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PubMed2002

Economic costs of HIV infection: an employer's perspective.

The introduction of highly active antiretroviral therapy has proven highly effective in treating patients with HIV/AIDS. However, the high cost of the advanced antiretroviral therapy has led to increased financial constraints on both patients and payers. From business firms'perspective, especially those with operations in developing countries, it is crucial to determine the long-term economic cost implications of alternative employment and benefit policies for HIV-infected workers or those at high risk for the disease. A simulation model is developed to predict the comprehensive lifetime economic costs of HIV-infected workers to an employer. This model employs age,CD4(+) cell counts,and plasma HIV-1 RNA level as major predictors of the disease progression and patient survival in the determination of various cost functions. Major cost components considered include direct expenses on health insurance premium,life insurance premium, short-term disability benefits, long-term disability benefits, hiring/training expenses, and indirect costs resulting from reduced or lost productivity at work. An individual model and a group model are derived to estimate the costs of an individual and a group of HIV-infected patients, respectively. Over a 10-year period, following the nonadvanced antiretroviral treatment regimen, the group model predicts that the total lifetime cost of an HIV-infected worker can be as high as U.S. 90,000 dollars to his/her employer, of which 60,000 dollars would be various explicit costs and 30,000 dollars lost work productivity. Sensitivity analysis further demonstrated that changes in the initial level of age,CD4(+) cell count, HIV-1 RNA viral load,CD4(+) cell decline rate, and the costs of medical care influence the dynamics of the cost functions. HIV infection can result in sizable economic costs to an employer over the lifetime course of an infected employee if not treated with the advanced antiretroviral therapy. These cost estimates provide a rational economic basis for an employer to optimally assess the longrun costs and benefits of alternative employment and insurance policies in the care of employees with HIV infection.

Journal Article↗
PubMed2000

Determinants of health care costs and patterns of care of asthmatic patients in Switzerland.

OBJECTIVE: To investigate whether medical resource utilisation, costs and clinical status were influenced by: (1) type of physician (specialist versus GP); (2) treatment modality (on-demand vs long-term continuous therapy); (3) labour force participation; (4) insurance coverage (private vs statutory); (5) geographic area (urban vs rural). MATERIAL AND METHODS: Chart reviews in the last 5 patients seen by treating physicians. Direct medical expenditure included charges for hospitalisation, outpatient services, physicians' services and medication, whereas indirect costs included the value of time lost from work. RESULTS: The overall annual mean cost per patient in 589 patients was CHF 2600 [95% confidence interval: 1956; 3245]. Costs in 117 children were CHF 824 [531; 1116], and CHF 3041 [2244; 3837] in adults. Compared with pulmonologists, adults treated by GPs had a higher rate of hospital admissions, equal specialist referrals and more days off work. Hospital admissions in children were similar in GPs and paediatricians. Total direct costs were highest for internists, followed by GPs. Pulmonologists incurred the lowest direct costs in adults compared to GPs or internists (p < 0.05). Total costs for children were equal for GPs and paediatricians. Differences in costs between on-demand and long-term prophylactic treatment were: CHF 834 [318; 1351] versus CHF 1856 [1488; 2224], (p = 0.002). Highest total costs were observed for unemployed patients and those receiving disability payments. Patients with supplementary insurance cover had a lower overall resource utilisation rate and costs than patients without: CHF 2284 [95% CI: 535; 4034] versus CHF 2670 [1844; 3496] (p = 0.8). Total costs were CHF 2319 [1660; 2979] for patients treated in cities and CHF 3062 [1742; 4382] in rural areas (p < 0.0001) as well as lower in the German-speaking part of the country (CHF 2320 [1743; 2897]) than in the French-speaking region (CHF 3610 [1479; 5740] [p < 0.005]). CONCLUSIONS: Factors determining higher resource utilisation and costs are: treatment by non-specialists, long-term continuous treatment, the absence of supplementary health care insurance, treatment in rural areas, and treatment in the French-speaking cantons.

