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PubMed2003

Use of willingness to pay to study values for pharmacotherapies for migraine headache.

BACKGROUND: There is a wide range of therapeutic options for migraine headaches, yet little is known about how patients value different treatment alternatives nor how to tailor treatments to patients' preferences. OBJECTIVE: Assess patients' preferences for outcomes of treatment of migraine headache based on their marginal willingness to pay (WTP) for treatment attributes. MATERIALS AND METHODS: In an Internet-based study, we used computer software to measure participants' WTP for a hypothetical ideal drug (one that was 100% effective, worked quickly, and had no adverse effects) and for other hypothetical drugs, each with one "less than ideal" attribute of performance. SUBJECTS: Two hundred fifty-seven self-identified migraineurs recruited via an Internet Web site. RESULTS: A high proportion of participants in the study had symptoms consistent with migraine etiology of headache (99%). Median "out-of-pocket" monthly WTP cost for an ideal migraine therapy was 130 dollars. WTP was associated with participants' own migraine experience: severity of pain, frequency of headaches, and the types of medications used in the past. WTP was reduced when pharmaceuticals offered less benefit, ranging from a mean of 74% of ideal for treatments that failed to relieve nausea, to 43% of ideal in treatments associated with a 50% chance of a rebound headache. CONCLUSIONS: There is wide variability in patients' strength of preference for different attributes of migraine therapy. Choice of therapy for migraine headache should be individualized based on patients' preferences. WTP measures appear to be a valid and feasible metric for quantifying treatment preferences for migraine therapies.

Adult↗
PubMed2003

Workers' decisions to take-up offered health insurance coverage: assessing the importance of out-of-pocket premium costs.

BACKGROUND: Many proposed policy initiatives involve subsidies directed toward encouraging employers to offer coverage and toward workers to encourage enrollment in offered plans. Given that insurance coverage reflects employers' decisions to offer coverage, eligibility requirements for such coverage, and employees' take-up decisions, all three elements are important when considering mechanisms to decrease the number of uninsured individuals. RESEARCH DESIGN: In this study, we examine the relationship between workers' decisions to take-up offers of health insurance and annual out-of-pocket contributions, total premiums, and employer and workforce characteristics. We model the take-up decision using cross-sectional data from approximately 18,000 establishments per year from the 1997 to 1999 Medical Expenditure Panel Survey - Insurance Component. RESULTS: We find that workers are less likely to enroll in coverage as single employee contributions increase. Our results for family contributions are much smaller than for single contributions and are not statistically significant in all years. Our simulation results suggest that reducing employee contribution levels for single coverage from existing levels in 1999 to zero would yield an increase in take-up rates of roughly 6% points in establishments that had required a positive level of contributions. Our results also indicate that of the 13.8 million private sector workers who decline coverage from their employers, 2.5 million would potentially enroll in employer-sponsored coverage if the cost of single coverage were to fall to zero. CONCLUSION: Reducing employee contributions will increase take-up rates; however, even when employees pay nothing for their coverage, some employees elect not to enroll.

Computer Simulation↗
PubMed2003

Health care expenditure burdens among elderly adults: 1987 and 1996.

OBJECTIVES: Concerns about the health care expenditure burdens of elderly adults underlie the ongoing debate over expanding Medicare benefits and strengthening Medicare+Choice. We examine burdens for this population using data from the 1987 National Medical Expenditure Survey (NMES) and the 1996 Medical Expenditure Panel Survey (MEPS). METHODS: We estimate how frequently elderly adults live in families whose health expenditures exceed 20% or 40% of their after-tax disposable incomes. Our methodology reduces bias due to errors in income while providing an intuitive measure of exposure to the risk of high burdens. RESULTS: Despite rapid increases in medical care prices, the percentage of elderly adults facing burdens over 20% of disposable income remained essentially constant at 20.9% in 1987 and 22.9% in 1996. The percentage with burdens exceeding 40% of disposable income was 7.3% in 1987 and 7.9% in 1996. High expenditure burdens were more prevalent among elderly adults who were poorer, older, female, higher risk, and covered only by traditional Medicare. Medicaid coverage helped to reduce burdens among the elderly poor, yet incomplete Medicaid take-up in 1996 left approximately 1.3 million elderly adults eligible for Medicaid but covered only by traditional Medicare. CONCLUSIONS: Our results highlight the widespread prevalence of high health care expenditure burdens among elderly adults and the varying extent to which insurance coverage helped to protect them from rising health care expenditures between 1987 and 1996.

