Total Medical Care Costs Research Articles

Spinal Cord Stimulation is not Cost-effective for Non-surgical Management of Critical Limb Ischaemia

Objective To quantify the costs of treatment in critical limb ischaemia (CLI) and to compare costs and effectiveness of two treatment strategies: spinal cord stimulation (SCS) and best medical treatment. Methods One hundred and twenty patients with CLI not suitable for vascular reconstruction were randomised to either SCS in addition to best medical treatment or best medical treatment alone. Primary outcomes were mortality, amputation and cost. Cost analysis was based on resources used by patients for 2 years after randomisation. Both medical and non-medical costs were included. Results Patient and limb survival were similar in the two treatment groups. Costs of in-hospital-stay and institutional rehabilitation constituted the predominant part (±70%) of the total costs of medical care in CLI. Cost of SCS-implantation and complications (€7950 per patient) exceeded by far cost due to amputation procedures (€410 per patient). The total costs of treatment were €36,600 per patient over 2 years for the SCS-group vs. €28,700 for best medical treatment alone (28% higher for SCS-group, p=0.009). Conclusions Total costs of treatment in CLI are high. Major components are hospital and rehabilitation costs. In contrast to recent reviews, there were no long-term benefits of SCS-treatment. Therefore, cost-effectiveness is reduced to cost-minimisation and SCS-treatment is considerably more expensive than best medical treatment.

Costos de la atención médica atribuibles al consumo de tabaco en el Instituto Mexicano del Seguro Social

To estimate the cost of medical care for the major diseases attributable to tobacco consumption at the IMSS. A cost of illness (COI) analysis was carried out from the perspective of the health provider. A random sample of clinical files (n= 1,596) was reviewed to estimate the human resources and medical supplies's utilization according to the health care facilities. The smoking attributable fraction (SAF) by disease was used to derive costs attributable to tobacco consumption. The unitary cost was valuated in 2004 Mexican pesos (MP). The estimated annual total cost of medical care was 7114 million MP for acute myocardial infarction (AMI); 3424 million MP for Cerebrovascular Disease, 1469 million MP for chronic obstructive pulmonary disease (COPD) and 102 million MP for lung cancer (LC). The annual total cost of medical care for IMSS was 12100 million MP. The total annual cost of medical care attributable to tobacco consumption corresponds to 7100 million MP, which is equivalent to 4.3% of the annual expenditures of the IMSS during 2004. These results confirm the high medical costs associated with smoking. This information would be used to reinforce the tobacco control preventive actions at IMSS and support decision-makers in strengthening public policies to control tobacco use in Mexico.

Costos de atención médica atribuibles al tabaquismo en el IMSS, Morelos

To estimate the cost of medical care for the major diseases attributable to tobacco consumption at the IMSS, Morelos.A cost of illness (COI) analysis was carried out from the perspective of the health provider. An expert panel characterized medical care in primary and secondary care levels according to severity of disease. The smoking attributable fraction (SAF) by disease was used to derive costs attributable to tobacco consumption. The unitary cost was valuated in 2001 Mexican pesos (MP).The estimated annual average cost of medical care (diagnosis and first year of treatment) was 79,530 MP for acute myocardial infarction (AMI); 73,303 MP for chronic obstructive pulmonary disease (COPD); and 102,215 MP for lung cancer (LC). The annual total cost of medical care for IMSS was 147,390 688 MP. The total annual cost of medical care attributable to tobacco consumption corresponds to dollars 124 million MP, which is equivalent to 7.3% of the annual budget of the Morelos Delegation.These results confirm the high medical costs associated with smoking. A repetition of this study at the national level is recommended in order to support decision-makers in strengthening public policies to control tobacco use in Mexico.

