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PubMed1993

A cell based approach to modelling public expenditure.

The paper examines the use of a cell based model to analyse the effects of demographic change on the level and distribution of public expenditure. The nature and advantages of a cell based model for this purpose are described. The level and distribution of the key components of welfare state expenditure--health, education, social security--and of direct taxes, is examined for the base year of 1985. The net transfer of resources is compared to the distribution of income across cells. The effect of demographic change on the level and distribution of health and education expenditure is analysed. Issues in the further development of this approach are then reviewed.

Adolescent↗
PubMedDate not supplied

An income-weighted international average for comparative analysis of health expenditures.

Data from 17 countries across 28 years are used to estimate an international health expenditure function based on real per capita GNP. Actual and expected spending levels are compared for 24 countries. Between 1960 and 1987, it has been rare for health expenditure in any country to be more than +/- 20 per cent from the projected value. The norm is for spending to rise at 1.5 times the growth rate of GDP. Two countries appear to display significant anomalies. Spending in the United Kingdom is consistently 15-25 per cent below normal for all years, and Danish expenditure has declined from 7 to 6 per cent of GDP since 1975.

Australia↗
PubMedDate not supplied

Health sector planning led by management of recurrent expenditure: an agenda for action-research.

Health services in developing countries face a crisis of recurrent costs. Far from being able to fund primary health care (PHC) developments, governments now have difficulty in keeping existing health services in operation. This article proposes an approach to the problem based on the proactive planning and management of recurrent health expenditure. The system addresses existing services as well as future plans and allows explicit trade-offs to be made in resource allocation. This may be termed 'recurrent-expenditureled planning'. The article describes a diagnostic health sector review, which incorporates a recurrent expenditure profile in four planes: by type of provider, source of finance, level of care and recipient population group. A fifth dimension of time trends for certain expenditure categories can be added. The steps of a strategic planning cycle for health services resources are then described, which allows health service strategies to be tested for broad economic feasibility. It also results in the establishment of resource targets that can act as benchmarks against which actual levels of funding can be compared. The targets help to maintain sectoral priorities in resource allocation even in times of economic constraint and to channel funds preferentially to localities and facilities in greatest need. The system calls for innovations in the methods of health planning and financial management in the health sector. Implementation will require health systems action-research at the country level. The essential purpose is to promote PHC policy-led resource allocation and use. No amount of planning can substitute for political action to realize 'health for all', but this system provides technical support to the political forces in favour of distributive PHC policies.

Developing Countries↗
PubMed1997

How well do ambulatory care groups predict expenditures on mental health and substance abuse patients?

This paper evaluates the ability of Ambulatory Care Groups (ACGs) to prospectively predict mental health and substance abuse expenditures and total health care expenditures of persons enrolled in the New Hampshire Medicaid Program during fiscal years 1993 and 1994. A series of multi-part models is estimated separately for adults and children and a synthetic R-squared and the mean absolute predictive error are calculated. The results show that with the exception of predicting total expenditures for children, ACGs do not perform as well as simple models containing various demographic and prior mental health/substance abuse utilization measures.

Adolescent↗
PubMedDate not supplied

The Iowa Managed Substance Abuse Care Plan: access, utilization, and expenditures for Medicaid recipients.

The Iowa Managed Substance Abuse Care Plan (IMSACP) used a behavioral health care organization to manage expenditures for treatment of alcohol and drug dependence financed through Medicaid, block grants, and state appropriations but maintained relatively distinct eligibility and benefit structures for Medicaid-eligible individuals. Medicaid claims, encounters, and eligibility files were reviewed for 2 years before and 3 year after implementation of IMSACP to evaluate changes in access, utilization, and expenditures. The rate of substance abuse treatment doubled, use of inpatient hospital services decreased, and residential and outpatient services increased. Direct care costs decreased, while total expenditures held steady. The Iowa experience suggests that a well-planned initiative can control costs and improve access and utilization.

Cost Control↗
PubMedDate not supplied

The Nebraska Medicaid managed behavioral health care initiative: impacts on utilization, expenditures, and quality of care for mental health.