Adult↗
PubMed2000

[Insufficient legal rights of traffic accident victims. Insurance companies should force more active compensation claims].

According to law, persons injured in road traffic accidents are entitled to compensation. In almost 92% of cases, victims accept a modified solution suggested by the insurance company involved. If an agreement cannot be reached, or the disability is 10% or more, the case is referred to The Road Traffic Injuries Commission (TSN). Insurance companies often claim that the lengthy wait for a final ruling--up to four years or more--is due to the lack of a doctor's certificate of disability.

Accidents, Traffic↗
PubMed1991

Medicare program; Part A premium for 1992 for the uninsured aged and for certain disabled individuals who have exhausted other entitlement--HCFA. Notice.

This notice announces the hospital insurance premium for calendar year 1992 under Medicare's hospital insurance program (Part A) for the uninsured aged and for certain disabled individuals who have exhausted other entitlement. The monthly Medicare Part A premium for the 12 months beginning January 1, 1992 for individuals who are not insured under the Social Security or Railroad Retirement Acts and do not otherwise meet the requirements for entitlement to Medicare Part A is $192. Section 1818(d) of the Social Security Act specifies the method to be used to determine this amount.

Aged↗
PubMed1993

[The concept of including psychiatry in insurance medicine].

Arguments for restructuring of psychiatric service on the principles of medical insurance are given. Because mental disorders are characterized by chronic development and high disability rate, the necessity of mixed budget-insurance financing of psychiatry is grounded. Obligatory state insurance must be conducted for all mentally ill persons. However, only a certain part of outpatient care and the treatment period in hospital are to be insured, while the remaining part of outpatient visits or hospital stay will be financed from the budget. The method of calculation of the incurred number of the doctor's visits and the length of hospital stay during the year is discussed.

Adult↗
PubMed2001

2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group.

STUDY DESIGN: A randomized controlled multicenter study with a 2-year follow-up by an independent observer. OBJECTIVES: To determine whether fusion of the lower lumbar spine could reduce pain and diminish disability more effectively when compared with nonsurgical treatment in patients with severe chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA: The reported results after fusion surgery on patients with CLBP vary considerably, and the evidence of treatment efficacy is weak in the absence of randomized controlled studies. PATIENTS AND METHODS: A total of 294 patients referred to 19 spinal centers from 1992 through 1998 were randomized blindly into four treatment groups. Patients aged 25-65 years with CLBP for at least 2 years and with radiologic evidence of disc degeneration at L4-L5, L5-S1, or both were eligible to participate in the study. The surgical group (n=222) included three different fusion techniques, not analyzed separately in this study. Patients in the nonsurgical group (n=72) were treated with different kinds of physical therapy. The surgical group comprised 49.5% men, and the mean age was 43 years. The corresponding figures for the nonsurgical group were 48.6% and 44 years. The patients had suffered from low back pain for a mean of 7.8 and 8.5 years and been on sick leave due to back pain for a mean of 3.2 and 2.9 years, respectively. The Visual Analogue Scale (VAS) was used to measure pain. The Oswestry Low Back Pain Questionnaire, the Million Score and the General Function Score (GFS) were used to measure disability. The Zung Depression Scale was used to measure depressive symptoms. The overall result was assessed by the patient and by an independent observer. Records from the Swedish Social Insurance were used to evaluate work disability. Patients who changed groups were included in the analyses of significance according to the intention-to-treat principle. RESULTS: At the 2-year follow-up 289 of 294 (98%) patients, including 25 who had changed groups, were examined. Back pain was reduced in the surgical group by 33% (64 to 43), compared with 7% (63 to 58) in the nonsurgical group (P=0.0002). Pain improved most during the first 6 months and then gradually deteriorated. Disability according to Oswestry was reduced by 25% (47 to 36) compared with 6% (48 to 46) among nonsurgical patients (P=0.015), according to Million by 28% (64 to 46) compared with 8% (66 to 60) (P=0.004), and accordingtoGFS by 31% (49 to 34) compared with 4% (48 to 46) (P=0.005). The depressive symptoms, according to Zung, were reduced by 20% (39 to 31) in the surgical group compared with 7% (39 to 36) in the nonsurgical group (P=0.123). In the surgical group 63% (122/195) rated themselves as "much better" or "better" compared with 29% (18/62) in the nonsurgical group (P<0.0001). The "net back to work rate" was significantly in favor of surgical treatment, or 36% vs. 13% (P=0.002). The early complication rate in the surgical group was 17%. CONCLUSION: Lumbar fusion in a well-informed and selected group of patients with severe CLBP can diminish pain and decrease disability more efficiently than commonly used nonsurgical treatment.