The Present and Future Organization of Medicine

The Present and Future Organization of Medicine

The American Approach to Health Insurance

Dans cet article, publie pour la premiere fois dans le Quarterly Vol. 12, No 2, 1934, l'A. presente l'approche americaine de l'assurance sante, qu'il compare a l'approche europeenne, dont une premiere partie retrace les grandes etapes historiques (au Royaume-Uni et en Allemagne). L'arriere-plan historique de l'assurance maladie, telle qu'elle s'est developpee en Europe, est economique, son premier objectif ayant ete la protection du revenu, le remboursement des soins medicaux y etant un objectif second. Si l'experience europeenne est pleine d'enseignements, le cas des Etats-Unis necessite une approche differente, du fait que les couts des soins medicaux mettent desormais en jeu des sommes plus importantes et affectent bien plus de gens que ne le fait la perte de salaire due a la maladie, et aussi du fait que la provision d'un soin medical adequat, curatif et preventif, implique des possibilites plus importantes que dans l'ancien temps, pour soulager la souffrance, promouvoir la sante, augmenter l'efficacite economique. L'A. conclut ainsi son article par une serie de recommandations pour un systeme de sante plus stable, dans lequel les soins medicaux seraient pris en charge par l'assurance maladie, soutenue par l'impot.

Effects of skeletal complications on total medical care costs in patients with bone metastases of solid tumors

8094 Background: Patients with bone metastases of breast, lung, and prostate cancer often experience skeletal-related complications including pathological fracture, spinal cord compression, hypercalcemia, or pain requiring surgery, radiotherapy, or opioid analgesics (collectively, skeletal-related events [SREs]). Effects of SREs on total medical-care costs have not been compared across patients with different tumor types. Methods: We used a US health insurance claims database (7/94–6/02) to quantify the impact of SREs on total medical-care costs in patients with bone metastases of various solid tumors. Subjects included in this analysis had ≥2 encounters with a diagnosis of primary breast, lung, or prostate cancer and ≥2 encounters with a diagnosis of metastases to bone. For each tumor type, Kaplan-Meier estimated medical-care costs were compared for propensity-matched samples of patients with SREs versus without SREs. Results: We identified 1702 patients with bone metastases of breast (n=617), lung (n=543), and prostate cancer (n=542), of whom 52% (breast and prostate) to 55% (lung) experienced at least one SRE during the observation period (mean 6.0 mos [lung] to 15 mos [breast]). After matching for age, gender, and comorbidities using propensity score, there were 201, 162 and 181 pairs of SRE/no SRE patients with breast, lung, and prostate cancer, respectively. In SRE patients, costs of SRE treatment ranged from $9,480 (95%CI $7,625-$11,374) in lung to $13,940 ($11,240-$16,856) in breast cancer. Differences (SRE vs no SRE) in total costs (SRE treatment and other care) ranged from $20,792 ($4,829-$36,475) in prostate to $48,173 ($19,068-$77,684) in breast cancer. Median survival was greater in SRE vs no SRE patients in lung cancer (p=.048); there was a similar trend in breast and prostate cancers. After adjusting for differences (SRE vs no SRE) in survival, differences (SRE vs no SRE) in total costs ranged from $18,051 in prostate to $43,548 in breast cancer. Conclusions: Costs of SREs in patients with solid tumors and bone metastases are substantial across tumor types and may be greatest in breast cancer. Treatments which prevent SREs, such as intravenous bisphosphonates, may reduce these costs. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Novartis Novartis Novartis Aventis

Medical care cost of patients with prostate cancer

Objective To analyze variations in direct medical care cost of patients with prostate across two racial groups after controlling for age, disease stage, and comorbidity. Methods In this retrospective cohort control study, we randomly selected 120 newly diagnosed prostate cancer patients (60 African Americans and 60 White) from the administrative database of a large urban academic hospital. Medical care costs data and clinical data were obtained. The control group consisted of 240 men without cancer, and matched by age and race. Demographics, clinical variables and treatment patterns were compared across race using t-test and χ 2. Mean medical care costs for prostate cancer patients were compared by race, using bootstrap and log t-test. Regression models were used to estimate the incremental cost of prostate cancer, and to analyze the association between race and direct medical care cost. Results Whites were more likely to receive radical prostatectomy, whereas African Americans were more likely to receive radiation therapy. The incremental cost of prostate cancer was 1.30 times higher than controls. Charlson comorbidity was a significant predictor of type of treatment received and cost. Race was not associated with total direct medical care cost after controlling for age, Charlson comorbidity and stage of cancer at diagnosis. Conclusions Charlson Comorbidity score was a predictor of type of treatment and direct medical care cost. While analyzing the association between race and cost of care, potential bias-inducing factors such as clinical characteristics at diagnosis and provider characteristics (physician and hospital) must be addressed.

