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PubMed2001

Theory versus practice: a review of 'willingness-to-pay' in health and health care.

This paper is based upon an extensive review of 71 willingness-to-pay (WTP) surveys of health and health care published in English during the period 1985--1998. The aim of the paper is to outline the arguments advanced for the superiority of WTP over quality-adjusted-life-years (QALYs) as a measure of benefit of health care programmes, and to review how empirical WTP studies adhere to their implications. An important argument is that WTP enables a more comprehensive valuation of benefits than QALYs. Our main focus is therefore to provide a careful review of the scenario descriptions used in the surveys, according to which types of benefits are being valued, and how comprehensively the descriptions are presented. Furthermore, the 'cost-benefit argument', that WTP can assist in improving social efficiency, is discussed before we inquire into the extent to which the studies actually compare WTP with social costs.

Attitude to Health↗
PubMedDate not supplied

Informal payments in transitional economies: implications for health sector reform.

Since the collapse of the Soviet Union increasing evidence is emerging of informal payments by patients for health care services that are officially free. There is little information, however, on the characteristics of these payments and the effect that they have on health care reform initiatives. This paper examines these issues and concludes that the endemic and complex nature of such payments suggests that a range of policy tools are necessary to address the negative features of informal payments in those countries undergoing transition.

Cost Sharing↗
PubMed2004

Feasibility and construct validity of the parent willingness-to-pay technique for children with juvenile idiopathic arthritis.

OBJECTIVE: To assess the feasibility and construct validity of the willingness-to-pay (WTP) technique for measuring health care preferences in families of children with juvenile idiopathic arthritis (JIA). METHODS: Parents were asked to estimate the monthly US dollar amount they would be willing to pay to obtain for their child the following hypothetical drugs: ARTHRO, which guarantees complete clinical response; and NO-STOM-ACHE, a drug that eliminates gastrointestinal (GI) symptoms. A yes/no question was used with random assignment of the starting bids. Parents who agreed to pay the starting bid were then asked whether they would be willing to pay 200% and then 400% of this initial bid. Socioeconomic data and information on medications, disease activity, patient physical function, wellbeing, and health-related quality of life (HRQOL) were obtained. RESULTS: Sixty-two families of children with JIA were interviewed. GI symptoms were present in 54%, and 53% of the children had joints with active arthritis or limited range of motion. Four parents (7%) were unwilling to pay anything for any of the studied medications. The mean amount (median; mean percentage of available family income) families were willing to pay was $395 ($300; 15%) for ARTHRO and $109 ($80; 4%) for NO-STOM-ACHE. Correlation and regression analysis supported that, adjusted for the available family income, the WTP for ARTHRO was associated with disease activity, pain, and the HRQOL of the patients. After correction for the starting bids and the available family income, the WTP for NO-STOM-ACHE was associated with the patient's HRQOL, pain, and the amount of GI discomfort. CONCLUSION: The WTP technique is feasible and has construct validity for measuring health care preferences for children with JIA. Relatively large WTP estimates support a possible important negative impact of the disease on families of children with JIA.

Adolescent↗
PubMed2005

Problem and pathological gambling are associated with poorer mental and physical health in older adults.

OBJECTIVE: To evaluate the prevalence and correlates of problem and pathological gambling in older adults. METHODS: Adults (n = 343) aged 60 years and older attending senior centers, bingo sites and other community activities completed a screening form containing the South Oaks Gambling Screen and the Short Form-12 Health Survey, to evaluate physical and mental health. RESULTS: Overall, 6.4% of the respondents were classified as problem gamblers and an additional 3.8% as pathological gamblers. Problem and pathological gamblers evidenced significantly greater physical and mental health problems than non-problem gamblers. CONCLUSIONS: These data suggest that about 10 percent of active older adults experience gambling problems, which are associated with poor physical and mental health.

Aged↗
PubMed2002

The cost of behavioral and psychological symptoms of dementia (BPSD) in community dwelling Alzheimer's disease patients.

