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The costs of obesity among full-time employees.

PURPOSE: To quantify annual costs attributable to obesity, including both increased medical expenditures and absenteeism, separately for overweight and three categories of obesity (i.e., obesity grades I, II, and III) among men and women with full-time employment. DESIGN: Standard econometric methods were used to separately estimate overweight and obesity-attributable medical expenditures and absenteeism. SETTING: The civilian noninstitutionalized population of the United States. SAMPLE: Two nationally representative and publicly available datasets (with response rates of at least 60%) were restricted to participants 18 to 64 years old and employed full-time for the entire year. The final datasets used to estimate obesity-attributable medical expenditures and absenteeism included 20,329 and 25,427 adults, respectively. MEASURES. Annual medical expenditures and missed work days due to illness or injury. ANALYSIS RESULTS: Overweight and obesity-attributable costs range from dollar 175 per year for overweight male employees to dollar 2485 per year for grade-II obese female employees. The costs of obesity (excluding overweight) at a firm with 1000 employees are estimated to be dollar 285,000 per year CONCLUSIONS: Obesity results in significant increases in medical expenditures and absenteeism among full-time employees. Approximately 30% of the total costs result from increased absenteeism, and although those with grade-III obesity represent only 3% of the employed population, they account for 21% of the costs due to obesity. These estimates do not consider other potential costs associated with obesity, including disability and presenteeism.

Adult↗

Gender bias among children in India in their diet and immunisation against disease.

This paper conducts an econometric analysis of data for a sample of over 4000 children in India, between the ages of 1 and 2 years, with a view to studying two aspects of the neglect of children: their likelihood of being immunised against disease and their likelihood of receiving a nutritious diet. The starting hypothesis, consistent with an universal interest in gender issues, was that girls were more likely to be neglected than boys. The analysis confirmed this hypothesis. In respect of vaccinations, the likelihood of girls being fully vaccinated, after controlling for other variables, was 5 percentage points lower than that for boys. In respect of receiving a nutritious diet, the treatment of girls depended very much on whether or not their mothers were literate: there was no gender discrimination between children of literate mothers; on the other hand, when the mother was illiterate, girls were 5 percentage points less likely to be well-fed relative to their brothers and the presence of a literate father did little to dent this gender gap. But the analysis also pointed to a broader conclusion which was that all children in India suffered from sharper, but less publicised forms of disadvantage than that engendered solely by gender. These were the consequences which stemmed from children being born to illiterate mothers and being brought up in the more impoverished parts of India.

Child Nutritional Physiological Phenomena↗

Lifetime earnings patterns, the distribution of future Social Security benefits, and the impact of pension reform.

