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PubMed1996

Differentiation and specialization in the California hospital industry 1983 to 1988.

This article examines changes in the service mix of California hospitals as part of their response to shifts in the system of reimbursement between 1983 and 1988. The Hospital Discharge Data Set and the Annual Hospital Disclosure Report produced by California Office of Statewide Health Planning and Development were used in this study. Characteristics of inpatient hospital services in California before and after the introduction of new reimbursement mechanisms (including the Medicare Prospective Payment System [PPS] and the growth of selective contracting plans) were compared. The factors that influence two measures of hospital service mix, one focusing on specialization and the other on differentiation, were studied. The factors included hospital characteristics and changes in hospital reimbursement. Variables describing a hospital's service mix and the level in its market were constructed from data in the annual discharge abstracts. Data pertaining to average hospital costs and reimbursements under the Medicare PPS were drawn from a file containing a 20% sample of hospital stay records for the year of PPS. Other hospital data, such as ownership and bed size, were taken from the California Annual Disclosure Report data set. The results indicate that completion among hospitals tended to increase differentiation whereas higher financial PPS pressure is associated with increased specialization. Hospitals tend to adopt some high visibility services offered by their competitors while filling market niches selectively overall. It also appears that the cost savings expected for specialization may prevail only for narrowly defined services. Study of subsequent data sets should show whether the cost containment strategies used by the hospitals to achieve these results have been maintained over a period of sustained financial pressure.

California↗
PubMed1997

From managed competition to managed cooperation: theory and lessons from the British experience.

The United Kingdom led the world in transforming the largest single health care system from a publicly administered service to a set of interlocking contracts. Policy lessons that can be adapted by employers, nations, and other large payers are identified. These lessons are drawn from the improvements that the British made over the design of managed competition, the mistakes and problems they experienced, the underlying trends toward privatization and class discrimination, and the limitations to competition that have led the British toward managed cooperation in collaborative purchasing for the health needs of communities. Yet market reform and the rhetoric of efficiency have justified the shrinking of health services, the shift of costs to household budgets, and the use of public moneys to support private services and investors at greater expense by moving properties and services off the public ledger. In these ways, managed competition can Americanize health care and pose fundamental questions about what policy goals are really being pursued.

Cooperative Behavior↗
PubMed2005

Foundation Trusts: economics in the 'postmodern hospital'.

Foundation Trust Hospitals are community-controlled health care providers which have increased autonomy about how they produce outcomes for the British National Health Service. Although there is a literature on hospital economics it is unclear how these innovative providers will behave, if they have to compete for scarce resources with other hospitals. This paper reviews some of the earlier theories, such as the neoclassical theory of the firm, and discusses their relevance along with 'newer' economic theories such as the transaction costs and evolutionary theory of the firm, plus organizational and human resources theory, to the performance of Foundation Trusts. Much contemporary health care provision is shaped along modernist lines, using scientific endeavour to maximize the impact on health outcomes and technical and social efficiency. However, there is an increasingly postmodern standpoint--critical of modernity--being taken by both patients and hospital staff, to deconstruct processes in the organizations that serve them. Foundation Trusts are postmodern hospitals insomuch as they (to attract scarce resources in a competitive environment), need to marshal the diverse theories of the firm together in order to provide a mass-customized, quality experience, transparently and at least cost--whilst maintaining a stable organizational culture for staff.

Community Health Services↗
PubMed2004

Reference pricing of pharmaceuticals for Medicare: evidence from Germany, The Netherlands, and New Zealand.

This paper describes three prototypical systems of therapeutic reference pricing (RP) for pharmaceuticals--Germany, the Netherlands, and New Zealand--and examines their effects on the availability of new drugs, reimbursement levels, manufacturer prices, and out-of-pocket surcharges to patients. RP for pharmaceuticals is not simply analogous to a defined contribution approach to subsidizing insurance coverage. Although a major purpose of RP is to stimulate competition, theory suggests that the achievement of this goal is unlikely, and this is confirmed by the empirical evidence. Other effects of RP differ across countries in predictable ways, reflecting each country's system design and other cost-control policies. New Zealand's RP system has reduced reimbursement and limited the availability of new drugs, particularly more expensive drugs. Compared to these three countries, if RP were applied in the United States, it would likely have a more negative effect on prices of onpatent products because of the more competitive U.S. generic market, and on research and development (R&D) and the future supply of new drugs, because of the much larger U.S. share of global pharmaceutical sales.

Cost Control↗
PubMed2001

The welfare economics of moral hazard.

