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PubMed1989

Patterns of care and expenditures by California Medicaid for peptic ulcer and other acid-related diseases.

We examined California Medicaid (Medi-Cal) service use and expenditures for peptic ulcer and other acid-related diseases during the 10-year period fiscal year (FY) 1976-1985. Between FY 1976 and FY 1980, hospitalizations rose irregularly, operations declined by 37%, endoscopies tripled, physician visits fluctuated from year to year, antacid prescriptions increased by 36%, and anticholinergic medication use was stable. From FY 1981 to FY 1985, hospitalizations declined by 52%, operations by 91%, endoscopies by 45%, physician visits by 30%, antacid use by 12%, and anticholinergic medication use by 48%. H2 antagonists were allowed onto Medi-Cal formulary near the end of FY 1980, and use rose sharply through 1985. Similar results were found across specific gastrointestinal (GI) diagnoses. Total payments for acid-related conditions were essentially stable during FY 1976-1980 period, although, for individual services, utilization and expenditures did not always move in the same direction. For example, declining operations rates and stable expenditures were found. However, during FY 1981-85, changes in rates of service use were generally matched by similar changes in total expenses for that service. For example, the 40% reduction in rate of endoscopies was accompanied by a near 50% decline in payments. Overall expenditures for all acid-related diagnoses fell by nearly 28% between 1981 and 1985. We concluded that the introduction of H2 antagonists had important positive clinical effects on all studied acid-related GI diagnoses.

California↗

PubMed1976

The measurement of expenditures for outpatient physician and dental services: methodological findings from the health insurance study.

Survey data measuring outpatient health expenditure are evaluated for item nonresponse, measurement error, and bias. Item nonresponse is high for persons whose health care is financed through the public sector, but is otherwise manageable. Estimates of mean total and out-of-pocket physician and dental expenditure from two surveys using indirect methods (including the Health Insurance Study) are compared with nonsurvey estimates. Out-of-pocket physician expenditure is overestimated, but the other measures appear unbiased. Estimates using direct, self-administrated methods appear biased upward. We demonstrate that commonly used record check methods for evaluating survey data will make random error appear as bias, and a methodology we develop shows substantial random error in the measurement of dental expenditure: 44 per cent of the total variance in survey data and 39 per cent of the variance in records.

Ambulatory Care↗

PubMed1979

Racial differences in medical care expenditures.

Out of pocket medical expenditures made by families for physician services, dental visits, medications, hospitalizations and insurance premiums are examined in a southern rural community using household survey interview data. White families paid an average out of pocket amount for total medical services of $709 as compared with $383 for black families over a 12-month period, 1974-75. Correlates of expenditure differences between blacks and whites are explored with respect to family characteristics (race, education of household head, family income, family size and family composition), illness levels (number of family members with perceived fair or poor health status and number of family members reporting chronic conditions), and use of services (number of doctor visits and type of usual source of care). We find that whites consistently report greater expenditures than blacks, regardless of the variables controlled for. We consider that expenditure differences are in part due to a mix of three factors: variations in the cost of doctor visits to whites and blacks; a lower level of use of services by blacks; and the differential availability and use of third party payors.

Black or African American↗

PubMed1997

The effect of universal coverage on health expenditures for the uninsured.

OBJECTIVES: Universal coverage will trigger an increase in health-care spending, because the uninsured will use more services after they are insured. The effect of insurance status on expenditures is estimated here from a multivariate statistical model. METHODS: The model is estimated with data from the 1987 National Medical Expenditure Survey, aged to 1994 using population projections from the US Bureau of the Census and expenditure projections from the Health Care Financing Administration. RESULTS: Expenditures for the full-year uninsured increase by approximately $700 per person in 1994 as a result of universal coverage. Nearly half of the increase is because of a substantial increase in the likelihood of hospitalization. CONCLUSIONS: If the uninsured are enrolled in plans similar to those offered by employers currently, personal health-care spending increases by approximately $20 billion in 1994. There are other costs associated with universal coverage that are not included in this figure.

Adolescent↗

PubMed1997

Expenditures on services for persons with acquired immunodeficiency syndrome under a Medicaid home and community-based waiver program. Are selection effects important?

