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PubMed2002

Is it really possible to build a bridge between cost-benefit analysis and cost-effectiveness analysis?

Cost-benefit analysis (CBA) is a recognised as the economic evaluation technique that accords most with the underlying principles of standard welfare economic theory. However, due to problems associated with the technique, economists evaluating resources allocation decisions in health care have most often used cost-effective analysis (CEA), in which health benefits are expressed in non-monetary units. As a result, attempts have been made to build a welfare economic bridge between cost-benefit analysis (CBA) and cost-effectiveness analysis (CEA). In this paper, we develops these attempts and finds that, while assumptions can be made to facilitate a constant willingness-to-pay per unit of health outcome, these restrictions are highly unrealistic. We develop an impossibility theorem that shows it is not possible to link CBA and CEA if: (i) the axioms of expected utility theory hold; (ii) the quality-adjusted life-year (QALY) model is valid in a welfare economic sense; and (iii) illness affects the ability to enjoy consumption. We conclude that, within a welfare economic framework, it would be unwise to rely on a link between CBA and CEA in economic evaluations.

Cost-Benefit Analysis↗
PubMed2002

The effects of drug subsidies on out-of-pocket prescription drug expenditures by seniors: regional evidence from Canada.

Between 1970 and 1986, all Canadian provinces introduced some version of a prescription drug subsidy for those aged 65 years or over and since 1986, all the provinces have increased copayments or deductibles to some degree. Employing a first-order approximation to the welfare gains from a subsidy, we find evidence that these subsidies have been less redistributive than an absolute per household cash transfer but slightly more redistributive than a transfer that would increase each household's income by the same percentage. Such evidence may have relevance for predicting the redistributive effects of a potential national prescription drug plan for seniors in the US.

Aged↗
PubMed2002

Exploring the effects of population change on the costs of physician services.

The effects of population aging on future health care costs are an important public policy concern in many countries. We focus in this paper on physician services and investigate how changes in the size and age distribution of a population can affect the aggregate and per capita costs of such services. The principal data set (unpublished, for Ontario) provides information about payments to physicians, by age and sex of patients. Using it, we derive age/cost profiles for 19 categories of physicians. Adopting an index-theoretic framework, we then use the profiles to analyse the "pure" effects of population change (historical and projected) on physician costs, and to decompose the effects into population growth effects and population aging effects. We present calculations for Ontario, for the population of 15 industrialized countries, and for four theoretical populations.

Adolescent↗
PubMed2002

Does drinking really decrease in bad times?

This paper investigates the relationship between macroeconomic conditions and drinking using individual-level data from 1987 to 1999 interview years of the "behavioral risk factor surveillance system" (BRFSS). We confirm the procyclical variation in overall drinking identified in previous research using aggregate sales data and show that this largely results from changes in consumption by existing drinkers, rather than movements into or out of drinking. Moreover, the decrease occurring during bad economic times is concentrated among heavy consumers, with light drinking actually rising. We also find no evidence that the decline in overall alcohol use masks a rise for persons becoming unemployed during contractions. These results suggest that any stress-induced increases in drinking during bad economic times are more than offset by declines resulting from changes in economic factors such as lower incomes.

Adaptation, Psychological↗
PubMed2002

Should the US allow prescription drug reimports from Canada?

As a result of public outrage over lower prescription drug prices in Canada, Congress passed legislation that would allow these drugs to be imported into the US. The lower Canadian prices reflect price regulation. Opponents of allowing these imports have argued that the US will import Canadian price controls and that profits of pharmaceutical companies will be hurt. In this paper, a model is developed in which a good sold in the foreign country is subject to a negotiated price which is determined in a Nash bargaining game. When imports back into the home country are allowed, this negotiated price also becomes the domestic price. This causes the home firm to make fewer price concession in the Nash bargaining game. Home firm profits are found to rise under the reimport regime for both of the demand functions analyzed in this paper.

Canada↗
PubMed2002

Economic implications of antibiotic resistance in a global economy.

This paper concerns the economic implications of antibiotic resistance in a global economy. The global economy consists of several countries, where antibiotic consumption creates a stock of bacteria which is resistant to antibiotics. This stock affects the welfare in all countries because of the risk that resistant bacterial strains may be transmitted. The main purpose of the paper is to compare the socially optimal resource allocation with the allocation brought forward by the decentralized market economy. In addition, a dynamic Pigouvian tax designed to implement the globally optimal resource allocation is presented.

