for recurrent costs and there was poor utilization of overseas aid for capital projects; 3) the balance of expenditure between primary and secondary health was appropriate; 4) there were regional inequities in expenditure; and 5) a disproportionate amount of recurrent expenditure was consumed by personnel costs. The need to increase nongovernment expenditure on health was identified and further investigation of alternative sources of financing the health sector is required.

Budgets↗
PubMed1986

Families with catastrophic health care expenditures.

This article describes the characteristics of families with catastrophic health care expenditures. Based on data from a national sample, three overlapping groups of families are considered: those incurring annual out-of-pocket expenditures that exceed, respectively, 5, 10, and 20 percent of the family's income. Such families represent a small percentage of all families, but they account for a disproportionally large share of total health care expenditures. Nevertheless, the actual amounts spent out of pocket by most of these families are relatively small. Modest sums are financially burdensome to these families because they are more likely to be low-income and to be headed by someone who is not employed. Families with catastrophic expenditures are also more likely to be headed by someone 65 or older and, consistent with that, a greater share of their total expenditures is covered by Medicare. However, all other third-party payers cover a relatively smaller share of total expenditures for these families than they do for all families, reflecting the generally worse third-party coverage of families with catastrophic health expenditures. The implications of these findings for several current issues are discussed, including catastrophic coverage proposals for Medicare and proposed programs to help the medically indigent and the uninsured.

Adolescent↗
PubMedDate not supplied

Health-care expenditures for tuberculosis in the United States.

BACKGROUND: The resurgence of tuberculosis (TB) and the increase in multidrug-resistant TB prompted this study, which estimates direct expenditures for TB treatment and public health activities in the United States. METHODS: This retrospective cost of illness study estimated 1991 direct expenditures for TB-related outpatient and inpatient diagnosis and treatment, screening, preventive therapy, contact investigations, surveillance, and outbreak investigations. Existing databases at the Centers for Disease Control and Prevention (Atlanta, Ga) and the Codman Research Group, Lebanon, NH, were supplemented by surveys of state and local TB programs and interviews of organizations that conduct large-scale screening. No estimates of indirect costs were made. RESULTS: The direct medical expenditures for TB in 1991 were estimated at $703.1 million. This cost includes $423.8 million for inpatient care, $182.3 million for outpatient care, $72.1 million for screening, $3.4 million for contact investigations, $17.9 for preventive therapy, and $3.6 million for surveillance and outbreak investigations. Sensitivity analyses yielded a range of expenditures between $515.7 million and $934.5 million. CONCLUSIONS: Treatment accounted for more than 86% of all TB-related expenditures; inpatient treatment accounted for 60% of the total. Prevention activities made up only 14% of all costs. Direct medical expenditures may be underestimated because of limitations in the database on hospital expenditures and health department cost-accounting systems and because of the lack of a national database on screening activities. Greater emphasis should be placed on outpatient treatment and prevention in high-risk populations, and improved cost-accounting systems should be developed in state and local health department TB control programs to facilitate economic evaluation and improve the allocation of health dollars.

Cost of Illness↗
PubMed1996

The effect of first-contact care with primary care clinicians on ambulatory health care expenditures.

BACKGROUND: A study was undertaken to examine the relationship between first-contact care, an essential feature of primary care, and expenditures for frequent ambulatory episodes of care in a nationally representative sample. METHODS: A nonconcurrent cohort study was conducted using data from the 1987 National Medical Expenditure Survey. Ambulatory claims data of respondents with an identified primary care source were used to develop 20,282 episodes of care for 24 preventive and acute illness conditions. The study examined the relationship of first-contact care, defined as the use of an identified primary care source for the first visit in an episode, and ambulatory episode-of-care expenditures. RESULTS: Episodes that began with visits to an individual's primary care clinician, as opposed to other sources of care, were associated with reductions in expenditures of 53% overall ($63 vs 134, P<.001), 62% for acute illnesses ($62 vs $164, P<.001), and 20 for preventive care ($64 vs $80, P<.001). For 23 of the 24 health problems studied, first-contact care was associated with reductions in expenditures. Multivariate regression analyses that controlled for sociodemographic characteristics, health status, case-mix, length of the episode, and number of visits to the emergency room did not substantively alter these results. CONCLUSIONS: First-contact care was associated with reductions in ambulatory episode-of-care expenditures of over 50% in a nationally representative sample. These findings suggest that systems of care may reduce ambulatory expenditures.

