National Medical Expenditure Research Articles

Generic antibiotics in Japan

Generic drugs have been used extensively in many developed countries, although their use in Japan has been limited. Generic drugs reduce drug expenses and thereby national medical expenditure. Because generic drugs provide advantages for both public administration and consumers, it is expected that they will be more widely used in the future. However, the diffusion rate of generic drugs in Japan is quite low compared with that of other developed countries. An investigation on generic drugs conducted by the Ministry of Health, Labour and Welfare in Japan revealed that 17.2 % of doctors and 37.2 % of patients had not used generic drugs. The major reasons for this low use rate included distrust of off-patent products and lower drug price margin compared with the brand name drug. The generic drugs available in the market include external drugs such as wet packs, antihypertensive agents, analgesics, anticancer drugs, and antibiotics. Among them, antibiotics are frequently used in cases of acute infectious diseases. When the treatment of these infections is delayed, the infection might be aggravated rapidly. The pharmacokinetics-pharmacodynamics (PK-PD) theory has been adopted in recent chemotherapy, and in many cases, the most appropriate dosage and administration of antibiotics are determined for individual patients considering renal function; high-dosage antibiotics are used preferably for a short duration. Therefore, a highly detailed antimicrobial agent is necessary. However, some of the generic antibiotics have less antibacterial potency or solubility than the brand name products. We showed that the potency of the generic products of vancomycin and teicoplanin is lower than that of the branded drugs by 14.6 % and 17.3 %, respectively. Furthermore, we confirmed that a generic meropenem drug for injection required about 82 s to solubilize in saline, whereas the brand product required only about 21 s. It was thought that the cause may be the difference in size of bulk particle and amount of solubilizer. The Japanese government hopes to increase the diffusion rate of generic drugs (in terms of quantity) from 20.2 % in 2010 to 30 % or more in 2012, and therefore it will be necessary to clarify the advantages of generic antibiotics in terms of expenditure and equivalency with the branded drugs.

Contracting with Limited Commitment: Evidence from Employment-Based Health Insurance Contracts

Impediments to worker mobility serve to mitigate the attrition of healthy individuals from employer-sponsored insurance pools, thereby creating a de facto commitment mechanism that allows for more complete insurance of health risks than would be possible in the absence of such frictions. Using data on health insurance contracts obtained from the 1987 National Medical Expenditure Survey, we find that the quantity of insurance provided is positively related to the degree of worker commitment. These results illustrate the importance of commitment in the design of long-term contracts, and provide an additional rationale for the bundling of health insurance with employment.

The burden of adult asthma in the United States: Evidence from the Medical Expenditure Panel Survey

It is important to have an accurate picture of the sources and extent of medical expenditures and productivity loss to understand the nature and scope of the burden of asthma in the United States (US). The current study aims to provide recent nationally representative estimates of direct and productivity-related costs attributable to asthma in adults in the US. The 2003 and 2005 Medical Expenditure Panel Surveys were used to estimate the effect of asthma on medical expenditures, use, productivity, and chronic comorbidity among adults (≥ 18 years). Productivity-related outcome variables included employment, annual wages, missed work days, days spent sick in bed, and activity limitations. Multivariate regression was conducted, controlling for sociodemographics and comorbidity. Of 44,795 adults, 1,935 reported an encounter for asthma [corrected]. Compared with those without, subjects with asthma were significantly less likely to be employed (odds ratio, 0.78), spent 1.4 more days sick in bed annually, and were significantly more likely to have activity limitations or to be unable to work. Adults with asthma incurred an additional $1,907 (2008 US dollars) annually and experienced higher health care use and comorbidity. The total national medical expenditure attributable to adult asthma was $18 billion. Adults with asthma were more likely to be covered by Medicaid (30%) than the general adult population (10%). The largest contributors to medical expenditures for adults with asthma were prescription drugs, followed by inpatient hospitalizations and home health care. In recent national data adult asthma is associated with a significant deleterious effect on direct and indirect costs in the US.

