Mean Annual Expenditures Research Articles

Estimating the prevalence and economic burden of overactive bladder among Medicare beneficiaries prior to Medicare Part D coverage

ABSTRACTObjective: The goal of this study is to provide annual estimates for the treated prevalence and expenditures attributable to overactive bladder (OAB) in the elderly prior to Medicare Part D drug coverage.Research design and methods: All Medicare claims were extracted for beneficiaries over 65 with continuous coverage for Medicare Parts A and B during 2003–2004. Two OAB definitions were created: (1) the base case included diagnosis codes that narrowly defined OAB, and (2) the sensitivity variant included additional codes indicative of OAB. Descriptive comparisons of baseline characteristics, annual expenditures, and events and procedures were performed for OAB vs. non-OAB subjects meeting the inclusion criteria. CMS expenditures (2004 US dollars) for individuals were totaled and multiple regression techniques were used to estimate costs attributable to OAB after adjusting for demographic characteristics and comorbid conditions.Results: The prevalence of subjects with an OAB diagnosis ranged from 8.8 to 13.6% for the base and sensitivity definitions, respectively. While mean total annual expenditures ranged from $9331 to $9655, mean annual expenditures attributable to OAB ranged from $825 to $1184 per subject (9–12% of total medical expenditures for OAB subjects), with aggregate total OAB-attributable expenditures of $1.8–3.9 billion per year.Conclusions: The treated prevalence of individuals seeking treatment for OAB in the elderly Medicare population is comparable to some common chronic conditions in that population, and OAB-attributable CMS expenditures are considerable. However, due to study limitations this is a conservative estimate of the direct cost of OAB in the elderly population. The reported estimates exclude pharmacy and out-of-pocket costs, are extrapolated to only two-thirds of the elderly Medicare population, and do not include expenditures by Medicaid for long-term care. Additionally, claims data limits detection of chronic conditions to patients who receive treatment or consultation for OAB; diagnosis codes used were based on expert opinion rather than a review of medical records to identify OAB patients; and long-term care costs are not included.

The economic burden of fibromyalgia: comparative analysis with rheumatoid arthritis

ABSTRACTObjective: To quantify and compare direct costs, utilization, and the rate of comorbidities in a sample of patients with fibromyalgia (FM), a poorly understood illness associated with chronic widespread pain that is commonly treated by rheumatologists, to patients with rheumatoid arthritis (RA), a well studied rheumatologic illness associated with inflammatory joint pain. Patients with both illnesses were isolated and reported as a third group. A secondary analysis of work loss was performed for an employed subset of these patients.Research design and methods: Retrospective cohort analysis of Thomson Reuters MarketScan administrative healthcare claims and employer-collected absence and disability data for adult patients with a diagnosis of FM (ICD-9-CM 729.1) and/or RA (ICD-9-CM 714.0x,–714.3x) on at least one inpatient or two outpatient claims during 2001–2004.Main outcome measures: The 12-month healthcare utilization, expenditures, and rates of comorbidities were quantified for all study-eligible patients; absence and short-term disability days and costs were quantified for an employed subset.Results: The sample included 14 034 FM, 7965 RA, and 331 FM + RA patients. Patients with FM had a higher prevalence of several comorbidities and greater emergency department (ED) utilization than those with RA. Mean annual expenditures for FM patients were $10 911 (SD = $16 075). RA patient annual expenditures were similar to FM: $10 716 (SD = $16 860). Annual expenditures were almost double in patients with FM+RA ($19 395, SD = $25 440). A greater proportion of patients with FM had any short-term disability days than those with RA (20 vs. 15%); and a greater proportion of patients with RA had any absence days (65 vs. 80%). Mean costs for absence from work and short-term disability in the FM and RA groups were substantial and similar. The FM+RA group was of insufficient sample size to report on work loss.Limitations: The availability of newer and more expensive FDA-approved medications since 2004 is not reflected in our findings. This analysis was restricted to commercially insured patients and therefore may not be generalizable to the entire U.S. population.Conclusions: The burden of illness in FM is substantial and comparable to RA. Patients with FM incurred direct costs approximately equal to RA patients. Patients with FM had more ED, physician, and physical therapy visits than RA patients. Patients in both groups had several comorbidities. Patients with FM+RA incurred direct costs almost double those of the patients with either diagnosis alone. FM and RA patients incurred similar overall absence and short-term disability costs.

