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PubMed2003

The impact of public voluntary health insurance on private health expenditures in Vietnam.

As a financing mechanism with the potential to raise additional funds for health services, whilst improving access to services amongst the poor, non-profit health insurance has become increasingly attractive to health policy-makers. Using data from a household survey in Vietnam, out of pocket health expenditure are compared between members and eligible non-members of the government-implemented voluntary health insurance scheme. Expenditures are analysed for individuals who sought care during their most recent illness. Using an endogenous dummy variable model to control for bias resulting from self-selection into the scheme, we find that health insurance reduces average out-of-pocket expenditures by approximately 200%. Whilst income inelastic, health expenditures are found to be significantly influenced by an individuals level of income, irrespective of insurance status. Despite this, insurance reduces expenditures significantly more for the poor than for the rich.

Cost Sharing↗
PubMed2002

A structural equation modeling approach to examining the predictive power of determinants of individuals' health expenditures.

Understanding the determinants of health expenditures is essential for a fair and effective utilization profiling, particularly in the setting of capitation rates in risk-adjustment models. The objective of the study was to examine the relative importance of determinants in predicting future health expenditures, using structural equation modeling. Based on Andersen's behavioral system model, individual determinants along with prior utilization and measures of health status from 1994 are evaluated in a longitudinal design for theirpredictive powerfor health expenditures in 1995. A total of 4,255 policy-holders enrolled in three health plans at Trigon BlueCross/BlueShield of Virginia who responded to a mail survey were included for analysis. Person-level annual charges for health services utilization were used as the dependent variable. Five health scales were excerpted from Health Survey SF-36 to represent an individual's health status. Excluding prior utilization in 1994, health status (gamma = -0.19, p < 0.001) and having diabetes (gamma = 0.08, p < 0.001) are two statistically significant predictors of health expenditures in 1995. Including prior utilization, both health status (gamma = -0.15, p < 0.001) and prior utilization (gamma = 0.15, p < 0.001) are the most important predictors, followed by having diabetes (gamma = 0.08, p < 0.001). Health status is a powerful predictor offuture health expenditures, even when prior utilization is controlled.

Adult↗
PubMed2002

Examining out-of-pocket expenditure on health care in Nouna, Burkina Faso: implications for health policy.

OBJECTIVE: To examine household out-of-pocket expenditure on health care, particularly malaria treatment, in rural Burkina Faso. METHOD: Comprehensive analysis of out-of-pocket expenditure on health care through a descriptive analysis and a second, multivariate analysis using the Tobit model with emphasis on malaria, based on 800 urban and rural households in Nouna health district. RESULTS: Households will spend less on malaria, either in or outside the health facility, if given the choice to do so, because they feel confident to self-treat malaria. Seeking health care from a qualified health worker incurs more out-of-pocket expenditure than self-treatment and traditional healers, and if necessary, households sell off assets to offset the expenditure. More than 80% of household out-of-pocket expenditure is allocated to drugs. CONCLUSION: This has policy implications for malaria control and the Roll Back Malaria Initiative. Communities need to be educated on the risks of malaria complications and the potential risk of inappropriate diagnosis and treatment. Drug or health services pricing policy needs to create an incentive to use the health services. In the fight against malaria, building alliances between households, traditional healers and health workers is essential.

Burkina Faso↗
PubMed2001

Use and expenditure on complementary medicine in England: a population based survey.