Self-Reported Delays in Receipt of Health Care among Women with Diabetes and Cardiovascular Conditions

Purpose Midlife and older adults have high rates of chronic conditions, and differences in health insurance coverage may affect their access to care. Women may be particularly at risk for access problems. This study examines the association of gender and health insurance status with delays in care, a dimension of access to care, among midlife (age 45–64) and older (age ≥65) adults with diabetes and cardiovascular conditions. Methods Data were from the 2004 through 2006 national Medical Expenditure Panel Survey. A total of 4,706 adults with self-identified diabetes and 17,636 adults with self-identified cardiovascular conditions, aged 45 years and older, were included. The analyses examined associations of gender and insurance status with self-reported delays in medical care, dental care, prescription medication, and illness/injury care, using bivariate and multivariate analyses adjusted for race/ethnicity, education, income, and perceived health status. Main Findings Midlife women with diabetes or cardiovascular conditions were more likely to report delays in care than men, even after adjusting for key factors (85%–111% higher odds of delays among diabetes patients, 56%–84% higher odds of delays among cardiovascular patients; all p < .01). Many, but not all, of these gender differences were eliminated among Medicare-insured older adults. Among midlife adults, health insurance coverage differences were also significantly associated with delays in care. Conclusion Women are more likely to experience delays in health care, even after adjusting for health coverage. Efforts are needed to understand factors that influence gender differences in these delays and to determine whether policy reforms eliminate or exacerbate these differences.

Long-term Health and Economic Impact of Preventing and Reducing Overweight and Obesity in Adolescence

Using data from the 2000 National Medical Expenditure Panel Survey and estimates from published studies, this study projected the long-term health and economic impacts of preventing and reducing overweight and obesity in today's adolescents. We developed a body mass index progression model to project the impact of a 1% point reduction in both overweight and obese adolescents aged 16-17 years at present on the number of nonoverweight, overweight, and obese adults at age 40 years. We then estimated its impact on the lifetime medical costs and quality-adjusted life years (QALYs) after age 40. Medical costs (in 2007 dollars) and QALYs were discounted to age 17 years. A 1% point reduction in both overweight and obese adolescents ages 16-17 years at present could reduce the number of obese adults by 52,821 in the future. As a result, lifetime medical care costs after age 40 years would decrease by $586 million and lifetime QALYs would increase by 47,138. In the worst case scenario, the 1% point reduction would lower medical costs by $463 million and increase QALYs by 34,394; in the best case scenario, it would reduce medical costs by $691 million and increase QALYs by 57,149. Obesity prevention in adolescents goes beyond its immediate benefits; it can also reduce medical costs and increase QALYs substantially in later life. Therefore, it is important to include long-term health and economic benefits when quantifying the impact of obesity prevention in adolescents.