Aged↗
PubMed2004

The health effects of restricting prescription medication use because of cost.

BACKGROUND: High out-of-pocket expenditures for prescription medications could lead people with chronic illnesses to restrict their use of these medications. Whether adults experience adverse health outcomes after having restricted medication use because of cost is not known. METHODS: We analyzed data from 2 prospective cohort studies of adults who reported regularly taking prescription medications using 2 waves of the Health and Retirement Study (HRS), a national survey of adults aged 51 to 61 in 1992, and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older in 1993 (n = 7991). We used multivariable logistic and Poisson regression models to assess the independent effect on health outcomes over 2 to 3 years of follow up of reporting in 1995-1996 having taken less medicine than prescribed because of cost during the prior 2 years. After adjusting for differences in sociodemographic characteristics, health status, smoking, alcohol consumption, body mass index (BMI), and comorbid chronic conditions, we determined the risk of a significant decline in overall health among respondents in good to excellent health at baseline and of developing new disease-related adverse outcomes among respondents with cardiovascular disease, diabetes, arthritis, and depression. RESULTS: In adjusted analyses, 32.1% of those who had restricted medications because of cost reported a significant decline in their health status compared with 21.2% of those who had not (adjusted odds ratio [AOR], 1.76; confidence interval [CI], 1.27-2.44). Respondents with cardiovascular disease who restricted medications reported higher rates of angina (11.9% vs. 8.2%; AOR, 1.50; CI, 1.09-2.07) and experienced higher rates of nonfatal heart attacks or strokes (7.8% vs. 5.3%; AOR, 1.51; CI, 1.02-2.25). After adjusting for potential confounders, we found no differences in disease-specific complications among respondents with arthritis and diabetes, and increased rates of depression only among the older cohort. CONCLUSIONS: Cost-related medication restriction among middle-aged and elderly Americans is associated with an increased risk of a subsequent decline in their self-reported health status, and among those with preexisting cardiovascular disease with higher rates of angina and nonfatal heart attacks or strokes. Such cost-related medication restriction could be a mechanism for worse health outcomes among low-income and other vulnerable populations who lack adequate insurance coverage.

Aged↗
PubMed2005

Effect of increased cost-sharing on oral hypoglycemic use in five managed care organizations: how much is too much?

BACKGROUND: For patients with a chronic disease, increased cost-sharing for medications may lead to unintended consequences, including reduced use of medications essential for control of their disease. OBJECTIVE: The objective of this study was to estimate the effects of small ($1-6 per 30-day supply), moderate ($7-10), and large (>$10) increases in medication cost-sharing on 12-month trends in oral hypoglycemic (OH) use among adults with type 2 diabetes. METHODS: We conducted a quasiexperimental study using a time series with comparison group design. Data were obtained from computerized membership, benefit, and pharmacy dispensing data of 5 managed care organizations (MCOs). A total of 13,110 12-month episodes of OH use and a medication cost-sharing increase ("intervention") were matched with 13,110 that had no increase. The dependent variable was OH average daily dose (ADD) standardized to each episode's mean OH ADD in the 6-month preintervention period. The principal independent variable was change in cost per 30-day OH supply between the 6-month pre- and postintervention periods. Effects of changes in cost-sharing on OH ADD were estimated using segmented time series regression. RESULTS: Episodes with >$10 increase in cost-sharing had significantly (alpha=0.05) decreased OH ADD in the postintervention period. At 6 months after this increase, OH ADD had decreased by 18.5% from that predicted from the preintervention trend. Episodes with a $1 to $10 increase in cost-sharing and those with no increase in cost-sharing had significant linear increases in OH use over the 12-month period. CONCLUSIONS: Large increases in medication cost-sharing were associated with immediate and persistent reductions in OH use. Small and moderate increases had little effect on OH use in the 6-month period after the increase.

Adolescent↗
PubMed2005

Booming prescription drug expenditure: a population-based analysis of age dynamics.

BACKGROUND: Prescription drug expenditures in North America have nearly doubled in the past 5 years, creating intense pressure for all public and private benefits managers and policymakers. OBJECTIVE: The objective of this study was to describe age-specific drug expenditure trends from 1996 to 2002 for the Canadian province of British Columbia. STUDY DESIGN: This study shows changes in expenditures per capita quantified for 5 age categories: residents aged 0 to 19, 20 to 44, 45 to 64, 65 to 84, and 85 and older. The cost impacts of 7 determinants of prescription drug expenditures are quantified. DATA: This study describes population-based, patient-specific pharmaceutical data showing the type, quantity, and cost of every prescription drug purchased by virtually all residents of British Columbia. RESULTS: Population-wide expenditures per capita grew at a rate of 11.6% per annum. Growth was primarily driven by the selection of more costly drugs per course of treatment and increases in the number concomitant treatments received per patient. Population aging did not have a major impact on expenditures. However, expenditure per capita grew most rapid among residents aged 45 to 64, the cohort that expended most over the period. The aging of this demographic cohort may threaten the financial viability of age-based drug benefit programs.