In order to assess the effect of Social Security reform on current and future workers, it is essential to accurately characterize the initial situations of representative workers affected by reform. For the purpose of analyzing typical reforms, the most important characteristic of a worker is the level and pattern of his or her preretirement earnings. Under the current system, pensions are determined largely by the level of the workers' earnings averaged over their work life. However, several reform proposals would create individual retirement accounts for which the pension would depend on the investment accumulation within the account. Thus, the pension would also depend on the timing of the contributions into the account and hence on the exact shape of the worker's lifetime earnings profile. Most analysis of the distributional impact of reform has focused, however, on calculating benefit changes among a handful of hypothetical workers whose relative earnings are constant over their work life. The earnings levels are not necessarily chosen to represent the situations of workers who have typical or truly representative earnings patterns. Consequently, the results of such analysis can be misleading, especially if reform involves introducing a fundamentally new kind of pension formula. This article presents two broad approaches to creating representative earnings profiles for policy evaluation. First, we use standard econometric methods to predict future earnings for a representative sample of workers drawn from the Survey of Income and Program Participation (SIPP). Our statistical estimates are based on a simple representation of typical career earnings paths and a fixed-effect statistical specification. Because our estimation file contains information on each worker's annual earnings from 1951 through 1996 as reported in the Social Security Administration's earnings files, we have a record (though an incomplete one) of the actual earnings that will be used to determine future benefit payments. Our estimates of the earnings function permit us to make highly differentiated predictions of future earnings for each member of our sample. By combining the historical information on individual earnings with our prediction of future earnings up through the normal retirement age, our first approach produces tens of thousands of predicted career earnings paths that can be used in microsimulation policy analysis. Our second approach to creating lifetime earnings profiles is similar in some ways to the traditional method. For example, it is based on the creation of only a handful of "stylized" career earnings patterns. An important difference with the traditional method, however, is that we define the career earnings patterns so that they are truly representative of patterns observed in the workforce. We use simple mathematical formulas to characterize each stylized earnings pattern, and we then produce estimates of the average path of annual earnings for workers whose career earning path falls within each of the stylized patterns we have defined. Finally, we calculate the percentage of workers in successive birth-year cohorts who have earnings profiles that match each of the stylized earnings patterns. Although this method may seem simple, it allows the analyst to create stylized earnings patterns that are widely varied but still representative of earnings patterns observed among sizable groups of U.S. workers. The effects of policy reforms can then be calculated for workers with each of the stylized earnings patterns. Our analysis of U.S. lifetime earnings patterns and of the impact of selected policy reforms produces a number of findings about past trends in earnings, typical earnings patterns in the population, and the potential impact of reform. The analysis focuses on men and women born between 1931 and 1960. Along with earlier analysts, we find that men earn substantially higher lifetime wages than women and typically attain their peak career earnings at a somewhat earlier age. However, the difference in career earnings patterns between men and women has narrowed dramatically over time. Workers with greater educational attainment earn substantially higher wages than those with less education, and they attain their peak career earnings later in life. For example, among men with the least education, peak earnings are often attained around or even before age 40, whereas many men with substantial postsecondary schooling do not reach their peak career earnings until after 50. Our tabulations of the lifetime earnings profiles of the oldest cohorts (born around 1930) and projections of the earnings of the youngest profiles (born around 1960) imply that the inequality of lifetime earnings has increased noticeably over time. Women in the top one-fifth of female earners and men in the top one-fifth of male earners are predicted to receive a growing multiple of the economy-wide average wage during their career. Women born between 1931 and 1935 who were in the top fifth of female earners had lifetime average earnings that were approximately equal to the average economy-wide wage. In contrast, women born after 1951 who were in the top fifth of earners are predicted to earn almost 50 percent more, that is, roughly 150 percent of the economy-wide average wage. Women with a lower rank in the female earnings distribution will also see gains in their lifetime average earnings, but their gains are predicted to be proportionately much smaller than those of women with a high rank in the distribution. Men with high earnings are also predicted to enjoy substantial gains in their relative lifetime earnings, while men with a lower rank in the earnings distribution will probably see a significant erosion in their typical wages relative to the economy-wide average wage. That is mainly the result of a sharp decline in the relative earnings of low-wage men born after 1950. In creating stylized earnings profiles that are representative of those of significant minorities of U.S. workers, we emphasized three critical elements of the earnings path: the average level of earnings over a worker's career, the upward or downward trend in earnings from the worker's 30s through his or her early 60s, and the "sagging" or "hump-shaped" profile of earnings over the worker's career. That classification scheme yields 27 characteristic patterns of lifetime earnings. Surprisingly, the differnce between men and women within each of those categories is quite modest. The main difference between men and women is in the proportions of workers who fall in each category. Only 14 percent of men born between 1931 and 1940 fall in earnings categories with the lowest one-third of lifetime earnings, whereas 53 percent of women born in those years have low-average-earnings profiles. On the other hand, women born in those years are more likely to have a rising trend in lifetime earnings, while men are more likely to have a declining trend. We find that the distribution of lifetime earnings contains relatively more workers with below-average earnings and relatively fewer with very high earnings than assumed in the Social Security Administration's traditional policy analysis. For example, the "low earner" traditionally assumed by the Office of the Chief Actuary is assigned a level of average lifetime earnings that we find to be higher than the average earnings of persons in the bottom one-third of the lifetime earnings distribution. The stylized earnings profiles developed here can be used for policy evaluation, and the results can be compared with those from the more traditional analysis. That comparison produces several notable findings. Because earnings profiles that are actually representative of the population tend to have lower average earnings than assumed in the traditional analysis, workers typically accumulate somewhat less Social Security wealth than implied in the traditional analysis. On the other hand, because the basic benefit formula is tilted in favor of lower-income workers, the internal rate of return on Social Security contributions is somewhat higher than detected in the traditional analysis. Moreover, the primary insurance amount measured as a percentage of the worker's average indexed earnings tends to be higher than implied by the traditional analysis. Finally, the stylized earnings patterns can be used to compare benefit levels enjoyed by workers under the traditional Social Security formula and under an alternative plan based on individual investment accounts. That comparison shows, as expected, that the traditional formula favors low-wage workers and one-earner couples, while an investment account favors single, high-wage workers. Comparing two workers with the same lifetime average earnings, the traditional formula favors workers with rising earnings profiles (that is, with lifetime earnings heavily concentrated at the end of their career), while investment account pensions favor workers with declining earnings profiles (that is, with earnings concentrated early in their career).