Number of Uninsured Appears Poised for Dramatic Surge

Back to table of contents Previous article Next article Professional NewsFull AccessNumber of Uninsured Appears Poised for Dramatic SurgeMark MoranMark MoranSearch for more papers by this authorPublished Online:17 Jul 2009https://doi.org/10.1176/pn.44.14.0012aRising health care costs and slow growth in personal income related to the current recession will add at least another 6.9 million nonelderly Americans to the rolls of the uninsured by 2010, according to a study published May 28 on the Web site of the journal Health Affairs.In the study report, researchers Todd Gilmer, Ph.D., and Richard Kronick, Ph.D., of the University of California, San Diego, predicted that 19.2 percent of all nonelderly Americans will be uninsured by 2010, an increase of 2 percentage points from 2007.The researchers used a complex method that involves several data sources to calculate an “affordability index,” defined as the ratio of per-capita health spending for insured adults to the median income among workers. Those data sources included the National Health Accounts developed by the Office of the Actuary at the Centers for Medicare and Medicaid Services, the 1977 National Medical Care Expenditure Survey, the 1987 National Medical Expenditure Survey, and the 1996 and 1999 Medical Expenditure Panel Surveys. Their analysis also takes into account employment characteristics such as firm size, industry, and self-employment and part-time status, as well as demographic and socioeconomic characteristics such as age, sex, marital status, race and ethnicity, education, and home ownership. After using their index to derive predictions for uninsurance rates among workers, Gilmer and Kronick used the historical relationship between coverage rates for workers and for all nonelderly adults to generate predicted uninsurance rates for all nonelderly adults.They estimate that the number of uninsured Americans will reach 52 million in 2010. Among workers not covered by a dependent's plan or by a public program, the fraction that is uninsured is expected to increase sharply, reaching 26.4 percent in 2010.Moreover, Gilmer and Kronick acknowledged that their model cannot completely account for uninsurance that will arise from job losses during the current recession.“Our model focuses on forecasting the rate of uninsurance among workers,” they write. “It does not directly take unemployment into account. During recessions we would expect the number of uninsured people to increase by more than projected by the model, because some of the newly unemployed will lose coverage when they lose their jobs.”They cited researchers at Kaiser Family Foundation who have estimated that each 1 percent increase in unemployment leads to a 0.59 percent increase in the percentage uninsured among nonelderly adults. If unemployment were to increase to 10 percent, the number of uninsured people would increase by close to 6 million in the absence of policy change.“Some of this projected increase would be in addition to our projected increase of 6.9 million, which will occur primarily as a result of the increasing unaffordability of health care for adults who continue working,” Gilmer and Kronick wrote.They noted that the American Recovery and Reinvestment Act of 2009 may somewhat attenuate the effects of increasing unemployment on the number of uninsured people and that extension and expansion of the State Children's Health Insurance Program is expected to reduce the number of uninsured children.“Given major uncertainties about the depth and length of the recession, about federal and state policy responses, and about the effect of any public policy response, it would be foolish to attempt to offer precise forecasts of the number of uninsured Americans,” the researchers observed. “These caveats notwithstanding, our work demonstrates that if personal income grows as slowly as projected... and health care costs grow at the rate projected by CMS, then the number of uninsured people is likely to grow by at least 6.9 million during 2008-10.”Gilmer is an associate professor in the Department of Family and Preventive Medicine at the University of California at San Diego, and Kronick is a professor in that department.“Hard Times and Health Insurance: How Many Americans Will be Uninsured in 2010” is posted at<http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.4.w573>.▪ ISSUES NewArchived

Overrepresentation of Black Americans in Psychiatric Inpatient Care

Overrepresentation of Black Americans in Psychiatric Inpatient Care

Overrepresentation of Black Americans in Psychiatric Inpatient Care

Numerous studies have documented overrepresentation of the black population in psychiatric inpatient settings, but none have included certain important covariates or examined heterogeneity within the black population. After controlling for key social, demographic, and clinical factors, the investigators sought to determine whether blacks are overrepresented in inpatient psychiatric settings; they examined differences within the black population by separately examining the prevalence of inpatient treatment of African Americans and U.S.- and foreign-born Caribbean blacks. Secondary analysis was performed on data from two population-based household surveys, the National Survey of American Life (NSAL) and the National Comorbidity Survey Replication (NCS-R), which provided a population-based sample of 9,371 community-dwelling adults, including 3,570 African Americans, 1,621 blacks of Caribbean descent, and 4,180 non-Hispanic whites. Using logistic regression, the investigators estimated self-reported lifetime psychiatric hospitalization as a function of racial-ethnic background after controlling for sociodemographic differences and differences in lifetime counseling or therapy and psychiatric diagnosis. With controls for demographic and clinical factors, both African Americans (odds ratio [OR]=2.52, 95% confidence interval [CI]=1.91-3.33) and Caribbean blacks (OR=2.74, CI=1.98-3.82) had higher odds than whites of having a psychiatric hospitalization in their lifetime. U.S.-born Caribbean blacks had much higher odds of hospitalization (OR=5.47, CI=3.60-8.32) than whites, whereas the likelihood of hospitalization of foreign-born Caribbean blacks did not differ from that of whites (OR=.96, CI=.51-1.82). Disparities between blacks and whites in the prevalence of psychiatric inpatient treatment appear to be persistent, but global comparisons mask important heterogeneity within the black population.

