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The lawyerization of medicine.
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An analysis of market shares of Maryland hospitals in their service areas.
The study analyzes market shares (or competitiveness) of Maryland hospitals based on a service area definition of hospitals used for acute care planning in Maryland. The study uses this service area definition to analyze market shares of Maryland hospitals, to test them under alternative hypotheses and, finally, to examine the impact of several key variables. The study finds that proximity of other hospitals, and hospital's occupied bed size, have statistically significant impacts on market shares of hospitals irrespective of hospital location in a metropolitan or rural area.
Economic evaluation of desirudin vs heparin in deep vein thrombosis prevention after hip replacement surgery.
Deep vein thrombosis is a serious complication of orthopaedic surgery and can lead to pulmonary embolism and long term post-thrombotic syndrome. A simulation model based on both epidemiological data and data from clinical trials was used to compare the long term cost effectiveness of standard prophylaxis with subcutaneous unfractionated heparin with that of desirudin (recombinant hirudin), in patients undergoing elective hip replacement. The analysis, which was performed before the price of desirudin was set, showed that prophylactic treatment with desirudin saved 4.5 life-years per 100 patients treated, compared with unfractionated heparin. Desirudin prophylaxis was dominant up to a total drug cost of 4400 Swedish kronor (SEK) per treatment. The results were robust against changes in the parameters used in several sensitivity analyses. This study showed that prophylactic therapy with desirudin compared with unfractionated heparin was more cost effective and potentially cost saving under a wide range of assumptions concerning the future price of desirudin in preventing deep vein thrombosis following elective hip surgery.
Health systems ownership: can regulation preserve community benefits?
This article addresses two questions. What determines the amount of community benefit a nonprofit firm will provide? What would be the expected effect of legal rules requiring nonprofit firms to provide more community benefit than they would otherwise have chosen? The amount of community benefit provided, it is argued, depends on the desires of the donors who endow the nonprofit firm with its equity capital and control its corporate board. The effect of a law requiring the provision of community benefit depends on the degree of competition in the local market. In competitive markets, such a rule is like a hidden tax. In markets in which nonprofit firms have market power, it may divert resources from types of benefit valued highly by the board toward activities valued highly by the political process. The definition of community benefit and the future of nonprofit hospitals are also discussed.
Simulating the impact of medical savings accounts on small business.
OBJECTIVE: To simulate whether allowing small businesses to offer employer-funded medical savings accounts (MSAs) would change the amount or type of insurance coverage. STUDY SETTING: Economic policy evaluation using a national probability sample of nonelderly non-institutionalized Americans from the 1993 Current Population Survey (CPS). STUDY DESIGN: We used a behavioral simulation model to predict the effect of MSAs on the insurance choices of employees of small businesses (and their families). The model predicts spending by each family in a FFS plan, an HMO plan, an MSA, and no insurance. These predictions allow us to compute community-rated premiums for each plan, but with firm-specific load fees. Within each firm, employees then evaluate each option, and the firm decides whether to offer insurance-and what type-based on these evaluations. If firms offer insurance, we consider two scenarios: (1) all workers elect coverage; and (2) workers can decline the coverage in return for a wage increase. PRINCIPAL FINDINGS: In the long run, under simulated conditions, tax-advantaged MSAs could attract 56 percent of all employees offered a plan by small businesses. However, the fraction of small-business employees offered insurance increases only from 41 percent to 43 percent when MSAs become an option. Many employees now signing up for a FFS plan would switch to MSAs if they were universally available. CONCLUSIONS: Our simulations suggest that MSAs will provide a limited impetus to businesses that do not currently cover insurance. However, MSAs could be desirable to workers in firms that already offer HMOs or standard FFS plans. As a result, expanding MSA availability could make it a major form of insurance for covered workers in small businesses. Overall welfare would increase slightly.
A multivariate analysis of measurements of socio-economic status in rural Bangladesh.
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[Modernization, globalization and territories: evolution of views on the articulation of urban and rural spaces in the development processes].
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[Thiazides or ACE inhibitors? A drug-economic analysis].