Pauly's analysis of the welfare effects of moral hazard assumes that consumption of health care does not increase with income, however, empirical evidence suggests it does. For health insurance contracts that pay off by reducing price, the income effect is represented by the additional health care consumed because of income transfers from those who remain healthy to those who become ill. This implies a different decomposition of demand than the standard Hicksian decomposition. When the effect of income transfers is removed, the price-related welfare loss is smaller than either the loss suggested by Pauly's analysis or a Hicksian decomposition.

Health Expenditures↗
PubMed1994

An economic analysis of AIDS--towards a proposed model of costing: a Singapore experience.

With the increasing prevalence of HIV infection/AIDS and the extending range of care and treatment, the economic implications of the various prevention and control strategies, and of treatment, have become the subject of interest to policy-makers, public health specialists and health economists. This paper presents an overview of the methods used for the economic analysis of AIDS/HIV infection. It proposes an activity-oriented, cost center-based model for the costing of the economic impact of AIDS, using cost figures in Singapore since 1985, when the National AIDS Control Program was started. Priorities for future research are also identified.

Acquired Immunodeficiency Syndrome↗
PubMed2001

Cost-benefit analysis of road safety measures: applicability and controversies.

This paper discusses the applicability of cost-benefit analysis as an aid to policy making for road safety measures. A framework for assessing the applicability of cost-benefit analysis is developed. Five main types of criticism of cost-benefit analysis are identified: 1. rejecting the basic principles of cost-benefit analysis as not applicable to road safety, 2. excluding some types of issues from the scope of calculation of costs and benefits, 3. setting policy objectives that are not amenable to cost-benefit analysis, 4. rejecting the need for maintaining a separation between policy objectives and policy programmes as required for cost-benefit analysis, and 5. rejecting, or denying the possibility of ever obtaining, acceptably valid and reliable economic valuations of the consequences of alternative policy programmes. It is concluded that rejecting the basic principles of cost-benefit analysis is a difficult position to defend, since these principles are simply a re-statement in economic terms of very general principles of rational choice. These principles are part of the normative basis of all formal techniques designed to aid policy making as well as the democratic system of government. Everybody, including those who advocate the use of cost-benefit analysis, agree that some issues are unsuitable for cost-benefit analysis, in particular those that involve basic human rights and fairness in distribution. There may, however, be disagreement with respect to the perception of a specific policy issue in terms of whether it is mainly about rights and fairness or mainly about the effective use of policy instruments to solve a social problem. Politicians may be tempted to set policy objectives that are ill suited for cost-benefit analysis, but this does not imply that cost-benefit analysis makes unreasonable assumptions. Perhaps the most important issue for the applicability of cost-benefit analysis is whether people in general have sufficiently well ordered preferences for economic valuations based on these preferences to make sense.

Accidents, Traffic↗
PubMedDate not supplied

An economic evaluation of triptan products for migraine.

OBJECTIVE: A composite outcome measure in migraine treatment assessment is useful to clinical decision-makers and payers as it can provide a more accurate reflection of effectiveness and allows for more complete modeling of economic value. The objective of this study was to compare the total triptan cost to treat 100 migraine patient attacks and the cost per successfully treated patient (CPSTP) for six marketed triptans using a composite measure of effectiveness, the "successfully treated" migraine (defined as requiring only one triptan dose to treat one migraine attack during a 24-h period). METHODS: This analysis was conducted from the perspective of the payer. Clinical data were abstracted from a rigorous, published meta-analysis. Two-hour response and pain-free response were used in conjunction with the recurrence rate reported in the meta-analysis to calculate the number of doses used by treatment successes and failures. The average wholesale price per dose was then used to calculate total triptan cost. RESULTS: Of the nine oral triptan doses compared, eletriptan 40 mg was associated with both the lowest total triptan cost for treating 100 migraine attacks ($1560) and with the lowest CPSTP ($56.39). CONCLUSIONS: The relative CPSTP rankings for migraine therapies are dependent on the definition of treatment success and relative pricing. The results of this study support the use of eletriptan for the treatment of acute migraine based on the model assumptions. This study can be used to assist in formulary considerations and offers a model that can be adapted by health-care decision-makers.

Drug Costs↗
PubMed2002

Tamoxifen plus chemotherapy versus tamoxifen alone as adjuvant therapies for node-positive postmenopausal women with early breast cancer: a stochastic economic evaluation.

