Level Of Health Care Spending Research Articles

How do low-income enrollees in the Affordable Care Act marketplaces respond to cost-sharing?

The Affordable Care Act requires insurers to offer cost sharing reductions (CSRs) to low-income consumers on the Marketplaces. We link 2013-2015 All-Payer Claims Data to 2004-2013 administrative hospital discharge data from Utah and exploit policy-driven differences in the actuarial value of CSR plans that are solely determined by income. This allows us to examine the effect of cost sharing on medical spending among low-income individuals. We find that enrollees facing lower levels of cost sharing have higher levels of health care spending, controlling for past health care use. We estimate demand elasticities of total health care spending among this low-income population of approximately -0.12, suggesting that demand-side price mechanisms in health insurance design work similarly for low-income and higher-income individuals. We also find that cost sharing subsidies substantially lower out-of-pocket medical care spending, showing that the CSR program is a key mechanism for making health care affordable to low-income individuals.

ANALYSIS OF THE HEALTHCARE MANAGEMENT SYSTEM IN UKRAINE

Objective. The objective of the present article is to analyze the health care system in Ukraine at different levels, the development of medical care in Ukraine, to determine the purpose and objectives of primary health care on the basis of family medicine and the classification of medical services. Methods. The research methods are historical-logical and system-structural approaches to the analysis of the medical field of Ukraine. Modern methods of analysis, method of expert assessments, comparative analysis, etc. are used. The information base of the research is scientific works of domestic and foreign scientists, Laws of Ukraine, resolutions of the Cabinet of Ministers of Ukraine, regulations and statistical materials of the State Statistics Service of Ukraine, World Data Bank, Eurostat and the Center for Medical Statistics of Ukraine, research and analytical materials, Internet resource. Results. the current state of the primary health care system on the basis of family medicine in Ukraine and Europe has been studied. The development of the health care system from social medicine to the current health care system has been studied. The structure of the Ministry of Health has been studied, and the responsibility of the sectors for the development of modern medicine in Ukraine has been studied. The hierarchy of the health care system was studied, it was found that it includes national, regional and local levels. The purpose and objectives of medical care are identified, namely - to ensure a guaranteed amount of affordable, timely, quality and effective primary care to the patient, improve public health, preserve, restore and strengthen the health of the population. The classification of medical services is determined. The basic principles of family medicine are revealed, which include - family approach, patient orientation, preventive orientation, accessibility, equality and non-discrimination, multidisciplinary, continuity, longevity and coordination. The assessment of medical care of the population in the countries of Europe and Ukraine is carried out. To do this, we analyzed the cost of health care. International experience shows that the optimal level of health care spending is 8-10% of GDP and data from EU member states confirm this. In Ukraine, per capita health expenditures have been steadily increasing during 2010-2016, with an average of 3.8% of GDP in recent years.

Health care system efficiency and life expectancy: A 140-country study.

Despite the evidence of links between health expenditure and health care efficiency, it is still unclear why countries with similar levels of health expenditures experience different outputs in terms of life expectancy at birth. Health care system efficiency might shed some light on the question. Using output-oriented data envelopment analysis, we compared the health systems of 140 countries in terms of attained life expectancy. Efficiency is determined by the distance from the closest country on the best practice frontier, which identifies the highest attainable life expectancy observed for any given level of health care spending. By using national data form the Human Development Data, we built the efficiency frontier and computed the potential life expectancy increase for each country. The potential improvement was, on average, 5.47 years [95%CI: 4.71-6.27 years]. The least efficient countries (10th percentile of the efficiency score) could improve by 11.78 years, while the most efficient countries (90th percentile of the efficiency score) could only improve by 0.83 years. We then analyzed, with regression analysis stratified by average education level, and by the role of health-related variables in differentiating efficient and inefficient countries from each other. The results suggest that, among countries with lower levels of education, decreasing unemployment and income inequality increases average life expectancy, without increasing health expenditure levels.