Adolescent↗
PubMed2006

Out-of-pocket health spending between low-and higher-income populations: who is at risk of having high expenses and high burdens?

OBJECTIVE: We studied the effects of health insurance, health care needs, and demographic and area characteristics on out-of-pocket health care spending for low and higher income insured populations. MATERIALS AND METHODS: We used the 2002 National Survey of America's Families to analyze out-of-pocket health spending. People were classified into 3 levels of expenses based on their out-of-pocket health care spending and 3 levels of financial burden based on spending as a share of family income. We used a multinomial logit model to estimate the effect of insurance status and other factors on expense and burden levels. RESULTS: Public insurance appears to offer the best financial protection from high out-of-pocket expenses and financial burden for those who are eligible. Families with private nongroup coverage have the highest odds of being in the high-expense and high-burden categories for all incomes. For higher-income families, having a family member in fair or poor health is a significant risk factor for high out-of-pocket expenses and financial burden. Having higher penetration of health maintenance organizations in an area appears to lower the odds of being in the high-burden category for all families. CONCLUSIONS: Health insurance may not prevent people from having high health care spending. Low-income people with serious health needs appear to be financially constrained and spend less on health care relative to higher-income people, and the presence of health maintenance organizations may help reduce out-of-pocket health care spending.

Cost of Illness↗
PubMed2006

Health care expenditure burdens among adults with diabetes in 2001.

OBJECTIVE: High out-of-pocket costs can pose a significant burden on patients with chronic conditions such as diabetes and contribute to decreased treatment adherence. We examined financial burdens among adults with diabetes using nationally representative data. METHODS: estimated how frequently adults with diabetes live in families in which spending on health insurance premiums and health care services exceed a specified percentage of family-level after-tax disposable income. RESULTS: We found that adults with diabetes face greater risks of high burdens compared with adults with any other highly prevalent medical condition. Adults with diabetes have lower incomes and pay a higher share of total expenditures out-of-pocket compared with adults with heart disease, hypertension, and cancer. Among adults with diabetes, women, those who live in poverty, and those with coexisting conditions are more likely to bear high burdens. Among nonelderly adults, those with public coverage and the uninsured have greater risk of high burdens compared with those with private insurance. More than 23% of the uninsured and more than 20% of those with public coverage spend more than half of their disposable income on health care. Among the elderly, those with private nonemployment related insurance have the greatest risk of high burdens followed by those with Medicare only, those with private employment-related coverage, and those enrolled in Medicaid. Prescription medications and diabetic supplies account for 63% to 70% of out-of-pocket expenditures among the nonelderly and 62% to 69% among the elderly. CONCLUSIONS: Our study identifies the subpopulations among adults with diabetes who are more likely to have high burdens, so that intervention measures can be targeted to help reduce treatment noncompliance. Our analysis also emphasizes the role of medications and diabetic supplies in contributing to high out-of-pocket burdens.

Adult↗
PubMed2007

Does the patient's payer matter in hospital patient safety?: a study of urban hospitals.

BACKGROUND: Previous studies have documented that hospitals decrease costs in response to reimbursement cutbacks. However, research concerning how this may affect quality of care has produced mixed results. Until recently, the ability to study changes in patient safety and payment has been limited. OBJECTIVE: The objective of the study was to determine whether changes in 4 hospital patient safety indicator (PSI) rates are related to changes in the generosity of payers over time. DATA AND METHODS: Study data are drawn from 1995-2000 hospital discharges in 11 states in the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project State Inpatient Database. Following the same organizations over time, we estimate hospital fixed-effects regression models of the association of payer-specific time and post Balanced Budget Act (BBA) payment changes with risk-adjusted hospital PSI rates controlling for patient, organizational, and market characteristics. Four PSIs relevant to a large number of patients and hospitals that reflect general care processes are studied. RESULTS: The time trend during 1995-2000 is consistently significantly positive for private and Medicare hospital PSI rates. Thus, after controlling for patient characteristics and organizational and market factors, performance worsened. The trend is less consistent for Medicaid and does not exist for self-pay hospital PSI rates. After adjusting for multiple comparisons, we also find that the Medicare trend is fairly consistently higher than that of the other payers. In contrast, there is a less consistent BBA effect, especially for Medicare.