INTRODUCTION: Behavioral and psychological symptoms of dementia (BPSD) are highly prevalent in Alzheimer's disease (AD) patients. They are a source of distress for the caregivers and one of the main reasons for nursing home placement, which is the major component of the cost of Alzheimer's disease. The aim of the present study was to assess the direct and indirect cost related to the care of BPSD within a prospective study examining the overall cost of AD in Israel. METHODS: Seventy-one community dwelling AD patients were interviewed. Interviews covered information about the number of caregivers' hours invested in caring for the patient and amount of expenditure such as in-house paid help and payments for day care. Effort devoted to BPSD was defined as the number of hours spent by primary and secondary caregivers in a typical week dealing with BPSD (managing aggression, pacing, attempts to leave the house under inappropriate circumstances, or comforting a hallucinating, depressed or anxious patient). RESULTS: The annual indirect cost for management of BPSD in an AD patient was approximately 2665 dollars -over 25% of the total annual indirect cost of care ($10 520). The annual direct cost of BPSD of an AD patient was approximately 1450 dollars -over 35% of the total annual direct cost of care (3900 dollars). CONCLUSIONS: Approximately 30% (4115 dollars) of the total annual cost of AD (14420 dollars) is invested in the direct management of BPSD. Given the importance of BPSD as one of the main components of the cost of AD, future cost studies should be designed to measure the cost of specific components of BPSD and verify which are the most costly aspects of the disease. Despite the considerable methodological difficulties in disentangling the costs of the specific symptoms of AD, cost effectiveness studies of different interventions should be conducted in order to determine the optimal intervention with relation to cost.

Activities of Daily Living↗
PubMed2006

Testing the construct validity of willingness to pay valuations using objective information about risk and health benefit.

This paper describes an experiment to test the construct validity of contingent valuation, by eliciting women's valuations for the NHS cervical cancer screening programme. It is known that, owing to low levels of knowledge of cancer and screening in the general population, women both over-estimate the risk of disease and the efficacy of screening. The study is constructed as a randomised experiment, in which one group is provided with accurate information about cervical cancer screening, whilst the other is not. The first hypothesis supporting construct validity, that controls who perceive greater benefits from screening will offer higher valuations, is substantiated. Both groups are then provided with objective information on an improvement to the screening programme, and are asked to value the improvement as an increment to their original valuations. The second hypothesis supporting construct validity, that controls who perceive the benefits of the programme to be high already will offer lower incremental valuations, is also substantiated.

Adult↗
PubMed2006

It's not just what you do, it's the way that you do it: the effect of different payment card formats and survey administration on willingness to pay for health gain.

A general population sample of 314 Australian respondents were randomly allocated to complete a contingent valuation survey administered by face-to-face or telephone ('phone-mail-phone') interview. Although the telephone interview was quicker to complete, no significant difference was found in values obtained through either method. Within each sub-sample, respondents were also randomly allocated to the three different versions of the payment card (PC) questionnaire format: values listed from high-to-low, values listed from low-to-high and values randomly shuffled. The high-to-low version resulted in significantly higher values than the other versions. Further analyses indicate that the randomly shuffled PC version may produce the most 'valid' values.

Adult↗
PubMed2006

How common is the 'prominence effect'? Additional evidence to Whynes et al.

In a recent issue of Health Economics Letters, Whynes et al. report an observation not previously reported in the willingness-to-pay (WTP) literature; that when people are asked to provide an estimate using payment scales they tend to disproportionately select prominent values (that is, 1, 2, 5, 10, 20, 50, 100, etc.). However, it remains an open question just how common this prominence effect actually is. Here we present data from several additional contingent valuation (CV) studies, which suggest that although prominence occurs, it does not reach statistical significance, as found by Whynes et al. A number of reasons are outlined to explain this.

Choice Behavior↗
PubMed2006

Willingness to pay for reductions in health risks when probabilities are distorted.

We study the willingness to pay for reductions in health risks when people do not evaluate probabilities linearly, as is commonly assumed in elicitations of willingness to pay, but weight probabilities, as is commonly observed in empirical studies of decision under risk. We show that for the levels of baseline risk typically considered, probability weighting strongly affects willingness to pay estimates and may lead to unstable monetary valuations of health.