Does Public Insurance Provide Better Financial Protection Against Rising Health Care Costs for Families of Children With Special Health Care Needs?

Health care costs grew rapidly since 2001, generating substantial economic pressures on families, especially those with children with special health care needs (CSHCN). To examine how the growth of health care costs affected financial burden for families of CSHCN between 2001 and 2004 and to determine the extent to which health insurance coverage protected families of CSHCN against financial burden. In 2001-2004, 5196 families of CSHCN were surveyed by the national Medical Expenditure Panel Survey (MEPS). The main outcome was financial burden, defined as the proportion of family income spent on out-of-pocket (OOP) health care expenditures for all family members, including OOP costs and premiums. Family insurance coverage was classified as: (1) all members publicly insured, (2) all members privately insured, (3) all members uninsured, (4) partial coverage, and (5) a mix of public and private with no uninsured periods. An upward trend in financial burden for families of CSHCN occurred and was associated with growth of economy-wide health care costs. A multivariate analysis indicated that, given the economy-wide increase in medical costs between 2001 and 2004, a family with CSHCN was at increased risk in 2004 for having financial burden exceeding 10% of family income [odds ratio (OR) = 1.39; P < 0.01]. Similar findings were noted for financial burden exceeding 20% of family income. Over 15% of families with public insurance had financial burden exceeding 10% of family income compared with 20% of families with private insurance (P < 0.05; chi2 test). After controlling for covariates, publicly-insured families of CSHCN had significantly lower likelihood of financial burden of >10% or 20% of family income than privately-insured families. Rising health care costs increased financial burden on families of CSHCN in 2001-2004. Public insurance coverage provided better financial protection than private insurance against the rapidly rising health care costs for families of CSHCN.

Who Pays When VA Users Are Hospitalized in the Private Sector?

Older veterans enrolled in VA healthcare receive much of their medical care in the private sector, through Medicare. Less is known about younger VA enrollees' use of the private sector, or its funding. We compare payers for younger and older enrollees' private sector use in 3 hospitalization datasets. From 1998 to 2000, using private sector discharge data for VA enrollees in New York State, we categorized hospitalizations according to payer (self/family, private insurance, Medicare, Medicaid, other sources). We compared this payer distribution to population-weighted national Medical Expenditure Panel Survey (MEPS) data from 1996-2003 for veterans in VA healthcare. We also compared Medicare utilization in either dataset to hospitalizations for New York veterans from 1998-2000 in the VA-Medicare dataset. Analyses separated patients younger than age 65 from those age 65 or older. VA enrollees under age 65 obtain roughly half their hospitalizations in the private sector; older enrollees use the private sector at least twice as often as the VA. Datasets generally agree on payer distributions. Although older enrollees rely heavily on Medicare, they also use commercial insurance and self/family payments substantially. Half of younger enrollees' non-VA hospitalizations are paid by private insurance, but Medicare, Medicaid, and self/family each pay for one-quarter to one-third of admissions. VA enrollees use the private sector for most of their inpatient care, which is funded by multiple sources. Developing a national UB-92/VA dataset would be critical to understanding veterans' use of the private sector for specific diagnoses and procedures, particularly for the fast growing population of younger veterans.

The cost of being a woman: A National Study of Health Care Utilization and Expenditures for Female-Specific Conditions

An important component of women's health care is for conditions that are exclusive to women, yet little research has addressed the economic impact of health care for these conditions. The purpose of this study was to describe health care utilization for female-specific conditions, the incremental expenditures attributable to these conditions, and the overall incremental expenditures across the lifespan. We analyzed 3 years of a nationally representative survey of the US noninstitutionalized population, the 2000-2002 National Medical Expenditure Panel Survey, which included 25,361 females aged > or =14, representing 38,170 person-years. More than one fifth of women (21.2%) reported having a female-specific condition during a 1-year period, the most common of which were gynecologic disorders (7.4%); pregnancy-related conditions (6.4%); and menopausal symptoms (5.3%). The mean increment in annual total expenditures attributable to female-specific conditions ranged from $483 for menopausal disorders to $3,896 for female cancers. The annual total health care expenditures of women with female-specific conditions were estimated to be $108 billion, of which >40% ($43.3 billion) was attributable to female-specific conditions. Women with female-specific conditions who had no health insurance were less likely to have visited a doctor (p = .0002), filled a prescription (p = .001), and been hospitalized (p = .0001) for these conditions, but more likely to have visited an emergency department (p = .02) seeking treatment for these conditions. In this nationally representative sample of American women aged > or =14, female-specific conditions were common and substantially increased costs of health care.

