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PubMed1999

The complementarity of teen smoking and drinking.

Teen drinkers are over twice as likely as abstainers to smoke cigarettes. This empirical study provides evidence of a robust complementarity between these health behaviors by exploiting the "cross-price" effects. The results indicate that the movement away from minimum legal drinking ages of 18 reduced teen smoking participation by 3 to 5%. The corresponding instrumental variable estimates suggest that teen drinking roughly doubles the mean probability of smoking participation. Similarly, higher cigarette taxes and reductions in teen smoking are associated with a lower prevalence of teen drinking. However, the results which rely on cigarette taxes for identification are estimated imprecisely.

Adolescent↗
PubMed2000

On stationarity and cointegration of international health expenditure and GDP.

This paper examines stationarity and cointegration of health expenditure and GDP, for a sample of 21 OECD countries using data for the period 1960-1997, by applying a test battery that allows robust inference to be made on the stationarity and cointegration issue. Trend stationarity and no-cointegration are tested using new country-by-country and panel tests, not previously applied in this setting. New results for country-by-country and panel tests of non-stationarity and cointegration are presented. Our unit root and trend stationarity results indicate that both health expenditure and GDP are non-stationary. The no-cointegration and cointegration results indicate that health expenditure and GDP are cointegrated.

Data Interpretation, Statistical↗
PubMed2000

The family as producer of health--an extended Grossman model.

Deriving a model, where each family member is the producer of his own and other family members' health, shows that the family will not try to equalise marginal benefits and marginal costs of health capital for each family member. They will rather invest in health until the rate of marginal consumption benefits equals the rate of marginal net effective costs of health capital. The level of compensation in the social insurance system, the effective price of care, health related information, and transfer payments will all affect the production possibility set, and therefore the optimal level and distribution of family health.

Decision Making↗
PubMed2000

Properties of actuarially fair and pay-as-you-go health insurance schemes for the elderly. An OLG model approach.

The aged dependency ratio or ADR is growing at a fast pace in many countries. This fact causes stress to the economy and might create conflicts of interest between young and old. In this paper the properties of different health insurance systems for the elderly are analysed within an overlapping generations (OLG) model. The properties of actuarial health insurance and different variations of pay-as-you-go (PAYG) health insurance are compared. It turns out that the welfare properties of these contracts are heavily dependent on the economy's dynamic properties. Of particular importance is the magnitude of the rate of population growth relative to the interest rate. In addition, it is shown that public health insurance is associated with an inherent externality resulting in a second-best solution.

Actuarial Analysis↗
PubMed2003

Assessment of cost-effectiveness of universal hepatitis B immunization in a low-income country with intermediate endemicity using a Markov model.

BACKGROUND/AIMS: Most countries with high hepatitis B (HB) virus endemicity and most high-income countries have introduced immunization programmes against this infection. However, several low-income countries with intermediate HB endemicity have not done so. We performed a cost-effectiveness analysis of universal childhood HB immunization in such countries using India as an example, since available data on this aspect are limited. METHODS: Marginal cost of every life-year and quality-adjusted life-year (QALY) gained with universal HB vaccination was calculated using a Markov model. Two types of analyses (including and excluding expenditure on treatment of long-term complications of HB infection) were done. Several sensitivity analyses and Monte-Carlo simulation were performed. RESULTS: Universal immunization reduced the HB carrier rate by 71%, and increased the number of years and QALY lived by a birth-cohort by 0.173 years (61.072 vs. 60.899 years) and 0.213 years (61.056 vs. 60.843 years), respectively. Marginal costs were US$16.27 per life-year gained and US$13.22 per QALY gained, much lower than annual per capita income. One-way sensitivity analysis and Monte-Carlo simulation confirmed the robustness of the conclusions. CONCLUSIONS: Universal HB immunization is highly cost-effective in low-income countries with intermediate endemicity rates.

Cost-Benefit Analysis↗
PubMed2000

The determinants of the public-private mix in Canadian health care expenditures: 1975-1996.