Brief Report: Quantifying the Impact of Autism Coverage on Private Insurance Premiums

Many states are considering legislation requiring private insurance companies to pay for autism-related services. Arguments against mandates include that they will result in higher premiums. Using Pennsylvania legislation as an example, which proposed covering services up to $36,000 per year for individuals less than 21 years of age, this paper estimates potential premium increases. The estimate relies on autism treated prevalence, the number of individuals insured by affected plans, mean annual autism expenditures, administrative costs, medical loss ratio, and total insurer revenue. Current treated prevalence and expenditures suggests that premium increases would approximate 1%, with a lower bound of 0.19% and an upper bound of 2.31%. Policy makers can use these results to assess the cost-effectiveness of similar legislation.

Self blood glucose monitoring in type 2 diabetes. A financial impact analysis based on UK primary care

UK consensus guidelines recommend limited use of self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes using diet and exercise, metformin and/or a glitazone. This analysis quantifies the usage of and costs associated with SMBG in type 2 diabetes according to treatment regimen. Prevalence data for diabetes were assessed using UK Quality and Outcomes Framework returns for 2006/2007. Data on current SMBG prescribing expenditure were extracted from UK Prescription Pricing Agency Data for 2007. Prescribing data were extracted from the records of 40,651 patients with diabetes on the IMS Disease Analyzer (MediPlus) database. These were combined to arrive at mean usage and expenditure data per patient, broken down by treatment type. The analysis assumes that it is appropriate to use patients' treatment regimen alone to compare the frequency of SMBG in clinical practice with the frequency recommended in treatment guidelines; it does not take into account other valid reasons for SMBG. Mean national expenditure on SMBG was 73.64 pound sterling per patient per year. Estimated mean weekly test strip usage by treatment was 2.5 (diet), 2.6 (glitazone monotherapy), 3.1 (metformin monotherapy) and 3.5 (sulphonylurea monotherapy). Combination oral therapy ranged from 3.3 to 4.1. Mean annual expenditure in patients with an identified treatment type was 62.06 pound sterling per patient, ranging from 9.83 pound sterling for diet-treated patients to 37.87 pound sterling for those on triple therapy, with insulin-treated patients incurring costs 3-5 times higher. Based on the assumptions that the treatment regimen is the sole factor in determining the appropriate level of SMBG frequency, this study demonstrates that the use of SMBG exceeds current guidelines in certain treatment groups. The study estimates that the potential savings of up to 17 million pound sterling could be made each year if guidelines were followed more closely. There is a need for further research into SMBG use in patients with type 2 diabetes.

Cost Analysis and Cost Determinants in a European Inflammatory Bowel Disease Inception Cohort With 10 Years of Follow-up Evaluation

Economic analysis in chronic diseases is a prerequisite for planning a proper distribution of health care resources. We aimed to determine the cost of inflammatory bowel disease, a lifetime illness with considerable morbidity. We studied 1321 patients from an inception cohort in 8 European countries and Israel over 10 years. Data on consumption of resources were obtained retrospectively. The cost of health care was calculated from the use of resources and their median prices. Data were analyzed using regression models based on the generalized estimating equations approach. The mean annual total expenditure on health care was 1871 Euro/patient-year for inflammatory bowel disease, 1524 Euro/patient-year for ulcerative colitis, and 2548 Euro/patient-year for Crohn's disease (P < .001). The most expensive resources were medical and surgical hospitalizations, together accounting for 63% of the cost in Crohn's disease and 45% in ulcerative colitis. Total and hospitalization costs were much higher in the first year after diagnosis than in subsequent years. Differences in medical and surgical hospitalizations were the primary cause of substantial intercountry variations of cost; the mean cost of health care was 3705 Euro/patient-year in Denmark and 888 Euro/patient-year in Norway. The outlay for mesalamine, a costly medication with extensive use, was greater than for all other drugs combined. Patient age at diagnosis and sex did not affect costs. In this multinational, population-based, time-dependent characterization of the health care cost of inflammatory bowel disease, increased expenditure was driven largely by country, diagnosis, hospitalization, and follow-up year.

