Reduce Health Spending Research Articles

Association of Hospital System Affiliation with Spending and Postoperative Outcomes: A Longitudinal Study of Hospital Mergers And Acquisitions From 2010 To 2018.

To determine whether hospital system affiliation was associated with changes in surgical episode spending or postoperative outcomes. Over 70% of US hospitals are now part of a hospital system. The presumed benefits of hospital consolidation include concentrating volume and expertise, care integration, and investment in quality improvement. However, there is conflicting evidence as to whether expanding hospital systems are actually reducing health spending or improving quality. These observations call into question whether systems are leveraging their collective volume and experience to standardize care and maximize efficiencies. The American Hospital Association Annual Survey was used to identify whether a hospital was part of a system and in which year a hospital joined the respective system. Using 100% Medicare claims data, we identified fee-for-service Medicare patients undergoing elective inpatient coronary artery bypass graft colon resection, lung resection, hip replacement, or knee replacement from 2010 to 2018. We used a difference-in-differences framework to evaluate hospital spending and outcomes before and after joining a system. The primary outcome was Medicare 30-day episode spending, with specific attention to the total episode payment, index hospitalization, and post-acute care components. Secondary outcomes included serious complications, 30-day mortality, and 30-day readmission. The cohort included 3,395,565 Medicare beneficiaries who underwent surgery between 2010 and 2018. Patients were treated at 3961 hospitals, of which 1097 (27.7%) were never in a system, 2262 (57.1%) were always in a system, and 602 (15.2%) joined a system during the study period. By 1 year after system affiliation, 30-day episode spending had decreased by $303 (95% CI: 63, 454, P=0.01), and after 5 years, 30-day episode spending decreased by $429 (95% CI: 5, 853, P=0.04). One year after system association, index hospitalization spending was not statistically different from before system affiliation ($-30, 95% CI: -160, 100, P=0.65). Conversely, 1 year after system association, postacute care spending decreased by $268 (95% CI: 107, 429, P<0.01) and remained lower for ≥5 years. There was no significant change in hospitals serious complications (-0.14, 95% CI: -0.40, 0.11, P=0.27), 30-day readmission (-0.14, 95% CI:-0.52, 0.25, P=0.48), or 30-day mortality (-0.08, 95% CI: -0.18, 0.03, P=0.17), 1 year after joining a system; similar patterns were observed at three and ≥5 years. system affiliation was associated with a small decrease in 30-day episode spending, driven by decreased spending in postacute care services. Notably, there was no difference in postoperative outcomes after system affiliation.

Digital public health in Romania

Abstract The Romanian digital public health story is far from the end or its highest point. As in all cases, the digital public health advancements were led by the COVID-19 pandemic and the need to move everything into a digital format. This came, of course, with its hiccups and trials and errors, but in the end, it all led to considerable advancements in the public health system. One of the most significant achievements in recent years is the settlement of telemedicine services for family doctors. Initially, this was approved for the duration of the lockdown as a measure to limit the spread of the virus. Still, this measure was extended after pressure from professional associations and civil society. Another national digital public health agenda point is using electronic health records. The project was launched several years ago with the National Health Insurance House insurance card. It was now continued, with the work underway for its development. This would be a significant achievement as it would alleviate the public health system quite a lot, and it would allow health surveillance for chronic conditions with longitudinal data. Additionally, it could potentially reduce health spending as it would reduce unnecessary or doubled investigations and tests. Romania presented numerous initiatives on digital public health, but unfortunately, many were limited or renounced. A characteristic of the Romanian digital public health ecosystem is the presence of grass-root initiatives led by innovators and system disruptors, small private entities with a strong desire to solve systemic issues. This presentation will highlight how the COVID-19 pandemic enabled Romania to move forward with its digitalization and will advocate for continuous and sustainable future development of the national digital public health system.

Improving low-value clinical practices inMurcia: a healthcare management area inSpain.