Commentary—How to Improve Federal Health Data for Coverage, Access, and State‐Specific Needs

Commentary—How to Improve Federal Health Data for Coverage, Access, and State‐Specific Needs

Recent Trends in Stimulant Medication Use Among U.S. Children

Stimulant medications, such as methylphenidate and amphetamines, are commonly prescribed to treat attention deficit hyperactivity disorder. Stimulant use increased fourfold from 1987 (0.6%) to 1996 (2.4%) among subjects 18-year-old and younger in the U.S. The aim of this study was to determine whether pediatric use of stimulants continued to rise during the period 1997-2002. The Medical Expenditure Panel Survey (MEPS) database for the years 1997-2001 was analyzed. The MEPS is a yearly survey of a nationally representative sample of civilian, noninstitutionalized U.S. households, conducted by the U.S. Agency for Health Care Research and Quality. Previously reported estimates from the 1996 MEPS and the 1987 National Medical Expenditure Survey, the predecessor to MEPS, were also replicated to compare recent trends to changes between 1987 and 1996. The prevalence use of stimulants among subjects under 19 years of age was 2.7% (95% C.I. 2.3-3.1) in 1997 and 2.9% (95% C.I. 2.5-3.3) in 2002, with no statistically significant change during these 6 years. Likewise, when pooling data across years and comparing the rate in 1997-1998 (2.8%) with the rate in 2001-2002 (3.0%), no statistically significant changes emerged. Use was highest among 6-12 year olds (4.8% in 2002), as compared with 3.2% among 13-19 year olds and 0.3% among children under 6. An estimated 2.2 million (95% C.I. 1.9-2.6) children received stimulant medication in 2002 as compared to 2.0 million (95% C.I. 1.7-2.3) in 1997. The steep increase in the utilization of stimulants among children 18 years and younger that occurred over the 1987-1996 period attenuated in the following years through 2002, and has remained stable among very young children.

Recent Trends in Stimulant Medication Use Among U.S. Children

Stimulant medications, such as methylphenidate and amphetamines, are commonly prescribed to treat attention deficit hyperactivity disorder. Stimulant use increased fourfold from 1987 (0.6%) to 1996 (2.4%) among subjects 18-year-old and younger in the U.S. The aim of this study was to determine whether pediatric use of stimulants continued to rise during the period 1997-2002. The Medical Expenditure Panel Survey (MEPS) database for the years 1997-2001 was analyzed. The MEPS is a yearly survey of a nationally representative sample of civilian, noninstitutionalized U.S. households, conducted by the U.S. Agency for Health Care Research and Quality. Previously reported estimates from the 1996 MEPS and the 1987 National Medical Expenditure Survey, the predecessor to MEPS, were also replicated to compare recent trends to changes between 1987 and 1996. The prevalence use of stimulants among subjects under 19 years of age was 2.7% (95% C.I. 2.3-3.1) in 1997 and 2.9% (95% C.I. 2.5-3.3) in 2002, with no statistically significant change during these 6 years. Likewise, when pooling data across years and comparing the rate in 1997-1998 (2.8%) with the rate in 2001-2002 (3.0%), no statistically significant changes emerged. Use was highest among 6-12 year olds (4.8% in 2002), as compared with 3.2% among 13-19 year olds and 0.3% among children under 6. An estimated 2.2 million (95% C.I. 1.9-2.6) children received stimulant medication in 2002 as compared to 2.0 million (95% C.I. 1.7-2.3) in 1997. The steep increase in the utilization of stimulants among children 18 years and younger that occurred over the 1987-1996 period attenuated in the following years through 2002, and has remained stable among very young children.