OBJECTIVES: Many claims are made that complementary medicine use is a substantial and growing part of health-care behaviour. Estimates of practitioner visits in the USA and Australia indicate high levels of use and expenditure. No reliable population-based estimates of practitioner use are available for the UK. METHODS: In 1998, a previously piloted postal questionnaire was sent to a geographically stratified, random sample of 5010 adults in England. The questionnaire focuses on practitioner contacts, but also asked about the purchase of over-the-counter remedies. Additional information was requested on socio-demographic characteristics, perceived health, and recent NHS resource use. Information on use included reason for encounter, expenditure, insurance, and location of visit. MAIN OUTCOMES MEASURES: Population estimates (by age group and sex) of lifetime use and use in the past 12 months for acupuncture, chiropractic, homoeopathy, hypnotherapy, medical herbalism, osteopathy. Estimates for two additional therapies (reflexology and aromatherapy), and homoeopathic or herbal remedies purchased over-the-counter. Estimates of annual out-of-pocket expenditure on practitioner visits in 1998. RESULTS: A crude response rate of 60% was achieved (adjusted response rate 59%). Responders were older and more likely to be female than non-responders. Usable responses (n = 2669) were weighted using the age/sex profile of the sample frame. From these adjusted data we estimate that 10.6% (95% CI 9.4 to 11.7) of the adult population of England had visited at least one therapist providing any one of the six more established therapies in the past 12 months (13.6% for use of any of the eight named therapies, 95% CI 12.3 to 14.9). If all eight therapies, and self-care using remedies purchased over the counter are included, the estimated proportion rises to 28.3% (95% CI 26.6 to 30.0) for use in the past 12 months, and 46.6% (95% CI 44.6 to 48.5) for lifetime use. All types of use declined in older age groups, and were more commonly reported by women than men (P < 0.01 for all comparisons). An estimated 22 million visits were made to practitioners of one of the six established therapies in 1998. The NHS provided an estimated 10% of these contacts. The majority of non-NHS visits were financed through direct out-of-pocket expenditure. Annual out-of-pocket expenditure on any of the six more established therapies was estimated at pound 450 million (95% CI 357 to 543). CONCLUSION: This survey has demonstrated substantial use of practitioner-provided complementary therapies in England in 1998. The findings suggest that CAM is making a measurable contribution to first-contact primary care. However, we have shown that 90% of this provision is purchased privately. Further research into the cost-effectiveness of different CAM therapies for particular patient groups is now urgently needed to facilitate equal and appropriate access via the NHS.

Adult↗
PubMed1993

Geographic variation in expenditures for physicians' services in the United States.

BACKGROUND: The national volume-performance standard recently implemented by Medicare does not account for geographic variation in expenditures for physicians' services. To study this variation, we examined expenditures for physicians' services in all metropolitan areas in the United States. METHODS: We used Medicare claims data for 1989 to measure rates of service use for beneficiaries living in the 317 U.S. metropolitan statistical areas (MSAs). The variables investigated were rates of admission to the hospital, payments to physicians for inpatient care per admission and per beneficiary, payments to physicians for outpatient care per beneficiary, and overall payments to physicians per beneficiary. Expenditures were measured in terms of allowed charges as adjusted to reflect prevailing charges in each MSA. Rates of use were adjusted for age and sex, with the exception of the variable for payments to physicians for inpatient care per admission, which was adjusted for case mix. RESULTS: Expenditures for the delivery of physicians' services to Medicare beneficiaries varied markedly among MSAs, with those for the areas with the lowest and the highest rates differing at least twofold on each measure. The measures for specific areas varied in parallel: areas with high rates of admission tended to have high levels of payment to physicians for inpatient care per admission, and areas with high payments for inpatient services tended to have high payments for outpatient services. Expenditures were not related to the number of physicians per capita but were lower in MSAs with a high proportion of primary care practitioners. The variation persisted when the 25 largest MSAs were examined; for total payments to physicians per beneficiary, there was a twofold difference between the area with the lowest rate and that with the highest, San Francisco ($872) and Miami ($1,874). The states with the highest overall payments to physicians per beneficiary were Florida, Louisiana, and Michigan. CONCLUSIONS: The marked variation among metropolitan areas in payments to physicians underscores the lack of consensus among physicians about which services are required. Moreover, the practice style in a given community appears to be influenced not by the aggregate supply of physicians but rather by the mixture of primary care physicians and specialists.

Ambulatory Care↗
PubMed2005

Direct costs of COPD in the U.S.: an analysis of Medical Expenditure Panel Survey (MEPS) data.

Chronic obstructive pulmonary disease (COPD) is a costly cause of morbidity and mortality in the U.S. The objective of this study was to use contemporary national data-specifically, those from the 2000 Medical Expenditure Panel Survey (MEPS)-to estimate direct costs of COPD in the U.S. from an all-payer perspective. Due to constraints of MEPS data, indirect costs were excluded from our analyses, as were costs of long-term oxygen therapy and costs from nursing homes and long-term care facilities. Two methods of cost estimation were employed. First, we estimated resources used and expenditures incurred by individuals with COPD that were directly attributable to the disease (attributable cost approach). Second, we compared overall medical expenditures of patients with COPD to those of the non-COPD population; the resulting difference represented excess costs of COPD. Approximately 1.7% (n = 144) of the nearly 8,300 persons in the analysis data set aged > or = 45 years used medical resources and incurred expenditures related to treatment of COPD. Mean attributable costs per patient were estimated at dollar 2,507, with more than one-half of these costs (dollar 1,365) associated with hospitalization. Mean excess costs of COPD, after adjustment for sociodemographic factors and smoking status, were substantially higher, at dollar 4,932 per patient. Results of our study indicate that COPD-associated healthcare utilization and expenditures are considerable, and that annual per-patient costs of COPD are comparable to those of other chronic diseases of the middle-aged and elderly.