The 'do not do' (DND) movement looks for improving patient safety and reducing health spending by decreasing the prevalence of unnecessary clinical practices through building and launching 'do not do' recommendations, although the impact is generally low. The objective of this study is to improve the quality of care and safety of patients assigned to a health management area by reducing the prevalence of DND practices. Quasi-experimental before and after study carried out in a Spanish health management area of 264 579 inhabitants, 14 primary care teams, and a 920-bed third level reference hospital. The study included the measurement of a set of 25 valid and reliable indicators on DND prevalence from different clinical areas previously designed, considering acceptable prevalence values of less than 5%. For those indicators that exceeded this value, a bunch of interventions was implemented: (i) inclusion in the annual objectives of the clinical units involved; (ii) discussion of results in a general clinical session; (iii) educational outreach visits to the clinical units involved; and (iv) detailed feedback reports. A second evaluation was subsequently carried out. In the first evaluation, 12 DNDs (48%) showed prevalence values below 5%. In the second evaluation, nine DND of the remaining 13 (75%) improved results, reaching five of them (42%) prevalence values below 5%. Thus, a total of 17 of the 25 DNDs initially evaluated (68%) achieved this goal. Reducing the prevalence of low-value clinical practices in a healthcare organization makes it necessary to turn them into easily measurable indicators and carry out multicomponent interventions. Among these, it seems essential that the professionals involved are informed and that training activities are carried out on-site. Improvement cycles are emerging as a useful tool to do this.

Identifying Unique Subgroups of High-Cost Patients With Schizophrenia: A Population-Based Study Using Latent Class Analysis.

Schizophrenia does not present uniformly among patients and as a result this patient population is characterized by a diversity in the type and amount of healthcare supports needed for daily functioning. Despite this, little work has been completed to understand the heterogeneity that exists among these patients. In this work we used a data-driven approach to identify subgroups of high-cost patients with schizophrenia to identify potentially actionable interventions for the improvement of outcomes and to inform conversations on how to most efficiently allocate resources in an already strained system. Administrative health data was used to conduct a retrospective analysis of "high-cost" adult patients with schizophrenia residing in Alberta, Canada in 2017. Costs were derived from inpatient encounters, outpatient primary care and specialist encounters, emergency department encounters, and drug costs. Latent class analysis was used to group patients based on their unique clinical profiles. Latent class analysis of 1659 patients revealed the following patient groups: (1) young, high-needs males early in their disease course; (2) actively managed middle-aged patients; (3) elderly patients with multiple chronic conditions and polypharmacy; (4) unstably housed males with low treatment rates; (5) unstably housed females with high acute care use and low treatment rates. This taxonomy may be used to inform policy, including the identification of interventions most likely to improve care and reduce health spending for each subgroup.

Health Insurance Design Meets Saving Incentives: Consumer Responses to Complex Contracts

To lower health care costs, Health Savings Accounts (HSAs) offer tax incentives encouraging people to trade off current consumption against future consumption. This paper tests whether consumers use HSAs as self-insurance over the life cycle. Using administrative data from a large employer and a regression discontinuity design, I estimate the marginal propensity to consume from HSA assets is 0.85 and reject the neoclassical benchmark of 0. Comparisons with 401(k) saving show most employees do not treat HSA money as fungible with retirement savings. In this setting, HSAs did not reduce health spending and instead increased the share that was financed tax-free. (JEL D15, D82, G22, G51, I13)

Magnitude and determinants of inpatient health expenditure among the elderly in India.

As India is experiencing both the epidemiological and demographic transition, the grey population is expected to incur huge expenditure on health care, especially hospitalization expenditure, in the coming decades. The present study, thus, examines the magnitude of different types of inpatient health expenditure (medical, non-medical, total and out-of-pocket expenditure) and factors affecting them among the Indian elderly, using a health expenditure model empirically tested by the World Health Organization. Data were drawn from the 75th Round of the Health Survey conducted by the National Sample Survey Office, Government of India. In addition to basic descriptive statistics, the study employs a two-stage least square and a generalized linear model with log-link and gamma distribution to conduct the econometric analysis. The study finds that higher income, education, and household size, diseases like cancer, treatment involving surgery, poor physical mobility, and the elderly opting for packages involve higher inpatient health spending, while both private and social health insurance tends to reduce the same. So, a thrust on insurance-financed health systems may reduce health spending among the elderly. In this context, the study suggests that a disease-specific policy is required for the elderly along with ensuring state-of-the-art treatment facilities for them in public hospitals for critical ailments.