The health care policy issue regarding the balance between public and private health spending is examined. An empirical model of the determinants of the public-private mix in Canadian health care expenditures over the period 1975-1996 is estimated for total health care expenditures as well as separate expenditure categories such as hospitals, physicians and drugs. The results find that the key determinants of the split are per capita income, government transfer variables and the share of individual income held by the top quintile of the income distribution. Much of the public-private split is determined by long term economic forces. However, the importance of the federal health transfer variables and the variables representing shifts in fiscal transfer regimes suggest the increase in the private share of health spending since 1975 is also partly the result of the policy choice to reduce federal health transfers.

Canada↗
PubMed2000

Appraising the financial reform in Bulgarian public health care sector: the Health Insurance Act of 1998.

The public health care services in Bulgaria were deteriorating, especially during the decade of transitional process. The method of health care finance was a major reason for the poor performance of the Bulgarian public health care sector. Bulgarian policy-makers decided that an insurance-based financial mechanism could help to rescue the failing public health care services. This paper explores the social benefits and the feasibility of the insurance-based finance in the Bulgarian public health care sector. The discussion in the paper implies that, in the current conditions of economic recession, the insurance-based health care finance can not be socially beneficial for Bulgaria. Moreover, the insurance implementation seams to be unfeasible due to a lack of sufficient financial resources.

Bulgaria↗
PubMed2002

Productivity costs before and after absence from work: as important as common?

Traditionally, production losses are estimated using the human capital or friction cost method. These methods base estimations of productivity costs on data on absence from work. For some diseases, like migraine, productivity losses without absence are occasionally calculated by estimating the production losses from reduced productivity at work. However, diseases typically only associated with absence may also be expected to cause reduced productivity before and after absence. In a previous study, Brouwer et al. concluded that productivity losses without absence are also very relevant in common diseases, like influenza, common cold or neck-problems. Studying a new sample of employees of a Dutch trade-firm (n = 51), who completed the questionnaire 'Ill and Recovered' upon return to work after absence due to illness, it was revealed that about 25% of the respondents experienced production losses before absence and about 20% of the respondents experience production losses after absence. This leads to an increase in estimated production losses of about 16% compared with only considering absence data. Current productivity costs estimates based solely on absence data may, therefore, underestimate real productivity costs. Compensation mechanisms in firms may reduce the underestimation.

Absenteeism↗
PubMed2003

A model for costs of stroke services.

In industrialised countries, stroke is one of the most common causes of death and handicap, and the costs for stroke services are high. However, rational planning of stroke services and estimation of the costs of their provision are complex, even when generic pathways for stroke diagnosis and treatment are well understood. The reason is the chronic nature of cerebro-vascular disease and the cumulative effect of disabling brain injury. In this paper we describe development of a computer model for estimating the costs of stroke services, intended for use by planners and purchasers of stroke care services. The model operates by incrementing patients' experience of stroke events and their outcomes in annual steps, and is calibrated using Swedish data. We demonstrate the cost consequences by simulating three different policy changes. The model facilitates comparisons between stroke prevention, treatment and rehabilitation, and we conclude that by combining the three policy options it is possible to reduce the costs for stroke services markedly.

Adult↗
PubMed2003

Belgium: risk adjustment and financial responsibility in a centralised system.

Since 1995 Belgian sickness funds are partially financed through a risk adjustment system and are held partially financially responsible for the difference between their actual and their risk-adjusted expenditures. However, they did not get the necessary instruments for exerting a real influence on expenditures and the health insurance market has not been opened for new entrants. At the same time the sickness funds have powerful tools for risk selection, because they also dominate the market for supplementary health insurance. The present risk-adjustment system is based on the results of a regression analysis with aggregate data. The main proclaimed purpose of this system is to guarantee a fair treatment to all the sickness funds. Until now the danger of risk selection has not been taken seriously. Consumer mobility has remained rather low. However, since the degree of financial responsibility is programmed to increase in the near future, the potential profits from cream skimming will increase.

Belgium↗
PubMed2003

Needs for further improvement: risk adjustment in the German health insurance system.