Aged↗
PubMed2001

A methodological note on combining health and social care expenditures into a single statistic for policy-making purposes.

Current national expenditure series in the health sector focus predominantly on spending for medical services. However, as the percentage of elderly individuals grows, national policy makers will increasingly require an expenditure series which includes combined expenditure for social care as well as medical expenditures. In one country, Sweden, national policy makers have begun to relate policy decisions to a 12.0% (1996) figure for combined health and social care expenditures. Calculating such a combined figure presents a number of methodological issues, such as which social care services to include and how to reflect donated care from relatives and friends. An international comparison of this new health and social care figure would enable national decision makers to judge better the efficiency and effectiveness of current policy.

Benchmarking↗
PubMed2004

Medicare and Medicaid home health and Medicaid waiver services for dually eligible older adults: risk factors for use and correlates of expenditures.

PURPOSE: The purpose of this work was to, among frail dually eligible older adults, determine risk factors for the likelihood of using Medicare home health and Medicaid home health services and to, among service users, determine correlates of Medicare home health, Medicaid home health, and Medicaid waiver service expenditures. DESIGN AND METHODS: Dually eligible individuals enrolled in Connecticut's Medicaid home- and community-based services (HCBS) waiver program for the aged (N = 5,232) were identified from a statewide database containing person-level linked data from Medicare claims, Medicaid claims, and uniform clinical assessment forms. Expenditures, based on claims data, were observed from the month following clinical assessment over the period August 1995 to December 1997. RESULTS: In multivariate models controlling for medical conditions and sociodemographic variables, similar functional disability measures were strongly associated with the probability of the use of, and expenditures for, Medicare home health and Medicaid home health services; severe cognitive impairment was strongly associated with greater Medicaid waiver service expenditures. IMPLICATIONS: Given the similarity of factors associated with Medicare and Medicaid home health service use and expenditures, greater integration of Medicare and Medicaid financing, reimbursement, and delivery strategies for home health services may be feasible and warranted for dually eligible older adults enrolled in state Medicaid HCBS waiver programs.

Aged↗
PubMed1989

The effects of an internal analgesic formulary restriction on Medicaid drug expenditures in Wisconsin.

The effects of removing propoxyphene napsylate products from the Wisconsin Medicaid drug program formulary were examined. Internal analgesic expenditures and usage data for 3-month periods before and after the removal were compared (April through June 1984 versus the same period in 1985). After adjusting for price and reimbursement changes between the two study periods, overall expenditures were slightly higher after removal of these products. Expenditures per recipient, prescription, and unit all increased, as did the number of prescriptions per recipient. Expenditures, prescriptions, and recipients increased more for propoxyphene hydrochloride products as substitutes for propoxyphene napsylate products than for products in any other category. Increases also occurred for nonsteroidal anti-inflammatory products, suggesting they may have been chosen as replacement therapy. The proportion of napsylate prescriptions converted to hydrochloride prescriptions was larger for institutional patients than for noninstitutional patients. Although program expenditures did not decrease, as intended by the formulary change, other qualitative outcomes also should be considered, such as any therapeutic advantages the replacement products may have had for the patients.

Analgesics↗
PubMed1999

Adding up provincial expenditures on health care for Manitobans: a POPULIS project. Population Health Information System.

OBJECTIVES: Using the POPULIS framework, this project estimated health care expenditures across the entire population of Manitoba for inpatient and outpatient hospital utilization, physician visits, mental health inpatient, and nursing home utilization. RESEARCH DESIGN: This estimated expenditure information was then used to compare per capita expenditures relative to premature mortality rates across the various areas of Manitoba. RESULTS: Considerable variation in health care expenditures was found, with those areas having high premature mortality rates also having higher health care expenditures.

Adolescent↗
PubMed2003

Racial and ethnic differences in public and private medical care expenditures among aged Medicare beneficiaries.

This study examines the current allocation of medical care expenditures among non-Hispanic white, non-Hispanic black, and Hispanic seniors who are Medicare beneficiaries. Analyses of both "need-based" and "demand-based" perspectives found that white, black, and Hispanic seniors in similar health had similar total annual expenditures for medical care. The groups did, however, differ substantially in the distribution of expenditures between public and private sources of payment. Notably, racial and ethnic differences in public and private expenditures all but vanished when socioeconomic variables and health insurance coverage were included in the analyses. The findings suggest that public sources of payment for medical care services, especially public supplementary coverage have helped to eliminate racial and ethnic gaps in expenditures.

