Higher Spending Research Articles

Abstract P533: Consumption of Foods Away From Home and Cardiometabolic Risk Among Adults in Puerto Rico

Consuming foods away from home (FAFH) is prevalent in the United States and contributes to high food spending and daily energy intake. We recently showed that adults in Puerto Rico (PR) who frequently consume FAFH had lower diet quality and adherence to dietary recommendations. It remains unknown if these associations translate into poor cardiometabolic health. We aimed to determine the association between the consumption of FAFH and cardiometabolic risk factors among adults in PR. Data were obtained from 1,246 adults (30-75 years) in the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic disease Trends (PROSPECT). Participants self-reported the frequency of consuming FAFH for any meal as "rarely" (<2 times/week), "sometimes" (2-4 times/week), or "frequently" (>4 times/week) at various commercial or noncommercial venues. A food frequency questionnaire assessed usual diet, and the Alternate Healthy Eating Index (AHEI) was calculated to capture diet quality. Clinical and laboratory markers from fasting blood samples were measured using standardized protocols. Generalized linear regression models were used to obtain means (SE) of cardiometabolic markers by FAFH category adjusted for sociodemographic and lifestyle behavioral factors. A second model was adjusted for AHEI. Frequently consuming commercial FAFH (cFAFH) was reported by 15.8% (192 of 1,218) and noncommercial FAFH (ncFAFH) by 4.4% (54 of 1,217), while cFAFH sometimes was reported by 31.8% (387 of 1,218) and ncFAFH by 19.0% (231 of 1,217). Participants who reported consuming cFAFH frequently (vs. rarely) had significantly higher waist circumference (107 (1.6) vs. 103 (1.3) cm; P= 0.003), BMI (31.5 (0.82) vs. 29.9 (0.64) kg/m 2 ; P= 0.032), and insulin (geometric mean 9.4 (2.1) vs. 7.8 (2.0) μIU/mL; p<0.001), and lower HDL-C (geometric mean 42.9 (1.0) vs. 45.6 (1.0) mg/dL; P= 0.012). Participants who reported consuming cFAFH sometimes (vs. rarely) had significantly higher plasma triglycerides (geometric mean 126.1 (1.5) vs. 102.1 (1.4) mg/dL; P= 0.012). Plasma glucose ( P= 0.004) and insulin ( P= 0.041) were higher in individuals frequently reporting (vs. rarely) consuming ncFAFH. Adjusting for AHEI did not appreciably change the models, except to nullify the association with BMI. Consuming FAFH, especially >4 times/week, was associated with adverse adiposity, lipids, and glucose markers and generally independent of overall diet quality. Future studies should identify the directionality of these associations and the potential mechanisms connecting them to cardiometabolic markers. Policymakers and food producers should enhance the quality of FAFH for commercial and at-home consumption for better cardiometabolic health.

Ethnic-Regional Differences in the Allocation of High Complexity Spending in Brazil: Time Analysis 2010-2019.

The following paper presents as a research problem the ethnic-regional differences in the allocation of high complexity spending in Brazil in an analysis from 2010 to 2019. This is a descriptive research in which a generalized linear model (GLM) was developed to analyze these hospital expenditures with high complexity procedures. The total spending on high complexity procedures in Brazil has increased over the past decade. The study shows that the lowest average expenditures are found in the North and Northeast regions. When comparing the spending between different ethnicities, it was observed that the only decrease between the years 2010 and 2019 was in the amount spent on procedures in indigenous people. The spending on male patients was significantly higher compared to female patients. The highest expenditures, on the other hand, are concentrated in the regions of state capitals favoring the strengthening of hub municipalities. Geographic inequalities in access still persist, even with most states already offering almost all procedures. The Brazilian territory is very heterogeneous and needs to organize its health system by regions, therefore integrated public policies and economic and social development are urgently needed.