Financing, Personal↗
PubMed2004

Emergency room coverage: an evolving crisis.

Historically, a newly graduated plastic surgeon in the United States could build a practice from his or her emergency room coverage. The historical cliche was for the surgeon to be affable, able, and available, and from that basis one's practice would grow. Emergency room exposure was an avenue for starting a practice, developing recognition, and, after that, building a referral pattern. Recently, the cross-shifting influence of management care, rising malpractice insurance costs, and risk ratio are changing this cliche to a crisis. An evaluation of a 2 1/2-year exposure to emergency room coverage has revealed a completely different profile. A total of 300 patient visits resulting in 69 surgical operations were evaluated for insurance and remuneration history. The findings indicated a significant remuneration dilemma for emergency room coverage. Interestingly, a remuneration problem exists in a market different from what one would expect. In this study, a sample from a suburban hospital, rather than an inner-city university hospital, is the greater problem.

Cost Control↗
PubMed2005

Use of complementary and alternative medicine by parents of children with HIV infection and asthma and well children.

OBJECTIVE: Although the use of complementary and alternative medicine (CAM) in children is increasing, little is known about its use in children with human immunodeficiency virus (HIV) infection. This study investigated the use of CAM by parents of children with HIV infection (H), children with asthma (A), and well children (W). Our hypothesis was that parents of the H group are more likely to use CAM than parents of the W or A group because of the nature and severity of the illness. MATERIALS AND METHODS: Parents of 152 subjects [H (n = 46), A (n = 53), and W (n = 53)] were interviewed on the use of CAM for their children, types of CAM, reasons for use/nonuse, methods of payment, and perceived benefits for their children. RESULTS: Compared with parents of the W and A groups, parents of the H group were less likely to be employed, were less likely to have private insurance, were less likely to have a high school or college education, and were more likely to be black. Interestingly, 38% of the W parents used CAM in their children compared with 22% in the H group and 25% in the A group. More than 80% of all three groups paid out of pocket for their use of CAM in their children. Within these groups, H parents were more likely to want CAM as part of their child's medical care (H = 91% vs W = 75% and A = 67%, P = 0.02) and were more likely to believe that CAM was expensive (H = 78% vs W = 57% and A = 60%, P < 0.01). CONCLUSIONS: Our study revealed a relatively high rate of CAM usage by parents of all three study groups. Although parents of children with HIV infection were more likely to want CAM as part of their children's medical care, their rate of CAM usage was not higher than that in well children. This may be related to their socioeconomic factors. A larger and more diverse study population may provide more information on factors contributing to CAM usage in chronically ill and well children.

Asthma↗
PubMed2006

The burden of noncompliance with seat belt use on a trauma center.

INTRODUCTION: It is well-known that noncompliance with seat belt use results in worse injury. The impact of noncompliance on hospital resource consumption and hospital charges is less well known. This study was carried out to examine the economic burden of noncompliance with seat belt use. METHODS: Trauma registry data were reviewed for patients involved in motor vehicle crashes in 2003 and 2004. Routine demographic data were analyzed. Outcome data included hospital length of stay, intensive care unit length of stay, number of ventilator days, and mortality. Hospital charges, rate of collection, hospital use (measured by need for admission), operating room use, and intensive care unit use were calculated to determine the burden of noncompliance with seat belt use. RESULTS: There were 3,426 patients identified for analysis. Of these patients, 1,744 (51%) were compliant with seat belt use (SEAT) while 1,682 were not compliant (NO SEAT). Patients in the NO SEAT group were significantly younger (31.2 versus 37.4 years old) and significantly more severely injured (Injury Severity Score of 11 versus 7) than those in the SEAT group. Patients in the NO SEAT group had a significantly longer hospital length of stay (4.4 versus 2.2 days) and intensive care unit length of stay (1.4 versus 0.3 days), as well as significantly more ventilator days (1.2 versus 0.2 days) than those in the SEAT group. Mortality was more than doubled in the NO SEAT group (2.2 versus 0.9%) as compared with the SEAT group. Resource consumption was significantly greater in the NO SEAT group, as evidenced by increased hospital use (64.9 versus 39%), increased critical care unit use (22.9 versus 10.3%) and increased operating room use (9.2 versus 4.9%) when compared with the SEAT group. Subsequently, hospital charges were significantly higher in the NO SEAT group ($32,138 versus $16,547) than in the SEAT group. Charge collection rate was lower in the NO SEAT group (30.5 versus 42.5%) than in the SEAT group. CONCLUSIONS: These data quantify the burden placed on a trauma center by noncompliance with seat belt use. This information should drive more focused education and injury prevention programs. It should also be clearly articulated to legislators to stimulate more support for more stringent legislative policy and improved trauma center funding.

