Capita Spending Research Articles

Community Living and Participation: Embracing the Complexity and Forging Forward

Community Living and Participation: Embracing the Complexity and Forging Forward

Accountable Care Organization Formation Is Associated With Integrated Systems But Not High Medical Spending

Medicare's approximately 250 accountable care organizations (ACOs) care for a growing portion of all fee-for-service beneficiaries across the United States. We examined where ACOs have formed and what regional factors are predictive of ACO formation. Understanding these factors could help policy makers foster growth in areas with limited ACO development. We found wide variation in ACO formation, with large areas, such as the Northwest, essentially empty of ACOs, and others, such as the Northeast and Midwest, dense with the organizations. Key regional factors associated with ACO formation include a greater fraction of hospital risk sharing (capitation), larger integrated hospital systems, and primary care physicians practicing in large groups. Area income, Medicare per capita spending, Medicare Advantage enrollment rates, and physician density were not associated with ACO formation. Together, these results imply that underlying provider integration in a region may help drive the formation of ACOs.

An Econometric Analysis of the Relationship Between Millennium Development Goals, Economic Growth and Financial Development in South Africa

The relationship between financial development, economic growth and millennium development goals are unsettled in the literature. Using four indicators of financial development, this paper studies the link between the three variables in South Africa. In general, per capita income improves per capita spending on education in the short run. However, total domestic credit to GDP ratio decreases spending on education. There are highly significant long run relationships among the variables. Improving access to private sector credit and increasing per capita incomes are associated with improvement in health outcomes in South Africa. There are no short run nor long run relationships between household spending on clothes, economic growth and financial sector development. Improved private sector credit also improves household spending on food. In general, there are long run relationships between per capita spending on food, per capita income and financial sector development.

A preliminary assessment of financial stability, efficiency, health systems and health outcomes using performance-based contracts in Belize

Over the last 10 years, Belize has implemented a National Health Insurance (NHI) program that uses performance-based contracts with both public and private facilities to improve financial sustainability, efficiency and service provision. Data were collected at the facility, district and national levels in order to assess trends in financial sustainability, efficiency payments, year-end bonuses and health system and health outcomes. A difference-in-difference approach was used to assess the difference in technical efficiency between private and public facilities. The results show that per capita spending on services provided by the NHI program has decreased over the period 2006–2009 from BZ$177 to BZ$136. The private sector has achieved higher levels of technical efficiency, but lower percentages of efficiency and year-end bonus payments. Districts with contracts through the NHI program showed greater improvements in facility births, nurse density, reducing maternal mortality, diabetes deaths and morbidity from bronchitis, emphysema and asthma than districts without contracts over the period 2006–2010. This preliminary assessment of Belize's pay-for-performance system provides some positive results, however further research is needed to use the lessons learned from Belize to implement similar reforms in other systems.

The Impact of Municipal Mergers on Local Public Expenditures in Finland

This article examines the effects on expenditure of municipal mergers that took place in Finland between 1970 and 1981. We collected data on pairs of municipalities that merged after 1970, and matched these with the similar municipal pairs that remained independent using characteristics from the years immediately before the merger. We compared the changes in per capita spending after the merger in the municipalities that merged to the municipalities that remained independent over the same time period. Our results indicate that municipal mergers did not lead to lower per capita spending. In most spending categories, the per capita expenditure increased more in the merged municipalities than in the comparison group. Only in the category of general administration did the per capita spending decrease; however this decrease was far smaller than the increase in spending in other categories. For the first years of the mergers, the spending increases may be explained by transitional costs, such as acquisition of new technology, renovation of existing facilities and upward harmonization of wages and salaries. Nevertheless, it is striking to find that even ten years after amalgamation, spending was still higher in the merged municipalities compared to similar municipalities that chose to stay independent.