“It is like an umbrella covering you, yet it does not protect you from the rain”: a mixed methods study of insurance affordability, coverage, and financial protection in rural western Kenya

Countries in Sub-Saharan Africa are increasingly adopting mandatory social health insurance programs. In Kenya, mandatory social health insurance is being implemented through the national health insurer, the National Hospital Insurance Fund (NHIF), but the level of coverage, affordability and financial risk protection provided by health insurance, especially for rural informal households, is unclear. This study provides as assessment of affordability of NHIF premiums, the need for financial risk protection, and the extent of financial protection provided by NHIF among rural informal workers in western Kenya.Methods We conducted a mixed methods study with a cross-sectional household survey (n = 1773), in-depth household interviews (n = 36), and 6 focus group discussions (FGDs) with community stakeholders in rural western Kenya. Health insurance status was self-reported and households were categorized into insured and uninsured. Using survey data, we calculated the affordability of health insurance (unaffordability was defined as the monthly premium being > 5% of total household expenditures), out of pocket expenditures (OOP) on healthcare and its impact on impoverishment, and incidence of catastrophic health expenditures (CHE). Logistic regression was used to assess household characteristics associated with CHE.Results Only 12% of households reported having health insurance and was unaffordable for the majority of households, both insured (60%) and uninsured (80%). Rural households spent an average of 12% of their household budget on OOP, with both insured and uninsured households reporting high OOP spending and similar levels of impoverishment due to OOP. Overall, 12% of households experienced CHE, with uninsured households more likely to experience CHE. Participants expressed concerns about value of health insurance given its cost, availability and quality of services, and financial protection relative to other social and economic household needs. Households resulted to borrowing, fundraising, taking short term loans and selling family assets to meet healthcare costs.Conclusion Health insurance coverage was low among rural informal sector households in western Kenya, with health insurance premiums being unaffordable to most households. Even among insured households, we found high levels of OOP and CHE. Our results suggest that significant reforms of NHIF and health system are required to provide adequate health services and financial risk protection for rural informal households in Kenya.

Policy Gains and Ongoing Collaboration in the House of Medicine

Back to table of contents Previous article Next article From the PresidentFull AccessPolicy Gains and Ongoing Collaboration in the House of MedicineRebecca Brendel, M.D., J.D.Rebecca BrendelSearch for more papers by this author, M.D., J.D.Published Online:25 Jan 2023https://doi.org/10.1176/appi.pn.2023.02.2.17As I write this column in the first month of 2023, the year is already turning out to be as busy and auspicious for mental health as in 2022! We began the new year against the backdrop of the latest findings of the APA Healthy Minds Poll, which showed that more Americans rated their mental health as fair or poor in 2022 than in 2021 (37% versus 31%) and that a significant number of Americans were making New Year’s resolutions about their mental health in anticipation of more stress ahead in 2023. As mental health remains front and center in our private lives, Congress ended 2022 with bipartisan legislation that funded key policy measures to improve access to mental health care (“Congress Passes Spending Bill With Several APA Priorities”). These policy gains addressed key issues and priorities for psychiatry and APA, including legislation proposed and championed by our policy and government relations teams and on which APA members testified in the House and the Senate over the past year, myself included.These are among the highlights of gains made during the final days of the 117th Congress: the addition of 200 graduate medical education slots, including 100 dedicated specifically to psychiatry and its subspecialties; extension of pandemic-era telehealth flexibilities under Medicare; and new grants to support implementation of the Collaborative Care Model in primary care practices. While these are important wins for advancing psychiatry and mental health, they are nonetheless just a start in what is needed to address the current and ongoing mental health needs of Americans post-pandemic. We have our work cut out for us in 2023, including continued advocacy for measures to bolster the effectiveness of the 988 mental health crisis hotline with community resources and investments; addressing ongoing workforce shortages; achieving mental health parity in practice; leveraging telehealth and other innovative technology to advance access to high-quality, evidence-based mental health care; and championing patient safety.While we continue to advance our policy initiatives in Washington, we cannot do this work alone. Collaboration with other medical organizations and professional societies is a key element of boosting our effectiveness in advancing health, including mental health, and gaining momentum and support for key legislation on the state and federal levels. One critical partnership is with the AMA—our psychiatry delegation to the policymaking House of Delegates is growing in influence and size with participation of psychiatry’s subspecialty organizations. Recent contributions of our psychiatry delegation include championing 988 to obtain critical AMA support, advocating for the end of discriminatory medical licensing questions related to mental health that are more restrictive and probing than questions about physical health, and recognizing the need for additional investments in the physician workforce.As we go to press, members of the AMA delegation and APA government relations staff have just returned from the annual AMA State Advocacy Summit, which met in person for the first time since 2019. Summit participants addressed challenges facing medicine at the state level—where the majority of medical practice and private insurance is regulated—and opportunities for action and change. Many of the featured topics had key relevance to APA and our members, including addressing physician wellness through the creation of confidential resources for physicians to address well-being and burnout, eliminating discriminatory medical licensing questions about mental health, and collaboration with state medical boards. Another central issue for both APA and the AMA is patient safety related to prescriptive authority and nonphysician practice parameters; one of the topics discussed at the meeting was the emerging evidence about gaps in quality and higher spending when nonphysician professionals serve in independent roles in primary care and emergency settings. Other important areas on the advocacy agenda included insurance priorities, discriminatory prior authorization requests, continued focus on effective measures to combat the opioid epidemic, and considerations in delivering comprehensive reproductive health care following the U.S. Supreme Court 2022 Dobbs decision.Our collaboration with the AMA is continuing at this year’s AMA National Advocacy Conference in Washington, D.C., to provide a critical assessment and call to action on federal law and policy influencing health and the practice of medicine.There is no question that in 2023 state and federal advocacy for health and mental health will continue to be front and center in APA’s work on behalf of our profession, members, and those whom we serve. You can follow my efforts in real time on Twitter @Pres_APA, and, as always, I look forward to hearing from you, especially about your advocacy adventures and successes! ■ ISSUES NewArchived

