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PubMed2005

Acute care restructuring in Newfoundland and Labrador: the history and impact on expenditure.

OBJECTIVES: To document the history of regionalization and its effects on the Newfoundland and Labrador acute care health system, and to describe changes in acute care expenditure in the St John's region where hospital redesign, closure and aggregation occurred in relation to other regions not exposed to aggregation. METHODS: Interviews were conducted with senior health officials. Transcripts and other reports were reviewed. Financial data were abstracted from audited general ledger statements received from the Ministry of Health. RESULTS: Regionalization achieved its objectives of hospital aggregation in St John's. The average number of full-time equivalent employees increased slightly by 2% (5304-5416). In some regions, integration of services was delayed because of conflict and resistance to change. There was some disparity between the Provincial Government's objectives for cost control and the CEOs' perceptions of economies of scale. Between 1995/96 and 2002/03, total expenditures for the St John's region and the other five regional hospitals increased by 46% and 54%, respectively; total personal income of the population and government revenues increased by only 18% and 16%, respectively. CONCLUSIONS: Regionalization in Newfoundland and Labrador facilitated aggregation of hospitals, but did not control the number of front-line workers and, consequently, total acute care expenditure. Expenditure increased significantly between 1995 and 2002, at a rate which exceeded the increase in government revenues. The government's ability to pay for acute care will not be achieved unless employee costs are controlled or provincial income increases.

Health Care Reform↗
PubMed2002

Getting the cat back in the bag: reforming the way provinces manage drug expenditures to make them manageable.

The fiscal "cat" of healthcare spending - drug expenditures - is out of the bag: drug costs are now the fastest rising component of healthcare expenditures in Canada. Laupacis, Anderson and O'Brien describe the current process of listing drugs on the provincial drug formulary in Ontario, identify factors that may contribute to the rapid growth in drug expenditures, and make a number of recommendations for controlling drug expenditures, including (1) improving the evidence on cost-effectiveness; (2) disseminating the evidence to prescribers; (3) re-evaluating the evidence; and (4) increasing the transparency about the acquisition costs of drugs. These are recommendations that, if implemented, would theoretically help decision-makers make more rational decisions about which drugs to list on provincial formularies. The question of how to implement the recommendations remains to be elucidated, as does an evaluation of the trade-offs between costs and benefits of obtaining better information on cost-effectiveness.

Canada↗
PubMed1986

State variations in home health expenditures and utilization under Medicare and Medicaid.

Expenditures for home health services provided under Medicare and Medicaid nearly tripled between 1977 and 1982. Utilization and expenditures for home health services vary widely across the states for both programs, and this article examines in some detail the nature and extent of these variations. States vary considerably with respect to relative utilization, visits, and visit-expenditures under Medicare; and states vary in terms the role visits versus visit-reimbursements play in shaping overall costs. The Medicaid program is effectively two programs: New York; and the other states, with eight accounting for half of Medicaid expenditures outside New York.

Health Expenditures↗
PubMed1992

Social context and personal expenditures for health care: federal policy and the experience of older adults in the 1970s.

The relationship between the intent and the outcome of legislated social policy is discussed. Specifically, this study documents some effects of federal health reimbursement and income policy in the late 1960s and early 1970s on health care behavior and expenditures in the decade 1970-1980. The Longitudinal Retirement History Study (LRHS), containing information on a panel of 6,270 men and unmarried women aged 58 to 63 in 1969, was used to provide information on the personal health expenditures in this decade. Medicare and Medicaid and the indexing of Social Security became operational at the beginning of the study, which permitted the exploration of intended and observed effects of legislation designed to make health care more accessible and affordable for older adults. As policy intended, utilization increased over the decade as indicated by both increases in the number of panelists with health care bills and increases in the size of total bills (constant dollars). Consistent with federal policy to reduce personal costs, out-of-pocket expenditures and the proportion of total bills paid out of pocket decreased. However, the effects of these federal policy initiatives were constrained by reimbursement rules and the social location of users. For instance, even at the end of the 1970s, out-of-pocket health care expenditures across subpopulations persisted. The 1980s and early 1990s have brought increased concern over the cost of health care and renewed concern over access. Data suggest that future proposals aimed at providing universal coverage along with high out-of-pocket costs may not result in equitable programs, and are likely to have a limited impact on constraining health care costs. The LRHS data indicate that utilization increased despite continued high out-of-pocket costs for all except the lower-income groups, who may be limited in their ability to purchase increasingly costly care.

Aged↗
PubMedDate not supplied

Health care for children and youth in the United States: annual report on patterns of coverage, utilization, quality, and expenditures by income.