Advancing Comparative Studies of Patterns of Care and Economic Outcomes in Cancer: Challenges and Opportunities

Advancing Comparative Studies of Patterns of Care and Economic Outcomes in Cancer: Challenges and Opportunities

Determinants of government HIV/AIDS financing: a 10-year trend analysis from 125 low- and middle-income countries

BackgroundTrends and predictors of domestic spending from public sources provide national authorities and international donors with a better understanding of the HIV financing architecture, the fulfillment of governments’ commitments and potential for long-term sustainability.MethodsWe analyzed government financing of HIV using evidence from country reports on domestic spending. Panel data from 2000 to 2010 included information from 647 country-years amongst 125 countries. A random-effects model was used to analyze ten year trends and identify independent predictors of public HIV spending.ResultsLow- and middle-income countries spent US$ 2.1 billion from government sources in 2000, growing to US$ 6.6 billion in 2010, a three-fold increase. Per capita spending in 2010 ranged from 5 cents in low-level HIV epidemics in the Middle East to US$ 32 in upper-middle income countries with generalized HIV epidemics in Southern Africa. The average domestic public spending per capita was US$ 2.55. The analysis found that GDP per capita and HIV prevalence are positively associated with increasing levels of HIV-spending from public sources; a 10 percent increase in HIV prevalence is associated with a 2.5 percent increase in domestic funding for HIV. Additionally, a 10 percent increase in GDP per capita is associated with an 11.49 percent increase in public spending for HIV and these associations were highly significant.ConclusionDomestic resources in low- and middle-income countries showed a threefold increase between 2000 and 2010 and currently support 50 percent of the global response with 41 percent coming from sub-Saharan Africa. Domestic spending in LMICs was associated with increased economic growth and an increased burden of HIV. Sustained increases in funding for HIV from public sources were observed in all regions and emphasize the increasing importance of government financing.

Impact of GDP, Spending on R&D, Number of Universities and Scientific Journals on Research Publications among Asian Countries

ObjectivesThis study aimed to compare the impact of Gross Domestic Product (GDP) per capita, spending on Research and Development (R&D), number of universities, and Indexed Scientific Journals on total number of research documents (papers), citations per document and Hirsch index (H-index) in various science and social science subjects among Asian countries.Materials and MethodsIn this study, 40 Asian countries were included. The information regarding Asian countries, their GDP per capita, spending on R&D, total number of universities and indexed scientific journals were collected. We recorded the bibliometric indicators, including total number of research documents, citations per document and H-index in various science and social sciences subjects during the period 1996–2011. The main sources for information were World Bank, SCI-mago/Scopus and Web of Science; Thomson Reuters.ResultsThe mean per capita GDP for all the Asian countries is 14448.31±2854.40 US$, yearly per capita spending on R&D 0.64±0.16 US$, number of universities 72.37±18.32 and mean number of ISI indexed journal per country is 17.97±7.35. The mean of research documents published in various science and social science subjects among all the Asian countries during the period 1996–2011 is 158086.92±69204.09; citations per document 8.67±0.48; and H-index 122.8±19.21. Spending on R&D, number of universities and indexed journals have a positive correlation with number of published documents, citations per document and H-index in various science and social science subjects. However, there was no association between the per capita GDP and research outcomes.ConclusionThe Asian countries who spend more on R&D have a large number of universities and scientific indexed journals produced more in research outcomes including total number of research publication, citations per documents and H-index in various science and social science subjects.

The Road to Health Reform: What Can Physicians Expect Over the Next 4 Years?

This commentary discusses the political and practical obstacles over the next 4 years on the “road to health care reform” and describes how physicians in the United States can chart a path to a bet...

World education finance policies and higher education access: A statistical analysis of World Development Indicators for 86 countries

This study uses panel data models to analyze international indicators and examines the relationship between education finance policies and higher education access among 86 countries from 1998 to 2009. We find that public expenditure per tertiary student bears a negative association with tertiary enrollment ratios, whereas GDP per capita and public spending on education as a percentage of GDP both have a positive effect on tertiary enrollment. These results imply that for a fixed amount of total budget and rising demands for higher education, various nations have reduced spending per college student and drawn on more private resources to expand higher education access.

Global health and the business of illness

There is increased recognition of both glaring disparities in the health of populations among countries around the globe and startling differences in per capita spending on ‘health’ among these same countries. This awareness raises disturbing questions about the relationship between global health and business opportunity. Historically, business opportunity has flourished in the domain of medical care, which is only one part of the larger domain of health. How feasible is it to imagine a world in which opportunity can flourish in the business of health as well as medical care? Improvements in global health depend on finding meaningful answers to this question.

Bantu Education: Destructive intervention or part reform?