Using Data-Driven Approaches to Classify and Predict Health Care Spending in Patients With Gout Using Urate-Lowering Therapy.

Despite increasing overall health care spending over the past several decades, little is known about long-term patterns of spending among US patients with gout. Current approaches to assessing spending typically focus on composite measures or patients agnostic to disease state; in contrast, examining spending using longitudinal measures may better discriminate patients and target interventions to those in need. We used a data-driven approach to classify and predict spending patterns in patients with gout. Using insurance claims data from 2017-2019, we used group-based trajectory modeling to classify patients ages 40 years or older diagnosed with gout and treated with urate-lowering therapy (ULT) by their total health care spending over 2 years. We assessed the ability to predict membership in each spending group using logistic and generalized boosted regression with split-sample validation. Models were estimated using different sets of predictors and evaluated using C statistics. In 57,980 patients, the mean ± SD age was 71.0 ± 10.5 years, and 17,194 patients (29.7%) were female. The best-fitting model included the following groups: minimal spending (13.2%), moderate spending (37.4%), and high spending (49.4%). The ability to predict groups was high overall (e.g., boosted C statistics with all predictors: minimal spending [0.89], moderate spending [0.78], and high spending [0.90]). Although average adherence was relatively high in the population, for the high-spending group, the most influential predictors were greater gout medication adherence and diabetes melllitus diagnosis. We identified distinct long-term health care spending patterns in patients with gout using ULT with high accuracy. Several clinical predictors could be key areas for intervention, such as gout medication use or diabetes melllitus.

Why do some terrorist campaigns escalate to civil wars but others do not?

ABSTRACT The recent literature on antecedents of civil wars focuses primarily on the escalation of non-violent movements to civil wars. Still, it remains silent on why some terrorist campaigns manage to turn their violent campaign into a sustained insurgency. By filling this lacuna, we provide empirically supported explanations for this puzzle. Specifically, we explore the effects of three factors on a terror group’s chance to escalate the civil war, which are 1) how the state responds to the group’s terror campaign, 2) how the group responds to the state’s counterterrorism strategies, 3) and the state’s relations with other states. By testing our theory with recently released data on terrorist groups, we find that a terror group’s campaign is more likely to escalate to a civil war when 1) the state uses more repression against the terror group and 2) the group diversifies its attack portfolio. In addition, we also find that a terror group is less likely to escalate its campaign to a civil war if the state engages in an interstate rivalry, and the state responds to the group with higher spending on public goods, specifically social welfare goods. The results provide implications for future studies on terrorism and civil war.

Analysis of deprescription strategies of proton pump inhibitors in primary care: a narrative review.

