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PubMed2004

Waiting time and doctor shopping in a mixed medical economy.

Waiting time generally acts as a rationing mechanism in the public health care system. In theory, patients who have a higher valuation of time are more likely to seek alternative care (i.e. doctor shopping) if there is a parallel private sector than those who have weaker time preference. However, the existing settings of many health care systems do not allow patients to reveal their preference of such. The data presented in this study suggest a positive association between patients' expressed value of time and doctor shopping behaviour in Hong Kong. Patients who were assigned longer waiting times relative to their expected horizon were more likely to seek private alternative care.

Adolescent↗
PubMed2004

Access to physician services: does supplemental insurance matter? evidence from France.

In France, public health insurance is universal but incomplete, with private payments accounting for roughly 25% of all spending. As a result, most people have supplemental private health insurance. We investigate the effects of such insurance on the utilization of physician services using data from the 1998 Enquête sur la santé et la protection sociale, a nationally representative survey of the non-institutionalized French population. Our results indicate that insurance has a strong and significant effect on the utilization of physician services. Individuals with supplemental coverage have substantially more physician visits than those without. While French patients have greater freedom than patients in other countries to choose to see a specialist rather than a general practitioner, we find no evidence that supplemental insurance affects this decision.

Adult↗
PubMed2004

Accounting for the cost of scaling-up health interventions.

Recent studies such as the Commission on Macroeconomics and Health have highlighted the need for expanding the coverage of services for HIV/AIDS, malaria, tuberculosis, immunisations and other diseases. In order for policy makers to plan for these changes, they need to analyse the change in costs when interventions are 'scaled-up' to cover greater percentages of the population. Previous studies suggest that applying current unit costs to an entire population can misconstrue the true costs of an intervention. This study presents the methodology used in WHO-CHOICE's generalised cost effectiveness analysis, which includes non-linear cost functions for health centres, transportation and supervision costs, as well as the presence of fixed costs of establishing a health infrastructure. Results show changing marginal costs as predicted by economic theory.

Africa↗
PubMed2004

The wage effects of obesity: a longitudinal study.

We use National Longitudinal Survey of Youth (NLSY) data to examine the effects of obesity on wages by gender. Sample means indicate that both men and women experience a persistent obesity wage penalty over the first two decades of their careers. We then control for a standard set of socioeconomic and familial variables but find that standard covariates do not explain why obese workers experience persistent wage penalties. This suggests that other variables -- including job discrimination, health-related factors and/or obese workers' behavior patterns -- may be the channels through which obesity adversely affects wages. The study closes with a discussion of the public policy implications suggested by these findings.

Activities of Daily Living↗
PubMed2004

Scope and scale inefficiencies in physician practices.

Using a national data set, this paper looks at the efficiency of physician practices, focusing on scopes of service by comparing single specialty groups and multispecialty groups. An analysis of efficiency using DEA indicates that there are scope inefficiencies from combining different types of providers into a single practice. Most of the inefficiency is due to technical rather than allocative reasons. In addition, we find that larger practices are able to capture efficiencies of scope, but incur inefficiencies of scale.

Analysis of Variance↗
PubMed2004

Cost efficiency in primary care contracting: a stochastic frontier cost function approach.

The principal aim of this paper is to estimate a stochastic frontier cost function and an inefficiency effects model in the analysis of the primary health-care services purchased by the public authority and supplied by 180 providers in 1996 in Catalonia. The evidence from our sample does not support the premise that contracting out has helped improve purchasing cost efficiency in primary care. Inefficient purchasing cost was observed in the component of this purchasing cost explicitly included in the contract between purchaser and provider. There were no observable incentives for the contracted-out primary health-care teams to minimise prescription costs, which were not explicitly included in the contracting system.

Adolescent↗
PubMed2004

The role of public and private transfers in the cost-benefit analysis of mental health programs.

This paper revisits the issue of whether to include maintenance costs in an economic evaluation in mental health. The source of these maintenance costs may be public or private transfers. The issue is discussed in terms of a formal cost-benefit criterion. It is shown that, when transfers have productivity effects, income distribution is important, and one recognizes that public transfers have tax implications, transfers can have real resource effects and cannot be ignored. The criterion is then applied to an evaluation of three case management programs in California that sought to reduce the intensive hospitalization of the severely mentally ill.

Aftercare↗
PubMed2004

Cost-effectiveness with multiple outcomes.

In a large number of situations, activities in health care have to be measured in terms of outcome and cost. However, the cases where outcome is fully captured by a single measure are rather few, so that one uses some index for outcome, computed by weighing together several outcome measures using subjective and somewhat arbitrary weights. In the paper we propose an approach to cost-effectiveness analysis where such artificial aggregation is avoided. This is achieved by assigning to each activity the weights which are the most favourable in a comparison with the other options available, so that activities which have a poor score in this method are guaranteed to be inferior. The method corresponds to applying Data envelopment analysis, known from the theory of productivity, to the context of health economic evaluations. The method is applied to an analysis of the cost-effectiveness of alternative health plans using data from the Medical Outcome Study (JAMA 1996; 276: 1039-1047), where outcome is measured as improvement in mental and physical health.

