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PubMed1993

The demand for health: an empirical reformulation of the Grossman model.

Previous tests of Grossman's model of the demand for health have been based on Grossman's own empirical formulation. This paper argues that this formulation fails to capture the dynamic character of the model. It proposes an alternative formulation, which appears to be more consistent with Grossman's theoretical model and which may also explain the apparent rejections of the model by the data in the author's earlier empirical work. The paper also presents some empirical results obtained using the new formulation, which are, on the whole, consistent with the predictions of Grossman's theoretical model.

Capital Financing↗
PubMedDate not supplied

US health services employment: a time series analysis.

The growth of health services employment in the United States is modelled using ARIMA analysis, and related to the growth in total U.S. employment. It is argued that specific features of the medical care sector (licensed professional manpower, non-profit firms, third-party financing) create institutional rigidities which delay adjustment to macroeconomic conditions and other shocks. Tests of Granger causality and the pattern of coefficients in the cross-correlation function show that health services employment does lag other sectors of the economy by an average of 2 to 4 years. A Box-Jenkins transfer-noise function model between total and health employment is constructed and evaluated, and the impact dynamics of adjustment to Medicare and Medicaid are estimated.

Employment↗
PubMedDate not supplied

Shared 'features' in prices: income and price elasticities for health care expenditures.

The evidence found in most studies suggests a strong positive relationship between health care expenditure and gross domestic product. However, this evidence weakens with respect to the actual value of the income elasticity. There are two possible sources of these discrepancies, the use of arbitrary deflators and specification errors. We find that health PPP cannot be taken as a 'universal' price index. The problem is that its components do not move together. Nevertheless, we derive a 'universal' health price index from a dynamic system in which its components share both short and long run co-movements. The omission of relevant explanatory variables seems to be the main cause of the discrepancies. We confirm that there exists a strong positive relationship between per capita health care expenditure and per capita GDP. However we estimate a long run income elasticity at or around unity, although it is greater than unity for the countries with lower per capita income (Spain and Ireland). The results for income elasticity are the same regardless of whether health care expenditure is converted using the GDP PPP or the 'universal' health price index. The importance of non-income variables is also confirmed, in particular the relative price of health care. We find that relative price has a strong rationing effect on the quantity of health demanded and has no effect on the expenditures.

Data Interpretation, Statistical↗
PubMedDate not supplied

The cost of rationing medical care by insurance coverage and by waiting.

This paper raises the question of the least-cost institutional mechanism to secure the value of certainty by reducing risk over the purchase of medical care. Two methods of reducing risk are evaluated: financing medical care with 'complete insurance', that is, ready access to medical care that is free at the point of purchase; and rationing by waiting time in a national health service that supplies a limited volume of medical care. The first system corresponds to the type of insurance held by most people in the United States, while the latter represents a stylized model of a national health service. The cost of over-utilization of services by insured consumers in the U.S. is substantial--larger on a per-family basis, and far larger for the nation, than the cost of under-utilization by those who lack insurance. The cost of rationing by waiting is estimated to be between $541 and $828 per family (in 1984 dollars). Thus, both systems involve costly mis-allocation of resources.

Actuarial Analysis↗
PubMedDate not supplied

An internal rate of return approach to investigate pharmacist supply in the United States.

Internal rates of return were used to examine the status of pharmacist supply in the United States between the years 1987-1991. Age-earnings profiles were estimated for pharmacists, college graduates and high school graduates. Rates of return to pharmacists and college graduates were compared and a ratio of the pharmacist rate to the college graduate rate was computed for each year. Results suggest a shortage of pharmacists in the United States. Enrollments in pharmacy schools and adopted changes in the training of pharmacists are discussed in relation to their effects on the pharmacist labour market.

Adult↗
PubMedDate not supplied

The impact of indirect costs on outcomes of health care programs.