Falling into the Doughnut Hole

The Medicare Part D prescription drug benefit may facilitate provision of medications by subsidizing drug costs. However, beneficiaries with higher drug utilization may face higher out-of-pocket (OOP) costs under the benefit's "doughnut hole" provisions that substantially increase beneficiary cost-sharing. The Medicare Current Beneficiary Survey Cost and Use data for 1997 through 2001 were used to estimate the impact of the standard Part D benefit on drug expenditures. The sample consisted of adults who were not dually enrolled in Medicaid (41,617 without ESRD, 256 with ESRD). Outcomes were annual total and OOP drug spending projected to 2006, as well as estimates of individual spending changes under Part D. In 2006, ESRD beneficiaries will have mean annual total and OOP expenditures that are approximately twice that of their Medicare peers. The overall impact of Part D on OOP expenditures is similar among all beneficiaries; however, many individuals with employer-sponsored coverage and those with higher costs (especially those with ESRD) may face cost increases with significant monthly variability as a result of reaching the "doughnut hole," a no-coverage gap in the standard benefit. Therefore, ESRD beneficiaries face substantial total and OOP annual expenditures for medications, causing most to reach the Part D benefit gap. Higher OOP costs may lead to reductions in spending and medication use with subsequent treatment gaps that may lead to increased use of medical services. As the new legislation takes effect, policy makers who are considering modifications in the program may benefit from further research to monitor patterns and gaps in coverage, medication use and spending, and hospitalization and survival trends.

Smoking attributable medical expenditures, years of potential life lost, and the cost of premature death in Taiwan

Objective: To estimate the smoking attributable medical expenditures and productivity loss of people aged 35 and over in Taiwan in 2001 from a societal viewpoint. Methods: A prevalence based approach...

The impact of population ageing on future Danish drug expenditure

Population ageing is likely to place an increasing burden on future health care budgets. Several studies, however, have demonstrated that the impact of ageing on future hospital expenditures will be overestimated when not accounting for proximity to death. This is because the greater health care expenditures among the elderly are not only due to age per se but due to the high “costs of dying”. Similar studies for pharmaceutical expenditures are scarce. The aim of this study was first to estimate the impact of the ageing Danish population on future total expenditures (public outlays as well as private co-payment) on out-of-hospital prescription drugs, holding everything but demographic changes constant. Second, it was to describe the association between age and drug expenditure among survivors compared to that of decedents, and to evaluate the extent to which drug expenditure is increasing with proximity to death in the last 2 years of life. Taking expenditure during the last year of life and the changes in mortality rates into account, future expenditure of prescription drugs was projected by multiplying the estimated mean annual drug expenditure according to age, gender and survival status by the predicted future number of Danes in each stratum, and subsequently, summing up across all strata. A generalized method was developed to account for expenditure several years prior to death. The projection was based on current drug utilisation from a representative prescription database covering the county of Funen, Denmark, and the most recent Danish population forecast for the period 2003–2030. The total population was projected to increase by 0.8% during the period 2003–2030, while the increase was 58% for people aged 75 years and over. The total drug expenditure was projected to increase by 16.9% during the same period when accounting for proximity to death, while it was 17.9% when this was not done. The projected growth in drug expenditure was not merely due to the drug consumption of the elderly. Moreover, the drug expenditure of elderly decedents was only increasing slightly with proximity to death. We conclude that the ageing of the population per se is likely to increase future expenditure on prescription drugs. This predicted increase, however, is small compared to recently observed increases in drug expenditures. The results of the study indicate that Danish policies aimed at limiting the increase in public drug expenditure should focus on rational pharmacotherapy and on the promotion of prescription of cost-effective pharmaceuticals—rather than targeting the drug use of the elderly or reducing the reimbursement generally.

Assessing health-related quality-of-life in individuals with haemophilia in China.