OBJECTIVES: To examine differences by income in insurance coverage, health care utilization, expenditures, and quality of care for children in the United States. METHODS: Two national health care databases serve as the sources of data for this report: the 2000-2002 Medical Expenditure Panel Survey (MEPS) and the 2001 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). In the MEPS analyses, low income is defined as less than 200% of the federal poverty level and higher income is defined as 200% of the federal poverty level or more. For the HCUP analyses, median household income for the patient's zip code of residence is used to assign community-level income to individual hospitalizations. RESULTS: Coverage. Children from low-income families were more likely than children from middle-high-income families to be uninsured (13.0% vs 5.8%) or covered by public insurance (50.8% vs 7.3%), and less likely to be privately insured (36.2% vs 87.0%). Utilization. Children from low-income families were less likely to have had a medical office visit or a dental visit than children from middle-high-income families (63.7% vs 76.5% for office-based visits and 28.8% vs 51.4% for dental visits) and less likely to have medicines prescribed (45.1% vs 56.4%) or have utilized hospital outpatient services (5.2% vs 7.0%), but more likely to have made trips to the emergency department (14.6% vs 11.4%). Although low-income children comprise almost 40% of the child population, one quarter of total medical expenditures were for these children. Hospital Discharges. Significant differences by community-level income occurred in specific characteristics of hospitalizations, including admissions through the emergency department, expected payer, mean total charges per day, and reasons for hospital admission. Leading reasons for admission varied by income within and across age groups. Quality. Low-income children were more likely than middle-high-income children to have their parents report a big problem getting necessary care (2.4% vs 1.0%) and getting a referral to a specialist (11.5% vs 5.3%). Low-income children were at least twice as likely as middle-high-income children to have their parents report that health providers never/sometimes listened carefully to them (10.0% vs 5.1%), explained things clearly to the parents (9.6% vs 3.4%), and showed respect for what the parents had to say (9.2% vs 4.2%). Children from families with lower community-level incomes were more likely to experience ambulatory-sensitive hospitalizations. Racial/Ethnic Differences Between Income Groups. Use and expenditure patterns for most services were not significantly different between low- and middle-high-income black children and were lower than those for white children. CONCLUSIONS: While health insurance coverage is still an important factor in obtaining health care, the data suggest that efforts beyond coverage may be needed to improve access and quality for low-income children overall and for children who are racial and ethnic minorities, regardless of income.

Adolescent↗
PubMed2001

The impact of insurance coverage on children's dental visits and expenditures, 1996.

BACKGROUND: Health insurance coverage has been shown to relate positively with the use of dental services. The purpose of the authors' study was to describe the level of dental coverage among U.S. children and to assess the impact of dental coverage on children's use of dental services and expenditures for dental care. METHODS: The focus of these analyses is on dental care coverage, use and expenditures for U.S. children during 1996. National estimates are provided for the population with dental coverage, the population with a dental visit, and mean total expenditure for each of several socioeconomic and demographic categories during 1996 using data from the Medical Expenditure Panel Survey. RESULTS: Fifty-two percent of children younger than 18 years of age had private dental coverage during 1996. Approximately 56 percent of children in families with a poverty status level of 133 percent of the federal poverty level or below were covered by Medicaid during 1996. Fifty-six percent of children with private coverage had made at least one dental visit, compared with 28 percent of noncovered children. Twenty-eight percent of children covered by Medicaid had made at least one dental visit compared with 19 percent of noncovered children. CONCLUSION: Medicaid dental coverage seems to have had a lesser effect on the likelihood of a child's having a dental visit than had private coverage. Improving oral health for poorer children may depend partly on improving the design of Medicaid dental coverage programs. PRACTICE IMPLICATIONS: By understanding these analyses, practitioners, advocates and policymakers will be better positioned to provide care, improve access and better meet the needs of all American children.

Adolescent↗
PubMed2001

Switching to gatekeeping: changes in expenditures and utilization for children.

BACKGROUND: Gatekeeping has been a central strategy in the cost-containment initiatives of managed care organizations. Little empirical research describes the impact of switching into a gatekeeping plan on health care expenditures and utilization for children. OBJECTIVE: To determine the likelihood of a parent with a chronically ill child enrolling in a health plan with gatekeeping, as well as the effects of gatekeeping on health care expenditures and utilization for children, especially those with chronic conditions. DESIGN: We followed a cohort of 1839 children who either voluntarily switched to a gatekeeping plan or remained in an indemnity plan from 1991 through 1994. Study participants were children of employees of a large hospital. The gatekeeping plan was virtually identical to the previous indemnity plan except for lower monthly employee contribution and the requirement for a primary care physician to preapprove subspecialty referrals. We determined the likelihood of a household containing a child with a chronic condition enrolling in the gatekeeping plan, as well as mean annual total, subspecialty, and primary care expenditures and utilization for all children and children with chronic conditions. RESULTS: Households switching to gatekeeping were less likely to have children with chronic illness (8% vs 15%). Total and subspecialty expenditures for all children decreased more in the gatekeeping group (53% and 59%, respectively) than in the indemnity group (11% and 6%, respectively). For children with chronic conditions, mean visits to subspecialists decreased 57% in the gatekeeping group but increased 31% in the indemnity group. Mean visits to primary care physicians decreased 23% in the gatekeeping group compared with 13% in indemnity group. CONCLUSION: Parents of children with a chronic condition were much less likely than other parents to switch to a gatekeeping plan. Switching to gatekeeping was associated with reduced visits to specialists but did not increase the involvement of primary care physicians in the management of children with chronic conditions. The implications of these findings for the health of children are unknown.