Europe↗
PubMed2006

Economic evaluation of health effects with preference imprecision.

The estimation of economic benefits of health effects through direct methods, such as contingent valuation, presents the problem of preference imprecision. This paper deals with this problem by proposing an elicitation method that allows the subject to state an interval for willingness to pay, without inducing any specific amount as a response. The paper also analyzes the effects of the context where changes in health occur on the associated imprecision level and the estimates, by comparing a situation without context with another in which effects are due to atmospheric pollution. The econometric modelling develops a Bayesian estimation method for censored intervals, which models the existing uncertainty between the lower and upper limits derived from the elicitation process. Results prove that data dispersion is significantly higher for the non-contextual scenario, and increases for the most severe symptoms.

Bayes Theorem↗
PubMed2006

Does non-profit health insurance reduce financial burden? Evidence from the Vietnam Living Standards Survey Panel.

Many low-income countries are implementing non-profit medical insurance to increase access to health services, especially among low-income households, and to raise additional revenue for financing public health services. This paper estimates the effect of insurance on out-of-pocket health expenditures using the Vietnam Living Standards Surveys for 1993 and 1998 and appropriate models for panel data. Our findings suggest that health insurance reduces health expenditure when unobserved heterogeneity is accounted for. Failure to capture unobserved heterogeneity produces contrary results that are consistent with previous cross-sectional studies in the literature. Health insurance is found to reduce out-of-pocket expenditure between 16 and 18% and the reduction in expenditure is more pronounced for individuals with lower incomes. At mean income, the effect of health insurance is to reduce health expenditures between 28 and 35%.

Cost of Illness↗
PubMed2006

Valuing avoided morbidity using meta-regression analysis: what can health status measures and QALYs tell us about WTP?

Many economists argue that willingness-to-pay (WTP) measures are most appropriate for assessing the welfare effects of health changes. Nevertheless, the health evaluation literature is still dominated by studies estimating nonmonetary health status measures (HSMs), which are often used to assess changes in quality-adjusted life years (QALYs). Using meta-regression analysis, this paper combines results from both WTP and HSM studies applied to acute morbidity, and it tests whether a systematic relationship exists between HSM and WTP estimates. We analyze over 230 WTP estimates from 17 different studies and find evidence that QALY-based estimates of illness severity--as measured by the Quality of Well-Being (QWB) Scale--are significant factors in explaining variation in WTP, as are changes in the duration of illness and the average income and age of the study populations. In addition, we test and reject the assumption of a constant WTP per QALY gain. We also demonstrate how the estimated meta-regression equations can serve as benefit transfer functions for policy analysis. By specifying the change in duration and severity of the acute illness and the characteristics of the affected population, we apply the regression functions to predict average WTP per case avoided.

Decision Making↗
PubMed2006

Empirical implications of response acquiescence in discrete-choice contingent valuation.

The use of discrete-choice contingent valuation (CV) to elicit individuals' preference, expressed as maximum willingness-to-pay (WTP), although primarily developed in environmental economics, has been popular in the economic evaluation of health and healthcare. However, a concern with this method is the potential for 'over-estimating' WTP values due to the presence of response acquiescence, or 'yea-saying' bias. Based on a CV survey conducted to estimate physicians' valuation of clinic computerization, the extent of such bias was estimated from a within-sample open-ended valuation question following the respondents' discrete choice response. Analysis of this data suggests that not only was response acquiescence an issue, but also that the parametric estimation of mean and median WTP, the most common approach to estimating WTP from discrete-choice data, would potentially magnify such bias (to various degrees depending on the distributional assumptions applied). The possible extent of CV design versus analysis in discrete-choice methods therefore warrants further exploration.

Choice Behavior↗
PubMed2006

Ordering effect and price sensitivity in discrete choice experiments: need we worry?

