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PubMed1995

Managed competition in The Netherlands: lessons from five years of health care reform.

In many European countries health care reforms are taking place. The guiding principle of the reforms is 'more market, less government'. In 1988 the Dutch Government launched proposals for the most radical market-oriented reform in Western Europe. The proposed system can be described as a national health insurance based on regulated competition among both insurers and providers of health care. It can be seen as an ingenious attempt to combine the 'efficiency' of competitive arrangements in the markets for health care and health insurance with the 'equity' of finance through predominantly income-related premiums (National Economic Research Associates 1993). Similar reforms have been proposed and discussed in other countries. In this paper we will concentrate on lessons that other countries may learn from the Dutch experience. What progress has been made since the proclamation of the reforms six years ago? What new issues and problems have arisen and how can we solve these new problems?

Economic Competition↗
PubMed1998

Contracting and the purchaser-provider split in western Europe a legal-organizational analysis.

Market forces have been introduced in the health care systems of many European countries. Fundamental to the introduction of the market was the need to distinguish between the roles of purchaser and provider. In this article the authors have analyzed the consequences of contracting and the purchaser-provider split from both a legal and organizational perspective. Using a modification of an existing theoretical framework for analyzing the basic health care models, contracting and the purchaser-provider split in some Western European countries has been analyzed. Including the legal and organizational dimension into these economically oriented models, these models can also be used for analyzing recent trends and developments. A four-country analysis indicates trends towards convergence of health care systems and both decentralization and integration in the systems. The future roles of both managers and lawyers working in health care need to be further defined.

Contract Services↗
PubMed2005

Further examination of the cross-country association between income inequality and population health.

Several scholars have put forward the view that the estimates by Rodgers [(1979). Income and inequality as determinants of mortality: An international cross-section analysis. Population Studies, 33 (2), 343-351], Flegg [(1982). Inequality of income, illiteracy and medical care as determinants of infant mortality in underdeveloped countries. Population Studies, 36 (3), 441-458] and Waldmann [(1992). Income distribution and infant mortality. Quarterly Journal of Economics, 107 (4), 1283-1302] showing a negative cross-country association between income inequality and population health, cannot be replicated from recent data. In view of the importance of this matter, the present study further examines the issue from the most recent, and probably more accurate, data for the largest cross-country sample used in this line of research. The main conclusion is that the negative cross-country association between income inequality and good health, reported by Rodgers, Flegg, and Waldmann, is replicated very well. The different findings indicated by some scholars may have been due to their samples or the models being unusual. Therefore, the recent skepticism about the existence of such a negative association needs to be reconsidered. Several additional points are also noted. First, income inequality shows significance even after an index of ethnic heterogeneity is included. Second, ethnic heterogeneity itself has a negative association with population health. Third, income inequality retains significance in the presence of a measure of social capital. Fourth, however, the association between the measure of social capital and population health appears weak. Fifth, a simple analysis does not support the view that the positive association between income inequality and infant mortality in less developed countries (LDCs) may just be a reflection of the role of poverty. Finally, there is some support for the proposition that while income may be relatively more important for health in LDCs, the role of income inequality may be stronger in developed economies.

Cross-Cultural Comparison↗
PubMed2000

[Public health economic aspects of antiretroviral therapy. Can we afford to do less?].

In Germany, politically motivated economic considerations are becoming even more important. In this connection, scientific research into the health system is not limited merely to a consideration of costs, but utilizes the same methods and conceptual models as economic research in general to investigate defined problems. The reduction of illness-related loss of production and quality of life to monetary units in the models used, often stimulates critical discussions of the ethical permissibility of such an approach. Public discussion of such models then makes it possible to justify rationally founded allocation decisions and to expose and thus prevent hidden forms of rationing. The medically successful concept of long-term administration of highly active antiretroviral combination treatment (HAART) was first considered by numerous studies to be cost-effective solely on the basis of the saving of inpatient treatment costs--a stance that in the light of the life-shortening HIV infection should not be thought to be only basis for the decision. Owing to a lack of experience with the long-term prognosis under HAART, it is difficult to assess indirect costs for HIV infection. An assessment of the quality of life in the symptom-free stages of HIV infection depends largely on coping strategies, so that the results of studies on quality of life measurement under antiretroviral treatment must not lightly be interpreted as a function of a given therapeutic strategy. Given the high costs of HIV infection to the economy, the marked reluctance to provide the necessary funding for research in the area of epidemiological monitoring, specific preventive measures and vaccination strategies is to be regretted.

Anti-HIV Agents↗
PubMed2005

Distributed perfusion educational model: a shift in perfusion economic realities.

In recent years, a steady decline in the number of perfusion education programs in the United States has been noted. At the same time, there has been a parallel decline in the number of students graduated from perfusion educational programs in the United States. Also, as noted by several authors, there has been an increase in demand for perfusion graduates. The decline in programs and graduates has also been noted in anesthesia and surgical residency programs. The shift is caused by a combination of economic and clinical factors. First, decreased reimbursement has led to reallocation of hospital resources. Second, the original enthusiasm for beating heart coronary artery bypass surgery was grossly overestimated and has led to further reallocation of hospital resources and denigration of cardiopulmonary bypass. This paper describes two models of perfusion education programs: serial perfusion education model (SPEM) and the distributed perfusion education model (DPEM). Arguments are presented that the SPEM has some serious limitations and challenges for long-term economic survival. The authors feel the DPEM along with dependence on tuition funding can survive the current clinical and economic conditions and allow the profession to adapt to changes in scope of practice.