The impact of including indirect costs of disease (as a result of absence from work, disability and mortality) on outcomes of economic evaluations of specific health care programs is analyzed. For eight health care programs, changes in indirect costs are estimated using the friction cost method, that seeks to estimate the economic losses due to disease or the economic gains of health care programs. The impact of indirect costs on outcomes varies considerably across programs. Indirect costs tend to play an important role if health care programs produce health effects in the short run, if (short term) absence from work is affected considerably and if a significant proportion of the target population is employed at the moment they benefit from the program. The possible induction of treatment related absence from work and disability may also be relevant.

Adult↗
PubMedDate not supplied

The demand for cigarettes in California and behavioural risk factors.

This study contributes to the understanding of the demand for cigarettes by taking into account the interdependence of smoking and other behavioural risk factors. Information on smoking and other behavioural risk factors including drinking, alcohol use, and obesity were obtained from the California Behavioural Risk Factor Survey for the period 1985-91. A monthly cigarette price index for California was constructed based on data obtained from the Bureau of Labor Statistics. A two-part model was used to examine separately the effect of price on the decision to be a smoker, and on the amount of cigarettes smoked by smokers. The overall price elasticity of cigarettes was estimated at -0.46, with a price elasticity of -0.33 for smoking participation and of -0.22 for the amount of cigarettes consumed by smokers. The inclusion of other behavioural risk factors reduced the estimated price elasticity for smoking participation substantially, but had no effect on the conditional price elasticity for the quantity of cigarettes smoked.

Adolescent↗
PubMedDate not supplied

An economic model of the market for hospital treatment for non-urgent conditions.

This paper develops an economic model of the market for treatment of waiting list conditions, in which complainants choose between private treatment, NHS treatment and no hospital treatment. This choice depends on a number of clinical and non-clinical factors, which enter the demand functions for private and NHS treatment. Among the key influences are the price of private treatment and the expected duration of wait for NHS treatment, both of which are endogenous variables in the model. Given a pair of private sector and NHS supply functions, expressions are obtained for the price and expected wait at which demand and supply are simultaneously equated in both the private sector and the NHS. The paper concludes by exploring the responsiveness of the equilibrium to various demand side and supply side shocks.

Choice Behavior↗
PubMedDate not supplied

A comparison of alternative models of prescription drug utilization.

The two-part estimation technique has been advocated for estimating models using individual level health care utilization data characterised by a large proportion of non-consumption and small proportions of heavy users. This paper compares the two-part model to several other estimators, including the Poisson, negative binomial and 'zero altered' negative binomial models on the basis of within-sample forecasting accuracy and non-nested model selection tests. The empirical model estimates the differential effect of the removal of copayments for prescription medicines on the prescription drug utilization by older adults with differing levels of health status. The two-part estimator of this model is found to dominate the competitors. Results from this model indicate that utilization increases appear to be higher among individuals with lower levels of health status.

Aged↗
PubMedDate not supplied

Determinants of expenditure variation in health care and care of the elderly among Finnish municipalities.

In Finland, municipal health care expenditure varies from FIM 3 800 per capita to FIM 7 800 per capita. The objective of this study was to estimate the impact of different economic, structural and demographic factors on the per capita costs of health services and care of the elderly. Using regression analysis we attempted to explain observed differences in expenditure by determining separately the effects of allocative and productive inefficiency and the effects of factors influencing the demand for services. We found income level of local population, generosity of central government matching grant, allocative efficiency (the mix of care between institutional and non-institutional care), productive efficiency of service providers, and factors associated with the need of services (age structure, morbidity) to be the most important determinants of health care expenditure. Our results reveal that municipalities have the means at their disposal (by shifting resources to outpatient care and increasing productivity) to significantly reduce expenditure on health services and care of the elderly.

Aged↗
PubMedDate not supplied

Patient charges and the utilisation of NHS prescription medicines: some estimates using a cointegration procedure.

Since the inception of the NHS, user charges have been present for prescription medication. However since 1968 there has been a steady increase in this charge, particularly notable during the 1980s. The main justification for user charges is their revenue raising potential, and a recent government report has backed the use of user charges for prescription drugs. Whilst there is extensive evidence of the impact of user charges on utilisation of health care in the US, few studies exist in the UK. An accurate estimation of the price elasticity of utilisation is necessary if the full consequences of user charges are to be examined. This paper uses a cointegration estimation technique to estimate the price elasticity for prescription drug utilisation in the UK.