Anti-Bacterial Agents↗
PubMed2002

Managed competition and consumer price sensitivity in social health insurance.

This paper examines whether the introduction of managed competition in Dutch social health insurance has resulted in effective price competition among insurance funds. We find evidence of limited price competition, which may be caused by low consumer price sensitivity. Using aggregate panel data from all insurance funds over the period 1996-1998, estimated premium elasticities of market share are -0.3 for compulsory coverage and -0.8 for supplementary coverage. These elasticities are much smaller than in managed competition settings in US group insurance. This may be explained by differences in switching experience and higher search costs associated with individual insurance.

Actuarial Analysis↗
PubMed2002

Learning and the evolution of medical technologies: the diffusion of coronary angioplasty.

This study uses longitudinal data on patients receiving percutaneous transluminal coronary angioplasty (PTCA) to examine changes in outcomes and costs. All hospitals achieved substantial reductions in inpatient mortality and emergency bypass surgery over time, regardless of the number of procedures performed. Annual hospital procedure volume was also associated with improved outcomes, although the effect is small. There was no evidence that learning by doing (cumulative PTCA volume) influenced outcomes. The high correlation between annual and cumulative procedure volume precludes a point estimate of the effect of learning by doing on costs, although the upper bound on the potential learning effect is sizeable. The results suggest that centralizing provision of PTCA may lead to lower costs, but only small outcomes improvements.

Adult↗
PubMed2002

Breast cancer survival, work, and earnings.

Relying on data from the Health and Retirement Study (HRS) linked to longitudinal social security earnings data, we examine differences between breast cancer survivors and a non-cancer control group in employment, hours worked, wages, and earnings. Overall, breast cancer has a negative impact on employment. However, among survivors who work, hours of work, wages, and earnings are higher compared to women in the control group. We explore possible biases underlying these estimates, focusing on selection, but cannot rule out a causal interpretation. Our research points to heterogeneous labor market responses to breast cancer, and shows that breast cancer does not appear to be debilitating for women who remain in the work force.

Breast Neoplasms↗
PubMed2002

Alternative health insurance schemes: a welfare comparison.

In this paper, we present a simple model of health insurance with asymmetric information, where we compare two alternative ways of organizing the insurance market. Either as a competitive insurance market, where some risks remain uninsured, or as a compulsory scheme, where however, the level of reimbursement of loss is to be determined by majority decision. In a simple welfare comparison, the compulsory scheme may in certain environments yield a solution which is inferior to that obtained in the market. We further consider the situation where the compulsory scheme may be supplemented by voluntary competitive insurance; this situation turns out to be at least as good as either of the alternatives.

Actuarial Analysis↗
PubMed2002

Community rating in health insurance and different benefit packages.

This paper presents a model of a competitive health insurance market with two risk types and two health benefits. In the benchmark case, community rating insurers (CRIs) are only allowed to offer the basic benefit. The additional benefit is sold by risk rating insurers (RRIs). It is shown that low risk types can only be better off at the expense of high risk types if CRIs are allowed to offer the additional benefit and no additional measures are taken. However, high risk types can be made better off if CRIs must offer the additional benefit or if community rating health insurers offering the additional benefit are subsidized while those selling only the basic benefit are taxed.

Actuarial Analysis↗
PubMed2002

Multiple payers, commonality and free-riding in health care: Medicare and private payers.

Managed health care plans and providers in the US and elsewhere sell their services to multiple payers. For example, the three largest groups of purchasers from health plans in the US are employers, Medicaid plans, and Medicare, with the first two accounting for over 90% of the total enrollees. In the case of hospitals, Medicare is the largest buyer, but it alone only accounts for 40% of the total payments. While payers have different objectives and use different contracting practices, the plans and providers set some elements of the quality in common for all payers. In this paper, we study the interactions between a public payer, modeled on Medicare, which sets a price and takes any willing provider, a private payer, which limits providers and pays a price on the basis of quality, and a provider/plan, in the presence of shared elements of quality. The provider compromises in response to divergent incentives from payers. The private sector dilutes Medicare payment initiatives, and may, under some circumstances, repair Medicare payment policy mistakes. If Medicare behaves strategically in the presence of private payers, it can free-ride on the private payer and set its prices too low. Our paper has many testable implications, including a new hypothesis for why Medicare has failed to gain acceptance of health plans in the US.