How Does Cost-Sharing Impact Spending Growth and Cost-Effective Treatments? Evidence from Deductibles

The growth of health care spending has been a longstanding policy concern. Over the years, several innovations have been proposed to lower levels of health care spending; however, their impact has been limited and not sustained over time. Costly new technology, while often an improvement to existing care, has been identified as a principal driver of health care spending growth. Recent literature has shown that high deductible health plans (HDHP) can have an immediate impact on levels of health care spending, but their medium- and long-run effects on spending growth remain unknown. In this paper, we use multiple-employer-group claims data from a large national insurer to (i) study whether HDHPs reduce the growth in spending over four years compared to lower deductible alternatives; and (ii) explore the mechanisms behind any reductions in growth by looking at whether HDHPs reduce the use of low- vs. high-value treatments. We find that HDHPs have a limited effect on spending growth, with a statistically significant reduction observed only for prescription drugs. HDHPs are not associated with significantly lower growth in spending on highly cost-effective medicines in a sample of drugs but do reduce spending growth for less cost-effective drugs. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

The association between medical care utilization and health outcomes: A spatial analysis

As health care spending continues to strain government and household budgets, there is increasing interest in measuring whether the incremental dollar spent on health care is worth it. In studying this question, researchers often make two key assumptions: that health care intensity can be summarized by a single index such as average spending, and that samples of hospitals or regions are spatially independent: Manhattan and the Bronx are no more alike than are Manhattan and San Diego, for example. In this paper we relax both assumptions. Using detailed data on 897,008 elderly Medicare enrolees with acute myocardial infarction (or a heart attack) during 2007–11, we find first that the total level of health care spending has little impact on health outcomes; more important is how the money is spent. Same-day stenting, a treatment with proven effectiveness, positively predicts survival, while home health care spending does not. Second, there is strong evidence of spatial autocorrelation; without corrections this can lead to inefficient estimates and standard errors that are biased downward. Spatial autocorrelation in outcomes appears to be the consequence both of unmeasured health status and spatial correlation in new and effective technology.

How Do Low-Income Enrollees in the Affordable Care Act Marketplaces Respond to Cost-Sharing?

The ACA requires insurers to provide cost-sharing reductions (CSRs) to low-income consumers on the marketplaces. We link 2013-2015 All-Payer Claims Data to 2004-2013 administrative hospital discharge data from Utah and exploit policy-driven differences in the value of CSRs that are solely determined by income. We find that enrollees with lower cost sharing have higher levels of health care spending, controlling for past health care use. We estimate the demand elasticity of total health care spending to be -0.10, but find larger elasticities for emergency room care, lifestyle drugs, and low-value care. We also find positive cross-price elasticities between outpatient and inpatient care.

Professional norms and physician behavior: Homo oeconomicus or homo hippocraticus?

Physicians' treatment decisions determine the level of health care spending to a large extent. The analysis of physician agency describes how doctors trade off their own and their patients' benefits, with a third party (such as the collective of insured individuals or the taxpayers) bearing the costs. Professional norms are viewed as restraining physicians' self-interest and as introducing altruism towards the patient. We present a controlled experiment that analyzes the impact of professional norms on prospective physicians' trade-offs between their own profits, the patients' benefits, and the payers' expenses for medical care. Our data support the notion that professional norms derived from the Hippocratic tradition shift weight to the patient in physicians' decisions while decreasing their self-interest and efficiency concerns.

Variations in life expectancy in Organization for Economic Co-operation and Development countries--1985-2010.

We examined the impact of different behavioral factors of health on the variations in the levels and rate of increase in life expectancy in Organization for Economic Co-operation and Development countries between 1985 and 2010. Using the World Health Organization's conceptual framework of socio-economic determinants of health, we incorporated Organization for Economic Co-operation and Development, World Bank and United Nations data to estimate the impact of these variables on life expectancy for 30 Organization for Economic Co-operation and Development countries. We used a random effect model to control the fixed effect of year and each country. Results show that the level of health care spending is the most important factor predicting life expectancy. Other important factors are gross domestic product per capita, labor productivity, years of schooling and percentage of gross domestic product spending allocated for public services. Life expectancy was reduced by smoking and higher daily calorie consumption. Countries that were previously part of the Soviet Union had lower life expectancies. Political factors had only a minor impact on life expectancy. Life expectancy increased an average of 5.1 years in Organization for Economic Co-operation and Development countries between 1985 and 2010, but there was wide variation. Health spending per capita, economic factors and two behavioral factors - smoking and caloric intake - explained most of the variation and suggest where increased policy attention could have the greatest impact on life expectancy. Policymakers who consider our estimates recognize that they may see greater or less impact depending on the characteristics of their nation.