Drug Utilization↗
PubMedDate not supplied

Time preference, duration and health state valuations.

There is increasing interest in health status measurement and the relative weights that people attach to different states of health and illness. One important issue which has been raised is the effect that the time spent in a health state may have on the way that state is perceived. Previous studies have suggested that the worse a state is, the more intolerable it becomes as it lasts longer. However, for most of these studies, it is impossible to determine how much of what was observed is attributable to the time spent in the state and how much is attributable to when it was occurring. This paper reports on a pilot study designed to test the feasibility of using the Time Trade-Off (TTO) method to isolate the effect of pure time preference from the effect of duration per se. Interviews were conducted with 39 members of the general population who were asked to rate 5 health states for durations of one month, one year and ten years. In aggregate, rates of time preference were very close to zero which suggests that the implicit assumption of the TTO method that there is no discounting may be a valid one. However, that more respondents had negative (rather than positive) rates, casts some doubt on the axions of discounted utility theory. In addition, implied valuations for states lasting for short periods were often counter-intuitive which questions the feasibility of using the TTO method to measure preferences for temporary health states.

Adult↗
PubMedDate not supplied

The changing distribution of a major surgical procedure across hospitals: were supply shifts and disequilibrium important?

This paper describes and analyzes the changing distribution across hospitals in the U.S. of total hip replacement surgery (THR) for the period 1980-1987. THR is one of the most costly single procedures contributing to health care expenses. Also, the use of THR exhibits a particularly high degree of geographic variation. Recent research pointed to shifts in demand as one plausible economic explanation for increasing use of THR. This paper questions whether shifts in supply may have been large enough to explain changes in patient mix and the relationship of patient mix to the number of procedures performed at a particular hospital. In addition, the relationship between total use of THR and the local availability of orthopaedic surgeons as well as the average allowable Medicare fee for standardized physician services is analyzed. These relationships might yield evidence to support a scenario of induced demand beyond the optimum for patients' welfare, or evidence of supply increase within a disequilibrium scenario. This study, using data for all THR patients in a large sample of hospitals, tends to reject the formulation of a market with independent supply and demand shifts where the supply shifts were the dominant forces. Hospitals with a larger number of THRs performed did not see a higher percentage of older, sicker, and lower income patients. It was more likely that demand shifts generated increases in capacity for surgical services. Moreover, there was little evidence for a persistent disequilibrium and only weak evidence for inducement. Also, we found little evidence that hospitals responded to financial incentives inherent in the Medicare payment system after 1983 to select among THR candidates in favour of those with below average expected cost. We did observe increased concentration over time of THR procedures in facilities with high volume--suggesting plausible demand shifts towards hospitals with a priori quality and cost advantages or who obtained those advantages with a high volume of patients.

Age Factors↗
PubMedDate not supplied

Demand for insurance by elderly persons: private purchases and employer provision.

Studies of the demand for health insurance by elderly persons often inadequately address the distinctions between those who receive insurance through a former employer and those who purchase insurance on their own. The failure to distinguish these two modes of supplementing Medicare can lead to an inability to identify the effects of important independent variables. Using data from the Survey of Income and Program Participation this paper examines the demand for employer provided health insurance among retired pensioners using a bivariate probit model with partial observability and compares these results to other models of insurance demand among elderly persons. The results indicate that unobserved factors reducing the probability of being offered employer provided insurance are associated with increased acceptance. A comparison of the employer provided results with results from other models of the demand for privately purchased insurance indicates that different independent variables may determine the probability of having these types of insurance. Previous studies of insurance that have not distinguished between these two types of insurance may not provide reliable estimates of the relationship between independent variables and the probability of insurance coverage.

Aged↗
PubMedDate not supplied

Sensitivity analysis in economic evaluation: a review of published studies.