Black or African American↗
PubMed2005

An episode-based framework for analyzing health care expenditures: an application of reward renewal models.

OBJECTIVE: To illustrate an episode-based framework for analyzing health care expenditures based on reward renewal models, a stochastic process used in engineering for describing processes that cycle on and off with "rewards" (or costs) occurring at the end of each cycle. DATA SOURCES/STUDY SETTING: Data used in the illustration were collected as part of an evaluation of a national initiative to improve mental health services for children and youth. Participants were enrolled in a longitudinal study at a demonstration site and in a comparison community between 1997 and 1999. The illustration involves analyses of mental health expenditures at the two sites and of the dynamics of service use behind those expenditures. DATA COLLECTION/EXTRACTION METHODS: Services data were derived from management information systems as well as patient records at inpatient facilities in the two communities. These data cover services received between 1997 and 2003. The analysis focuses on the year following study entry. PRINCIPAL FINDINGS: Between-site differences in expenditures reflect complex between-site differences in the timing of service use. In particular, children at the demonstration stayed in treatment longer but were less likely to return for treatment later. In contrast, children at the comparison site experienced substantially less continuity of care. Costs per day of treatment within an episode were comparable at the two sites. CONCLUSIONS: Reward renewal models offer a promising means for integrating research on service episodes and the dynamics of service use with that on health care expenditures.

Adolescent↗
PubMed1990

How age influences expenditure for dental services in Norway.

Several studies have shown that demand for dental services decreases with increasing age. There is a lack of research to examine how utilization (as opposed to demand) varies with age. This relationship is likely to depend on family income and number of teeth. This study had two aims: Firstly, to examine the relationship between age, family income, number of teeth, and expenditure for dental services in Norway. Secondly, to compare a model where expenditure was the dependent variable with a model where demand was the dependent variable, using the same set of explanatory variables (age, income, and number of teeth). The analysis was performed on a set of national data collected in 1987, which was representative of the non-institutionalized Norwegian population 20 yr and above. The sample size was 1216 individuals. The data were analyzed according to a path analysis design, using regression analysis (OLS). Age had no effect on expenditure after controlling for family income and number of teeth. Expenditure decreased and demand increased with increasing number of teeth. This has two implications: Firstly, expenditure will rise and demand decrease with increasing age because number of teeth decreases with age. Secondly, utilization of dental services is likely to decrease, and demand increase as oral health improves.

Adult↗
PubMed1998

Expenditures for the treatment of major depression.

OBJECTIVE: Health policy makers lack accurate information about per capita spending for the treatment of major depression, the distribution of those expenditures, and the proportion of the health care dollar consumed by depression treatment. METHOD: The authors recruited and followed a community cohort of individuals with major depression; the 298 subjects were either enrolled in fee-for-service insurance plans or self-insured. Charges for all health care services received during the year following baseline were abstracted from medical and insurance records. RESULTS: Over the course of 1 year, 48.1% of the subjects received depression treatment. The per capita total expenditure for inpatient and outpatient depression treatment averaged $631, with a median of $152, for the treated subjects. Just 4.9% of the treated subjects consumed 45.0% of the outpatient expenditures. Depression treatment consumed only 8 cents of every health care dollar spent on the patients treated for depression. CONCLUSIONS: Studies are needed to examine how the level and distribution of expenditures for depression treatment change under managed care and to determine whether and how any differences affect outcomes in the afflicted population. Managed care attempts to contain costs by limiting outpatient care may not affect total health care expenditures dramatically, since depression treatment consumes such a minuscule portion of the health care dollar spent on this population.

Adolescent↗
PubMed2001

Lessons learned from trends in psychotropic drug expenditures in a canadian province.

Although prescription drug prices are lower in Canada than in the United States, trends indicate that there has nevertheless been a steep increase in expenditures on psychotropic drugs. Between 1992 and 1998, such expenditures increased by 216 percent; 61 percent of these expenditures were on antidepressants, 33 percent on antipsychotics, and less than 7 percent on anxiolytics. Most of the increase in costs in Canada is attributable to a greater use of newer agents and the higher prices of these agents. These trends are a reminder not only that the use of newer, more expensive psychotherapeutic agents has become a widely embraced part of care but also that lower drug prices do not necessarily insulate a health care system from rising expenditures. The authors' findings prompt the questions of whether the use of these newer agents meets practice guidelines and whether there are ways to control the increases in drug expenditures while ensuring high-quality care.