Adult↗
PubMed2005

The high costs of aggression: public expenditures resulting from conduct disorder.

OBJECTIVES: We explored the economic implications of conduct disorder (CD) among adolescents in 4 poor communities in the United States. We examined a range of expenditures related to this disorder across multiple public sectors, including mental health, general health, school, and juvenile justice. METHODS: We used self- and parental-report data to estimate expenditures during a 7-year period in late adolescence of a sample of youths. We contrasted expenditures for youths with CD and youths with oppositional defiant disorder, elevated symptoms (no CD diagnosis), and all others. Diagnosis was determined with a structured assessment. RESULTS: Additional public costs per child related to CD exceeded $70000 over a 7-year period. CONCLUSIONS: Public expenditures on youths with CD are substantially larger than for youths with closely related conditions, reflecting the importance of prevention and early treatment for the disorder.

Adolescent↗
PubMed1988

Comparing state-only expenditures for AIDS.

The State AIDS Policy Center at the Inter-governmental Health Policy Project (IHPP) at George Washington University surveyed all 50 states to determine state AIDS (acquired immunodeficiency syndrome) expenditures, without Medicaid or federal funds, for fiscal 1984-88. During this period, state-only expenditures increased 15-fold, to $156.3 million. Between fiscal 1986-1988, the distribution of state funding for AIDS patient care and support services doubled from 16 to 35 per cent and the number of states supplementing federal funds for testing and counseling increased from eight to 20. Five states continue to account for the largest AIDS appropriations. Of these, California leads in funding research; New York, Florida, and New Jersey have directed funds to provide care and services to IV (intravenous) drug users, prisoners, and children. The average state expenditure per diagnosed AIDS case is $3,323 and an increasing number of states with relatively low case loads are appropriating funds beyond this level. Across states, AIDS expenditures per person average $.65 and $.21 for education, testing and counseling--below the level recommended by the Institute of Medicine for AIDS prevention activities. Some jurisdictions support AIDS activities indirectly by shifting resources, often from their STD (sexually transmitted disease) programs--this trend deserves continuing review given the rise in STD cases and their relationship to diagnosed AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1994

State family planning and abortion expenditures: their effect on public health.

OBJECTIVES: This study examines whether state family planning expenditures and abortion funding for Medicaid-eligible women might reduce the number of low-birthweight babies, babies with late or no prenatal care, and premature births, as well as the rates of infant and neonatal mortality. METHODS: Using a pooled time-series analysis from 1982 to 1988 with the 50 states as units of analysis, this study assessed the impact of family planning expenditures and abortion funding on several public health outcomes while controlling for other important variables and statistical problems inherent in pooled time-series studies. RESULTS: States that funded abortions had a significantly higher rate of abortions and significantly lower rates of teen pregnancy, low-birthweight babies, premature births, and births with late or no prenatal care. States that had higher expenditures for family planning had significantly fewer abortions, low-birthweight babies, births with late or no prenatal care, infant deaths, and neonatal deaths. CONCLUSIONS: Funding abortions for Medicaid-eligible women and increasing the level of expenditures for family planning are associated with major differences in infant and maternal health in the United States.

Abortion, Induced↗
PubMed1997

Determinants of US local health department expenditures, 1992 through 1993.

OBJECTIVES: This study examined local health department expenditures and their relationship to several departmental characteristics, including the size of the population in the department's jurisdiction. METHODS: Local health department characteristics were obtained from a 1992/93 nationwide mail survey and modeled by means of multiple linear regression. RESULTS: Great variability existed in the per capita expenditures of local health departments, and approximately 70% of the variability was accounted for by differences in jurisdiction population size. Additional characteristics of the health departments explained another 11%. The average unadjusted per capita expenditure by local health departments nationwide was $26. CONCLUSIONS: Local health department expenditures that support essential public health services average a dime a day per person.

Health Expenditures↗
PubMed1998

Antidepressant selection and use and healthcare expenditures. An empirical approach.