Allied Health Occupations↗
PubMed1998

Routine treatment of insulin-dependent diabetic patients with ACE inhibitors to prevent renal failure: an economic evaluation.

The objective of this study was to determine how effective angiotensin-converting enzymes (ACEs) must be in preventing diabetic nephropathy to warrant routine administration to insulin-dependent diabetic patients. A Markov model was used to compare three strategies designed to prevent the development of end-stage renal disease in insulin-dependent diabetic patients. Strategy I, screening for microalbuminuria and treatment of incipient nephropathy as currently recommended, was compared with strategy II, a protocol in which patients were routinely administered an ACE inhibitor 5 years after diagnosis of diabetes, and strategy III, in which patients at high risk for nephropathy were routinely treated and low-risk patients followed a protocol in which patients were treated with an ACE inhibitor if they developed hypertension and/or macroproteinuria. The model predicted that strategy II would produce as many quality-adjusted life-years as strategy I at nearly the same cost if routine drug therapy reduced the rate of development of microalbuminuria by 26% in all patients. Strategy III produced as many quality-adjusted life-years at less cost than strategy I if a high-risk cohort could be identified with a rate of developing microalbuminuria at four times the rate of low-risk patients and if drug therapy reduced the rate of developing microalbuminuria in this high-risk group by 20%. In conclusion, routine ACE inhibitor therapy could prove to be cost-effective, especially if high-risk individuals could be identified. A prospective trial examining this goal should be considered.

Adult↗
PubMed1998

Prevention of chickenpox in reproductive-age women: cost-effectiveness of routine prenatal screening with postpartum vaccination of susceptibles.

OBJECTIVE: To evaluate economic and clinical outcomes of a program of routine prenatal serotesting for varicella and postpartum vaccination of seronegative women. METHODS: An analytic cost-effectiveness model was constructed to compare the current strategy of no serotesting with 1) selective serotesting of pregnant women without a prior history of chickenpox and 2) serotesting of all pregnant women. In both serotesting strategies, seronegative women were vaccinated postpartum. The model followed a hypothetical cohort of 4 million women over 20 years. Costs and chickenpox disease outcomes during and outside of subsequent pregnancies were considered. The incremental cost-effectiveness (cost per adult chickenpox case prevented) of selective serotesting compared with the current strategy was measured. RESULTS: Compared to no testing, selective serotesting would prevent 43% (48,577 of 112,654) of adult chickenpox cases, save $21.8 million in discounted medical and work loss costs from the societal perspective, and cost $1126 per case prevented from the health payer's perspective (medical costs only). The model was sensitive to varicella seroprevalence and incidence of chickenpox among susceptible women but was relatively insensitive to the cost of serologic testing and vaccination. Compared with selective serotesting, the serotest-all strategy would prevent an additional 15,645 cases, at a societal cost of $7653 per additional case prevented. CONCLUSION: The selective serotesting strategy could prevent nearly half of chickenpox cases among this cohort and is cost-saving from the societal perspective. From the health payer's perspective, it compares favorably with other generally accepted preventive practices. It should be considered for prevention of chickenpox among women of childbearing age.

Adult↗
PubMed1997

Economic evaluation of diagnostic technology. Methodological challenges and viable solutions.

The principles of economic evaluation are increasingly accepted by clinicians and policy makers as evidence from a significant number of studies becomes available to support their decisions. However, methods of assessment still need to be improved. This paper reports a comprehensive review of methodological challenges in the economic evaluation of diagnostic technology, where such challenges are more evident. This review formed the basis for a prioritized research agenda, with four main areas: modeling techniques for dealing with complexity; measures of the opportunity cost of shared resources; techniques for eliciting decision makers' utility functions for diagnostic tests; and ways of assessing the robustness of decisions. A number of methodological solutions are proposed, aimed at capturing elements and relationships that are usually neglected and fully recognizing the presence of an inductive cognitive component in decision-making processes.

Cost-Benefit Analysis↗
PubMed2006

Forest environmental investments and implications for climate change mitigation.

Forest environmental conditions are affected by climate change, but investments in forest environmental quality can be used as part of the climate change mitigation strategy. A key question involving the potential use of forests to store more carbon as part of climate change mitigation is the impact of forest investments on the timing and quantity of forest volumes that affect carbon storage. Using an economic optimization model, we project levels of U.S. forest volumes as indicators of carbon storage for a wide range of private forest investment scenarios. Results show that economic opportunities exist to further intensify timber management on some hectares and reduce the average timber rotation length such that the national volume of standing timber stocks could be reduced relative to projections reflecting historical trends. The national amount of timber volume is projected to increase over the next 50 yr, but then is projected to decline if private owners follow an economic optimization path, such as with more forest type conversions and shorter timber rotations. With perfect foresight, future forest investments can affect current timber harvest levels, with intertemporal linkages based on adjustments through markets. Forest investments that boost regenerated timber yields per hectare would act to enhance ecosystem services (e.g., forest carbon storage) if they are related to the rate of growth and extent of growing stock inventory.