Cost Control↗
PubMed2000

Expenditures for physician services under alternative models of managed care.

This study compares expenditures for physician services in a closed panel gatekeeper health maintenance organization (HMO) and an open panel point of service HMO that share the same physician network. The study uses administrative files of the two study HMOs for 1994-1995 to assess differences in spending for primary care physicians' (PCPs') services, specialists' services, and total physician services. When the copayments for PCP visits and PCP-referred specialist visits were $0, total physician expenditures were 4 percent higher in the gatekeeper HMO than in the point of service plan (p < .05). When the copayments for PCP visits and PCP-referred specialist visits were $10, total physician expenditures ranged from equal in both HMOs to 7 percent higher in the gatekeeper HMO (p < .01), depending on the copayment for self-referred visits. Expenditures for specialists' services were not higher in the point of service plan. The authors conclude that direct patient access to specialists does not necessarily result in higher physician or specialist expenditures in HMOs.

Adult↗
PubMed2005

Household expenditures and wealth among young Guatemalan adults.

In this article, we describe expenditure and wealth patterns, indicators of long-run economic well-being, for a sample of young Guatemalan adults interviewed for the Human Capital Study 2002-04, finding a number of differences across subgroups of the sample. The main difference across birth-year cohorts is that younger subjects tend to live in smaller households, with lower total annual household expenditures (and fewer durable goods), though per capita measures are similar across cohorts. This appears to be related to life-cycle fertility patterns. There is a clear positive association between parental socioeconomic status (SES) and current levels of expenditure and durable goods ownership. This association does not hold for all households, however, as there is both upward and downward "mobility" in the sample. Those living in the capital have the highest overall wealth levels, consistent with typical rural-urban patterns. Where there are expenditure differences across groups, they tend to be driven by differences in nonfood rather than food expenditures. Lastly, the study sample is relatively well off compared with their compatriots, with a poverty rate of 35% and an extreme poverty rate of only 3%, against national averages of 56% and 15%, respectively.

Adult↗
PubMedDate not supplied

Health care expenditure, laboratory services and IVD market.

What has been written until now should not be misinterpreted: without doubt there is wastage in the Italian health care expenditure which must be rationalized. Moreover, the public deficit-now over two million billion lira-will probably prevent any reinvestment in health care of resources liberated through the above-mentioned rationalization process. In the near future, the attention of the authorities should be focused on how to reduce public spending, which probably also includes spending on health care. The message which needed to be passed on here does not refuse to recognize the possibility of rationalizing health care expenditure in Italy nor does it reject the need for this course of action. Instead it tries to give the following warning: in the light of the above circumstances-or the fact that even now the authorities cannot admit to spending "much" in the absolute sense, especially with regard to technology, or the fundamental role of IVDs in health care processes, or the difficulties in which the companies of the sector have been placed-it is possible to state that any blind, or worse still, ill-equipped, intervention in this field would have the undoubted effect of damaging the health care sector, or even place many companies on their knees, without receiving the expected benefits on the balance sheet. Benefits in the form of efficiency and saving can only be obtained from an effective reorganisation of the health structures, in line with the reforms provided for by legislative decree n. 502/92 (and subsequent modifications)--which, due to aspects too numerous to mention, is still a dead letter--and by taking steps towards valuing the laboratory services. As already stated, to talk of inefficiency in general terms means talking of unproductive expenditure: this occurs when utilizing factors whose cost is "too high" and/or productivity is "too low". It is with this distinction in mind that intervention must come; assessing factors not individually but rationally integrated in the production process of which they are part. Given the values at issue, any action not specifically aimed at the elimination of process inefficiency penalizes the already "healthy" elements, causes damage to the system and does not result in any significant benefits for expenditure. To summarize further, the need is for: a definition of what and how much to guarantee that can be taken from the National Budget; the realization of models which, surpassing the current macroscopic causes of inefficiency (which reside in structural and process type diseconomies), would make a correct economic assessment of investments and expenditure viable. In this respect, clinical pathology could play a fundamental role, in that the investments in this particular sector, if well programmed, would lead to significant savings for the entire health care system. The path followed until now must be abandoned at all costs; a path which starts by underestimating the needs and continues with the utilization of resources in an irrational manner, finishing with a proposal for the following year to allocate fewer resources to technology, almost as if it were on the same level as the potatoes (with or maybe even get hungry), at least this would resolve balance sheet problems without affecting the running of the services.

Clinical Laboratory Techniques↗