The effects of health spending on the propagation of infectious diseases.

We explore the discontinuity in the allocation of the main federal grant to Brazilian municipalities to identify the local effects of health spending and the spillovers into the bordering jurisdictions. Fiscal reactions are asymmetric: small neighbors reduce health spending, while we do not find a significant budgetary response in the largest neighbor. Our results suggest a reduction in the spread of infectious diseases in the neighbors, with fewer residents hospitalized with gastrointestinal infections. In addition, the elderly demand less hospitalization in the largest bordering jurisdictions due to respiratory infectious diseases. Finally, we find a direct and significant reduction in infant mortality, consistent with the observed pediatricians' increase, while the spillover effects on neighbors' mortality rates are not conclusive.

Variations in surgical spending within hospital systems for complex cancer surgery.

Approximately 70% of hospitals today are part of larger health systems. Proponents of hospital consolidation tout its potential to reduce health spending and improve outcomes, but to the authors' knowledge the available evidence has suggested that this promise is unrealized. Variations in costs and outcomes within systems may highlight opportunities for collaborative quality improvement and practice standardization. To assess this potential, the authors sought to measure variations in episode spending within and across hospital systems among Medicare beneficiaries undergoing complex cancer surgery. Using 100% Medicare claims data, the authors identified fee-for-service Medicare patients who were undergoing elective pancreatectomy, lung resection, or colectomy for cancer from 2014 through 2016. Risk-adjusted, price-standardized payments for the surgical episode from admission through 30 days after discharge were calculated. The authors then assessed the reliability-adjusted variations at the hospital and system levels. Average episode payments varied nearly as much within hospital systems for pancreatectomy ($1946 between the lowest and highest spending systems; 95% CI, $1910-$1972), lung resection ($625 between the lowest and highest spending systems; 95% CI, $621-$630), and colectomy ($813 between the lowest and highest spending systems; 95% CI, $809-$817) as they did between the lowest and highest spending hospitals (pancreatectomy: $2034; lung resection: $1789; and colectomy: $770). For pancreatectomy, this variation was driven by index hospitalization spending whereas both index hospitalization and postacute care use drove variations for lung resection and colectomy. In this analysis of Medicare patients undergoing complex cancer surgery, wide variations in surgical episode spending were noted both within and across hospital systems. System leaders may seek to better understand variations in practices among their hospitals to standardize care and reduce variations in outcomes, use, and costs.

The Present and Future of eHealth in Spain From a Health Management Perspective.

eHealth has grown significantly over the last decade. The aim of this study was to determine the level of use of information and communication technologies for health care in Spain and identify the main barriers to development. We used a qualitative study based on data obtained from 8 Spanish autonomous communities through semi-structured, in-depth interviews with key informants in eHealth management and planning. Programs present varying degrees of implementation. Services such as electronic prescriptions, digital medical records, and appointment requests via the Internet are advanced and widespread; others, such as digital imaging, are advanced but not fully deployed; and some, such as telecare programs, are experimental. The study also revealed diverse levels of interoperability and barriers to the expansion of these technologies, which can be classified into 4 fields: technological, organizational, human, and economic. eHealth might evolve more slowly in the coming years. Unless the payoff is clearly seen, major budget cuts in the current economic climate will prevent the implementation of new projects. Programs that help reduce health spending are more likely to be implemented, to the detriment of projects involving simple techniques or even clear health care improvements.