Adult↗
PubMed2000

Empirical evidence on the demand for carve-outs in employment group mental health coverage.

BACKGROUND AND AIMS OF THE STUDY: The use of specialized behavioral health companies to manage mental/health benefits has become widespread in recent years. Recent studies have reported on the cost and utilization impacts of behavioral health carve-outs. Yet little previous research has examined the factors which lead employer-based health plans to adopt a carve-out strategy for mental health benefits. The examination of these factors is the main focus of our study. Our empirical analysis is also intended to explore several hypotheses (moral hazard, adverse selection, economies of scale and alternate utilization management strategies) that have recently been advanced to explain the popularity of carve-outs. METHODS: The data for this study are from a survey of employers who have long-term disability contracts with one large insurer. The analysis uses data from 248 employers who offer mental health benefits combined with local market information (e.g. health care price proxies, state tax rates etc), state regulations (mental health and substance abuse mandate and parity laws) and employee characteristics. Two different measures of carve-out use were used as dependent variables in the analysis: (1) the fraction of health plans offered by the employer that contained carve-out provisions and (2) a dichotomous indicator for those employers who included a carve-out arrangement in all the health plans they offered. RESULTS: Our results tended to support the general cost-control hypothesis that factors associated with higher use and/or costs of mental health services increase the demand for carve-outs. Our results gave less consistent support to the argument that carve-outs are demanded to control adverse selection, though only a few variables provided a direct test of this hypothesis. The role of economies of scale (i.e., group size) and the effectiveness of alternative strategies for managing moral hazard costs (i.e., HMOs) were confirmed by our results. DISCUSSION: We considered a number of different hypotheses concerning employers' demands for mental health carve-outs and found varying degrees of support for these hypotheses in our data. Our results tended to support the general cost-control hypothesis that factors associated with higher use and/or costs of mental health services increase the demand for carve-outs. LIMITATIONS: Our database includes a small number of relatively large employers and is not representative of employers nationally. Our selection criteria, concerning size and the requirement that some employees are covered by LTD insurance, probably resulted in a study sample that offers richer benefits than do employers nationally. Our employers also report a higher percentage of salaried employees relative to the national data. Another deficiency in the current study is the lack of detailed information on the socio-demographic and behavioral characteristics of covered employees. Finally, the cross-sectional nature of our analysis raises concerns about susceptibility of our findings to omitted variables bias. IMPLICATIONS FOR FURTHER RESEARCH: Research with more information on covered employee characteristics will allow for a stronger test of the general hypothesis that factors associated with a higher demand for services are also associated with a higher demand for carve-outs. Also, future analyses that capture the experience of states that have recently passed mandate and parity laws, and that use pooled data to control for omitted variables bias, will provide more definitive evidence on the relationship between these laws and carve-out demand.

Journal Article↗
PubMed1999

Psychopathology and attrition in the Baltimore ECA 15-year follow-up 1981-1996.