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Economics and the education of nurse anesthetists: part 1.
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Ultrasound for central venous cannulation: economic evaluation of cost effectiveness.
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The cost-effectiveness of acetaminophen, NSAIDs, and selective COX-2 inhibitors in the treatment of symptomatic knee osteoarthritis.
OBJECTIVE: The objective of this study was to conduct an economic evaluation of rofecoxib and celecoxib compared with high-dose acetaminophen or ibuprofen with and without misoprostol for patients with symptomatic knee osteoarthritis (OA). METHODS: A decision analysis model was designed over 6 months using two measures of effectiveness: 1) number of upper gastrointestinal (GI) adverse events averted; and 2) number of patients who achieved perceptible pain relief. Separate analyses were conducted for all patients and for those who did not respond to acetaminophen. Outcome probabilities were obtained from a comprehensive review of randomized controlled trials and observational studies. Costs were derived from actual resource utilization of OA patients. RESULTS: In terms of averting GI events, acetaminophen dominates the other options for an average risk patient population. For patients who did not respond to acetaminophen, rofecoxib had the lowest incremental cost-effectiveness ratio (ICER) per GI event avoided (32,000 US dollars) relative to ibuprofen. In terms of pain control, ibuprofen had an ICER of 610.77 US dollars per additional patient achieving minimal perceptible clinical improvement (MPCI) relative to acetaminophen, while rofecoxib had an ICER of 12,000 US dollars relative to ibuprofen. For patients who did not respond to acetaminophen and who are at high risk of developing an adverse GI event, rofecoxib dominates ibuprofen as the preferred alternative for both measures of effectiveness. One-way, two-way, and probabilistic sensitivity analyses established that these results were generally robust. CONCLUSIONS: Our results suggest that for average-risk knee OA patients, acetaminophen dominates the other therapies in terms of cost per GI event averted. In terms of pain relief, cost-effectiveness acceptability curves indicate that if one values pain relief below 275 US dollars per patient achieving MPCI, acetaminophen is the therapy most likely to be optimal; between 275 US dollars and 14,150 US dollars, ibuprofen is most likely to be optimal; and above 14,150 US dollars, rofecoxib is most likely to be optimal.
Some aspects of secular changes in Hungary over the twentieth century.
Growth and maturation are considered the most reliable indicators of health status. Their progression rates in turn are strongly influenced by nutrition and socio-economic status, a well-documented relationship. The pattern of the so-called positive secular changes, i.e. the increase in size and earlier maturation, fits the populations' historical model of economic development very well. The historical, political and economic changes occurring in this century in Hungary have had a remarkably strong impact. Until World War I Hungary was an agrarian part of the Austro-Hungarian monarchy, its ethnic composition was most variegated. Both World Wars caused fundamental changes, namely in respect of post-war Hungary they were associated with marked territorial losses and considerable population mobility. In interpreting the developmental differences in the data collected before and after these wars one should take account of the important facts that, in addition to the changes in socio-economic conditions, affected the gene pool of the populations in Hungary. Over the past 100 years profound changes have occurred in the mean body size, growth rate and timing of maturation of the country's population. This paper is a brief analytic summary of the tendencies observed in adult stature, maturation and some socio-economic conditions. It also compares the cohorts of sub-populations as reflected by the reviewed reports. In summarizing the change in adult stature estimated by the data on recruits, soldiers and students of higher education, it could be stated that adult mean stature had become markedly taller in Hungary since the end of the fifties. However, any estimation of the absolute increment and the exact rate is severely biased by the variable character of the samples' representativeness. Similar problems arose in dealing with sexual maturation, because the retrospective and status-quo methods of assessment were found incomparable. Nevertheless, menarche was observed to have shifted to an appreciably younger age lately, a trend that by the end of the 20th century seemed to have reached a more or less stable level.
Dental school teaching clinics as cost centers.