The objective of this paper is to analyse the impact that attribute ordering has on the relative importance of the price attribute. A discrete choice experiment was performed in order to elicit psoriasis patients' preferences for treatment. We tested for ordering effect with respect to the price attribute, and disclosed noticeable higher price sensitivity when the price attribute was placed at the end of the program description. Our results indicate that preferences are context dependent and that heuristics may be used in the choice process. Our result does not, however, suggest that ordering effect is a symptom of lexicographic ordering.

Choice Behavior↗
PubMed2007

Progressive segmented health insurance: Colombian health reform and access to health services.

Equal access for poor populations to health services is a comprehensive objective for any health reform. The Colombian health reform addressed this issue through a segmented progressive social health insurance approach. The strategy was to assure universal coverage expanding the population covered through payroll linked insurance, and implementing a subsidized insurance program for the poorest populations, those not affiliated through formal employment. A prospective study was performed to follow-up health service utilization and out-of-pocket expenses using a cohort design. It was representative of four Colombian cities (Cendex Health Services Use and Expenditure Study, 2001). A four part econometric model was applied. The model related medical service utilization and medication with different socioeconomic, geographic, and risk associated variables. Results showed that subsidized health insurance improves health service utilization and reduces the financial burden for the poorest, as compared to those non-insured. Other social health insurance schemes preserved high utilization with variable out-of-pocket expenditures. Family and age conditions have significant effect on medical service utilization. Geographic variables play a significant role in hospital inpatient service utilization. Both, geographic and income variables also have significant impact on out-of-pocket expenses. Projected utilization rates and a simulation favor a dual policy for two-stage income segmented insurance to progress towards the universal insurance goal.

Colombia↗
PubMed2007

The relationship between reliability and size of willingness-to-pay values: a qualitative insight.

In a previous paper, the reliability of willingness-to-pay (WTP) values was found to be an increasing function of the size of WTP expressed. Here, the results of a qualitative exercise conducted alongside this quantitative study are presented. The results of this exercise suggest that higher WTP values may require more thought from the respondent which, in turn, gives them greater stability. At low levels of WTP, values appear to be taken from a 'discretionary account', where expenditure is more volatile. Caveats to this result, and suggestions for future research, are considered in the discussion.

Adult↗
PubMed2007

Health care quality, economic inequality, and precautionary saving.

We argue that health care quality has an important impact on economic inequality and on saving behavior. We exploit district-wide variability in health care quality provided by the Italian universal public health system to identify the effect of quality on income inequality, health inequality and precautionary saving. We find that in lower quality districts there is greater income and health dispersion and higher precautionary saving. The analysis carries important insights for the ongoing debate about the validity of the life-cycle model and interesting policy implications for the design of health care systems.

Female↗
PubMed2007

Health systems in East Asia: what can developing countries learn from Japan and the Asian Tigers?

The health systems of Japan and the Asian Tigers (Hong Kong, Korea, Singapore and Taiwan), and the recent reforms to them, provide many potentially valuable lessons to East Asia's developing countries. All five systems have managed to keep a check on health spending despite their different approaches to financing and delivery. These differences are reflected in the progressivity of health finance, but the precise degree of progressivity of individual sources and the extent to which households are vulnerable to catastrophic health payments depend on the design features of the system - the height of any ceilings on social insurance contributions, the fraction of health spending covered by the benefit package, the extent to which the poor face reduced copayments, whether there are caps on copayments, and so on. On the delivery side, too, Japan and the Tigers offer some interesting lessons. Singapore's experience with corporatizing public hospitals - rapid cost and price inflation, a race for the best technology, and so on - illustrates the difficulties of corporatization. Korea's experience with a narrow benefit package illustrates the danger of providers shifting demand from insured services with regulated prices to uninsured services with unregulated prices. Japan, in its approach to rate setting for insured services, has managed to combine careful cost control with fine-tuning of profit margins on different types of care. Experiences with DRGs in Korea and Taiwan point to cost-savings but also to possible knock-on effects on service volume and total health spending. Korea and Taiwan both offer important lessons for the separation of prescribing and dispensing, including the risks of compensation costs outweighing the cost savings caused by more 'rational' prescribing, and cost-savings never being realized because of other concessions to providers, such as allowing them to have onsite pharmacists.

Delivery of Health Care↗