This study evaluates the impact of Nebraska's Medicaid managed care program for behavioral health services on mental health service utilization, expenditures, and quality of care. Implementation of the program is correlated with progressive reductions in both total (about 13% over 3 years) and per eligible per month (20%) expenditures and a rapid, extensive decline in inpatient utilization and admissions. The percentage of enrollees receiving any type of treatment for a mental disorder actually increased modestly. Most important, several indicators of quality of care (e.g., timely receipt of ambulatory care following discharge from inpatient care and readmission to inpatient care shortly following discharge) suggest that quality of care did not materially change under the carve-out. Although a thorough assessment of quality of care impacts is warranted, this study suggests implementation of a managed care program may allow states to reduce Medicaid expenditures without compromising quality of care.

Data Collection↗
PubMed2006

The relationship between health care expenditure and health outcomes. Evidence and caveats for a causal link.

The relationship between health care expenditure and health outcomes is of interest to policy makers in the light of steady increases in health care spending for most industrialised countries. However, establishing causal relationships is complex because, firstly, health care expenditure is only one of many quantitative and qualitative factors that contribute to health outcomes, and, secondly, measurement of health status is an imperfect process. This study reviews key findings and methodological approaches in this field and reports the results of our own empirical study of countries of the European Union. Our analysis examines life expectancy and infant mortality as the 'output' of the health care system, and various life-style, environmental and occupational factors as 'inputs'. Econometric analyses using a fixed effects model are conducted on a panel data set for the former 15 members of the European Union over the period 1980-1995. The findings show that increases in health care expenditure are significantly associated with large improvements in infant mortality but only marginally in relation to life expectancy. The findings are generally consistent with those of several previous studies. Caveats and improvements for future research are presented.

Causality↗
PubMed2007

A multilevel analysis on the determinants of regional health care expenditure: a note.

Health care in most countries is a rather "local good" for which the fiscal decentralization theory applies and heterogeneity is the result. In order to address the issue of multijurisdictional health care in estimating income elasticity, we constructed a unique sample using data for 110 regions in eight Organisation for Economic Co-operation and Development (OECD) countries in 1997. We estimated this sample data with a multilevel hierarchical model. In doing this, we tried to identify two sources of random variation: within- and between-country variation. The basic purpose was to find out whether the different relationships between health care spending and the explanatory variables are country specific. We concluded that to take into account the degree of fiscal decentralization within countries in estimating income elasticity of health expenditure proves to be important. Two plausible reasons lie behind this: (a) where there is decentralization to the regions, policies aimed at emulating diversity tend to increase national health care expenditure and (b) without fiscal decentralization, central monitoring of finance tends to reduce regional diversity and therefore decrease national health expenditure. The results of our estimation do seem to validate both these points.

Age Factors↗
PubMed1992

An econometric analysis of health care expenditure: a cross-section study of the OECD countries.

This paper is an empirical examination of the determinants of aggregate health care expenditure. The paper presents a systematic analysis of relationships across 19 OECD countries, showing the effects of aggregate income, institutional and socio-demographic factors on health care expenditure. The results indicate that institutional factors of the health systems, in addition to per capita Gross Domestic Product (GDP), contribute significantly to the explanation of the health care expenditure variation between countries; for example the way physicians in outpatient care are paid, and the mixture of public/private funding and inpatient/outpatient care.

Ambulatory Care↗
PubMed1989

The rising expenditure on antihypertensive drugs in New Zealand, 1981-1987.

The rising cost of treating hypertension has become an issue of concern in several countries, including the United States, parts of Europe, and more recently, New Zealand. In New Zealand between 1981 and 1987, the total inflation-adjusted expenditure on antihypertensive drugs increased by 61.7%, from $21.4 million to $34.6 million in constant 1981 dollars. The major part (56.3%) of this increase in overall expenditure was explained by the rise in real cost of drug treatment, while the number of patients on drug therapy remained virtually static over the same period. The average cost of a prescription for hypertension was estimated to have risen by 46.1% between 1981 and 1987, i.e. from $7.30 to $10.66 in constant 1981 dollars. Pardoxically the mean inflation-adjusted price of antihypertensive drugs fell by 10.8% over the same period. Changing patterns of prescription and the entry of new drugs into the market accounted for most of the rise in average cost per prescription over the study period. Unless the rising expenditure can be justified by demonstrable improvements in treatment outcome, continuation of these trends will have profound effects on the cost-effectiveness of antihypertensive therapy.