Cost-Benefit Analysis↗
PubMed2005

Assessing generalisability by location in trial-based cost-effectiveness analysis: the use of multilevel models.

Cost-effectiveness analysis (CEA) in health care is increasingly conducted alongside multicentre and multinational randomised controlled clinical trials (RCTs). The increased use of stochastic CEA is designed to account for between-patient sampling variability in cost-effectiveness data assuming that observations are independently distributed. However, between-location variability in cost-effectiveness may result if there is a hierarchical structure in the data; that is, if there is correlation in costs and outcomes between patients recruited in particular locations. This may be expected in multi-location trials given that centres and countries often differ in factors such as clinical practice, patient case-mix and the unit costs of delivering health care. A failure to acknowledge this feature may lead to misleading conclusions in a trial-based economic study. Multilevel modelling (MLM) is an analytical framework that can be used to handle hierarchical cost-effectiveness data. Using data from a recently conducted economic analysis, this paper shows how multilevel modelling can be used to obtain (a) more appropriate estimates of the population average incremental cost-effectiveness and associated standard errors compared to standard stochastic CEA; and (b) location-specific estimates of incremental cost-effectiveness which can be used to explore appropriately the variability between centres/countries of the cost-effectiveness results.

Cost-Benefit Analysis↗
PubMed2005

Risk aversion and uncertainty in cost-effectiveness analysis: the expected-utility, moment-generating function approach.

The availability of patient-level data from clinical trials has spurred a lot of interest in developing methods for quantifying and presenting uncertainty in cost-effectiveness analysis (CEA). Although the majority has focused on developing methods for using sample data to estimate a confidence interval for an incremental cost-effectiveness ratio (ICER), a small strand of the literature has emphasized the importance of incorporating risk preferences and the trade-off between the mean and the variance of returns to investment in health and medicine (mean-variance analysis). This paper shows how the exponential utility-moment-generating function approach is a natural extension to this branch of the literature for modelling choices from healthcare interventions with uncertain costs and effects. The paper assumes an exponential utility function, which implies constant absolute risk aversion, and is based on the fact that the expected value of this function results in a convenient expression that depends only on the moment-generating function of the random variables. The mean-variance approach is shown to be a special case of this more general framework. The paper characterizes the solution to the resource allocation problem using standard optimization techniques and derives the summary measure researchers need to estimate for each programme, when the assumption of risk neutrality does not hold, and compares it to the standard incremental cost-effectiveness ratio. The importance of choosing the correct distribution of costs and effects and the issues related to estimation of the parameters of the distribution are also discussed. An empirical example to illustrate the methods and concepts is provided.

Cost-Benefit Analysis↗
PubMed2005

Using multilevel models for assessing the variability of multinational resource use and cost data.

Multinational economic evaluations often calculate a single measure of cost-effectiveness using cost data pooled across several countries. To assess the validity of pooling international cost data the reasons for cost variation across countries need to be assessed. Previously, ordinary least-squares (OLS) regression models have been used to identify factors associated with variability in resource use and total costs. However, multilevel models (MLMs), which accommodate the hierarchical structure of the data, may be more appropriate. This paper compares these different techniques using a multinational dataset comprising case-mix, resource use and cost data on 1300 stroke admissions from 13 centres in 11 European countries. OLS and MLMs were used to estimate the effect of patient and centre-level covariates on the total length of hospital stay (LOS) and total cost. MLMs with normal and gamma distributions for the data within centres were compared. The results from the OLS model showed that both patient and centre-level covariates were associated with LOS and total cost. The estimates from the MLMs showed that none of the centre-level characteristics were associated with LOS, and the level of spending on health was the centre-level variable most highly associated with total cost. We conclude that using OLS models for assessing international variation can lead to incorrect inferences, and that MLMs are more appropriate for assessing why resource use and costs vary across centres.

Age Factors↗
PubMed2004

Measuring horizontal inequity in Belgian health care using a Gaussian random effects two part count data model.

We estimate the determinants of utilisation of physician and hospital services in Belgium using a one- and two-part panel count data model, and a one- and two-part pooled count data model. We conclude that the two-part panel count data model is most appropriate as it controls for unobserved heterogeneity and allows for a two-part decision-making process. The estimates of the determinants of utilisation of health care are then used to calculate indices of horizontal inequity. We find that inequity for general practitioner and hospital services is stable across time and in favour of low-income individuals, in the sense that, overall, they consume more than one would expect on the basis of their need, albeit the indices for hospital care are not significant. Horizontal equity applies to specialist care in all years, but from 1999 onwards, some evidence (although not statistically significant) of pro-rich inequity is found.

Belgium↗
PubMed2005

The effect of welfare reform on prenatal care and birth weight.