Consumer Behavior↗
PubMed2003

Inequalities in self-reported health: validation of a new approach to measurement.

This paper assesses the internal validity of using the McMaster 'Health Utility Index Mark III' (HUI) to scale the responses on the typical self-assessed health (SAH) question, "how do you rate your health status in general?" It compares alternative procedures to impose cardinality on the ordinal responses. These include OLS, ordered probit and interval regression approaches. The cardinal measures of health are used to compute and to decompose concentration indices for income-related inequality in health. These results are validated by comparison with the individual variation in the 'benchmark' HUI responses obtained from the Canadian 'National Population Health Survey 1994-1995'. The interval regression approach, which exploits a mapping from the empirical distribution function (EDF) of HUI into SAH, outperforms the other approaches. In addition, we show how the method can be extended to allow for differences in SAH thresholds across different groups of people and to measuring and decomposing 'pure' health inequality.

Bias↗
PubMed2003

A game theoretic model of the relationship between prices and waiting times.

ISSUE: The role of prices charged to patients as a policy instrument for altering waiting times. METHOD: A game theoretic model is used to examine the determinants of waiting times. RESULTS: Under certain circumstances an increase in the price charged to patients at some institutions will lower the waiting times at all institutions. CONCLUSIONS: The results provide a set of policy implications and testable predictions that arise under a certain set of assumptions. Alternative assumptions as well as the policy implications and testable predictions associated with them are also examined.

Budgets↗
PubMed2003

Enrollee mix, treatment intensity, and cost in competing indemnity and HMO plans.

Why do indemnity insurance plans cost substantially more per capita--77% more in our study--than HMOs? We answer this question using data from a large organization's insurance pool, covering 215,000 lives. We decompose cost differences for eight major medical conditions into four sources: demographics, incidence within demographic groups, treatment intensity, and prices per service. Greater incidence of disease in the indemnity plan (both from demographics themselves and within demographic groups) and higher prices each explain nearly 50% of the difference. Contrary to conventional wisdom, indemnity plans do not have greater treatment intensity.

Adult↗
PubMed2003

Socio-economic inequality in ill-health amongst the elderly. Should one use current or permanent income?

In Belgium, income-related inequality in ill-health among the 65- is present, but reduces significantly as soon as one restricts the analysis to the 65+. The main goal of this paper is to check whether these findings (based on current income) are robust to the income concept used. The analysis is repeated using estimates of permanent income. Measured inequality among the 65+ remains very limited, suggesting that the observed findings are not heavily dependent upon the income concept. Finally, I suggest an explanation for the observed difference in inequality between the 65- and the 65+. I argue that this difference is likely to be correlated with differences across income groups of (1) sample attrition; and (2) mortality.

Adult↗
PubMed2003

Income related inequalities in mental health in Great Britain: analysing the causes of health inequality over time.

Using regression techniques this paper estimates the level of income related health inequality in GB in 1992 and 1998. Inequality is decomposed to investigate which socio-demographic factors are important contributors to health differences. The paper includes a range of measured and subjective income variables to control for absolute income. A relative deprivation measure is included to test the impact of income inequality on health inequality. It is found that subjective financial status is a major determinant of ill-health and makes a major contribution to income related inequalities in health. Relative deprivation is an important contributor for women but not for men.

Adult↗
PubMed2003

Take some days off, why don't you? Endogenous sick leave and pay.

This is a model of endogenous sick leave in the presence of endemic infectious diseases. The prevalence rate elasticity with respect to sick leave is unity, when workers are paid their marginal product, and firms profit maximise. Full information contracts yield a compensating higher wage to the sick than to the healthy workers. Sick leave pay is greater than the healthy working wage. The contracted sick leave period falls with: the external disease transmission, the productivity of the ill, the discomfort when ill on sick leave and reductions in the work discomfort of the ill. Full insurance breaks down under asymmetric information, where implicit contract firms may offer more sick leave than profit maximising firms with the same payment schedule.

Absenteeism↗