Since the introduction of omeprazole in 1989, proton pump inhibitors (PPIs) have become the mainstream of treatment for acid-related pathologies, but nowadays, it is estimated that between 20% and 80% of people worldwide who are using PPIs are doing so without an approved indication. Overusing PPIs is known to involve a tremendous cost in financial terms, and many western countries have reported high spending on these medicines. We conducted a narrative review to evaluate PPI deprescription strategies carried out entirely or in collaboration with primary care and to identify factors that could influence the success of these strategies. This review was conducted in November 2022, following PRISMA guidelines. Four databases were searched: PubMed, Web of Science, Scopus and CINAHL Complete, using the MeSH terms 'proton pump inhibitors' AND 'deprescriptions'. The search with the established criteria found eight studies. The different success rates obtained by the various studies analysed in this review may be due to the different methodologies used when establishing the protocols, sample selection and monitoring of the results. We can conclude that the two factors related to the most successful strategies were a) the clarity and simplicity of the de-escalation protocols, in which patients were instructed on the measures to follow in the event of the reappearance of symptoms, and b) the training of the physicians responsible for deprescribing. Long-term conclusions cannot be drawn about the effectiveness of these protocols, given that the studies are limited in time. Other barriers to generalizing the results are the small sample size and the absence of control groups.

MEDICAL MARIJUANA LAWS AND OUT OF POCKET EXPENSES AT END OF LIFE

Abstract Resource intensive and costly End-of-Life (EOL) care is a significant healthcare policy concern in the U.S. In addition to the high Medicare spending, out of pocket (OOP) expenses are also high during EOL adding considerable stress during terminal days. The Medical Marijuana Laws (MMLs) is a significant policy in this context. Previous studies have shown increased use of MM among older adults, better pain management, influence on site of death as well as evidence of reduction in Medicare expenditure on drugs in states with MMLs. In this study, we explore the association between MML and OOP expenses during EOL using data from the Health and Retirement Study exit and core interviews from 1995 to 2018. We use a difference in differences (DD) and event study models to examine this question. We find evidence of increased OOP expenses on drugs and doctor visits with the effects concentrated among the early implementing states, among decedents who are White and among cancer patients. Despite its growing acceptance in palliative medicine, affordability of MM could pose a significant hurdle to terminally ill patients especially since MM and related costs are not covered by insurance.

Sleepiness Moderates the Associations between Personality and Financial Risk Tolerance and Spending Habits among College Students

ABSTRACT Objectives Personality and sleep characteristics are related to financial attitudes and behaviors. However, to our knowledge no study has examined how personality and sleep may be conjointly associated with these financial outcomes. The present study examined sleepiness as a moderator of the associations between college students’ personality traits and financial risk tolerance and spending habits. Methods Undergraduates (N = 177, 77% women, 78% White) self-reported their personality traits and sleepiness using well-established questionnaires. Financial attitudes and behaviors were assessed via students’ self-reported responses to a set of scenarios assessing risk tolerance as well as their spending habits over the prior two weeks. Results Multiple regression analyses were run. Across five significant two-way interactions, high levels of sleepiness exacerbated risk for greater financial risk tolerance and higher spending among those characterized by high open-mindedness and low neuroticism, whereas low sleepiness increased protection for lower risk tolerance and less spending among those high in agreeableness and conscientiousness. Conclusions Sleepiness may act as both a vulnerability and protective factor in relations between personality and financial attitudes and behaviors. Improvements in sleepiness, which is modifiable via intervention, may have significant implications for individuals’ financial well-being.

Can higher spending on primary healthcare mitigate the impact of ageing and non-communicable diseases on health expenditure?

IntroductionFinancing healthcare for ageing populations has become an increasingly urgent policy concern. Primary healthcare (PHC) has been viewed as the cornerstone of health systems. While most research has examined the...

Estimating Savings Opportunities From Therapeutic Substitutions of High-Cost Generic Medications

Use of generics is generally understood as a cost-saving practice. However, pharmacy benefit managers have an incentive to place higher-priced generic drugs on insurers' drug formularies to profit by creating a large difference between the price negotiated with pharmacies and the price paid by insurers (what is known as spread pricing). To examine price differentials and savings potential between high-cost generics and corresponding therapeutic alternatives of same clinical value and lower cost. This cross-sectional analysis examined the top 1000 generics in Colorado's all-payer claims database (CO-APCD) in 2019. High-cost generics and lower-cost generic therapeutic alternatives of same clinical value constituted the study sample. Data were analyzed from January 2019 to December 2019. Generic drug prices measured by transaction prices, average wholesale price (AWP), and national drug acquisition average cost (NADAC). Price differentials between the high-cost generics and the corresponding therapeutic alternatives. Levels of discounts and savings that could be achieved if the high-cost generics had been substituted by their therapeutic alternatives. This cross-sectional study of the top 1000 CO-APCD generics identified 45 high-cost products that had lower-cost therapeutic alternatives of same clinical value. Overall, high-cost generics were 15.6 times more expensive than their therapeutic alternatives (median values). If the lower-cost alternatives had been used, total spending would have been reduced from $7.5 million to $873 711, resulting in 88.3% savings. Most substitutions (28 of 45 [62.2]%) involved different dosage forms or different strengths of the same drug and provided mean (SD) discounts of 94.9% (3.8%) and 77.1% (19.9%), respectively. In this study, replacing high-cost generics with lower-cost alternatives of same clinical value would produce savings of nearly 90%. Plan sponsors should be aware that some generics are associated with higher spending and should periodically review the specific products driving their generic drug spending. Substitution of high-cost generics may provide a simple pathway to offer the same therapeutic benefit at lower cost to patients and insurers.