Epigenetic targets for novel therapies of lung diseases

In spite of substantial advances in defining the immunobiology and function of structural cells in lung diseases there is still insufficient knowledge to develop fundamentally new classes of drugs to treat many lung diseases. For example, there is a compelling need for new therapeutic approaches to address severe persistent asthma that is insensitive to inhaled corticosteroids. Although the prevalence of steroid-resistant asthma is 5-10%, severe asthmatics require a disproportionate level of health care spending and constitute a majority of fatal asthma episodes. None of the established drug therapies including long-acting beta agonists or inhaled corticosteroids reverse established airway remodeling. Obstructive airways remodeling in patients with chronic obstructive pulmonary disease (COPD), restrictive remodeling in idiopathic pulmonary fibrosis (IPF) and occlusive vascular remodeling in pulmonary hypertension are similarly unresponsive to current drug therapy. Therefore, drugs are needed to achieve long-acting suppression and reversal of pathological airway and vascular remodeling. Novel drug classes are emerging from advances in epigenetics. Novel mechanisms are emerging by which cells adapt to environmental cues, which include changes in DNA methylation, histone modifications and regulation of transcription and translation by noncoding RNAs. In this review we will summarize current epigenetic approaches being applied to preclinical drug development addressing important therapeutic challenges in lung diseases. These challenges are being addressed by advances in lung delivery of oligonucleotides and small molecules that modify the histone code, DNA methylation patterns and miRNA function.

Trends in cost sharing among selected high income countries—2000–2010

Many high income countries increased their level of patient cost sharing between 2000 and 2010 as one component of their policy agenda to reduce the level of health care spending. We use data from the OECD, European Observatory, and country-specific resources to analyze trends in the UK, Germany, Japan, France, and the United States. Some forms of cost sharing—deductibles, co-insurance, or co-payments—increased in all these countries, with the highest rates of increase occurring in the pharmaceutical sector. In spite of higher levels of cost-sharing, out-of-pocket spending as a percentage of total spending remained unchanged in most of these countries because they instituted programs to protect certain categories of individuals by creating out-of-pocket limits, exempting people with certain chronic diseases, or eliminating cost sharing for certain demographic groups and low-income people.

Waste Not, Want Not: Promoting Efficient Use of Health Care Resources

Editorials1 January 2013Waste Not, Want Not: Promoting Efficient Use of Health Care ResourcesAlyna T. Chien, MD, MS and Meredith B. Rosenthal, PhDAlyna T. Chien, MD, MSFrom Harvard Medical School, Boston Children's Hospital, and Harvard School of Public Health, Boston, Massachusetts.Search for more papers by this author and Meredith B. Rosenthal, PhDFrom Harvard Medical School, Boston Children's Hospital, and Harvard School of Public Health, Boston, Massachusetts.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-158-1-201301010-00014 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The pressure to control health care costs in the United States is at an all-time high. In the governmental sector, Medicare and Medicaid consume approximately one quarter of the federal budget and are growing more rapidly than revenues; the commercial sector is no different (1). Despite these exceptional levels of health care spending, Americans do not live any longer or better than their counterparts in other industrialized countries (2). Indeed, many experts believe that a significant proportion (as much as 30%) of the excess health care spending in the United States generates little or no health benefit. These facts and ...

Protecting Pakistan's health during the global economic crisis

The world is facing an unprecedented global economic crisis, with many countries needing to reconsider their level of health care spending. This paper explores the many consequences of the global economic turndown on Pakistan's health, including reduced government and donor spending and increased poverty with the consequent diversion of funds away from health. Nevertheless, these challenges may provide opportunities not only to mitigate the adverse effects of the economic crisis but also to institute some much-needed reforms that may not receive political support during more affluent times. Our suggestions focus on setting priorities based on the national disease burden, prioritizing prevention interventions, demanding results, curbing corruption, experimenting with innovative funding mechanisms, advocating for increased funding by presenting health spending as an investment rather than an expense and by selected recourse to civil society interventions and philanthropy to bridge the gap between available and needed resources.

Opportunities for Cost Reduction of Medical Care: Part 3

The level of health care spending in the United States and other developed nations is rising at a disturbingly rapid rate. However, in the United States, these increases are not justified by superior performance. Rather, most other wealthy countries' inhabitants live longer and suffer from fewer medical problems than the average American. This paper demonstrates the continued abundance of opportunities for substantially reducing health care costs without decreasing the quality of care. In particular, it emphasizes the need to reduce the practice of defensive medicine and to enlarge the cadre of non-specialist physicians who educate future doctors. Such cost-saving opportunities are not rare phenomena but are widely available and offer the United States opportunities to move toward the markedly lower cost levels that have been achieved in other countries.