Haemophilia is a group of inherited, congenital diseases present all through the life. Those disorders are associated with a chronic burden of morbidity punctuated by episodes of acute deterioration in health-related quality-of-life (HR-QL). The significances of assessing HR-QL in individuals with haemophilia as an important component of the clinical database have gained increasing recognition in recent years. To the best of our knowledge, reports on the HR-QL of Chinese patients with haemophilia are not available. The purpose of this paper was to assess the HR-QL of patients with haemophilia in China. In order to do this, 179 patients with haemophilia (age 16-70) were mailed China quality-of-life questionnaire, which was designed specially for this study taking into account the culture characters of Chinese. Compared with the normal male general population, individuals with haemophilia experienced significantly lower levels of HR-QL and within the subgroups of patients, there was a gradation of HR-QL from mild < moderate < severe haemophilia patients. Age, clinical severity, degree of arthropathy, hepatitis status, salary and mean annual expenditure for replacement therapy were predictors of HR-QL. Clinical severity of the disease manifestation rather than the severity of the disease based on molecular classification was a factor that negatively influenced the HR-QL of patients with haemophilia. Arthropathies of patients with haemophilia in China were more severe than that in western countries because of the poorer medical care and were associated with their lower income and therapy cost. A large number of patients never had hepatitis or HIV serological examination. The exact prevalence of hepatitis and HIV was difficult to obtain and the HR-QL of hepatitis and HIV positive patients required further study.

Analgesic therapy for headache: consumption, appropriateness and costs

Headache represents not only an individual disease, but also an important pathology for society because its prevalence in the population is about 50.0%. Its physical, emotional, social and economic impacts are often neglected and it is only recently that headache is being considered in a public health perspective, especially its disabling burden, its treatment and its costs. The aim of this work was to investigate the pharmacological treatment of headache and its costs. An anonymous questionnaire on headache was distributed in a waiting room of a general hospital in Rome, Italy. Both patients and visitors were included in the sample with the exclusion of those who had an appointment at Headache Centre of the hospital. The study was conducted on 294 subjects; the mean age was 46.7 years (SD=16.1). The prevalence of headache was 65.6% (95% CI, 60.0%–71.0%). There was no statistically significant difference between patients and visitors, while there was between men and women (53.0% vs. 79.4%; p<0.05). In the age group 30–49 years, the prevalence was significantly higher than in the other age groups (86.0%; p<0.05). Drugs only to treat headache were used by 67.9% of the sample and Aulin was the most used drug, followed by Novalgina and aspirin used, respectively, by 41.6%, 11.0% and 9.7% of the subjects. The economic evaluation of the pharmacological treatment of headache was conducted on the 101 patients (65.6%) who gave complete information on posology. Since the distribution of costs was strongly skewed to the right due to a few expensive treatments, the mean annual pharmaceutical expenditure per patient is not a good indicator, and we also calculated the median and the mode, the maximum and the minimum. Attention was focused also on two subgroups: those who used self-prescription and those who turned to healthcare specialists. The median annual pharmaceutical expenditure per patient was euro 4.30 for the whole group who used drugs and euro 3.93 and 8.51 for the self-prescription and the prescribed by specialist groups, respectively. In conclusion, considering the possible danger which may arise from inappropriate use of drugs and the costs of therapy, our data suggest that consultation with a specialist would be particularly helpful in patients with headache.

Medical expenditures during the last year of life: findings from the 1992-1996 Medicare current beneficiary survey.

To compare medical expenditures for the elderly (65 years old) over the last year of life with those for nonterminal years. From the 1992-1996 Medicare Current Beneficiary Survey (MCBS) data from about ten thousand elderly persons each year. Medical expenditures for the last year of life and nonterminal years by source of payment and type of care were estimated using robust covariance linear model approaches applied to MCBS data. The MCBS is a panel survey of a complex weighted multilevel random sample of Medicare beneficiaries. A structured questionnaire is administered at four-month intervals to collect all medical costs by payer and service. Medicare costs are validated by claims records. From 1992 to 1996, mean annual medical expenditures (1996 dollars) for persons aged 65 and older were $37,581 during the last year of life versus $7,365 for nonterminal years. Mean total last-year-of-life expenditures did not differ greatly by age at death. However, non-Medicare last-year-of-life expenditures were higher and Medicare last-year-of-life expenditures were lower for those dying at older ages. Last-year-of-life expenses constituted 22 percent of all medical, 26 percent of Medicare, 18 percent of all non-Medicare expenditures, and 25 percent of Medicaid expenditures. While health services delivered near the end of life will continue to consume large portions of medical dollars, the portion paid by non-Medicare sources will likely rise as the population ages. Policies promoting improved allocation of resources for end-of-life care may not affect non-Medicare expenditures, which disproportionately support chronic and custodial care.