High deductible health plans and spending among families with a substance use disorder

BackgroundThe United States faces an ongoing drug crisis, worsened by the undertreatment of substance use disorders (SUDs). Family enrollment in high deductible health plans (HDHPs) and the resulting increased cost exposure could exacerbate the undertreatment of SUD. This study characterized the distribution of health care spending within families where a member has a SUD and estimated the association between HDHPs and family health care spending. MethodsUsing commercial claims and enrollment data from OptumLabs (2007–2017), we identified a treatment group of enrollees whose employers began offering an HDHP and comparison group whose employers never offered an HDHP. We used a difference-in-differences analysis that compared health care spending in families at firms that did vs. did not offer an HDHP before and after the HDHP offer. All models were adjusted for employer and year fixed effects, as well as family demographics, size, and chronic conditions. ResultsOur sample was comprised of 317,353 family-years. Family members with a SUD, on average, contributed an outsized proportion of total family health care expenditures (56.9% in a family of three). Offering a family HDHP was associated with a 6.1% reduction (95% confidence interval [CI]: 9.7–2.6%) in the probability of families having any SUD-related expenditures. The HDHP offer was associated with a $1546 reduction in family total expenditures and a $1185 reduction for the individual with SUD (95% CI: −2272 to −821 and −1845 to −525, respectively). ConclusionsThe increased prevalence of family enrollment in HDHPs may further the existing issue of undertreatment of SUDs.

Improving risk stratification using AI and social determinants of health.

To determine whether a risk prediction model using artificial intelligence (AI) to combine multiple data sources, including claims data, demographics, socialdeterminants of health (SDOH) data, and admission, discharge, and transfer (ADT) alerts, more accurately identifies high-cost members than traditional models. The study used data from a Medicaid accountable care organization and included a population of61,850 members continuously enrolled between May 2018 and April 2019. Risk scores generated by 2 models were estimated for each member. One model, developed by Medical Home Network, used AI to analyze SDOH data, ADT activity, and claims and demographic characteristics, whereas the other model (Chronic Illness and Disability Payment System [CDPS]) relied only on demographic and claims information. To compare models, we calculated mean, median, and total spending for members with the highest 5% of AI risk scores and compared these with spending metrics for members with the highest 5% of CDPS scores. We also compared the number of members with the highest 5% of costs prospectively identified by each model as highest risk. We segmented the population by length of prior enrollment to control for varying levels of claims experience. The AI model consistently identified a higher proportion of the highest-spending members. Members deemed highest risk by the AI model also had higher spending than members deemed highest risk by the CDPSmodel. Identification of high-cost members can be improved by using AI to combine traditional sources of data (eg, claims and demographic information) with nontraditional sources (eg, SDOH, admission alerts).

Utilizing SEM-RFC to predict factors affecting online shopping cart abandonment during the COVID-19 pandemic

Online shopping has accelerated during to the pandemic and an increase in online shopping cart abandonment (SCA) was also evident. The growth of online shopping is contributed by the rising middle class, high consumer spending, millennials, and a tech-savvy population which is valuable to the growth of e-commerce. This study aimed to predict the factors that affect SCA during the COVID-19 Pandemic utilizing the SEM-RFC hybrid. Several factors such as self-efficacy, attribute conflicts, hesitation at checkout, emotional ambivalence, choice process satisfaction, attitude, subjective norms, and perceived behavioral control were analyzed simultaneously. This study integrated the cognition-affect-behavior paradigm with the Theory of Planned Behavior to provide a conceptual framework measured through an online survey questionnaire answered by 1015 valid responses collected by convenience sampling. Results showed that Attitude, Attribute Conflict, Self-Efficacy, and Emotional Ambivalence are the primary significant factors affecting SCA. Amidst the pandemic, consumers still value the ease of use, convenience and safety of the mobile online shopping applications that they have, which they do not positively experience at this time. The findings of this study may be applied and extended by researchers, online retailers, and businesses to understand consumer's abandonment intentions. Moreover, the results and framework of this study may be capitalized on by the business sector to create marketing strategies and develop business models for a sustainable online shopping business worldwide.