BACKGROUND: There remains uncertainty around the appropriate choice of adjuvant therapies to offer postmenopausal women with node-positive early breast cancer. OBJECTIVE AND STUDY DESIGN: To present the results derived from a discrete event simulation (DES) model that compared tamoxifen plus chemotherapy versus tamoxifen alone in node-positive postmenopausal women diagnosed with early breast cancer. METHODS: The data populating the model were mainly derived from the existing literature, which was analysed to specify probability distributions describing the uncertainty around the true value of each input parameter. The specified probability distributions facilitated the stochastic analysis of the decision model, whereby distributions of the model's outputs [aggregate costs and quality-adjusted life years (QALYs)] were estimated. RESULTS: The baseline results show that the addition of chemotherapy to tamoxifen in this patient group is relatively cost effective (under pound 4000 per additional QALY), but the distribution of the incremental cost-effectiveness ratio shows a wide range, including 10% of observations in which tamoxifen dominates tamoxifen plus chemotherapy. CONCLUSIONS: The results demonstrate the intuitive nature of stochastic evaluations of healthcare technologies, which may ease decision-makers' interpretation of cost-effectiveness results.

Aged↗
PubMedDate not supplied

Market concentration in secondary health services under a purchaser-provider split: the New Zealand experience.

The separation of purchaser and provider in government-funded health systems enables competition to develop between providers. Competition is seen as a means to drive technical efficiencies by providers. While it is difficult to assess comprehensively the level of competition in a market taking into account contestability and substitutability effects, it is possible to measure the degree of market concentration. This paper employs the Hirschman-Herfindahl index to provide measures of market concentration in selected secondary health care markets in New Zealand immediately prior to (1992) and following (1994) implementation of a purchaser-provider split. The results show that, generally, the selected markets are highly concentrated and that there has been little change in the degree of concentration over the 2 year period under investigation. The paper also discusses some of the methodological problems associated with the measurement of market concentration and acknowledges the limitations of such measures as indicators of competition.

Catchment Area, Health↗
PubMed1998

The effects of regulation and competition in the NHS internal market: the case of general practice fundholder prices.

The 1989 reforms of the UK National Health Service introduced competition in supply within a tightly regulated framework. The paper examines whether this competition affects the prices posted by sellers of medical services. We argue that despite regulation market forces may have an impact on price. We test this using the posted prices for one of the two types of buyer, General Practice Fundholders. We find the regulatory rules are not observed, and some evidence of the impact of market forces on price.

Budgets↗
PubMed2002

Vaccinating first-year college students living in dormitories for Meningococcal disease: an economic analysis.

BACKGROUND: Surveillance of meningococcal disease among U.S. college students found an elevated rate of this disease among first-year students living in dormitories. OBJECTIVE: This study examines the economics of routinely vaccinating a cohort of 591,587 incoming first-year students who will live in dormitories for > or =1 years. METHODS: A cost-benefit model (societal perspective) was constructed to measure the net present value (NPV) of various vaccination scenarios, as well as the cost/case and cost/death averted. Input values included hospitalization costs from $10,924 to $24,030 per hospitalization; immunization costs (vaccine plus administration costs) from $54 to $88 per vaccine; 30 nonfatal, vaccine-preventable cases over a 4-year period (includes 3 with sequelae); 3 premature deaths; value of human life from $1.2 million to $4.8 million; and long-run sequelae costs from $1298 to $14,600. Sensitivity analyses were also conducted on vaccine efficacy (80% to 90%); discount rate (0% to 5%); and coverage (60% to 100%). RESULTS: The costs of vaccination outweighed the benefits gained with NPVs ranging from -$11 million to -$49 million. The net cost per case averted ranged from $0.6 million to $1.9 million. The net cost per death averted ranged from $7 million to $20 million. The break-even costs of vaccination (when NPV=$0) at 60% coverage ranged from $23 (90% vaccine efficacy) to $5 (80% efficacy). CONCLUSIONS: The model showed that the vaccination program is not cost-saving. Key variables influencing the results were the low number of vaccine-preventable cases and the high cost of vaccination. However, from the perspective of students and parents, the cost of vaccination might be worth the real or perceived benefit of reducing the risk to an individual student of developing meningococcal disease.

Adolescent↗
PubMedDate not supplied

Why not person-centered care? The challenges of implementation.

Do we always "keep our eye on the ball"--the patient? Do we continue to put our hearts and souls, as leaders, into building and supporting that relationship between persons serving and persons served? This article illuminates both the challenges and benefits of implementing a sustainable person centered care model. Patient-centered care (PCC) models have been around for many years, and in fact, many hear "PCC" and cringe. Nurses in particular view such models as economic tools for productivity. It is then hypocrisy to be carrying a name such as PCC. And yet, despite the history and the barriers, it is the only model for a better way of providing health care in America. The author shares her models on how to begin this work of transformation and create a new culture that always "points to true north"--the persons served and the persons serving.

Attitude of Health Personnel↗