Antihypertensive Agents↗
PubMed1991

Evaluation from population registry data of health care expenditure during the 6 months after cancer diagnosis.

It is currently estimated in France, that the cost of cancer has risen to $3.8 billion, with an annual growth of 5-10%. This represents approximately 6% of all health expenditure. The data from the Registry of Tumors in the Doubs region have enabled us to make an evaluation of health expenditure, reimbursed by the French Securite Sociale (S.S.), and its distribution in relation to different activities (diagnosis, type of treatment, follow-up, transport), according to cancer site. In 1984, the average cost per patient within the first 6 months of the illness was evaluated at $4,000. The results show major differences for the cancer sites, care facilities and budget items. Diagnosis assessment represents 27% of all expenditure, surgery 37%, radiotherapy, chemotherapy and transport, 11% each. All kinds of expenses are fully reimbursed by the French S.S. and transportation, which at the beginning used to avoid hospitalization, is now used as a comfort system and represents a high cost to the S.S. The different costs for the same illness between private, general public and university hospitals do not reflect a difference in care, but rather different systems of calculating and functioning. Till now there has not been any logical evaluation of care in the French health system.

Data Collection↗
PubMed1990

Health care expenditure patterns for adolescents.

Health care expenditure patterns are described using a sample of 2,767 adolescents aged 10 to 18 years from the National Medical Care Utilization and Expenditure Survey. Average total per capita health care expenditures were $525. Average out-of-pocket expenses were $151 in 1988 dollars. The burden of out-of-pocket expenses was distributed unevenly among the families of adolescents. The 10% of adolescents with the highest expenses accounted for 65% of all out-of-pocket expenses. The presence of health insurance coverage greatly reduced the risk of incurring burdensome out-of-pocket expenses. Health policy interventions to improve health insurance coverage of adolescents are discussed.

Adolescent↗
PubMed1985

Health care expenditure containment in the United States: strategies at the state and local level.

The current status of state and local strategies to contain health care expenditures in the United States is described. These strategies are classified as predominantly regulatory, competitive or voluntary. The actions of two major groups of purchasers of care--state government programs for the indigent and private employers--in support of expenditure containment strategies are discussed as well. The large number of approaches to expenditure containment currently being attempted, and their diverse character, are hypothesized to be a result not only of increased health care inflation and the concern it causes purchasers of care, but also of fundamental changes in the health care industry in the United States which have realigned traditional provider interest groups.

Budgets↗
PubMed1993

Health needs, demand for health services and expenditure across social groups in Italy: an empirical investigation.

The shortage of empirical studies on socio-economic factors influencing demand for health care and inequalities across social groups is dramatic in the case of Italy. The present study aims at discussing these issues, although its results are to be considered mainly methodological, given the small dimension of the sample (n = 807). A survey was carried out in a 'qualitative' sample of 9 Local Health Units of different Italian regions. Attention was paid to report every 'illness episode', considered as a cause of demand for health services, within the reference period (4 weeks) in order to properly link health needs with utilization of health services and relative expenditure. The assessment of health status across social groups, using 4 different indicators, shows the weakest social groups as the most vulnerable. The same groups report higher per capita health services uses and expenditures than their morbidity conditions would require. Assuming equity to be defined as 'equal use for equal need' a particular use-need ratio is developed (i.e. health services used per illness episode) able to capture the 'intensity' of health services use and expenditure per need. The 'over-equity' towards the less favoured groups is interpreted as a possible accomplishment of the N.H.S. fundative goals. A structural model of determinants of health services utilization, carried out through the LISREL technique (R2 = 0.36), confirms the irrelevance of the social variables with respect to need variables.

Adolescent↗
PubMed1996

Regulatory effects of health examination programs on medical expenditures for the elderly in Japan.