Air Pollution↗
PubMed2004

Measuring economic outcomes of cancer.

Economic outcomes are increasingly important in cancer research. This article provides an introduction to the nature and measurement of economic outcomes in cancer and gives the reader entry points to a considerable literature on measuring economic endpoints in health and medicine. Economic outcomes data are defined here as measures of resources consumed in prevention, detection, and treatment of cancer and its sequellae. Part I of this essay discusses the questions addressed by economic outcomes. Part II presents a typology of and introduction to measurement of economic outcomes. Part III discusses important measurement issues and calls for development and validation of standardized protocols and questionnaires to measure economic outcomes, especially at the patient level.

Health Care Costs↗
PubMed2000

Health economics and orthopaedics.

It is becoming widely accepted that research which considers only the outcome and not the costs associated with new technologies in health care, is of limited value in making decisions about the use of scarce resources. Economic evaluation is becoming a standard feature of clinical research but many published economic evaluations fall short of best practice in their methodology. We have described the essential features of economic evaluation, using published studies in orthopaedics, in order to try to improve the ability of orthopaedic surgeons to read, understand and appraise such studies critically, and to encourage them to consider including economic evaluation in future investigations.

Cost-Benefit Analysis↗
PubMed1996

Effects of global competition on health care administration in Finland and the United States. What you can do to save your practice.

Global competition, a faltering Finnish economy, and deep recession are forcing difficult decisions on the health care administrators of this Nordic country known for its extensive social welfare safety net and socialized health care system. In the first part of this article the Finnish health care system and its problems, as well as possible solutions, are presented. Similarities to our own system are noted and discussed. In an interview, the director general for the Minister of Social Affairs and Health of Finland, Kimmo Leppo, expressed concern about future funding sources in his country for the same levels of social welfare and health care programs that presently exist. The Finns are considering managed competition among providers, increasing copayments, excess hospital beds, anticipated hospital closures in their country, block grants, and how to deal with rising physician unemployment. He was interested in the proposed US government health care plans, and especially the state of Tennessee's TennCare plan, a state plan that closely resembled the failed Clinton health care reform package. The second part of this article explores how global competition has brought the pressure of modern competitive economics into the US medical arena.

Cost Savings↗
PubMed2001

A comment on Neudeck and Podczeck's "adverse selection and regulation in health insurance markets".

Using the Grossman equilibrium concept, Neudeck and Podczeck [Journal of Health Economics 15 (1996) 387] show that imposing a minimum standard on a perfectly competitive insurance market can result in anti-competitive effects: decreased welfare with some insurers earning positive profits. However, the Grossman concept precludes an insurer from offering two separating, cross-subsidizing health plans. When an insurer can offer multiple plans (as under both the Nash and Miyazaki-Wilson equilibrium concepts), I show that minimum standards result in a doubleton equilibrium, never allow positive total profits, and increase welfare. This is of interest since in 1997 more than half of establishments in the US offering choice of multiple plans did so through a single insurer.

Economic Competition↗
PubMed2003

Cost-effectiveness of solvent/detergent-treated fresh-frozen plasma.

BACKGROUND AND OBJECTIVES: Although transfusion-transmitted infections are rare, non-infectious complications occur relatively frequently. Solvent/detergent-treated fresh-frozen plasma (SD-FFP) has been shown to reduce the frequency of both types of complication, although previous economic evaluations failed to consider non-infective events and subsequently underestimated the benefits of SD-FFP. MATERIALS AND METHODS: A time-series analytical model was used to estimate the incremental cost/life year saved for SD-FFP compared with untreated FFP, having controlled for post-transfusion mortality and patient age. Various infective and non-infective transfusion-related complications were considered. RESULTS: The discounted cost/life year saved for SD-FFP use in the UK was pound sterling 22,728 [95% confidence interval (95% CI): pound sterling 22,604-22,853] for neonates and pound sterling 98,465 (95% CI: pound sterling 97,924-99,005) for patients aged 70. The cost-effectiveness ratio was below pound sterling 50,000/life year saved for patients < or = 48 years of age, and below pound sterling 30,000/life year saved for those < or = 21 years of age. In transfusion recipients with no significant morbidity, the cost-effectiveness ratio was pound sterling 12,335 for neonates and pound sterling 61,692 for 70-year olds. The most important driver of cost-effectiveness was transfusion-related acute lung injury (TRALI), on account of its relatively high incidence and mortality rate. CONCLUSIONS: Previous analyses greatly underestimated the cost-effectiveness of SD-FFP. Inclusion of non-infectious complications suggests that SD-FFP is cost-effective in patients < or = 48 years of age and in older patients with good clinical prognosis, which may justify the wider use of this technology.

Algorithms↗