OBJECTIVES: In 1990, the state of Florida implemented an acquired immunodeficiency syndrome (AIDS)-specific Medicaid waiver program to provide home and community-based services to AIDS patients as an alternative to institutional care. The program is available to Medicaid beneficiaries with AIDS who are at risk of institutionalization. This study examines whether the waiver option was effective in reducing Medicaid expenditures per beneficiary during its first 2 years of operation. METHODS: The authors used Medicaid claims data and county information on the availability of health services to model the selection of the waiver option by AIDS patients and then to estimate the effect of the waiver on expenditures controlling for nonrandom program selection. RESULTS: The results indicate that the selection model is highly significant, but that the influence of nonrandom selection on the estimation of the program effects is negligible. More importantly, the regression results indicate that persons with AIDS who use waiver services incur monthly Medicaid expenditures that are on average 22% to 27% lower than otherwise similar nonparticipants. CONCLUSIONS: These results, based on the first 2 years that Project AIDS Care was operational, suggest that home and community-based care for AIDS patients results in lower expenditures per beneficiary.

Adolescent↗

PubMed1999

Using the POPULIS framework for interprovincial comparisons of expenditures on health care. Population Health Information System.

OBJECTIVES: Motivated by Manitoba Health's desire to know how health spending in Manitoba compared with other provinces, this study is a descriptive project designed to inform the health policy process by comparing indicators of need and expenditure across Canada. RESEARCH DESIGN: Population characteristics that are known to influence the need for health care constitute the comparative data categories. FINDINGS: In terms of all five health status indicators and five of eight socioeconomic indicators, Manitoba ranked medium (fourth to seventh of 10 provinces) or average. Demographic characteristics placed Manitoba second to Saskatchewan in proportion of both elderly residents and Registered Indians. This is notable, because both groups traditionally have high health needs. With provincial characteristics established, the second part of the study compares provincial per capita health expenditure data with expected need for health care services. RESULTS: Overall, the study finds provincial health expenditures are not related to health care need indicators. Saskatchewan is a case in point; despite having similar population characteristics to Manitoba, Saskatchewan has a population with good health status and lower health care expenditures. This offers a model that invites further exploration. CONCLUSIONS: At the provincial level the amount of health care spending is not positively related to the need for health care.

Adolescent↗

PubMed2000

Gender-specific effects of modifiable health risk factors on coronary heart disease and related expenditures. HERO Research Committee. Health Enhancement Research Organization.

There is a general lack of health-related research focusing on gender-specific differences within a working population. This research attempts to address that void. Our study relied on the Health Enhancement Research Organization (HERO) database, which consists of claims, enrollment information, and health risk data for 39,999 employees of six large employers. The research objective was to determine the gender-specific association between coronary heart disease (CHD) and (1) the prevalence of modifiable health risks and (2) medical expenditures. To accomplish this, the International Classification of Diseases, 9th Revision-Clinical Modification and Current Procedural Terminology codes were used to identify 2452 employees with CHD within the HERO database. These individuals made up the study group, which included 66% male and 34% female participants. Health risk data were obtained from voluntary participation in a health risk appraisal and biometric evaluation provided by the employers. Health risks evaluated were tobacco use, hypertension, obesity, elevated cholesterol, high blood glucose, sedentary lifestyle, stress, depression, and excessive use of alcohol. Descriptive and multivariate statistical techniques were used to analyze the HERO database. We found that obesity was the most consistent predictor of CHD. It was number one (of 10 health risks) in the male and female group, number two in the male-only group, and number one in the female-only group. High stress was the second most consistent predictor. There was no such consistency relative to medical expenditures. This lack of consistency across the male and female groups relative to the association between health risks and medical expenditures was demonstrated for nearly all other health risks evaluated. This study suggests that within a group of employees with CHD, there are important similarities and differences between men and women with respect to the prevalence of risk factors and the association between health risks and medical expenditures.

Adult↗

PubMed2006

The development of a Local Index of Need (LIN) and its use to explain variations in social services expenditure on mental health care in England.

Wide variations in deprivation exist across England and it is likely that these variations translate into differences in the need for mental health care. Social Services Departments in England account for a substantial proportion of mental health expenditure. It is important that the distribution of expenditure reflects mental health needs. This paper's aims are to (1) describe the development of a new indicator of mental health needs, (2) use the index to explain variations in social services expenditure on mental health, and (3) compare the index with other established measures of need. A principal components analysis of sociodemographic variables considered to be indicators of need was used to produce four distinct factors for 148 Local Authority areas in England. A weighted sum of these factors was used to produce a single index. (Weights were the proportion of variance explained by each factor.) The index was used in a regression model to explain variations in spending on mental health care and was compared with (1) a model containing the four individual factors, (2) the current method of allocating resources, (3) the index used to allocate resources to primary care trusts, (4) the Mental Illness Needs Index (MINI), (5) four indices of deprivation produced by the Office of the Deputy Prime Minister, and (6) the average of the above four indices. The new index could explain 54% of variation, compared with 56% using the current method. The four-factor model could explain 66%, whilst the other models could explain between 37% and 20%. This new index has the advantage that it is not based on previous levels of utilisation or expenditure and yet still explains a comparable amount of variation as the current method. However, a disaggregated model containing individual factors may be preferable.