Accidents, Traffic↗
PubMed2006

Maintaining patient throughput on an evolving trauma/emergency surgery service.

BACKGROUND: The case-management team (CMT) has been an effective tool to decrease denied days and improve hospital throughput on a trauma service. With the addition of emergency general surgery (EGS) to our practice, we reviewed the ability of the case management team to absorb EGS patients on the inpatient trauma service while maintaining the improvements initially realized. METHODS: An interdisciplinary CMT was implemented in January 1999. CRNPs were added in August 2003 to address the Accreditation Council for Graduate Medical Education resident work-hour restrictions. "Key communications" for each CMT member are reported three times per week as defined by a hospital-approved policy. Beginning in August 2001, the trauma service was expanded to include EGS patients. Data from the trauma registry, hospital utilization review, and finance office were analyzed before (1998 and 1999) and after (2003 and 2004) the addition of EGS. Tests of proportion were used to evaluate questions of interest. RESULTS: The number of injured patients admitted to the trauma service remained relatively constant during the study periods, ranging from a high of 1,365 in 1999 to a low of 1,116 in 2003. Beginning in 2003, the influx of emergency surgery patients to the service was marked. By 2004, there were 561 emergency surgery admissions, representing more than 30% of the total service admissions. As a result, the total number of service admissions has dramatically increased, reaching 1,833 in CY 2004, a 56% increase from CY 1998 levels. Hospital length of stay data varied from a low of 5.5 days in CY 1999 to a high of 6.9 days in CY 2003. Length of stay appeared to be associated with injury severity (mean Injury Severity Score 11.8 in 1999 and 13.1 in 2003) and case mix, but not associated with denied days. The percent of denied days decreased over the study periods, from 4.6% in 1998 (before the implementation of the CMT) to 0.5% in 2004 (p<0.01). The percent of readmissions also fell significantly over the study periods (4.0% in 1998 to 1.8% in 2004; p<0.01). CONCLUSIONS: The initial improvements in patient throughput noted after the introduction of a CMT in January 1999 have been maintained in recent years despite the addition of an EGS component to the trauma service. Percent denied days and readmissions have continued to decrease. The length of stay for these patients remains, in part, dependent on other factors. The CMT plays an integral role in maintaining the efficiency of a trauma/emergency surgery service.

Adolescent↗
PubMedDate not supplied

Early-onset Alzheimer disease: when is genetic testing appropriate?

Alzheimer disease (AD) is a neurodegenerative disease that is currently not preventable or curable. Early-onset AD can be due to mutations in several autosomal dominant genes. Clinical testing is available for presenilin 1 (PS1), which is the most common of these genes. However, many practical and ethical issues must be considered before ordering this test for patients with early-onset AD. In this paper, we present a case that demonstrates the complexities of genetic testing for early-onset AD.

Alzheimer Disease↗
PubMedDate not supplied

Out-of-pocket health care expenditures among older Americans with dementia.

The number of older individuals with dementia will likely increase significantly in the next decades, but there is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by cognitively impaired individuals and their families. We used data from the 1993 and 1995 Asset and Health Dynamics Study, a nationally representative longitudinal survey of older Americans, to determine the OOPE for individuals with and without dementia. Dementia was identified in 1993 using a modified version of the Telephone Interview for Cognitive Status for self-respondents, and proxy assessment of memory and judgment for proxy respondents. In 1995, respondents reported OOPE over the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. The adjusted mean annual OOPE was 1,350 US dollars for those without dementia, 2,150 US dollars for those with mild/moderate dementia, and 3,010 US dollars for those with severe dementia (p < 0.01). Expenditures for hospital/nursing home care (1,770 per year US dollars) and prescription medications (800 per year US dollars) were the largest OOPE components for those with severe dementia. We conclude that dementia is independently associated with significantly higher OOPE for medical care compared with those with normal cognitive function. Severe dementia is associated with a doubling of OOPE, mainly due to higher payments for long-term care. Given that the number of older Americans with dementia will likely increase significantly in the coming decades, changes in public funding aimed at reducing OOPE for both long-term care and prescription medications would have considerable impact on individuals with dementia and their families.

Aged↗