Switching to Gatekeeping: Changes in Expenditures and Utilization for Children

Gatekeeping has been a central strategy in the cost-containment initiatives of managed care organizations. Little empirical research describes the impact of switching into a gatekeeping plan on health care expenditures and utilization for children. To determine the likelihood of a parent with a chronically ill child enrolling in a health plan with gatekeeping, as well as the effects of gatekeeping on health care expenditures and utilization for children, especially those with chronic conditions. We followed a cohort of 1839 children who either voluntarily switched to a gatekeeping plan or remained in an indemnity plan from 1991 through 1994. Study participants were children of employees of a large hospital. The gatekeeping plan was virtually identical to the previous indemnity plan except for lower monthly employee contribution and the requirement for a primary care physician to preapprove subspecialty referrals. We determined the likelihood of a household containing a child with a chronic condition enrolling in the gatekeeping plan, as well as mean annual total, subspecialty, and primary care expenditures and utilization for all children and children with chronic conditions. Households switching to gatekeeping were less likely to have children with chronic illness (8% vs 15%). Total and subspecialty expenditures for all children decreased more in the gatekeeping group (53% and 59%, respectively) than in the indemnity group (11% and 6%, respectively). For children with chronic conditions, mean visits to subspecialists decreased 57% in the gatekeeping group but increased 31% in the indemnity group. Mean visits to primary care physicians decreased 23% in the gatekeeping group compared with 13% in indemnity group. Parents of children with a chronic condition were much less likely than other parents to switch to a gatekeeping plan. Switching to gatekeeping was associated with reduced visits to specialists but did not increase the involvement of primary care physicians in the management of children with chronic conditions. The implications of these findings for the health of children are unknown.

An economic overview of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity. Relatively few pharmacoeconomic studies have been conducted on this disease. This article reviews available information about the utilisation of healthcare resources and cost of care, and the cost or cost effectiveness of therapeutic interventions reported for this disease. Burden-of-illness data indicate that hospital care, medications and oxygen therapy were the major cost drivers in these studies. Mean annual Medicare expenditures in the US were $US11,841 (2000 values) for patients with COPD compared with $US4,901 for all covered patients. Utilisation was skewed; the most expensive 10% of the Medicare beneficiaries accounted for nearly 50% of total expenditures for this disease. Costs are associated with health status, age, physician specialty, geographic location and type of insurance coverage. Six types of interventions were assessed in the literature--pharmacotherapy, oxygen therapy, home care, surgery, exercise and rehabilitation and health education. The studies used different analytic strategies (e.g. cost-minimisation and cost-effectiveness analyses) and even within the realm of cost-effectiveness analyses, no uniformity existed as to how outcome was measured. Patient severity was not always delineated, and the length of the follow-up period, while quite short, varied. Only 11 of the 34 evaluations were based on randomised controlled trials. Cost-minimisation studies generally found no significant difference in the cost of antimicrobial treatment for first-line, second-line and third-line agents. Studies of bronchodilators indicated that ipratropium bromide alone or in combination with salbutamol (albuterol) was the preferred medication. The major area for achieving cost savings is by reducing hospital utilisation. As the annual rate of hospitalisation is relatively low, large patient samples will be required to demonstrate an economic advantage for a new therapy. The major challenges will be financing such a study, and selecting an outcome measure that satisfies both clinical and economic conventions.

Treatment costs and loss of work time to individuals with chronic lymphatic filariasis in rural communities in south India.