Adult↗

A cost-effectiveness analysis of newborn hearing screening strategies.

CONTEXT: Congenital hearing loss affects between 1 and 3 out of every 1,000 children. Screening of all neonates has been made possible by the development of portable automated devices. Universal screening is a 2-stage screening process using automated transient-evoked otoacoustic emissions, followed when indicated by automated auditory brain response testing. Targeted screening reserves the 2-stage screening process for those infants at risk for congenital hearing loss. OBJECTIVE: To compare the expected costs and benefits of targeted screening with universal screening for the detection of significant bilateral congenital hearing loss. DESIGN: Cost-effectiveness analysis from the health care system perspective. including costs directly related to screening and initial follow-up evaluation. MAIN OUTCOME MEASURES: Number of cases identified, number of false positives, and cost per case. RESULTS: For every 100,000 newborns screened, universal screening detects 86 of 110 cases of congenital hearing loss, at a cost of $11,650 per case identified. Targeted screening identifies 51 of 110 cases, at $3,120 per case identified. Universal screening produces 320 false-positive results, 304 more than targeted screening. Switching to universal screening from targeted screening would cost an additional $23, 930 for each extra case detected. CONCLUSIONS: Universal screening detects more cases of congenital hearing loss, at the expense of both greater cost and more false-positive screening results. Little is known about the negative impact of false-positive screening and about the benefits of early intervention for congenital hearing loss. Those who advocate adoption of universal screening should be aware not only of the direct costs of universal screening, but of the indirect costs and strategies to increase the benefits of screening.

Cost-Benefit Analysis↗

Inpatient childhood asthma treatment: relationship of hospital characteristics to length of stay and cost: analyses of New York State discharge data, 1995.

BACKGROUND: There is increasing pressure to optimize asthma treatment efficiency. It is possible that hospital characteristics influence such efficiency. OBJECTIVE: To examine the association of selected hospital characteristics with cost and length of stay (LOS) among pediatric patients with asthma after adjusting for patient characteristics. DESIGN: Secondary analysis of 1995 hospital discharge data in the state of New York. SUBJECTS: Nineteen thousand six hundred eighty-eight patients aged 1 to 17 years with asthma discharged from 206 acute care hospitals in New York in 1995. MAIN OUTCOME MEASURES: Length of stay and hospital cost. ANALYSIS: Hospitals were described with respect to teaching status and ownership. The differences in the distribution of children within each hospital type were assessed by chi(2) tests. In multivariate analyses, hierarchical models were constructed to analyze cost and LOS, adjusting for both hospital- and patient-level covariance. RESULTS: Asthma severity did not meaningfully differ by hospital ownership and teaching status. Public and teaching hospitals had more minority and Medicaid patients. After adjusting for patient- and hospital-level covariates and for the hierarchical nature of the data, there were no statistically significant differences between public and private hospitals in mean cost or LOS. Adjusted mean LOS in teaching hospitals was not significantly shorter, while costs were significantly but not meaningfully greater ($2459 vs $2271; P<.001). CONCLUSION: Hospitals providing medical education to pediatricians and safety net care do so without increasing LOS or cost of care for pediatric asthma.

Adolescent↗

Impact of a new universal purchase vaccine program in North Carolina.