Do Higher Deductibles Slow Health Spending Growth?

High health care spending growth is regarded in all countries as a potential policy problem. The potential for patient cost-sharing to reduce spending levels has been studied extensively; however, there has been very little work on how cost-sharing may also influence spending growth. In this paper, we relate deductibles as a measure of cost-sharing to health care spending growth at the market level. We analyze a novel combination of US state-level panel datasets from 2002 to 2012 and find that higher deductible levels in private group insurance are associated with significantly lower spending growth, particularly for pharmaceuticals. We observe similar results in both OLS and instrumental variables models, where we use measures of employer and worker preferences as instruments for deductible levels. We theorize and conclude that cost-sharing affects spending growth by constraining the use of more costly new technology, a major driver of health care spending growth worldwide.

Association Between Buprenorphine Treatment Gaps, Opioid Overdose, and Health Care Spending in US Medicare Beneficiaries With Opioid Use Disorder

Nonadherence to buprenorphine may increase patient risk of opioid overdose and increase health care spending. Quantifying the impacts of nonadherence can help inform clinician practice and policy. To estimate the association between buprenorphine treatment gaps, opioid overdose, and health care spending. This longitudinal case-control study compared patient opioid overdose and health care spending in buprenorphine-treated months with treatment gap months. Individuals who were US Medicare fee-for-service beneficiaries diagnosed with opioid use disorder who received at least 1 two-week period of continuous buprenorphine treatment between 2010 and 2017 were included. Analysis took place between January 2010 and December 2017. A gap in buprenorphine treatment in a month lasting more than 15 consecutive days. Opioid overdose and total, medical, and drug spending (combined patient out-of-pocket and Medicare spending). Of 34 505 Medicare beneficiaries (17 927 [520%] male; 16 578 [48.1%] female; mean [SD] age, 49.5 [12.7] years; 168 [0.5%] Asian; 2949 [8.5%] Black; 2089 [6.0%] Hispanic; 266 [0.8%] Native American; 28 525 [82.7%] White; 508 [1.5%] other race), 11 524 beneficiaries (33.4%) experienced 1 or more buprenorphine treatment gaps. Treatment gap beneficiaries, compared with nontreatment gap beneficiaries, were more likely to be younger, be male, have a disability, and be Medicaid dual-eligible while less likely to be White, close to a buprenorphine prescriber, and treated with buprenorphine monotherapy (ie, buprenorphine hydrochloride). Beneficiaries were 2.89 (95% CI, 2.20-3.79) times more likely to experience an opioid overdose during buprenorphine treatment gap months compared with treated months. During treatment gap months, spending was $196.41 (95% CI, $110.53-$282.30) more than in treated months. Patients who continued to take buprenorphine dosages of greater than 8 mg/d and 16 mg/d were 2.61 and 2.84 times more likely to overdose in a treatment gap month, respectively, while patients taking buprenorphine dosages of 8 mg/d or less were 3.62 times more likely to overdose in a treatment gap month (maintenance of >16 mg/d: hazard ratio (HR), 2.64 [95% CI, 1.80-3.87]; maintenance of >8 mg/d: HR, 2.84 [95% CI, 2.13-3.78]; maintenance of ≤8 mg/d: HR, 3.62 [95% CI, 1.54-8.50]). Buprenorphine monotherapy was associated with greater risk of overdose and higher spending during treatment gaps months than buprenorphine/naloxone. Medicare patients treated with buprenorphine between 2010 and 2017 had a lower associated opioid overdose risk and spending during treatment months than treatment gap months.

Factors associated with high health care spending among patients with schizophrenia.