Predictors of non-response were investigated in a 15-year follow-up (1981-1996) of 3,481 individuals in a probability sample from the household population of East Baltimore. Demographics (age, sex, race, education, marital status, and unemployment), household factors (living arrangements, household income, household size, and number of children), cultural variables (ancestral ethnicity and foreign language), social variables (social support and networks, committing felony, carrying a weapon, using an alias, and wandering), health factors (physical illness, health insurance, medical assistance, Medicare, receiving disability benefits, social security, and welfare), interviewer's observation, and psychopathologic variables (mental disorders, suicide behavior, comorbidity, and drug use) were collected at baseline in 1981 and in 1982, then linked to follow-up data between 1993 and 1996. A tracing process involving mail, phone, criss-cross directories, motor vehicle administration records, a commercial credit bureau, the state criminal justice system, hospital records, the US National Death Index, and field tracing were used to locate the original sample. A total of 3,066 respondents of the original sample (88.1%) were traced. Non-response was categorized into Sample Mortality (that part of the original sample that died during follow-up), Sample Loss (that part of the original sample that survived but could not be found) and Refusal (that part of the original sample that survived and was found but refused to participate). Stratified analysis and adjusted multiple logistic regression modeling found sample mortality and sample loss were strongly influenced by individual and household variables and by psychopathology. Sample mortality was influenced by specific mental disorders or conditions as mania, drug abuse/dependency, antisocial personality, cognitive impairment, alcohol abuse/dependency, phobia, drug use (except PCP), and comorbidity. Household factors protective against mortality include higher household income, not living as extended members in a married couple family, and living with children in the household. Persons who were unemployed, widowed or single, without high school education, male, and 65 years of age or older were more likely to die. Sample loss was influenced by cognitive impairment, antisocial personality, and cocaine use. Household factors linked to sample loss include living in female-headed families, or non-family households, and living alone. Young nonwhite, divorced/separated, without high school education, and unemployed were also harder to find. Refusal was associated with being white, with incomplete elementary education, living as a spouse in traditional married couple families, or as a child in female-headed families. Psychopathology did not influence refusal.

Adolescent↗
PubMed1988

The case for selective cholangiography.

Seven hundred sixty-five patients were operated on in two hospitals in 1979 and 1980, 190 of whom were submitted to operative cholangiography, 41 to primary common duct exploration, and 534 to neither. The incidence of common duct stones was 4 percent in the minimal indications group, 21 percent in the moderate indications group, and 91 percent in the maximal indications group. Follow-up of 5 years revealed 1 recurrence in the minimal group subjected to cholangiography and none among the 534 in whom no cholangiogram was obtained. In the period from 1981 through 1985, eight patients returned with common duct stones, having had no common duct stones at the primary operation. In the same period, 1,722 of 2,533 patients were operated on without cholangiography. The ratio of recurrences to primary operations without cholangiography was 1:225 or 0.45 percent. From these findings, we conclude that on the basis of cost-effectiveness and insurance against subsequent disease and disability, cholangiography is only indicated in patients with moderate indications (minimal jaundice, moderately dilated common duct, pancreatitis, or an increased serum amylase level). Cholangiography is not indicated if there are no indications of obstruction of the common duct by stones (as a routine for small stones in the gallbladder, if the cystic duct is patent, or if there is an isolated increased serum alkaline phosphatase level). Cholangiography is also unnecessary, when the indications of common duct stones are maximal (deep jaundice, huge common duct, cholangitis, or palpable stone). In our geographic area, intraoperative cholangiography should be selected in 7 to 8 percent of patients.

Cholangiography↗
PubMed1998

Societal and personal costs of obesity.

The economic costs of obesity can be broken down into three levels: 1. DIRECT COSTS: Costs to the community, related to the diversion of resources to the diagnosis and treatment of diseases directly related to obesity, as well as the treatment of obesity itself. These costs have been estimated to vary between 1-5% of total healthcare costs for various countries. Usually, the cost of obesity alone has been calculated, although it is known that the costs associated with being overweight [body mass index (BMI) 25-30 kg/m2] are also substantial because of the large proportion of individuals involved. These constitute costs to the health service (visits to general practitioners, consultations with medical specialists, hospital admissions and medication). 2. SOCIETAL OR INDIRECT COSTS: These costs are related to the loss of productivity caused by absenteeism, disability pensions and premature death. There is a lack of good economic analysis on this subject, although research from Sweden, Finland and the Netherlands has clearly shown that obesity is associated with increased sick leave and disability pensions. 3. PERSONAL COSTS: Obese subjects may earn less than their lean counterparts because of job discrimination (related to the stigma associated with obesity, or due to diseases and disabilities caused by obesity). Many insurance companies (particularly life insurance) charge higher premiums with increasing degrees of overweight. Obesity is further related to poor physical functioning and limitations in daily life. Some of these require assistance or adaptations which may be costly for an individual. In conclusion, there is much indirect information that obesity and overweight contribute substantially to healthcare-related costs. Data on aspects such as societal costs and personal costs are too fragmentary to allow calculation of the expenses involved. An appropriate analysis of all costs associated with obesity is important in order to persuade responsible bodies to develop strategies towards the prevention and long-term management of obesity.