OBJECTIVE: To explore the effects of state universal purchase (UP) of vaccines for all children, regardless of income or insurance status, on North Carolina physicians and families. DESIGN: Cross-sectional survey. PARTICIPANTS: Pediatricians and family physicians (N = 2163) were surveyed in 1995 to compare immunization charges in North Carolina (new UP) with those of Massachusetts (UP) and Texas (free market). MAIN OUTCOME MEASURES: Patient charges for immunizations and well-child visits and physician perceptions of the effects of state immunization programs. Models were devised to simulate the net effect of the North Carolina UP program on immunization revenue for physicians and on families' out-of-pocket costs for well-child care. RESULTS: Physician participation rates in the 2 UP programs were very high. North Carolina physicians reported substantial decreases in immunization charges and reduced referrals to public clinics, but thought that UP increased their administrative burden. Sixty percent of North Carolina physicians increased charges for well-child visits, nearly twice that in the 2 control states. Families who previously had received immunizations from public clinics but chose to remain in the private-sector "medical home" for immunizations after implementation of UP had increased out-of-pocket expenses that varied by their insurance status. CONCLUSIONS: The North Carolina UP program is effective in decreasing patient immunization charges and reducing referrals to public clinics. However, UP does not eliminate cost as a barrier to immunization, nor does it enable all children to remain in their medical homes. Underinsured children still may face considerable financial barriers to immunization in a UP system.

Cross-Sectional Studies↗

Projected cost-effectiveness of pneumococcal conjugate vaccination of healthy infants and young children.

CONTEXT: Pneumococcal conjugate vaccine for infants has recently been found effective against meningitis, bacteremia, pneumonia, and otitis media. OBJECTIVE: To evaluate the projected health and economic impact of pneumococcal conjugate vaccination of healthy US infants and young children. DESIGN: Cost-effectiveness analysis based on data from the Northern California Kaiser Permanente randomized trial and other published and unpublished sources. SETTING AND PATIENTS: A hypothetical US birth cohort of 3.8 million infants. INTERVENTIONS: Hypothetical comparisons of routine vaccination of healthy infants, requiring 4 doses of pneumococcal conjugate vaccine (at 2, 4, 6, and 12-15 months), and catch-up vaccination of children aged 2 to 4.9 years requiring 1 dose, with children receiving no intervention. MAIN OUTCOME MEASURES: Cost per life-year saved and cost per episode of meningitis, bacteremia, pneumonia, and otitis media prevented. RESULTS: Vaccination of healthy infants would prevent more than 12000 cases of meningitis and bacteremia, 53000 cases of pneumonia, 1 million episodes of otitis media, and 116 deaths due to pneumococcal infection. Before accounting for vaccine costs, the vaccination program would save $342 million in medical and $415 million in work-loss and other costs from averted pneumococcal disease. Vaccination of healthy infants would result in net savings for society if the vaccine cost less than $46 per dose, and net savings for the health care payer if the vaccine cost less than $18 per dose. At the manufacturer's list price of $58 per dose, infant vaccination would cost society $80000 per life-year saved or $160 per otitis media episode prevented (other estimated costs would be $3200 per pneumonia case prevented, $15000 for bacteremia, and $280000 for meningitis). The cost-effectiveness of an additional program to administer 1 dose of vaccine to children aged 2 to 4.9 years would vary depending on the children's ages, relative risks of pneumococcal disease, and vaccine cost. CONCLUSIONS: Pneumococcal conjugate vaccination of healthy US infants has the potential to be cost-effective. To achieve cost savings, its cost would need to be lower than the manufacturer's list price. In addition to tangible costs, the vaccine should be appraised based on the less tangible value of preventing mortality and morbidity from pneumococcal disease.

Bacterial Vaccines↗

Development of the Rural-Urban Demand Indicator (RUDI).

In this article we describe development of RUDI (Rural-Urban Demand Indicator), a multivariate interval level measure of demand for health services. RUDI ranks counties by population and purchasing power and was developed for use in a wide variety of health-related research and for policy analyses. RUDI is based on microeconomic theory and Grossman's (1972) extension of the theory, that the family produces health and that the family's demand for health services is derived from the demand for health. Two factors define RUDI: DEMOS (demographics) and EWB (economic well-being). These two factors accounted for 66.2% of the variance observed in 1990 census data. A variety of other analyses offer evidence of known- groups, convergent, factorial, and predictive validity.

Analysis of Variance↗

Willingness to pay and cost of illness for changes in health capital depreciation.