The purpose of this study was to evaluate whether 1-year total healthcare expenditures differed between patients who initiated therapy on a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) after controlling for initial antidepressant selection and antidepressant use pattern. A retrospective claims database covering a privately insured population in the US was used. Patients who initiated therapy in the outpatient setting (primary care or psychiatrist) were considered. Two-stage sample selection models were estimated that included controls for initial antidepressant selection and use pattern. The analyses indicated that: (i) self-selection due to initial antidepressant selection was a statistically significant determinant of expenditures for patients who initiated therapy on a TCA but not an SSRI; (ii) after controlling for initial antidepressant selection, antidepressant use pattern was a statistically significant and positive determinant of expenditures for both TCA and SSRI patients; and (iii) after controlling for initial antidepressant selection and use pattern, 1-year total direct healthcare expenditures were significantly lower for patients who initiated therapy on an SSRI than for patients who initiated therapy on a TCA.

Antidepressive Agents↗
PubMed2000

Pharmaceutical expenditure in Spain: cost and control.

In recent years, the Spanish government has been battling to keep pharmaceutical expenditures under control. Its measures include control of prices, introduction of a "negative list" of drugs no longer reimbursed, increased cost-sharing, and introduction of overall budgets for pharmaceutical expenditures. Although the average prices of old pharmaceutical products declined by 39 percent over the last 15 years and consumption in value increased by only 10 percent, real pharmaceutical expenditures in Spain increased by 264 percent over that period. The main reason for the continuing rise in these expenditures and the failure of cost-containment measures is the introduction of new, more expensive drugs, which often fail to offer any real therapeutic advantages over products already on the market. This situation is exacerbated by a lack of effective demand-side measures such as budgets for doctors and lack of a generics market.

Cost Control↗
PubMed1995

[Analysis of factors associated with medical expenditure for the elderly in Fukuoka].

Based on "the Report of National Health Insurance Plan in Fukuoka", "the Report of Health Services for the Elderly in Fukuoka", and "the Health Statistics of Fukuoka" of 1987 and 1991, factors associated with medical expenditures for the elderly were examined. According to the result of correlation analyses, the general medical examination participation rate under the Health Service Law for the Elderly showed a statistically significant negative correlation with the in-patient medical expenditures as well as the out-patient medical expenditures for the elderly. The analysis concerning the three components of medical expenditure has clarified that this negative correlation is mainly explained by the low utilization of medical services among communities with a high general medical examination participation rate under the Law. This fact suggests that the general medical examination service might have a complementary effect against receiving care in medical facilities. However, there exists a possibility that the negative correlation observed in this study might be explained by the existence of "the third factor" intervening the pathway. In order to clarify the mechanism of relation observed, a micro-level analysis should be required.

Aged↗
PubMed1991

Health expenditure growth in Japan and the United States.

This paper compares the effects of governmental policy changes on health care expenditures in Japan with similar effects in the United States. Our results indicate that Japanese economic expansion and inflation before 1982 generated higher health expenditure growth rates than those in the United States. But after a policy change in 1982, Japanese health expenditure growth dropped from 15 to 5.5 percent annually while expenditure growth in the United States remained high despite Medicare's Prospective Payment System (PPS).

Data Collection↗
PubMed1991

National health expenditures, 1990.

During 1990, health expenditures as a share of gross national product rose to 12.2 percent, up from 11.6 percent in 1989. This dramatic increase is the second largest increase in the past three decades. The national health expenditure estimates presented in this article document rapidly rising health care costs and provide a context for understanding the health care financing crisis facing the Nation today. The 1990 national health expenditures incorporate the most recently available data. They differ from historical estimates presented in the preceding article. The length of time and complicated process of producing projections required use of 1989 national health expenditures--data available prior to the completion of the 1990 estimates presented here.

Actuarial Analysis↗
PubMed1993

Containing use and expenditures in publicly insured long-term care programs.

British Columbia and Manitoba have the most developed and comprehensive publicly financed long-term care (LTC) programs in North America. For U.S. policymakers, these programs are large-scale natural experiments with public LTC insurance. During the 1980s, both provinces successfully contained the growth of public expenditures on nursing homes, and one province successfully contained the growth of public expenditures on home support services, adjusting for population growth. Because provincial cost-control methods are similar to those that some States already use, it is likely that managers could contain the growth of public expenditures once a publicly insured U.S. LTC program was implemented. The level of public expenditure would depend partly on the level of compensation for LTC sector personnel, which is relatively low in the United States.

Aged↗
PubMed1994

National health expenditures, 1993.

This article presents data on health care spending for the United States, covering expenditures for various types of medical services and products and their sources of funding from 1960 to 1993. Although these statistics show a slowing in the growth of health care expenditures over the past few years, spending continues to increase faster than the overall economy. The share of the Nation's health care bill funded by the Federal Government through the Medicaid and Medicare programs steadily increased from 1991 to 1993. This significant change in the share of health expenditures funded by the public sector has caused Federal health expenditures as a share of all Federal spending to increase dramatically.

Cost Allocation↗