The introduction of public education for blacks in 1953 and the withdrawal of state subsidies from mission schools were among the most controversial measures that the National Party (NP) government took. In introducing Bantu Education the NP government was within the broad parameters of white interests and thinking at the time. There was no strong support in either the NP or United Party (UP) for large scale state spending on black education, no real demand from employers for well-educated black workers and a general concern among whites that educated blacks would become politicised if they were unable to find appropriate work. The state’s priority in introducing Bantu education was to reduce widespread black illiteracy. While Minister of Native Affairs Hendrik Verwoerd spelled out in crude and offensive terms that blacks would not be able to perform high-level jobs in “white South Africa”, it is wrong to assume that this was based on the assumption of black intellectual inferiority. Bantu education always lagged far behind white education with respect to per capita spending and the ratio of teacher to pupils in the class room. After 1994, ANC (African National Congress) leaders criticised the introduction of Bantu education in ever more strident terms, suggesting that it should be considered as a destructive intervention. The article argues that, viewed against the state of education that existed before 1953, it can be considered as part-reform in that it brought primary education to a far greater number of black children than was the case before 1953. The extensive use of mother tongue education was contentious, but several comparative studies show that the use of such a system in at least the first seven or eight years of the child’s education is superior to other systems. The school-leaving pass rate of 83.7% for black students in 1976 is the highest pass rate to date.

Evolución de la prestación real media en España por edad y sexo (1998-2008) y su repercusión en las proyecciones de gasto sanitario público

ObjectivesTo analyze changes in real per capita spending by age and sex from 1998 to 2008 in Spain, and to assess their effects on public healthcare expenditure projections. MethodsAge- and sex-related expenditure profiles in constant terms were estimated for the Spanish population for 3 distinct years (1998, 2003 and 2008) by using data from hospital records and several National Health Surveys. These profiles were used to compare actual healthcare expenditure for 2003 and 2008 with the projections obtained by considering 1998 as the base year and by applying the methodology used by the Working Group on Aging of the European Union. ResultsThe average annual growth rate of real per capita spending per person from 1998 to 2008 was 2.79%, which was higher than the GDP per capita growth rate (1.90%), basically due to its high rate of increase in the second half of the decade. From 1998 to 2008, per capita healthcare expenditure increased in most age groups, particularly in the groups aged 45-49 years, 60-64 years and 75 years and older. Projections of per capita expenditure in constant terms covered the real value observed for 2003, but were below the real value for 2008. ConclusionsChanges in the quantity and quality of healthcare services consumed by each person are an important factor in changes in healthcare expenditure and must be included in spending projections.

A SECOND LOOK AT PHARMACEUTICAL SPENDING AS DETERMINANTS OF HEALTH OUTCOMES IN CANADA

Per capita spending on pharmaceutical products has increased substantially in recent decades in Canada. Recent Canadian research by Crémieux et al. concludes that there is a strong statistical relationship between pharmaceutical spending and health outcomes (Health Econ. 2005a; 14: 117, Health Econ. 2005b; 14(2): 107-116). This paper takes a second look at pharmaceutical spending as determinants of health outcomes in Canada. In doing so, it examines the robustness of the findings of Crémieux et al. by considering the appropriateness of the data used and statistical approach utilized. Particular attention is given to the potential for non-stationarity and spurious regression, issues related to unit heterogeneity and the choice of estimators. In contrast with earlier findings, on the whole, no discernable relationship between spending on private or public pharmaceutical products and infant mortality or life expectancy at 65 is observed.

Geographic variation in Medicare spending and mortality for diabetic patients with foot ulcers and amputations

AimsThe purpose of this study was to identify the presence or absence of geographic variation in Medicare spending and mortality rates for diabetic patients with foot ulcers (DFU) and lower extremity amputations (LEA). MethodsDiabetic beneficiaries with foot ulcers (n=682,887) and lower extremity amputations (n=151,752) were enrolled in Medicare Parts A and B during the calendar year 2007. We used ordinary least squares (OLS) regression to explain geographic variation in per capita Medicare spending and one-year mortality rates. ResultsHealth care spending and mortality rates varied considerably across the nation for our two patient cohorts. However, higher spending was not associated with a statistically significant reduction in one-year patient mortality (P=.12 for DFU, P=.20 for LEA). Macrovascular complications for amputees were more common in parts of the country with higher mortality rates (P<.001), but this association was not observed for our foot ulcer cohort (P=.12). In contrast, macrovascular complications were associated with increased per capita spending for beneficiaries with foot ulcers (P=.01). Rates of hospital admission were also associated with higher per capita spending and increased mortality rates for individuals with foot ulcers (P<.001 for health spending and mortality) and lower extremity amputations (P<.001 for health spending, P=.01 for mortality). ConclusionsGeographic variation in Medicare spending and mortality rates for diabetic patients with foot ulcers and amputations is associated with regional differences in the utilization of inpatient services and the prevalence of macrovascular complications.