A structured methodological review of journal articles published in 1992 was undertaken to determine whether recently published economic evaluation studies deal systematically and comprehensively with uncertainty. Ninety three journal articles were identified from a range of searches including a computerised search of the MEDLINE CD-Rom database. Articles were reviewed to determine how they had handled uncertainty in: a) data sources; b) generalisability; c) extrapolation; and d) analytic method. Articles were subsequently assessed to determine how they had represented this uncertainty in terms of the overall results of their analysis. Finally, studies were rated on the basis of their overall performance with respect to dealing systematically and comprehensively with uncertainty. Despite the numerous books and articles devoted to the appropriate methods to be employed by analysts conducting economic evaluation, 22 (24%) studies failed to consider uncertainty at all and 35 (38%) studies employed sensitivity analysis in a manner judged as inadequate. In all, 36 (39%) studies were judged to have given at least an adequate account of uncertainty with 13 (14%) of those judged to have provided a good account of uncertainty. Such disappointing results may reflect a general lack of detail in much of the methods literature concerning how sensitivity analysis should be applied and how results should be presented. Journal editors and readers of economic evaluation articles should acquaint themselves with the methods for handling uncertainty in order that they can critically evaluate the extent to which authors have allowed for uncertainties inherent in their analysis.

Cost-Benefit Analysis↗
PubMedDate not supplied

Confidence intervals for cost/effectiveness ratios.

The reduction of costs is becoming increasingly important in the medical field. The relevant topic of many clinical trials is not effectiveness per se, but rather cost-effectiveness ratios. Surprisingly, no statistical tools for analyzing cost-effectiveness ratios have been provided in the medical literature yet. This paper explains the gap in the literature, and provides a first technique for obtaining confidence intervals for cost-effectiveness ratios. The technique does not use sophisticated tools to achieve maximal optimality, but seeks for tractability and ease of application while still satisfying all formal statistical requirements.

Clinical Trials as Topic↗
PubMedDate not supplied

Performance of Belgian hospitals: a frontier approach.

The purpose of the paper is to measure and to compare performance of Belgian hospitals during the year 1991. In order to measure hospitals' efficiency, we estimate a resource function which is defined as the relationship between medical fees incurred in the treatment of a patient and the patient's pathology. From this relation, we construct a best practice reference frontier which defines the minimal hospital medical fees needed to treat the pathology. Efficiency is assessed relative to this resource frontier using a parametric stochastic method proposed by Schmidt and Sickles. It appears that some specializations (circulatory system) involve more overproduction than others. Among the other results, we note that public hospitals are more efficient than the private ones and that university hospitals tend to use more resources than regular hospitals. The relationships between efficiency and different variables (location, size, costs and management) are finally analysed.

Age Factors↗
PubMedDate not supplied

Controlling for mental health in earnings equations: what do we gain and what do we lose?

This paper examines the biases in estimating wage equations that may arise from measurement errors in various mental health indicators--two subjective proxies and one clinical assessment. The results suggest that a self-reported measure based on whether the individual reported missing school or work for mental-health-related reasons leads to the smallest measurement error bias in the coefficients of the explanatory variables in an earnings equation. Two specific results lead to this conclusion. For one, the variance of the random component of its measurement error is the smallest among the three indicators leading to the least biased estimates of the impact of mental health on wages. Second, systematic reporting biases which vary with the non-health regressors in a wage equation do not appear to exit in this measure. Consequently, this indicator follows the classical measurement error model. This implies that the coefficient estimates of the impact of non-health variables are always improved, in the sense of having a smaller bias, when this mental health proxy is included in the regression. The measurement error in a self-evaluation according to the scale of excellent, good, fair, or poor has the largest variance thus leading to a substantial understatement of the impact of mental health on earnings. This measure also contains significant reporting biases that vary with gender, race, and education--many of the non-health regressors in a wage equation. The measurement error variance in the simulated diagnostic measure analyzed in this paper is also large. Thus this proxy will yield poor estimates of the impact of mental health on earnings.

Absenteeism↗