Adolescent↗

PubMed1996

Health care expenditure and life expectancy in Australia: how well do we perform?

The Australian health care system consists of mixed public and private financing underpinned by Medicare, a universal government-run insurance scheme paid through taxation (and levy) on income. Australia has improved its ranking for life expectancy (at birth) since 1960, and in 1990 ranked ninth and seventh of 24 countries for females and males respectively; this is ahead of the United States and United Kingdom, and approximately equal to Canada. Australian hospital bed supply and utilisation are average, after deletion of day-only cases. The proportion of gross domestic product (GDP) spent on health, in relation to GDP per capita (adjusted for purchasing power), in Australia in 1990 was average, and the prices for health care from 1975 to 1990 did not increase when adjusted for inflation. Although 68 per cent of health expenditure emanates from public sources in Australia, this is lower than in the majority of European countries and Canada. Some countries are doing poorly (such as the United States, with lower than average life expectancy and higher than predicted health expenditure) and some countries are doing well (with higher than average life expectancy and lower than predicted health expenditure; for example, Japan). Australia has higher than average life expectancy and only slightly higher than predicted health expenditure per capita. Although the Australian system could be improved, there are no indications that radical changes are required. The relatively high life expectancy in Australia can be attributed to favourable social and economic conditions, successful public health programs, and the availability of universal quality health care.

Australia↗

PubMed2006

Mental health expenditure in Australia: time for affirmative action.

In Australia, there is a clear relationship (r=-0.56) between the ratio of health expenditure to burden and the ratio of mortality to disability across illness groups. Those illnesses with high mortality relative to disability (e.g. cancer and cardiovascular) are associated with lower health expenditure, relative to the burden they impose. Conversely, illnesses with low mortality but high disability (e.g. musculoskeletal disorders) demonstrate higher expenditure. The notable exception is mental health, which has low mortality, high disability and very low health expenditure. Indeed, the relationship between the mortality/disability and health expenditure/burden ratios is stronger (r=-0.72) when mental health is excluded. As this disparity cannot be explained by a lack of cost-effective treatments for mental disorders, we propose a process of affirmative action for mental health. Urgent investments in cost-effective modes of care are required and these should prioritise increased access among those subpopulations disadvantaged by other social, economic or geographic factors.

Australia↗

PubMed2003

The effect of a Helicobacter pylori treatment strategy on health care expenditures in patients with peptic ulcer disease and dyspepsia.

OBJECTIVE: The aim of this study was to determine whether treatment for Helicobacter pylori (H. pylori) for patients with dyspepsia or a history of peptic ulcer decreases hospital expenditures. METHODS: Patients receiving acid suppressive medications were interviewed. Those with a documented ulcer, a self-reported ulcer, or dyspepsia were tested for H. pylori and treated with antibiotics if seropositive. Acid suppressive medications were stopped on completion of H. pylori therapy unless there was a history of gastroesophageal reflux disease (GERD) or Barrett's esophagus, and were started again at the discretion of primary care providers. Total hospital costs and GI medication costs in the 12 months before H. pylori treatment were compared to costs 12 months after H. pylori treatment. RESULTS: A total of 432 consecutive patients were treated for H. pylori. Of the patients, 125 (29%) had dyspepsia, 45 (10%) documented peptic ulcer, and 262 (61%) self-reported peptic ulcer. Total costs (mean 327 US dollars +/- 349 vs 291 USA dollars +/- 362, p = 0.06) and medication costs (mean 207 US dollars +/- 237 vs 224 US dollars +/- 277, p = 0.38) were not significantly different after treatment versus before treatment. A significant decrease in expenditures was limited to patients chronically on acid suppressive medications who had documented peptic ulcers and no history of GERD or Barrett's esophagus (mean 482 US dollars +/- 274 vs 282 US dollars +/- 218, p = 0.03). CONCLUSIONS: Treatment of H. pylori for patients with chronic dyspepsia or self-reported peptic ulcer does not reduce expenditures over 1 yr of follow up. H. pylori treatment for patients chronically receiving acid suppressive treatment with a prior documented ulcer significantly reduces expenditures if GERD and Barrett's esophagus are absent.