The paper investigates the relationship between the willingness to pay and the cost of illness approach with respect to the evaluation of economic burden due to adverse health effects. The basic intertemporal framework is provided by Grossman's pure investment model, while effects on individual morbidity are taken to be generated by marginal changes in the rate of health capital depreciation. More specifically, both the simple example of purely temporary changes and the more general case of persistent variations in health capital depreciation are discussed. The analysis generates two principal findings. First, for a class of identical individuals cost as measured by the cost of illness approach is demonstrated to provide a lower bound on the true welfare cost to the individual, i.e. cost as given by the willingness to pay approach. Moreover, the cost of illness is increasing in the size of the welfare loss. Second, if one takes into account the possible heterogeneity of individuals, a clear relationship between the cost values supplied by the two approaches no longer exists. As an example, the impact of variations in either financial wealth or health capital endowment is discussed. Thus, diversity in individual type turns out to blur the link between cost of illness and the true economic cost.

Attitude to Health↗

An economic approach to clinical trial design and research priority-setting.

Whilst significant advances have been made in persuading clinical researchers of the value of conducting economic evaluation alongside clinical trials, a number of problems remain. The most fundamental is the fact that economic principles are almost entirely ignored in the traditional approach to trial design. For example, in the selection of an optimal sample size no consideration is given to the marginal costs or benefits of sample information. In the traditional approach this can lead to either unbounded or arbitrary sample sizes. This paper presents a decision-analytic approach to trial design which takes explicit account of the costs of sampling, the benefits of sample information and the decision rules of cost-effectiveness analysis. It also provides a consistent framework for setting priorities in research funding and establishes a set of screens (or hurdles) to evaluate the potential cost-effectiveness of research proposals. The framework permits research priority setting based explicitly on the budget constraint faced by clinical practitioners and on the information available prior to prospective research. It demonstrates the link between the value of clinical research and the budgetary restrictions on service provision, and it provides practical tools to establish the optimal allocation of resources between areas of clinical research or between service provision and research.

Bayes Theorem↗

Valuation of health changes with the contingent valuation method: a test of scope and question order effects.

In recent years, there has been a growing interest in the contingent valuation method for measurement of monetary values of various commodities. However, the validity and reliability of the method need to be examined thoroughly. This paper reports results of a test of scope and question order effects in a contingent valuation experiment in the health care field. Using three binary valuation questions, data were collected on willingness to pay for superior treatment of reflux oesophagitis. To test for scope effects, different probabilities of successful short- and long-term treatments were evaluated using a split sample approach. The presence of question order effects was tested by assigning respondents to different question orders. The contingent valuation method proved sensitive to changes in scope in that the willingness to pay increased with the probability of being free from symptoms and with a reduced risk of having a relapse once recovered. Also, regression analysis indicate that people who suffer from severe reflux oesophagitis are more willing to pay for more effective treatment. No question order effects were detected in the data.

Aged↗

Using willingness to pay to assess the benefits of assisted reproductive techniques.

Current economic evaluations of Assisted Reproductive Techniques (ARTs) are criticized for assuming that the only factor important to users is whether they leave the service with a child. Such an approach ignores, first, outcomes beyond some narrow medical definition of success, second, the majority of users who leave the service childless and, third, the actual process of treatment. The aim of this study was to establish the importance of factors beyond some medical definition of success in the provision of ARTs, using the economic instrument of willingness to pay (WTP). The results suggest that there is some value in going through the service, even if the couple leaves it childless. It is concluded that the WTP technique is potentially useful in evaluating ARTs but further studies need to be undertaken to assess its reliability and validity.

Adult↗

Uncompensated hospital care: charitable mission or profitable business decision?

Provision of hospital uncompensated care is generally assumed to be adversely affected as increased healthcare competition decreases demand for compensated hospital services. Economic theory, however, suggests the question is more complex. Non-profit hospitals are assumed in this paper to maximize utility as a function of uncompensated care, subject to the constraint that revenues cover costs. For-profit hospitals, in contrast, are assumed to maximize profit while recognizing that failure to meet community expectations regarding provision of uncompensated care could negatively impact profits. Therefore, for-profit hospital supply of uncompensated care focuses on balancing the hospital's marginal costs and marginal benefits. These models predict that non-profit hospitals will respond to increased competition by reducing the supply of uncompensated care. In contrast, for-profit hospitals will increase the supply of uncompensated care when market demand decreases since the concurrent decrease in compensated care reduces the marginal cost of producing uncompensated care. The models also predict that for-profit hospitals will respond to changes in community expectations regarding the provision of uncompensated care.