Welfare reform has resulted in a dramatic decline in welfare caseloads and some have claimed that a significant number of low-income women may be without health insurance as a result. The loss of insurance may reduce low-income, pregnant women's health care utilization, and this may adversely affect infant health. Welfare reform also may affect healthcare utilization and health of pregnant women and infants because of welfare-induced changes in family disposable income, time available for health investments, and levels of stress. In this paper we examine the effect of welfare reform on prenatal care utilization and birth weight of low-educated women and their infants. We find that a 50% reduction in the caseload, which is similar to that which occurred in the 1990s, is associated with a zero to seven percent decrease in first trimester prenatal care; a zero to five percent decrease in the number of prenatal care visits; and a zero to 10% increase in low birth weight. Since welfare reform was responsible for only part of the decline in the caseload, welfare reform per se had even smaller effects.

Adult↗
PubMed2005

Public and private pharmaceutical spending as determinants of health outcomes in Canada.

Canadian per capita drug expenditures increased markedly in recent years and have become center stage in the debate on health care cost containment. To inform public policy, these costs must be compared with the benefits provided by these drugs. This paper measures the statistical relationship between drug spending in Canadian provinces and overall health outcomes. The analysis relies on more homogenous data and includes a more complete set of controls for confounding factors than previous studies. Results show a strong statistical relationship between drug spending and health outcomes, especially for infant mortality and life expectancy at 65. This relationship is almost always stronger for private drug spending than for public drug spending. The analysis further indicates that substantially better health outcomes are observed in provinces where higher drug spending occurs. Simulations show that if all provinces increased per capita drug spending to the levels observed in the two provinces with the highest spending level, an average of 584 fewer infant deaths per year and over 6 months of increased life expectancy at birth would result.

Aged↗
PubMed2005

Smokers' expectations to quit smoking.

We investigate the effectiveness of different smoking policies on smokers' expectations to quit smoking using a choice experiment on a sample of smokers identified within the World Health Organization (WHO) MONICA Project. Our results indicate that restricted availability, increased cigarette prices, cessation subsidies and regulations at restaurants, bars and cafes increase the expected probability of smoking cessation. Regulations at work places do not seem to have any effect. The results also show the significant role of limited self-control; smokers who have the intent to quit smoking are more likely to quit smoking if a stricter regulation is implemented. Further, smokers who have received advice from their children to quit smoking or who perceive the health risks as considerable, are more likely to expect to quit smoking.

Health Policy↗
PubMed2005

QALY maximisation and people's preferences: a methodological review of the literature.

In cost-utility analysis, the numbers of quality-adjusted life years (QALYs) gained are aggregated according to the sum-ranking (or QALY maximisation) rule. This requires that the social value from health improvements is a simple product of gains in quality of life, length of life and the number of persons treated. The results from a systematic review of the literature suggest that QALY maximisation is descriptively flawed. Rather than being linear in quality and length of life, it would seem that social value diminishes in marginal increments of both. And rather than being neutral to the characteristics of people other than their propensity to generate QALYs, the social value of a health improvement seems to be higher if the person has worse lifetime health prospects and higher if that person has dependents. In addition, there is a desire to reduce inequalities in health. However, there are some uncertainties surrounding the results, particularly in relation to what might be affecting the responses, and there is the need for more studies of the general public that attempt to highlight the relative importance of various key factors.

Age Factors↗
PubMed2004

The effect of the tobacco settlement and smoking bans on alcohol consumption.

In the last few years, the price of cigarettes has increased considerably in the USA. In addition, a number of states have also imposed smoking bans. These increases in the cost and barriers to smoking have created a natural experiment to study relationships between smoking and drinking behaviors. In this study, we employ data from the first six waves of the Health and Retirement Survey (HRS) to analyze the effects of smoking bans and cigarette prices on alcohol consumption. We also test if past cigarette and alcohol consumption affect current alcohol consumption as predicted by co-addiction models. We estimate dynamic panel models using GMM estimators. Our approach allows us to obtain consistent estimates irrespective of the number of time periods. The three main findings of this study are: (1) there is positive reinforcement effect of past cigarette consumption on current alcohol consumption, (2) smoking bans reduce alcohol consumption and (3) there is a positive effect of cigarette prices on alcohol consumption.

Aged↗
PubMed2004

Accounting for misclassification error in retrospective smoking data.

Recent waves of major longitudinal surveys in the US and other countries include retrospective questions about the timing of smoking initiation and cessation, creating a potentially important but under-utilized source of information on smoking behavior over the life course. In this paper, we explore the extent of, consequences of, and possible solutions to misclassification errors in models of smoking participation that use data generated from retrospective reports. In our empirical work, we exploit the fact that the National Longitudinal Survey of Youth 1979 provides both contemporaneous and retrospective information about smoking status in certain years. We compare the results from four sets of models of smoking participation. The first set of results are from baseline probit models of smoking participation from contemporaneously reported information. The second set of results are from models that are identical except that the dependent variable is based on retrospective information. The last two sets of results are from models that take a parametric approach to account for a simple form of misclassification error. Our preliminary results suggest that accounting for misclassification error is important. However, the adjusted maximum likelihood estimation approach to account for misclassification does not always perform as expected.

Data Interpretation, Statistical↗