Acute Disease↗
PubMedDate not supplied

Income class and pharmaceutical expenditure in Canada: 1964-1990.

In the 1970s, nearly all Canadian provinces introduced drug programs to subsidize purchases by low-income families. This study was undertaken to determine whether these programs were successful in reducing out-of-pocket pharmaceutical expenditures for low-income families and individuals, and to compare expenditures in this group with those of high-income families. Expenditures were calculated for a low- and a high-income group from Statistics Canada surveys conducted between 1964 and 1990. In the low-income group there was a 40% decline in drug expenditure measured as a percentage of total family expenditure and this was coincident with the introduction of provincial drug programs. However, the high-income group had an even larger decrease in drug expenditure. Per capita spending as a percentage of total family expenditure in the low-income group, was seven times that of the high-income group and there was no change in this ratio after the introduction of the drug plans.

Canada↗
PubMed1989

Measured energy expenditure in pediatric intensive care patients.

Few data are available on energy requirements of mechanically ventilated, critically ill children. We measured the resting energy expenditure in 18 mechanically ventilated patients between ages 2 and 18 years, using indirect calorimetry. All patients had fractional inspired oxygen concentration less than 0.6, no spontaneous respirations, hemodynamic stability, and no fever or active infection, and were receiving 5% dextrose. All subjects were hypermetabolic, since the measured resting energy expenditure divided by the predicted basal energy expenditure from the Harris-Benedict equations was 1.48 +/- 0.09 (mean +/- SEM). The energy requirements calculated using "injury factors" and "activity factors" adapted for adults is 1.62 times basal energy expenditure. The injury factor for the pediatric multiple trauma patients should be 1.25 compared with 1.35 in adults. In these pediatric intensive care patients 33% +/- 8% of the energy is derived from carbohydrates, 53% +/- 8% from fat, and 14% +/- 2% from protein oxidation. In individual critically ill pediatric patients, energy requirements should be estimated by measuring their resting energy expenditure whenever possible and adding 5% for their activity. In the absence of the actual measurement of resting energy expenditure, the recommended energy requirement is 1.5 times basal energy expenditure. In this acute phase of injury, the daily nitrogen requirement is 250 mg per kilogram of body weight.

Adolescent↗
PubMed1984

Energy expenditure in malnourished gastrointestinal cancer patients.

Cancer cachexia, a common finding in patients with gastrointestinal (GI) malignancy, is frequently attributed to tumor-induced aberrations in host energy expenditure. To characterize the frequency and severity of aberrations in energy expenditure in GI cancer patients, and to identify the potential influence of tumor characteristics in this group, the authors measured resting energy expenditure (REE) by indirect calorimetry in 173 patients and compared REE to predicted-energy expenditure (PEE) from the Harris-Benedict formulae based on current body weight. Fifty-eight percent of patients had abnormal REE (normal REE = +/- 10% PEE); 36% (62 of 173) were hypometabolic (REE less than 90% PEE), and 22% (39 of 173) were hypermetabolic (REE greater than 110% PEE). Host and tumor factors were compared between metabolic groups to identify potential determinants of abnormal energy expenditure. Differences between groups cannot be explained by differences in patient age, sex, body size, nutritional status, tumor burden, or duration of disease. Resting energy expenditure does not correlate with percent of weight loss, serum albumin, or duration of disease. Analysis by tumor site reveals patients with pancreatic or hepatobiliary tumors to be predominantly hypometabolic; gastric cancer patients tend to be hypermetabolic, whereas patients with colorectal or esophageal neoplasms are more evenly distributed across metabolic groups, the largest portion being normometabolic (X2 = 20.7, P less than 0.02). The majority of GI cancer patients have abnormal REE which is unpredictable and not uniformly hypermetabolic. The determinants of these abnormalities do not appear to be age, sex, body size, nutritional status or tumor burden. Primary tumor site is a major determinant of energy expenditure in GI cancer patients.

Age Factors↗