California↗

Haggling for a patent: what a government would have to pay for prescription drug patents.

In previous papers (Guell, R. and Fischbaum, M. The Milbank Quarterly 1995; 73: 2 and Applied Economics letters in press), we established that the allocative inefficiency in the prescription drug industry is so pervasive that some remedy is warranted. In the first paper, we estimated a lower bound on this inefficiency at approximately $3 billion, with an upper bound of approximately $30 billion; all on total industry sales of approximately $50 billion. In the second paper, on a narrower set of drugs for which sales were $8 billion, we more precisely estimated this dead weight loss to be $5 billion. From this we showed that a system could exist whereby a government would purchase a drug patent from a willing seller, freely distribute it and reap significant efficiency benefits. In those papers we considered the possibility that the innovating firm would not want to relinquish the patent, but we assumed that they would be indifferent between being paid the expected net present value of future monopoly profits and reaping those uncertain profits over time. While that may be the case, a more likely scenario would be that a negotiation would take place. In the current paper I show the bargaining range that would exist under different risk preference assumptions and show that this range widens as each side becomes more risk averse and narrows if the government threatens to use its power of eminent domain. Lastly, I acknowledge the risk of firms "capturing' the government agents doing the negotiation. To conclude, I present the circumstances under which the proposed agency would likely improve societal welfare and contrast that with the circumstances where the presently inefficient system would be made more so by government intervention.

Costs and Cost Analysis↗

Saving future lives. A comparison of three discounting models.

This paper compares three models of intertemporal choice concerning saving future lives: the constant discounting model, the proportional discounting model and the hyperbolic discounting model. The three models were investigated using data collected from the general public. Since these data have a multilevel structure, ordinary least-squares (OLS) estimates were supplemented by multilevel analysis. There is evidence in favour of the proportional (and to a lesser extent) the hyperbolic model over the constant discounting model. There is clear evidence for this data set that multilevel analysis is more appropriate than OLS.

Adult↗

Health care policy evaluation using longitudinal insurance claims data: an application of the panel Tobit estimator.

The British Columbia Ministry of Health provides enhanced prescription drug insurance coverage to residents aged 65 and older. This exogenous change in the effective price of prescription drugs is used to investigate aspects of the drug use by seniors. Three sets of issues are of interest. First, what is the effect of enhanced insurance coverage on drug use and programme costs once drugs are provided free of charge? Second, is this effect permanent, or transitory? Third, are any increases in use observed concentrated among those with lower incomes? Longitudinal administrative claims payment data on 18,000 seniors over the period 1985-92 are used. All individuals in the sample turned 65 at some point and therefore became eligible for subsidized prescription drugs. Health status information is not collected; instead, health status is treated as an individual-specific fixed endowment, subject to a common rate of decay. Estimation is complicated by censoring of real drug expenditures for those under 65, rendering 'first differencing' methods invalid. A semi-parametric fixed effects Tobit estimator is used instead. For most individuals, the extension of insurance does not permanently increase drug use. Males with lower income were the exception. Little evidence of transitory effects to insurance coverage was found. Finally, the extension of insurance has made only a minor contribution to growth in seniors' drug use, relative to secular growth in drug use over time.

Age Factors↗

Down and out: estimating the relationship between mental health and unemployment.

We utilized a unique dataset of Montreal residents to estimate the relationship between employment and mental health, controlling for endogeneity. We applied a maximum likelihood, simultaneous equation generalized probit model to estimate jointly the determinants of an individual's latent index of employability and their mental health as measured by the Psychiatric Symptom Index (PSI). The likelihood function was adjusted to account for the fact that individuals were sampled based on their employment status, and also for the fact that repeated observations of individuals in different periods were used in the analysis. We found tangible beneficial effects of mental health on employability. In addition, employment appears to improve mental health. The ML estimates of the endogenous relationship between employment and mental health indicate that OLS estimates are biased upwards, but the effects of unemployment on deteriorating mental health are not spurious.

Adult↗