The Effects of Health Spending on the Propagation of Infectious Diseases

Unraveling the relation of health spending and outcomes between bordering jurisdictions is a first-order concern to better coordinate public health provision. In this paper, we explore the rules governing the main federal grant to Brazilian municipalities, which varies discontinuously near population thresholds, to identify the effects of a subsequent exogenous increase in local health spending on bordering towns' health inputs and outcomes. We provide evidence that 1% increase in health spending reduces hospitalization for respiratory infectious diseases by 1 to 3%. Second, we find that both the smallest and largest neighbors benefit by reducing infant and elderly mortality and hospitalization for infectious diseases. Third, the only input that significantly increases is the number of physicians, corroborating that primary care by medical professionals helps to detain the proliferation an the worsening of infectious diseases. Finally, fiscal reactions are asymmetric: small jurisdictions reduce health spending while large neighbors spend more, mainly hiring more physicians.

Advancing Well-Being and Health of Elderly with Integrative Nursing Principles.

There is a need for holistic care for the survival of the elderly, to increase their independence in their daily life activities, to improve their health and their well-being in order to ensure a healthy aging. Integrative nursing principles are a field of application of holistic philosophy and may be a guide to health professionals in improving the health of individuals, families and communities. These principles were first announced in 2014, and have been described as a health approach that takes the individual, family and society as a whole together with their environment and relationships and adopts the principle of using all the healing methods in health care. Integrative nursing principles can be used as a guide to holistic assessment and improvement of the health of the elderly. Interventions who take care of them with the environment they live in (home visits), support their existing healing process (focusing to patient during nursing care), benefit from the healing effect of the nature (spending time in nature), strengthen the relationship (mobilization of the social environment) and use all evidence-based healing methods (yoga, tai chi) should be included in the care of elderly individuals. Health professionals should learn integrative nursing principles and care for these principles in order to improve the health and well-being of the elderly. Giving care according to integrative nursing principles can increase the quality of life of the elderly and reduce health spending.

Inadequate visits to the emergency department by pregnant women

Inadequate emergency visits, which could be resolved in primary care, are an unnecessary expense for the healthcare service. We did a review of all gynaecology and obstetrics emergency visits by pregnant or postpartum women during 2010 and 2011 in order to describe the adequacy of the visits by pregnant women to the emergency service. We defined three levels of adequacy: adequate, moderately adequate, and inadequate. One thousand seven hundred and forty-three visits to the emergency room of gynaecology and obstetrics were studied. These consultation motivations were adequate in 38.9%, moderately adequate in 46.7% and inadequate in 14.4%. This shows that the amount of inadequate and moderately adequate visits to the emergency department could be reduced by 61% by implementing different interventions, and also reducing health spending for emergencies. Impact statement What is already known on this subject: Visits to the emergency room constitute a basic pillar in the hospital structure, and it generates great health expense. Other authors have reported high rates of inadequacy of these visits to the emergency services. They find inadequate visits are associated with young age and female gender among other factors. What the results of this study add: Knowing the adequacy of the visits generated by pregnant young women is a starting point for implementing health policies that could reduce these inadequate visits and consequently health expenditure could be reduced. What the implications are of these findings for clinical practice and/or further research: These health policies could consequently reduce health expenditure.

Dietitian in health care – the missing link of the medical staff

So far forecasting and planning of medical personnel in health care has not included a professional nutritionist, even though it was entered in the International Standard Classification of Occupations (International Standard Classification of Occupations, ISCO) as early as in 1967. It has been determined that this is the person responsible for planning and supervising the preparation of therapeutic diets for individuals and population groups in hospitals, as well as supervising the choice and preparation of food and meals, participating in programs of nutrition and educating the public. The development of medicine and nutritional science has provided evidence that a balanced diet is one of the most important factors that reduce the risk of chronic non-communicable diseases (cardiovascular diseases, diabetes, cancer, obesity, osteoporosis and tooth decay). It has been shown that treatment of most diseases requires the use of dietary treatment, which increases the effectiveness of drug therapy, reduces the risk of complications, shortens hospitalization and rehabilitation, thus reducing health spending. That is why the health care system in Poland should introduce dietary advice to the range of medical services.