Understanding the reasons for the wide variation in health care spending among patients with schizophrenia may benefit the development of interventions aimed at improving patient outcomes and health care spending efficiency. The aim of our study was to determine factors associated with high health care spending in the patient population. A serial cross-sectional study used the administrative health records of residents of Alberta, Canada between 1 January 2008 and 31 December 2017 and provincial costing methodologies to calculate total health care spending and sector-specific costs. Factors that modified the odds of being a high cost (i.e. 95th percentile or higher) patient with schizophrenia were estimated using generalized estimating equations. This study captured 242 818 person-years of observations among 38 177 unique patients with schizophrenia. Increased odds of being a high-cost patient were associated with younger age (18-29 years), male sex, unstable housing status and requiring care from multiple medical specialties. The strongest estimated associations between high cost status and comorbidity were for metastatic cancer (OR = 2.26) and cirrhosis (OR = 2.07). In contrast, polypharmacy was associated with a decreased odds of being high cost compared with untreated patients. Factors associated with being a high-cost patient are the result of complex interactions between individual, structural and treatment-related factors. Efforts to improve patient outcomes and address rising health care costs must consider the value of allocating resources towards early detection and support of patients with schizophrenia along with the prevention/management of comorbidity.

Caffeine’s Effects on Consumer Spending

Caffeine is the world's most popular stimulant and is consumed daily by a significant portion of the world's population through coffee, tea, soda, and energy drinks. Consumers often shop online and in physical stores immediately after or while consuming caffeine. This is further facilitated by the increasing prevalence of coffee shops and by the phenomenon of some retail stores having in-store coffee bars and offering complimentary caffeinated beverages. This research examines how caffeine consumption before shopping influences purchase behavior. The results of a series of experiments conducted in the field (at multiple retail stores across different countries) and in the lab show that consuming a caffeinated (vs. noncaffeinated) beverage before shopping enhances impulsivity in terms of more items purchased and higher spending. This effect is stronger for “high-hedonic” products and attenuated for “low-hedonic” products. These findings are important for managers to understand how a seemingly unrelated behavior (i.e., caffeine consumption) in and/or around the store affects spending. From a consumer perspective, although moderate amounts of caffeine consumption can have positive health benefits, there can be unintended negative financial consequences of caffeine intake on spending. Thus, consumers trying to control impulsive spending should avoid consuming caffeinated beverages before shopping.

Articles: Multinational enterprises and the welfare state

This paper presents an empirical analysis on the extent to which a country’s welfare spending influences foreign direct investment (FDI) decisions, particularly as they relate to relocations. We argue, and subsequently empirically test, that higher welfare spending by governments attracts foreign investment. Moreover, multinational enterprises (MNEs) located in high welfare spending countries have a lower likelihood of relocating to foreign markets compared with MNEs in countries with lower levels of welfare spending. Using data for MNEs in 27 OECD countries, our results show that MNE location decisions are positively related to welfare spending. These findings appear to be more pronounced for MNEs operating in high-tech rather than in low-tech manufacturing industries. Our results suggest that high welfare spending does deter FDI in the case of host developing economies, but that these effects are small. We suggest that this is a result of firms being more hesitant to invest in developing countries where they will be expected to contribute to welfare. This suggests that a degree of trust between firms and host country governments is required on institution building and the delivery of welfare. Our results suggest that the conventional wisdom of firms avoiding or relocating away from locations due to the associated additional costs of high welfare spending is questionable, but that firms need to be confident on the efficacy of this welfare expenditure.

Who are the Big Spenders at a Grand Prix In a Gaming Destination?

Market segmentation by expenditure enables the identification of high-spending visitors to festivals and events, enabling organizers to target this group with appropriate product offerings and promotions, thereby facilitating the achievement of economic goals from smaller participant numbers. Despite the potential usefulness of this tool, few studies have applied this technique in the festival and event literature. This article examines the existing studies with a view to identifying similarities and differences among high spenders and other points of interest. An additional case study of visitors to the 2019 Macau Grand Prix is added to the current research. High, medium, and light spending categories of Grand Prix attendees are identified and profiled. High spenders are found to differ from their counterparts on a number of sociodemographic and trip-related characteristics, including age, income, length of stay in Macau, and most of all a desire to thoroughly enjoy their whole Grand Prix trip, staying in comfortable accommodation, dinning and drinking, and trying their luck in the city's casinos. In addition, they exhibit a higher level of interest or attachment to the Macau Grand Prix and to motor sports more broadly. These outcomes support the findings of other studies using expenditure to segment festival and event goers, and provide valuable information for the event organizers and tourism operators in Macau.