Increasing net patient revenues from teaching clinics is one of the alternatives available to dental schools seeking to alleviate economic pressures. Managerial decisions directed to this end require accurate and useful data on clinic finances and economic organization. An important step in this direction can be taken by defining the teaching clinic as a cost center, that is as an economic entity in a dental school with identifiable specific resources, costs, and revenues. This paper describes the accounting and economics frameworks within which resources and costs are classified and allocated into direct and indirect, and fixed and variable categories. The development and structure of a cost-revenue model designed for the teaching clinics at the University of Connecticut School of Dental Medicine is described to illustrate an application of the cost center concept.
The economics of public health: financing drug abuse treatment services.
Drug abuse treatment financing exhibits a heterogeneous set of sources from federal, state, and local governments, as well as private sources from insurance, patient out-of-pocket, and charity. A public health model of drug abuse treatment is presented for a market that can be characterized by excess demand in many communities and an implied policy of rationing. According to best estimates, as many as 6.7 million individuals may need treatment, but only an estimated 1.5 million individuals actually participated in treatment episodes. Since, as demonstrated empirically, drug abuse treatment has a robust and positive social net benefit to society, it is perplexing that treatment financing stops with a rationing outcome that inhibits social welfare. The justification for public financing is centered on the external costs of drug addiction, but subsidization is grounded in the reality that a large number of addicted individuals do not have sufficient resources to pay for treatment out-of-pocket, nor do they have private insurance coverage. Social welfare losses are generated by financial arrangements that are inconsistent with rational budgeting theory and as such would lead to non-optimal organization and management of the drug abuse treatment system.
Altruism and the macroeconomic effects of demographic changes.
"In this paper we show that the macroeconomic effects of demographic changes strongly depend on the degree of altruism and on the specification of the intertemporal utility function. We allow for agents either to be altruistic in the sense of Barro (1974) or non-altruistic. In the latter case, generations are heterogeneous like in the ¿unloved children' model of Weil (1989). In the former case, where the model is a standard Ramsey model with identical agents, we distinguish a Millian and a Benthamite intertemporal utility function. For each of these models, we study the effects of an anticipated and unanticipated permanent decline in population growth as well as the consequences of a baby-boom/baby-bust scenario."
What reimbursement for coronary revascularization with drug-eluting stents?
We investigated the clinical and economic impact of sirolimus-eluting coronary stents (SES) at a nationwide level as to advice about the feasible reimbursement policy for the Italian Health Care System (SSN). A decision model compared bare metal stents (BMS) and SES in terms of costs and repeat coronary revascularizations incurred in 12 months following the first revascularization. The model was compiled for eight subgroups of patients. Rates of events were derived from randomized trials and an 1,809-patient survey. National charges were used to evaluate resources consumption. Compared with BMS, the number of averted revascularizations with SES is 0.16 per patient. SES also save Euro 1,371 per patient. Total savings to SSN are proportional to the rate of SES adoption by Italian hospitals: assuming a complete replacement of BMS with SES, the model estimates that 7,095 revascularizations would be averted and more than Euro 60 million saved by the SSN in 1 year. To stimulate SES adoption a SES-specific DRG might by introduced with a reimbursement value 23% higher than the current charge. SES is thus a cost-saving strategy in the perspective of the SSN that could therefore support the introduction of the new technology by reimbursing about 80% of its current incremental acquisition cost.
Preferences for outcomes in economic evaluation: an economic approach to addressing economic problems.
In this paper we critically appraise the appropriateness and validity from an economic perspective of alternative preference-based approaches to measuring outcomes in economic evaluations of health care interventions. We describe the properties of an outcome measure for economic evaluation to make it compatible with the principles of economics when applied to the problem of resource allocation. We also describe the difference and similarities between the psychometric and the economic approaches for the measurement of outcome. Using these properties we critically appraise the use of QALY and HYE methods of measuring individual and social preferences for health outcome. We argue that the most advanced measure currently available that meets these required properties is the HYE. Because the HYE, unlike the QALY, has its foundations in utility theory under uncertainty, it neither assumes particular formulations of the individual utility function, nor is it incompatible with the principles of economics. As such it represents a further stage in the continuing development of methods for economic evaluation of health care programmes.