Nexus between Education and Poverty in Africa: Evidence from Sierra Leone

We have discovered education as a lead predictor of poverty in Sub-Saharan Africa with evidence from Sierra Leone based on the country's integrated household survey 2011. Noticeably, education expenditure could have negative direct impact on welfare in the short run even though it delivers long run positive effect through indirect effect of covariates. This explains an inevitability of policy trade-offs with the simultaneous decision making problems a poor household faces, which would sometimes have to reduce health spending in favour of child education. Thus, careful policy is critical to ensuring optimal balance of effects on general household welfare that derive from household decision making problems.

The Double-Edged Sword of Health Care Integration: Consolidation and Cost Control

The average family of four in the United States spends $24,671 per year on health care. American health care costs so much because we both overuse and overpay for health care goods and services. The Affordable Care Act's cost control policies focus on curbing overutilization by encouraging health care providers to integrate to promote efficiency and eliminate waste, but largely ignore prices. This article examines this overlooked half of health care cost control policy: rising prices and the policy levers held by states to address it. We challenge the conventional wisdom that reducing overutilization through health care integration will effectively reduce health spending. We argue that vertical integration - bringing together disparate providers from hospitals to physicians - is a double-edged sword, with the potential to reduce wasteful and unnecessary use of services, but also downside risks of increasing market consolidation and health care prices. Due to already highly concentrated health care markets and the limits of federal antitrust enforcement of vertical health care integration, states have both an opportunity and an obligation to supplement federal antitrust efforts to control rising health care prices stemming from health care integration. The way to manage the double-edged sword of health care integration is to require price and quality oversight to avoid harm to competition. We offer a menu of six policy initiatives for states to choose from ranging from data collection to rate regulation. If we are to control our personal and national health care spending, states have a critical role to play in overseeing health care integration and private health care price increases.

Perceptions of the population regarding generic drugs in Brazil: a nationwide survey.

BackgroundGeneric drugs (GDs) offer a way to reduce health spending without sacrificing quality. Despite this, there are doubts as to their acceptance by the population. This work aims to assess perceptions of GDs among the Brazilian population.MethodsWe conducted a national household survey face-to-face between April and May 2013, with 5000 individuals aged over 15 years. The questions explored socioeconomic and demographic characteristics, the use of GDs, and perceptions about GDs as compared to brand drugs (BDs). The chi-square test was used to examine the associations between the perceptions and the characteristics of the population.ResultsOf the 5000 participants, 51.3% were women, 40.2% were white, 48.6% were between 15 and 34 years of age, and 52.3% had income of less than two minimum wages (US$627.78). In terms of the use of GDs, 44.6% of the participants were taking or had taken GDs in the past three months, with the highest figures among the elderly (61.1%) and female (49.2%) populations. Regarding perceptions, 30.4% of the respondents considered GDs less effective than BDs; provided the same price, 59% would prefer BD, and 45.8% agreed that physicians prefer to prescribe GDs. The most negative perceptions about GDs were observed among lower income, elderly and nonwhite populations.ConclusionThe findings provide a better understanding of Brazilians’ perceptions regarding GDs. This should be considered when formulating healthcare policies aiming at improving access to effective and quality drugs, and reduction of health costs.

More Health Expenditure, Better Economic Performance? Empirical Evidence From OECD Countries.

Recent economic downturns have led many countries to reduce health spending dramatically, with the World Health Organization raising concerns over the effects of this, in particular among the poor and vulnerable. With the provision of appropriate health care, the population of a country could have better health, thus strengthening the nation’s human capital, which could contribute to economic growth through improved productivity. How much should countries spend on health care? This study aims to estimate the optimal health care expenditure in a growing economy. Applying the experiences of countries from the Organization for Economic Co-Operation and Development (OECD) over the period 1990 to 2009, this research introduces the method of system generalized method of moments (GMM) to derive the design of the estimators of the focal variables. Empirical evidence indicates that when the ratio of health spending to gross domestic product (GDP) is less than the optimal level of 7.55%, increases in health spending effectively lead to better economic performance. Above this, more spending does not equate to better care. The real level of health spending in OECD countries is 5.48% of GDP, with a 1.87% economic growth rate. The question which is posed by this study is a pertinent one, especially in the current context of financially constrained health systems around the world. The analytical results of this work will allow policymakers to better allocate scarce resources to achieve their macroeconomic goals.