When Less Might Be More

When Less Might Be More

Comparative Effectiveness Research

America's present level of health care spending is unsustainable. The rising costs of health care would be less concerning if there was evidence suggesting that more spending made Americans healthier; the evidence, however, suggests otherwise. The purpose of this article is to describe one tool that can potentially address quality and cost concerns for all health care professionals, including critical-care nurses.

The economics of comparative effectiveness research

Comparative effectiveness research (CER)—evidence that compares alternative methods of prevention, diagnosis, treatment, and monitoring or care delivery1—holds the promise of improving care and reducing health care costs. In this issue of Neurology ®, French and England2 highlight how CER can improve care by informing clinical practice and guideline development. Here we examine whether and how CER may affect both the level and growth of health care expenditures. In 2008, the United States spent more than $2.3 trillion or over 16% of its gross domestic product on health care,3 far more than any other country. However, by many health metrics, the United States lags behind its peers.4 Maximizing the value of health care expenditures, the majority of which goes to health care delivery,3 is thus an important objective, but to date only 0.1% of health care spending has been devoted to research aimed at improving health care delivery.5 This funding may increase; the Institute of Medicine identified health delivery as the top priority for $1.1 billion of new federal funding for CER as part of the American Recovery and Reinvestment Act of 2009. By identifying cost-effective ways to deliver care, CER may reduce the level of health care spending. Delivering health care to those with neurologic …

Politics and health in eight European countries: A comparative study of mortality decline under social democracies and right-wing governments

Recent publications have argued that the welfare state is an important determinant of population health, and that social democracy in office and higher levels of health expenditure promote health progress. In the period 1950-2000, Greece, Portugal, and Spain were the poorest market economies in Europe, with a fragmented system of welfare provision, and many years of military or authoritarian right-wing regimes. In contrast, the five Nordic countries were the richest market economies in Europe, governed mostly by center or center-left coalitions often including the social democratic parties, and having a generous and universal welfare state. In spite of the socioeconomic and political differences, and a large gap between the five Nordic and the three southern nations in levels of health in 1950, population health indicators converged among these eight countries. Mean decadal gains in longevity of Portugal and Spain between 1950 and 2000 were almost three times greater than gains in Denmark, and about twice as great as those in Iceland, Norway and Sweden during the same period. All this raises serious doubts regarding the hypothesis that the political regime, the political party in office, the level of health care spending, and the type of welfare state exert major influences on population health. Either these factors are not major determinants of mortality decline, or their impact on population health in Nordic countries was more than offset by other health-promoting factors present in Southern Europe.

The Nature of Healthcare: A Cross-National Time Series Perspective

Is healthcare a luxury? An answer to this question in the health economics literature mostly relied on the use of the level of healthcare spending as the explained variable. But by using the level of healthcare spending as the dependent variable, we may fail to identify pure income effects and therefore, may not be able to estimate the income elasticity properly. Employing standard welfare comparison methods widely used in the development economics literature, it is argued that budget-share of healthcare in national income is a more convenient and better policy-relavant variable than the level of spending on healthcare. Using panel data from 23 OECD countries for the years 1960-1998, it is showed that aggregate healthcare is strictly a necessary and not a luxury service. Similarly, publicly provided healthcare is a necessary service too. Results on the privately provided healthcare are ambiguous and depends in part on the inclusion of the US in the sample of countries. The policy implications of the results found are also discussed briefly.