Improving Value in Healthcare

Despite having the highest per capita spending on healthcare in the world, seriously ill patients in the United States often do not receive the highest quality care. Improving the value of healthcare by increasing quality while reducing escalating costs is at the heart of US health reform. With the passage of the Patient Protection and Affordable Care Act of 2010, new healthcare delivery and payment models are being implemented to achieve these goals. This article reviews areas of health reform that have specific relevance for hospice and palliative care, highlights palliative care’s positive outcomes, and reflects on current challenges within the healthcare system as well as within the field itself. Considerations regarding the language we use are explored, and recommendations are provided to ensure hospice and palliative care is represented in the planning and implementation of health reform initiatives.

The influence of state mental health perceptions and spending on an individual’s use of mental health services

To explore the possible contextual effects of state-level mental health perceptions and public spending for mental health treatment on an individual's use of mental health services, independent of the individual's own perceptions. Cross-sectional data from the 2007 Behavioral Risk Factor Surveillance System were used. A total of 216,514 participants from 35 states and the District of Columbia were included in the study. Logistic regression and multilevel modeling were used to estimate the effects of individual-level characteristics and three state-level factors-per capita spending on community mental health services, aggregated perceptions of the effectiveness of mental health treatment and the stigma of mental illness-on the individual's current use of mental health services. Adjusting for the individual's perceptions and characteristics, state-level perception of treatment effectiveness was positively associated with the use of mental health services [odds ratio (OR) for 5 % increase in the percentage perceiving effectiveness = 1.08; 95 % confidence interval (CI): 1.01, 1.16]. This association was strongest for individuals who experienced 1-4 days of mental distress in the past 30 days (OR = 1.17; 95 % CI 1.06, 1.29). State-level public spending on community mental health services was also positively associated with an individual's use of mental health services (OR for a $40 increase in spending = 1.09; 95 % CI 1.01, 1.17); however, state-level perceptions of mental-illness stigma was not. Our findings suggest there may be contextual effects of state-level perceptions of treatment effectiveness and state spending on community mental health services on the use of mental health services.

Is There a Starling Curve for Intensive Care?

Large differences exist in the provision of ICU beds worldwide, with a complicated mix of risks and benefits to the population of having either too few or too many beds. Having too few beds can result in delayed admission of patients to the ICU or no admission at all, with either scenario potentially increasing mortality. Potential societal benefits of having few beds include lower costs for health care and less futile intensive care at the end of life. With added ICU beds for a population, mortality benefit should accrue, but there is still the question of whether the addition of beds always means that more lives will be saved or whether there is a point at which no additional mortality benefit is gained. With an abundance of ICU beds may come the possibility of increasing harm in the forms of unnecessary costs, poor quality of deaths (ie, excessively intensive), and iatrogenic complications. The possibility of harm may be likened to the concept of falling off a Starling curve, which is traditionally used to describe worsening heart function when overfilling occurs. This commentary examines the possible implications of having too few or too many ICU beds and proposes the concept of a family of Starling curves as a way to conceptualize the balance of societal benefits and harms associated with different availability of ICU beds for a population.

How to Control Health Care Costs

How to Control Health Care Costs

Among Dual Eligibles, Identifying The Highest-Cost Individuals Could Help In Crafting More Targeted And Effective Responses

The nearly nine million people who receive Medicare and Medicaid benefits, known as dual eligibles, constitute one of the nation's most vulnerable and costly populations. Several initiatives authorized by the Affordable Care Act are intended to improve the health care delivered to dual eligibles and, at the same time, to achieve greater control of spending growth for the two government programs. We examined the 2007 costs and service use associated with dual eligibles. Although the population is indeed costly, we found nearly 40 percent of dual eligibles had lower average per capita spending than non-dual-eligible Medicare beneficiaries. In addition, we found that about 20 percent of dual eligibles accounted for more than 60 percent of combined Medicaid and Medicare spending on the dual-eligible population. But even among these high-cost dual eligibles, we found subgroups. For example, fewer than 1 percent of dual eligibles were in high-cost categories for both Medicare and Medicaid. These findings suggest that decision makers should tailor reform initiatives to account for subpopulations of dual eligibles, their costs, and their service use.