Reducing variation in hospital admissions from the emergency department for low-mortality conditions may produce savings.

The emergency department (ED) is now the primary source for hospitalizations in the United States, and admission rates for all causes differ widely between EDs. In this study we used a national sample of ED visits to examine variation in risk-standardized hospital admission rates from EDs and the relationship of this variation to inpatient mortality for the fifteen most commonly admitted medical and surgical conditions. We then estimated the impact of variation on national health expenditures under different utilization scenarios. Risk-standardized admission rates differed substantially across EDs, ranging from 1.03-fold for sepsis to 6.55-fold for chest pain between the twenty-fifth and seventy-fifth percentiles of the visits. Conditions such as chest pain, soft tissue infection, asthma, chronic obstructive pulmonary disease, and urinary tract infection were low-mortality conditions that showed the greatest variation. This suggests that some of these admissions might not be necessary, thus representing opportunities to improve efficiency and reduce health spending. Our data indicate that there may be sizeable savings to US payers if differences in ED hospitalization practices could be narrowed among a few of these high-variation, low-mortality conditions.

Healthcare reform in the United States and China: pharmaceutical market implications.

ObjectivesThe United States and China are broadening health insurance coverage and increasing spending on pharmaceuticals, in contrast to other major economies that are reducing health spending and implementing a variety of drug price controls. This article analyzes the implications of health system reforms in the United States and China for national pharmaceutical markets. It follows a historical institutionalist approach that identifies path dependency in the design and operation of national health systems. On that basis, we estimate prescription sales for 2015 and 2020, analyze the sustainability of free-market pricing for drugs in the two countries, and assess future competitive dynamics in the pharmaceutical sector.MethodsThe institutional trajectories of health system reform and insurance coverage were studied for the United States and China. Next, data were collected from government, industry, and analyst reports on total healthcare spending and prescription drug expenditure by insurance status (in the United States) and by site of care (in China). Simple quantitative models were developed to estimate future drug spending based on insurance coverage, treatment locations, and health spending as a percentage of GDP.ResultsBoth countries will see rising total pharmaceutical spending and will be the two largest country markets for prescription drugs through at least 2020. In dollar terms, the U.S. pharmaceutical market will be over $440 billion in 2015 and $700 billion in 2020; China’s prescription market will be over $155 billion in 2015 and grow further to $260 billion in 2020. In both countries, generics will increase their share of all prescriptions, but economic and structural incentives for new drug invention and brand-name prescribing by physicians will keep the share of patented drug sales high compared to countries with more direct government control over the pharmaceutical market.ConclusionsExpanding private insurance contributes to spending on branded drugs, since insurers compete for market share rather than cost savings. Health system reforms presently being enacted in the United States and China align to historical institutional trajectories in each country, but leave unresolved a core tension between incentives for new drug invention and universal access to affordable medicines.

Vertical integration: hospital ownership of physician practices is associated with higher prices and spending.

We examined the consequences of contractual or ownership relationships between hospitals and physician practices, often described as vertical integration. Such integration can reduce health spending and increase the quality of care by improving communication across care settings, but it can also increase providers' market power and facilitate the payment of what are effectively kickbacks for inappropriate referrals. We investigated the impact of vertical integration on hospital prices, volumes (admissions), and spending for privately insured patients. Using hospital claims from Truven Analytics MarketScan for the nonelderly privately insured in the period 2001-07, we constructed county-level indices of prices, volumes, and spending and adjusted them for enrollees' age and sex. We measured hospital-physician integration using information from the American Hospital Association on the types of relationships hospitals have with physicians. We found that an increase in the market share of hospitals with the tightest vertically integrated relationship with physicians--ownership of physician practices--was associated with higher hospital prices and spending. We found that an increase in contractual integration reduced the frequency of hospital admissions, but this effect was relatively small. Taken together, our results provide a mixed, although somewhat negative, picture of vertical integration from the perspective of the privately insured.