Absenteeism↗
PubMed1981

Medicare: an advocacy perspective for social workers.

Many Medicare recipients and social work advocates assume this program of federal health care insurance for the elderly and disabled to be relatively trouble free and, therefore, not relevant for advocacy efforts. Only when confronted with a reimbursement denial do the internal complexities and contradictions of the Medicare program, and the resultant need for advocacy, become apparent to recipient and worker alike. This paper presents a conceptual framework and advocacy perspective on Medicare's structure, benefits, and appeals procedures in order to aid a social work advocate in deciding whether to deal with recurrent Medicare problems through techniques to maximize benefits, appeals procedures, or legislative advocacy.

Aged↗
PubMed2006

Rates and correlates of seeking mental health services among Cambodian refugees.

OBJECTIVES: We assessed the rates and correlates of seeking mental health services among a probability sample of Cambodian refugees who needed such services. METHODS: Interviewers conducted face-to-face interviews with a representative sample drawn from the largest US community of Cambodian refugees. The analytic sample included 339 persons who met past 12-month criteria for posttraumatic stress disorder, major depression disorder, or alcohol use disorder. Respondents described contact with service providers for psychological problems during the preceding 12 months. We examined bivariate and multivariate predictors of seeking services. RESULTS: Respondents reported high rates of contact with both medical care providers (70%) and mental health care providers (46%). Seeking services from both types of providers was associated with lack of English-speaking proficiency, unemployment, 3 or fewer years of preimmigration education, and being retired or disabled. Women, individuals with health insurance, and persons receiving government assistance also were more likely to seek services. CONCLUSIONS: Cambodian refugees with mental health problems had high rates of seeking service for psychological problems during the preceding 12 months. Research is needed to examine the effectiveness of services received by Cambodian refugees.

Adult↗
PubMed1986

Hearing damage in military service. A study on 38,294 conscripts.

In an audiometric study on 38,294 conscripts, noise-induced high-frequency hearing deterioration during basic training (mean 245 days) was studied. On reporting for training, 29% were found to have hearing defects, predominantly in the high-frequency area. After training, high-frequency deterioration, predominantly unilateral or asymmetrical, was found in 5%. In 0.5%, this deterioration had reached a symptomatic level, causing minor handicap. In 0.03% (12 conscripts), it fulfilled the criterion of "10% hearing disability" applied in Swedish industrial insurance. The incidence of high-frequency deterioration rose from 3% in conscripts having 'normal' hearing on reporting, to 17% among those with the greatest hearing loss on reporting. This means that the presence of sensorineural hearing loss implies an increased risk of noise-induced hearing deterioration. No correlation was found between hearing status on reporting and magnitude of deterioration during training. The results imply that hearing data obtained on reporting for training should be taken into account in deciding the assignability of conscripts to noisy training courses and posts.

Adolescent↗
PubMed1990

Estimates of new compensated cases of occupational diseases in Finland in 1977-1983.

The increase in the new cases of occupational disease reported in Finland in 1977-1983 has been analyzed. First, the technical nature of the concept of occupational disease as used in the context of compensation insurance is described and a disability grading for the severity of occupational diseases is presented. It is then shown, with the use of a stratified probability sample, that the fraction of compensated cases has remained roughly constant during the study period. However, evidence is presented indicating that the severity of the cases compensated in 1977-1983 has, on the average, decreased.

Disability Evaluation↗