Anti-Bacterial Agents↗

PubMed1982

Effects of fluoride and regular dental care on personal dental expenditures of young adults in Finland.

This paper analyzes the relationship among presence of fluoride in the drinking water, oral health and dental expenditures in four towns in Finland. A two-stage least-squares model is used to determine the effect of fluoridated water and other independent variables on the number of missing teeth and per capita annual dental service expenditures for 555 adults. The results show that regularity of dental visits is the only significant factor explaining per capita expenditures. In contrast, many factors affect the number of missing teeth; most importantly, the number of dentists per capita, level of fluoride, age, education, use of services and smoking habits. These findings suggest that fluoride significantly improves oral health status but does not reduce adult per capita dental expenditures.

Adult↗

PubMed2002

Rural-urban differences in health risks, resource use and expenditures within three state medicaid programs: implications for medicaid managed care.

This study uses Medicaid claims data for income-eligible enrollees in California, Georgia and Mississippi to compare expenditures, resource usage and health risks between residents of rural and urban areas of the states. Resource use is measured using the Resource Based Relative Value Scale (RBRVS) system for professional services, hospital days and outpatient facility visits; it also is valued at private insurance reimbursement rates for the states. Health risks are measured using the diagnosis-based Adjusted Clinical Group system. Resource use is compared on a risk-adjusted basis with the use of urban Medicaid enrollees as the benchmark. We find that actual expenditures for rural care users are lower than for urban care users. However, because the proportion of Medicaid enrollees who use care is higher in rural than in urban areas in all three states, expenditures per rural enrollee are not consistently lower. Case mix is more resource intensive for rural compared to urban residents in all three states. Although resource usage is not systematically lower overall for rural enrollees, on a risk-adjusted basis they tend to use less hospital resources than urban enrollees. Capitation rates based on historical per enrollee expenditures would not appear to under-reimburse managed care organizations for the care of rural as opposed to urban residents in the study states.

California↗

PubMed2001

What's behind the health expenditure trends?

In this paper, we review the literature on a number of the potential explanations for the rise in health care expenditures in the United States: the aging population, the costs of dying, technology, physician incomes, administrative costs, prescription drugs, managed care, and the underfunding of public health. Our goal is not to pass definitive judgment on the force(s) driving health care costs, but rather to make the reader a more educated consumer of these widely cited data. We place special emphasis on how health expenditures are measured and the inherent weaknesses in the methodology. We find that frequently it is difficult to accurately estimate how individual forces influence total health care expenditures. Moreover, we conclude that interpreting the causes of the rise in expenditures goes beyond simple observations of trends and depends on how we value various segments and aspects of health and health care.

Health Care Reform↗

PubMed2003

Insurance expenditures on bipolar disorder: clinical and parity implications.

OBJECTIVE: This study assessed treatment rates and expenditures for behavioral health care by employers and behavioral health care patients in a large national database of employer-sponsored health insurance claims. METHOD: Insurance claims from 1996 from approximately 1.66 million individuals were examined. Average annual charges per person and payments for behavioral health care were calculated along with patient out-of-pocket expenses and inpatient hospital admission rates. Behavioral health care expenditures for bipolar disorder were compared to expenditures for other behavioral health care diagnoses in these same insurance plans. RESULTS: A total of 7.5% of all covered individuals filed a behavioral health care claim. Of those, 3.0% were identified as having bipolar disorder, but they accounted for 12.4% of total plan expenditures. Patients with bipolar disorder incurred annual out-of-pocket expenses of $568, more than double the $232 out-of-pocket expenses incurred by all claimants. The inpatient hospital admission rate for patients with bipolar disorder was also higher (39.1%) compared to 4.5% for all other behavioral health care claimants. Furthermore, annual insurance payments were higher for covered medical services for individuals with bipolar disorder than for patients with other behavioral health care diagnoses. CONCLUSIONS: Bipolar disorder is the most expensive behavioral health care diagnosis, both for patients with bipolar disorder and for their insurance plans. For every behavioral health care dollar spent on outpatient care for patients with bipolar disorder, $1.80 is spent on inpatient care, suggesting that better prevention management could decrease the financial burden of bipolar disorder.