In order to evaluate if there is any correlation between the use of general medical examination programs organized by each community under the Health Service Law for the Elderly, and the medical expenditures for the elderly, an analysis was conducted based on 97 communal data of Fukuoka prefecture, Japan in 1991. According to the results, the use of health examinations showed a statistically significant negative correlation with the medical expenditures for the elderly both for in- and outpatient services. The analysis of the medical expenditure components has clarified that this negative correlation is mainly due to the low utilization rate of services at medical facilities among the communities with a high participation rate in the examination. A part of this low utilization rate could be explained by the complementary effect of the examination program as an alternative for the elderly instead of going to a medical facility for consultation. The present result suggests that a community health service program could decrease the demand for medical services of the elderly.

Aged↗
PubMed2006

The impact of community risks and resources on adolescent risky behavior and health care expenditures.

PURPOSE: To examine a nested model that predicts adolescent risky behavior, health care use, and health care expenditures from individual characteristics, such as age and gender, and community characteristics such as social capital and community-level risky behavior rates. METHODS: Claims and encounter data were used to classify adolescents enrolled in Florida's Healthy Kids Program into two groups: those who engaged in risky behavior (ARB) and those who did not (NRB). Hierarchical linear modeling techniques were used to predict the odds of risky behavior, the odds of health care use, and health care expenditures based on individual and community characteristics. RESULTS: ARB consumed significantly more health care services than NRB, and their higher use and charges were attributable not only to individual level factors (i.e., age, gender, presence of special health care need, metropolitan residence status), but also to community level factors (i.e., social capital, risky behavior rates, violence, and ethnic/racial composition) as well. In particular, community investment in social capital predicted lower levels of risky behavior as well as lower health care expenditures. CONCLUSIONS: This information is important in terms of policy efforts at providing health care for this vulnerable group of individuals, as well as in developing prevention and intervention programs that can be delivered through the health care system and via links to community supports.

Adolescent↗
PubMed2004

On the international stability of health care expenditure functions: are government and private functions similar?

This paper studies the stability of health care expenditure functions in a sample of OECD countries. We adopt the cointegration approach and the results show that there is a long-term relationship between total health care expenditure (HCE) and gross domestic product (GDP). However, the existence of cointegration is only shown when we admit the presence of some changes in the elasticities of the model. Our results also provide evidence against the existence of a unique relationship between health and GDP for the sample. Thus, we can conclude that the differences in health systems may cause differences in the aggregate functions. Additionally, we examine aggregate health functions for government (GHCE) and private expenditures (PHCE), again finding evidence of different patterns of behaviour. Finally, we open a discussion on the character of health as a necessary or luxury good. In this context, we find differences between the government and the private function. In order to illustrate these findings, we propose a theoretical model as an example of the influence of political decisions on income elasticity.

Global Health↗
PubMed2005

Understanding the impact of eliminating user fees: utilization and catastrophic health expenditures in Uganda.

There is currently considerable discussion between governments, international agencies, bilateral donors and advocacy groups on whether user fees levied at government health facilities in poor countries should be abolished. It is claimed that this would lead to greater access for the poor and reduce the risks of catastrophic health expenditures if all other factors remained constant, though other factors rarely remain constant in practice. Accordingly, it is important to understand what has actually happened when user fees have been abolished, and why. All fees at first level government health facilities in Uganda were removed in March 2001. This study explores the impact on health service utilization and catastrophic health expenditures using data from National Household Surveys undertaken in 1997, 2000 and 2003. Utilization increased for the non-poor, but at a lower rate than it had in the period immediately before fees were abolished. Utilization among the poor increased much more rapidly after the abolition of fees than beforehand. Unexpectedly, the incidence of catastrophic health expenditure among the poor did not fall. The most likely explanation is that frequent unavailability of drugs at government facilities after 2001 forced patients to purchase from private pharmacies. Informal payments to health workers may also have increased to offset the lost revenue from fees. Countries thinking of removing user charges should first examine what types of activities and inputs at the facility level are funded from the revenue collected by fees, and then develop mechanisms to ensure that these activities can be sustained subsequently.

Adolescent↗