Aspects of Type 2 Diabetes and Related Insulin-Resistant States

This is the fourth in a series of articles on presentations at the American Diabetes Association Annual Meeting, San Diego, California, 10–14 June 2005. Addressing the debate over aerobic versus anaerobic exercise, Sigal et al. (abstract 371) reported results of the Diabetes Aerobic and Resistance Exercise (DARE) clinical trial of 251 previously inactive persons with type 2 diabetes exercising at local YMCAs, supervised by personal trainers. Both aerobic and resistance training improved HbA1c (A1C) similarly over 6months, with the combination of both forms of exercise improving A1C more than either type alone. Goh et al. (abstract 1089) reported a similar study from Singapore comparing 22 persons with type 2 diabetes randomized to either aerobic exercise, with a 10/10-mmHg decrease in blood pressure and a 0.3% decrease in A1C, or resistance training, with a 0.6% decrease in A1C. Morrato et al. (abstracts 1041 and 1063), analyzing the national Medical Expenditure Panel Survey (2000–2002) found that 55% of 97,422 adults ≥18 years of age, but 39% of those with self-reported diabetes, stated they participated in moderate/vigorous activity for at least 30 min at least three times weekly. Among those with BMI <25, 25–29.9, 30–39.9, and ≥40 kg/m2, the likelihood of diabetes was 52, 59, 41, and 13% greater in inactive than in active persons, respectively, adjusting for age, sex, education level, race, ethnicity, and cigarette smoking. Gaillard et al. (abstract 1086) reported a study of 46 African-American women without diabetes, showing that those with moderately good aerobic fitness had lower weight and blood pressure and higher insulin sensitivity than those with low or very low levels of fitness. Similarly, Snitker et al. (abstract 1094) found that among 80 Amish persons, who habitually engage in physical exercise, the time spent in moderate to vigorous activity correlated directly with the degree …

Disparities in the Financial Burden of Children's Healthcare Expenditures

To examine whether income-related disparities in the burden of children's out-of-pocket health care expenditures have diminished with the expansions in public insurance for children in low-income families. We compared absolute financial burden (out-of-pocket expenditures per child) and relative financial burden (out-of-pocket expenditures per child as a proportion of family income) among children aged 0 to 18 years in 6 poverty level groups using the 1980 National Medical Care Utilization and Expenditure Survey and the 2000 Medical Expenditure Panel Survey. Regression models were used to assess whether disparities in financial burden diminished between 1980 and 2000. There were significant reductions (P<.01) in absolute burden over time for children above 200% of the federal poverty level. Relative financial burden decreased significantly (P<.01) for all of the income groups, ranging from a reduction of 36.49% for those below 100% of the federal poverty level (95% CI, -49.54% to -20.07%) to a reduction of 46.69% for those at or above 300% of the federal poverty level (95% CI, -54.43% to -37.62%). For low-income children, relative financial burden was 49.49% less with public insurance (95% CI, -66.24% to -24.35%) and 79.14% greater with private insurance (95% CI, 9.31% to 193.59%) than relative financial burden for low-income children without insurance. While the financial burden of children's out-of-pocket health care expenditures has decreased for all of the income groups over time, socioeconomic disparities persist. However, public insurance coverage appears to mitigate the financial burden for low-income children.