The German risk adjustment mechanism is used only within the public system. It was introduced in two steps, 1994 and 1995. Because of the income-related contribution, which the insured pay directly to their sickness fund, income of the insured is equalized by the mechanism and causes the biggest part of the payments among the sickness funds. On the expenditure side age, gender, disability and entitlement for sickness allowances are used as risk adjusters. The mechanism is retrospective, calculating average costs for each of the 670 risk cells defined by the risk adjusters and using these "standardized expenditures" as a base for the payment a single sickness fund gets because of its risk structure. There do still exist incentives for risk selection. The experience shows that mostly the young and healthy are willing to change sickness funds motivated by lower contribution rates. This can be used and is used for self-selection. Another cause of risk selection is regional differences. The central suggestion of an expertise on behalf of the German Ministry of Health on experiences and improvement proposals is the change to a direct modeling of morbidity.

Actuarial Analysis↗
PubMed2003

Risk adjusted premium subsidies and risk sharing: key elements of the competitive sickness fund market in the Netherlands.

As part of a market-oriented health care reform, in 1991 risk adjusted premium subsidies were introduced in the Dutch social health insurance sector. Currently the premium subsidies are primarily based on demographic variables. To mitigate the obvious inadequacy of these risk adjusters, the system of risk adjustment is supplemented with a system of risk sharing. This paper describes the main characteristics of the Dutch health care system and the development of risk adjustment and risk sharing in the last decade. The effects of introducing financial risk for Dutch sickness funds on risk selection and consumer mobility are analysed. The paper concludes with a description of expected future developments.

Capitation Fee↗
PubMed2003

Risk adjustment in Switzerland.

In Switzerland the new law on Health Insurance, effective since 1996, introduced pro competitive changes in the market of sickness funds. The legislator expected high mobility between sickness funds of both healthy and sick insured as open enrolment was introduced with the new law. That is why the risk adjustment scheme, that was already introduced 1993, was limited until 2005. However, consumer mobility remained low and risk selection strategies are still profitable, since risk-adjustment is based only on demographic variables. This paper describes risk adjustment, consumer mobility, risk selection activities of sickness funds and the impact of imperfect risk adjustment on the development of HMO and PPO models. The paper concludes with a description of the current political and scientific discussion in Switzerland.

Capitation Fee↗
PubMed2003

The shortage of registered nurses and some new estimates of the effects of wages on registered nurses labor supply: a look at the past and a preview of the 21st century.

The US and many other countries are in the midst of a severe shortage of registered nurses (RNs). Labor supply models for currently trained RNs are estimated by gender and marital status using the 1992, 1996, and 2000 data from the National Sample Surveys of Registered Nurses. This analysis extends earlier work by Link (Res. Labor Econ. 13 (1992) 287) which provided labor supply estimates for 1960, 1970, 1977, 1980, 1984, and 1988. Since the methodology and variables employed in the present study are the same as those used by Link, the empirical literature on RN labor supply is brought together for the last 40 years. Moreover, comparisons are made with other studies in the literature of the labor supply of nurses and females in the general population. Results for the key variables are consistent over the different data sets and consistent with earlier work by Link. The RN's own wage had minor effects on both labor force participation and hours worked given participation. The RN wage is still an important variable since it has a significant and positive effect on the number of people who enter first-degree nursing programs in the US. These results are important to policy-makers in light of the current shortage of RNs.

Adult↗
PubMed2003

Politicians' and hospital managers' trade-offs in the choice of reimbursement scheme: a discrete choice experiment.

Trade-offs in the choice of hospital reimbursement schemes are widely discussed in the health economics literature but no one has previously, to this authors' knowledge, made an attempt at quantifying how purchasers and providers trade-off anticipated outcomes of reimbursement schemes. The purpose of this study is to elicit Danish county council politicians' and hospital managers' preferences for the anticipated incentives and consequences embedded in reimbursement schemes using the discrete choice method. Results indicate that politicians and hospital managers agree that increasing the number of patients treated is the most important objective for the choice of reimbursement scheme. The second most important objective to the politicians is to provide budget safety whereas inducing increased quality of treatment is third. Hospital managers rank inducement of increased quality of treatment as the second most important objective and have the county's budget safety as their third most important objective.