Spending on Medical Care

ACCORDING TO CONVENTIONAL ECONOMIC THEORY, “more is better.” The most obvious example from economics is the assumption that more money leads to more happiness. Economists also believe in the law of diminishing returns—each additional unit provides a smaller increment in happiness than the previous unit. Behavioral economists recognize that individuals frequently compare their level of goods and services with that of their neighbors and are often happier when they have more than their neighbors. Many studies have examined if these same principles apply to medical care. For example, are patients healthier and happier when they receive more medical care? Do the last few dollars spent on medical care provide as much benefit and satisfaction as the first few dollars? Does an individual’s level of satisfaction with medical care depend on what his or her neighbors receive? Studies examining these issues have been conducted at different levels of aggregation, with some studies comparing health spending, health outcomes, and satisfaction at the international level, across different regions of the United States, or at the institutional or clinician level, and some comparing these issues at the individual patient or person level. In this issue of JAMA, Fowler and colleagues compare the level of health expenditures with the level of satisfaction with health care at the regional level and in doing so provide information that contributes to the “is more better’’ debate in health care. Studies that have compared the level of health spending across various countries using a variety of health outcomes such as life expectancy and infant mortality generally have found that level of health spending is a relatively poor predictor of health outcomes. Factors such as education among women, average per capita income, and degree of income inequality explain more of the cross-national variation in overall health status than the level of health spending. These studies also seem to show that the law of diminishing returns applies. Above a certain level of health care spending, roughly $2000 per capita, additional spending on health care seems to result in minimal improvements in health outcomes. Surveys of satisfaction conducted by the World Health Organization and by the Gallup Organization across a wide range of countries have found only minimal correlation between higher levels of health spending and levels of satisfaction with care or between health spending and the broader notion of system “responsiveness,” a measure of how well individuals believe the health care system responds to their own needs. Other studies have focused on industrialized countries. The Organization for Economic Co-operation and Development (OECD), a membership organization of the 30 industrialized countries, recently had its members collect data on 21 different health outcome indicators. The study showed that no country scored consistently high or low on all 21 indicators, that most countries scored well on certain indicators, and that some areas needed improvement in all countries. Overall, the correlation between level of health spending and scores on most indicators was relatively low. The United States, by far the biggest spender on health care, scored high on some indicators, such as breast cancer survival, and average or low on others, such as in-hospital mortality rates following myocardial infarction or mortality from asthma. The OECD study builds on a previous study that reached similar conclusions comparing the health outcomes in the United States, Canada, Australia, New Zealand, and the United Kingdom. The Commonwealth Fund has conducted a series of surveys with Harris International comparing the levels of satisfaction with care among industrialized countries. These surveys have compared a cross-section of the population, individuals with health problems and those with recent experience in using the health care system, physicians, and hospital executives. These studies show little correlation between the level of health care spending and satisfaction with care. Despite significantly higher levels of spending, US patients, physicians, hospital executives, and the general population are often less satisfied with the performance of their health care system as compared with those in other industrialized countries.

Back to the Future: The Managed Care Revolution

I INTRODUCTION Revolutions that result in sudden and radical change to a society's essential attributes are rare occurrences. Rather, from biology to social policy, the present is the result of an evolutionary progression of interrelated phenomena. The forces that prompt a period of rapid evolution are often not apparent, except in hindsight. The evolutionary process, once begun, is difficult to orchestrate, and the results hard to predict. The evolution of the managed care industry is a case in point. Initiatives by the private sector and government to make medical care accessible to a larger percentage of the population exacerbated, rather than ameliorated, the costs of health care services. The market-based reforms that followed were intended to provide consumers with information and financial incentives to make wise economical choices, but instead gave rise to a clamor of consumer complaints, while posting only temporary gains in controlling health care costs. The nation is once again faced with calls for reform of its patchwork system of health care delivery and financing. This article provides an overview of the interrelated events that led to the present-day managed care system. We begin with the stimuli for change to the longstanding medical model status quo. A paradigmatic shift from a physician-dominated professional model to a market-based system characterized the revolutionary period that followed. Before that shift could occur, however, Congress had to abandon its regulatory zeal to create a political climate in which policy-makers perceived market-based reform as a viable alternative to both regulatory fiat and professional control. Equally important to legislative willingness was the elimination of systemic impediments to market reforms, principally the organized resistance of the professionals who controlled the system. These events opened the way for suggestions about the direction that market-driven evolution should follow and the translation of scholarly insight into political reality. In this article, we revisit these events, describe the system that evolved, and conclude with some suggestions for future directions. II THE PAST AS PRELUDE The story of the pre-managed care era is one of miscues and well-intentioned missteps. Although the stirrings of the health care revolution became readily apparent shortly after the enactment of the Medicare and Medicaid programs, both the events that gave rise to the need for change and the form that change took had much earlier origins. The years that preceded the managed care era were remarkable for the juxtaposition of the relative stability and lack of diversity among the organizational arrangements for the delivery and financing of health care services, and the rapid changes in society and medical science. As third-party financing grew and physicians expanded their sphere of influence to include payment mechanisms as well as health care delivery, attempts to expand access to health care services without fundamentally changing highly prized practice patterns led to unsustainable levels of health care spending. The health care delivery system had long been static. Most physicians were self-employed, predominantly in solo practice, and the ratio between capital and labor in the typical practice was low. (1) Vertical integration of individual and institutional providers was rare. The result was a non-system of independent small business bereft of any means to coordinate the delivery of medical services to ensure their continuity, quality, or cost-effectiveness. The efforts to finance health care services exhibited only slightly more variation. In the early years of the twentieth century, medical services were a market good. As with all market goods, an individual's access to health care services was based primarily on her ability to buy them. …