Rural women’s health: A research agenda for the future

The interrelationship between mental and physical health, and between mental health and behavioral health, links closely to the overall health of communities: in this regard, the health of rural America is at risk. Rural residents have higher rates of chronic illness, life-threatening medical conditions (such as motor vehicle accidents), greater environmental hazards, and increased overall age-adjusted mortality ( Braden and Beauregard 1994 Braden J. Beauregard K. Health status and access to care of rural and urban populations. National Medical Expenditure Survey Research Findings 18. Agency for Health Care Policy and Research, Rockville, MD1994 Google Scholar ). Mental health issues, and medical–psychiatric comorbidities are among the most prominent health issues of rural residents ( Braden and Beauregard 1994 Braden J. Beauregard K. Health status and access to care of rural and urban populations. National Medical Expenditure Survey Research Findings 18. Agency for Health Care Policy and Research, Rockville, MD1994 Google Scholar ; Wagenfeld et al., 1993; Robertson et al 1997 Robertson E.B. Sloboda Z. Boyd G.M. Beatty L. Kozel N.J. Rural substance abuse State of knowledge and Issues. National Institute on Alcoholism and Alcohol Abuse, Rockville, MD1997: 168 Google Scholar ). At least 15 million rural residents, women and men, suffer with significant mental illness, substance abuse/dependence, and medical–psychiatric comorbidities (Wagenfeld et al., 1993). Finding solutions to the difficulty of providing mental health services for rural populations, preventing comorbidity, disability and other consequences of mental illness is a significant rural—and national—policy need.

Treatment of Anxiety Increases, But Some Groups Left Out

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessTreatment of Anxiety Increases, But Some Groups Left OutJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:19 Nov 2004https://doi.org/10.1176/pn.39.22.00390025aAnxiety disorders are among the most prevalent psychiatric conditions in the United States, yet people with anxiety disorders have tended to be under-diagnosed and undertreated (Psychiatric News, August 20).Now there is some good news: The outpatient treatment of people with such conditions nearly doubled between 1987 and 1999—from 0.43 per 100 Americans to 0.83 per 100 Americans, a highly significant difference.This finding has emerged from a study headed by Mark Olfson, M.D., a professor of clinical psychiatry at Columbia University and reported in the September Journal of Clinical Psychiatry.Several factors may have contributed to this increase in treatment. For example, during the 1990s the drug industry intensely promoted the treatment of anxiety. The National Anxiety Disorders Screening Day program, which started in 1994, now operates in more than 1,200 sites in the United States. The Anxiety Disorders Association of America, which reorganized and expanded in 1990, provides consumer education material and a national network to facilitate local mental health referrals.The study also contains some less upbeat results for the years 1987 to 1999, however—African Americans, Hispanics, and Americans with less than a high-school education had outpatient treatment rates for anxiety far below those of whites and Americans with more education. For example, the national rates per 100 persons treated for anxiety disorders in 1999 were 1.03 for whites, but only 0.37 for Hispanics and 0.24 for blacks.These are among the other results of the outpatient treatment of anxiety:In 1987 anxiolytics such as benzodiapezines were the most commonly prescribed medications for the treatment of anxiety. By 1999, antidepressants were. This shift can probably be explained by various factors. For example, benzodiazepine use carries the risk of abuse and dependence, especially in patients with comorbid alcohol use disorders. In contrast, clinical trials have come to demonstrate the safety and efficacy of SSRI antidepressants for a range of anxiety disorders. In fact, since the completion of the 1999 survey, several of the newer antidepressants, including venlafaxine–extended release, sertraline, and paroxetine, have received Food and Drug Administration approval for the treatment of additional anxiety disorders.Nonetheless, nearly one-third of anxiety patients treated in 1999 were given benzodiazepines. One reason may be because some psychopharmacologists continue to endorse benzodiazepines as a primary or adjunctive treatment for several anxiety disorders.Patients treated for anxiety in 1999 were about half as likely to receive psychotherapy as they were in 1987. This decline occurred despite accumulating evidence of the efficacy of specific psychotherapies, especially cognitive-behavioral therapy, for anxiety conditions. In contrast, the treatment of anxiety with a combination of psychotherapy and psychotropic medication increased significantly between 1987 and 1999.In 1987, 76 percent of anxious patients were treated by a physician, 18 percent by a psychologist, 5 percent by a social worker, and the remaining by other providers. In 1999, in contrast, 78 percent were treated by a physician, 12 percent by a psychologist, 15 percent by a social worker, and the remaining by other providers.Data for this study were drawn from the 1987 National Medical Expenditure Survey and the 1999 Medical Expenditure Panel Survey, two nationally representative surveys sponsored by the Agency for Healthcare Research and Quality to provide national estimates of the use, expenditures, and financing of health services. Some 35,000 individuals participated in the 1987 survey, some 24,000 in the 1999 one. Survey staff contacted medical providers to supplement and validate diagnostic and other clinical information given by participants.The study had certain limitations. For example, whereas data about survey respondents' outpatient visits for the treatment of panic disorder, generalized anxiety disorder, phobias, obsessive-compulsive disorder, acute stress disorder, other anxiety states, and anxiety disorders, unspecified, were available for analysis, no information was accessible about respondents' visits for the treatment of posttraumatic stress disorder or about respondents' visits for the treatment of anxiety due to specific medical illnesses. It was also not possible to determine whether respondents who received treatment for anxiety actually met diagnostic criteria for the selected anxiety disorder codes.“It was encouraging to see the extent to which advances in treatment, especially advances in the use of antidepressants to treat anxiety disorders, have been disseminated into routine practice,” Olfson said in an interview. Nonetheless, “little is currently done in a systematic manner to detect anxiety disorders in primary care.... Because many socioeconomically disadvantaged groups receive much of their mental health care within primary care settings, efforts should be made to improve the recognition of anxiety disorders in primary care together with referrals as appropriate to psychiatric care.”The study was funded by Wyeth Research.The study, “National Trends in the Outpatient Treatment of Anxiety Disorders,” is posted online at<www.psychiatrist.com/privatepdf/2004/v65n09/v65n0903.pdf>.▪ ISSUES NewArchived