Attitude of Health Personnel↗
PubMed2003

Measuring geographic inequities in the Portuguese health care system: an estimation of hospital care needs.

Portugal created a NHS to achieve greater equity of access to health care. Successive governments continued to assert the importance of equity in the face of evidence of inequities in supply of hospital resources, but lacked methods to provide sound information on the degree of inequities in Portugal and hence how to achieve greater equity. Capitation formulae have been increasingly used in other countries with a NHS to measure geographical inequities and allocate resources to reduce them. The main objective of this paper was to develop a capitation formula to measure need for hospital care for the Portuguese system by transferring this technology from methods used in other countries, and, in particular, in England. We find, however, problems with the common use of standardised mortality ratios (SMRs) as a measure of need and found age-specific mortality ratios to offer more soundly-based estimates. We also raise questions on the use of empirical estimates of utilisation of health care by age and sex as they appear to reflect inadequacies of health care in Portugal. We also believe it is important to improve knowledge of health insurance and care outside the NHS. Our results show that there are considerable inequities on the distribution of hospital resources in Portugal.

Adolescent↗
PubMed1997

Caring: the neglected health outcome? or input?

In most forms of evaluation of health care--and it is certainly true of economic evaluation--and is considering the outcomes of such care, caring tends to be omitted, or simply forgotten. It is often the case that little more than lip service is paid to the inclusion of caring as an input. This paper takes a closer look at caring, the neglected outcome of health care. The perspective starts from that of economics but other disciplines are examined briefly along the way to determine whether they deal better with caring than does the dismal science of economics. It is concluded that there is a need for greater consideration of caring as both an outcome and an input in evaluation of health care and that in the specific context of economic evaluation, when considering caring, economists might usefully look to other disciplines to broaden and deepen their conceptualisation of both benefits and costs in their economic evaluation studies.

Australia↗
PubMed1997

The cost-effectiveness of a cardiovascular risk reduction program in general practice.

An economic evaluation was conducted alongside a randomised controlled trial of two lifestyle interventions and a routine care (control) group to assess the cost-effectiveness of a general practice-based lifestyle change program for patients with risk factors for cardiovascular disease. Routine care was the base case comparator because it represents 'current therapy' for cardiovascular disease (CVD). A 'no care' control group was not considered a clinically acceptable alternative to lifestyle interventions. The interventions consisted of an education guide and video for GPs to assess individual patient risk factors and plan a program for risk factor behavior change. Each patient received a risk factor assessment, education materials, a series of videos to watch on lifestyle behaviors and some patients received a self-help booklet. Eighty-two general practitioners were randomised from 75 general practices in Sydney's Western Metropolitan Region to (i) routine care (n = 25), (ii) video group (n = 29) or (iii) video + self help group (n = 28). GPs enrolled patients into the trial who met selection criteria for being at risk of CVD. There were 255 patients in the routine care (control) group, 270 in the video (intervention) group and 232 in the video + self help (intervention) group enrolled in the trial. Outcome measures included patient risk factor status: blood pressure, body mass index, cholesterol and smoking status at entry to trial and after 1 year. Changes in risk factors were used to estimate quality adjusted life years (QALYs) gained. One hundred and thirty patients in the routine care group, 199 in the video group and 155 in the video + self help group remained in the trial at the 12-month review and had complete data. The cost per QALY for males ranged from $AUD152,000 to 204,000. Further analysis suggests that a program targeted at 'high risk' males would cost approximately $30,000 per QALY. The lifestyle interventions had no significant effect on cardiovascular risk factors when compared to routine patient care. There remains insufficient evidence that lifestyle programs conducted in general practices are effective. Resources for general practice-based lifestyle programs may be better spent on high risk patients who are contemplating changes in risk factor behaviours.

Australia↗