This year-round case-control study investigated treatment costs and work time loss to people affected by chronic lymphatic filariasis in two rural communities in south India. About three-quarters of the patients sought treatment for filariasis at least once and 52% of them paid for treatment, incurring a mean annual expenditure of Rs. 72 (US $2.1; range Rs. 0-1360 (US $39.0)). Doctor's fees and medicines constituted 57% and 23% of treatment costs. The proportion of people seeking treatment was smaller and treatment costs constituted a higher proportion of household income in lower income groups. Most patients did not leave work, but spent only 4.36+/-3.41 h per day on economic activity compared to 5.25+/-3.52 h worked by controls; the mean difference of 0.89+/-4.20 h per day was highly significant (P<0.01). This loss of work time is perpetual, as chronic disease manifestations are mostly irreversible. An estimated 8% of potential male labour input is lost due to the disease. Regression analyses revealed that lymphatic filariasis has a significant effect on work time allotted to economic activity (P<0.05) but not on absenteeism from work (P>0.05). Female patients spent 0.31+/-1.42 h less on domestic activity compared to their matched controls (P<0.05). The results clearly show that the chronic form of lymphatic filariasis inflicts a considerable economic burden on affected individuals.

Capitation for cardiologists: Accepting risk for coronary artery disease under managed care

Patients with chronic disease may be excluded from capitated managed care plans due to higher than average expected costs. In an attempt to remedy this inequity, one type of risk adjustment technique proposes to set separate capitation rates for certain chronic illnesses, including coronary artery disease (CAD). Cardiologists, who increasingly are requested to accept capitation, will benefit from understanding the impact of using clinical factors as opposed to using demographic factors to set capitation rates. Using a 5% national random sample of the 1992 Medicare population, we determined mean annual expenditures and variation in expenditures of individuals with CAD. We compared the use of 2 demographic factors currently used for capitation rate adjustment (age and gender) with 2 factors not currently used—3-digit International Classification of Disease (ICD-9) code (a measure for severity) and Charlson index (a measure for comorbidily). Mean annual expenditures for individuals with CAD were more than double mean annual expenditures for the general Medicare population ($6,944 vs $3,247). Among individuals with CAD, mean expenditures of subgroups defined by both age and gender ranged from $6,205 to $7,724. In comparison, stratifying by measures of severity and comorbidity identified subgroups with lower and higher mean expenditures, producing a range of $1,702 to $19,959. Substantial variation of expenditures for individuals within subgroups defined by severity and comorbidity remained, with few patients having substantially higher expenditures than the rest. When capitation rates are set with the use of demographic factors alone, patients may be subjected to risk selection and physicians to financial loss. Using clinical measures may decrease the incentive for patient risk selection, but substantial financial risk to physicians would remain, because of a relatively few patients with high expenditures (or costs).

Expenditures on Family Dental Care by Active Duty Soldiers

Expenditures on family dental care by U.S. active duty soldiers were explored in this 1992 worldwide survey. Of 9,560 respondents (62% response rate), 7,187 claimed dependents and 5,569 provided reliable data. Mean annual expenditures and multinomial regression on a distribution of expenditures were calculated. Results show average family dental care expenditures were as follows: total sample, $135; childless couples, $59; couples with children, $154; and single parents, $120. Between 72 and 83% of families spent $0 on dental care. Excluding non-spenders, overall expenditures averaged as follows: total sample, $531; childless couples, $354; couples with children, $560; and single parents, $470. Regression results show that expenditures on family dental care by soldiers are influenced by different factors depending on family composition. Policy measures to encourage optimal dental care by families of active duty soldiers should focus on increasing insurance coverage and use.

Fundholding in general practice and financial risk.

To estimate the financial effect of random yearly variations in need for services on fundholding practices with various list sizes. A simulation model was derived using historical data on general practitioner referrals for the 113 surgical procedures covered by the general practitioner fund, combined with data on the hospital prices for those procedures. Resident population of Central Birmingham Health Authority. Expected expenditure on the relevant surgical procedures for the whole district and for practices with list sizes of 9000, 12,000, 15,000, 18,000, 21,000, or 24,000 for each of 100 simulated years. By using average hospital prices for the West Midlands region the mean (SD) annual expenditure for the 179,400 residents was 4,832,471 pounds (87,149 pounds); the random variation between the 5th and 95th most expensive years was 5.7% of the mean cost. For a practice with a list size of 9000 the values were 244,891 pounds (18,349 pounds), with a variation of 27.5%. With a list size of 24,000 the values were 652,762 pounds (32,512 pounds), with a variation of 15.3%. Random variations in need for inpatient services will have a significant financial impact on the practice fund. The problem will be particularly great for smaller practices. Additional measures are required to ensure that the scheme is not undermined and that the potential benefits are secured.