Nonlinearity in medical expenditures: a new semiparametric approach

Research in empirical health economics has found that the relationship between medical expenditures and age, income and other variables can be highly nonlinear. Moreover, men and women can have quite different medical expenditure patterns due to their differences in life expectancy. Thus it may be difficult to find an appropriate parametric model to capture the highly complicated nonlinearity in medical expenditures, and introducing a simple gender dummy variable in a parametric model may not reveal all the medical expenditure differences between men and women. This study takes a semiparametric approach. In particular, an additive partially linear specification is employed to study the relationship between medical expenditures and age, income, gender and other individual characteristics. Using data from the National Medical Expenditure Survey, the results indicate that the semiparametric approach taken in this study is very promising. They confirm that medical expenditures are nonlinear in income and age, and that men and women have quite different medical expenditure patterns.

Health Care for Children and Youth in the United States: 2002 Report on Trends in Access, Utilization, Quality, and Expenditures

To examine changes in insurance coverage, health care utilization, perceived quality of care, and expenditures for children and youth in the United States using data from 1987-2001. Three national health care databases serve as the sources of data for this report. The Medical Expenditure Panel Survey (1996-2001) provides data on insurance coverage, utilization, expenditures, and perceived quality of care. The National Medical Expenditure Survey (1987) provides additional data on utilization and expenditures. The Nationwide Inpatient Sample (1995-2000) from the Healthcare Cost and Utilization Project provides information on hospitalizations. The percent of children uninsured for an entire year declined from 10.4% in 1996 to 7.7% in 1999. Most changes in children's health care occurred between 1987 and the late 1990s. Overall utilization of hospital-based services has declined significantly since 1987, especially for inpatient hospitalization. Several of the observed changes from 1987 varied significantly by type of health insurance coverage, poverty status, and geographic region. Quality of care data indicate some improvement between 2000 and 2001, which varies by insurance coverage. Overall, mean length of stay of hospitalizations did not change significantly from 1995 to 2000, but changes in the prevalence of hospitalizations and the length of stay associated with age-specific diagnoses were evident during this time period. Health care for children and youth has changed significantly since 1987, with most of the changes occurring between 1987 and 1996. Insurance coverage has improved, the site of care has shifted toward ambulatory sites, hospital utilization has declined, and expenditures on children as a proportion of total expenditures have decreased. Variation in these changes is evident by insurance status, poverty, and region.