Adult↗

PubMed2002

The effects of copayments on substance abuse treatment expenditures and treatment reoccurrence.

OBJECTIVE: Employers can influence treatment decisions by adjusting characteristics of the structure of the benefits they offer, such as copayments. The authors estimated the relationship between copayment levels for substance abuse treatment and both the insurers' expenditures for treatment and the reoccurrence of treatment. METHODS: Retrospective data from a Midwestern behavioral health insurer were used to identify persons with a diagnosis of a substance use disorder. The claims data were used to construct episodes of treatment. Using the variation in copayment levels across 211 different employer groups, the authors used multiple regression models to estimate the effect of copayment levels on treatment expenditures and the likelihood of a treatment reoccurrence. RESULTS: Copayment levels had a significant effect on the reoccurrence of substance abuse treatment. Each 10 percent increase in copayment was associated with a 1 percent increase in the probability of reoccurrence. Copayment levels had a significant effect on current-episode treatment expenditures. Each 10 percent increase in copayment was associated with an 8.7 percent decrease in total per-episode expenditures. From the plan's perspective, a $1 increase in copayment for outpatient substance abuse treatment reduced per-episode spending by $110; however, roughly $13 is lost from that saving because of the increased likelihood of treatment reoccurrence. CONCLUSIONS: The longer a person is retained in substance abuse treatment, the greater the likelihood of recovery. Copayments may represent a barrier to retention in treatment. Higher copayments for substance abuse treatment make treatment reoccurrence more likely.

Adult↗

PubMed2005

Delays to treatment and out-of-pocket medical expenditure for tuberculosis patients, in an urban area of South America.

Short delays to treatment are important for the control of tuberculosis (TB). National Tuberculosis Programmes provide free diagnosis and treatment for smear-positive patients, so that the patients' out-of-pocket medical expenditure could be almost nil. The factors associated with delays in starting treatment, and the pre-treatment out-of-pocket medical expenditure for TB patients, have now been investigated in the Bolivian city of Cochabamba. Bolivia is the Latin American country with the highest incidence of TB. It is covered by a national TB programme that provides free diagnosis and free treatment for smear-positive patients. Structured interviews with 144 smear-positive patients enrolled in this programme revealed median patient, provider and total delays of 3.6, 6.2 and 12.9 weeks, respectively. The total delays were longer for the female patients than for the male, and for patients who consulted private doctors than for the other patients. When the first healthcare provider was a doctor, the median provider delay was 4.9 weeks in the public sector but 7.2 weeks in the private. The median out-of-pocket medical expenditure per patient, which was U.S.$13.2 overall, was much higher for those who consulted a private doctor than for those who did not (U.S.$21.9 v. U.S.$5.4, respectively; P<0.001). It appears that interventions targeting doctors (in both the private and public sectors) are likely to have a larger impact on the shortening of delays in TB treatment than interventions targeting patients. They could also reduce unnecessary out-of-pocket expenditure.

Adolescent↗

PubMed2005

Opioid purchases and expenditure in nine western European countries: 'are we killing off morphine?'.

BACKGROUND: In clinical practice the major role of opioid drugs is the management of malignant and nonmalignant pain. The primary aim of this study is to evaluate the trend in sales of four opioid analgesic drugs (codeine, tramadol, morphine, fentanyl), from wholesalers to community pharmacies, as an indicator of opioid consumption in nine European countries in 2001, 2002 and 2003. Secondary aims are to compare: (a) the amount of each drug purchased by different countries in 2003; (b) the average price for each drug in the different countries in 2003; and (c) the total expenditure for each opioid from 2001 to 2003. METHODS: Data from the Statistical Report on drugs purchased by pharmacies was supplied by IMS Health, an internationally accepted information provider for the pharmaceutical and health care industries. FINDING: In the period 2001 2003, while the percentage increase of purchases of fentanyl and tramadol was considerable, that of morphine was the lowest in most of the nine countries. The largest consumer of codeine was the UK and of tramadol was Belgium. The consumption of morphine was the lowest reported in all the countries together and was three times lower than that of transdermal fentanyl. There was a high variability in the costs of the opioids among the different countries. In 2003, the total expenditure for fentanyl reached the highest total expenditure [corrected] followed by codeine. Morphine presents the lowest expenditure in all nine countries and over all three years. INTERPRETATION: These results open up many questions. What factors influence opioid purchasing and costs in these European countries? It would be interesting to have the answers from those people who know the actual situation in the individual countries.

Codeine↗