General medical and pharmacy claims expenditures in users of behavioral health services

To quantify the magnitude of general medical and/or pharmacy claims expenditures for individuals who use behavioral health services and to assess future claims when behavioral service use persists. Retrospective cost trends and 24-month cohort analyses. A Midwest health plan. Over 250,000 health plan enrollees during 2000 and 2001. Claims expenditures for behavioral health services, general medical services, and prescription medications. Just over one tenth of enrollees (10.7%) in 2001 had at least 1 behavioral health claim and accounted for 21.4% of total general medical, behavioral health, and pharmacy claims expenditures. Costs for enrollees who used behavioral health services were double that for enrollees who did not use such services. Almost 80% of health care costs were for general medical services and medications, two thirds of which were not psychotropics. Total claims expenditures in enrollees with claims for both substance use and mental disorders in 2000 were 4 times that of those with general medical and/or pharmacy claims only. These expenditures returned to within 15% of nonbehavioral health service user levels in 2001 when clinical need for behavioral health services was no longer required but increased by another 37% between 2000 and 2001 when both chemical dependence and mental health service needs persisted. The majority of total claims expenditures in patients who utilize behavioral health services are for medical, not behavioral, health benefits. Continued service use is associated with persistently elevated total general medical and pharmacy care costs. These findings call for studies that better delineate: 1) the interaction of general medical, pharmacy, and behavioral health service use and 2) clinical and/or administrative approaches that reverse the high use of general medical resources in behavioral health patients.

Association between Lifestyle-Disease Diagnosis or Risk Status and Medical Care Costs in a Japanese Corporation

This study examined the differences in medical care costs among (1) individuals who carried the diagnosis of selected lifestyle diseases (diabetes mellitus, hypertension, and hyperlipidemia), (2) individuals whose levels of risks (blood glucose, blood pressure, and total cholesterol) satisfied the diagnosis guidelines yet who did not carry the diagnoses, (3) individuals who had these risks but whose risk levels were not high enough to satisfy the diagnosis guidelines, and (4) individuals without the risks. A one-time cross-sectional design was used. Health checkup data and medical-claims data obtained from the fiscal year 2000 were examined for correlations. A total of 3292 employees aged 34 years and older were selected from the entire employee population of 6543 in a Japanese corporation. Employees younger than 34 years old were excluded because their clinical risk data were not available. On the basis of their absence or presence of diagnoses (obtained from medical claims) and underlying risk levels (obtained from health checkups), employees were categorized into (1) the diagnosed group, (2) the extremely high-risk group, (3) the high-risk group, or (4) the no-risk group. Reimbursement points on medical care claims were summed for each individual during the study period and multiplied by 10 to calculate the total medical care costs, as each point in the reimbursement request form represents 10 yen. The high-cost case analysis was used. First, the high costs were determined as the costs at or above the 90th percentile. The diagnosis or risk status was examined in its relation to the newly created dichotomous variable (whether the medical costs were at or above the threshold or were lower than the threshold) by using a chi2 test. Furthermore, excluding the diagnosed group, a chi2 test was performed to examine the relationships between the levels of risk and the likelihood of incurring any medical care costs (use vs. nonuse). Approximately 15% of employees were already diagnosed with at least one of the three diseases (the diagnosed group; n = 490). One-quarter of employees had at least one risk that was high enough to be diagnosed with the corresponding disease if they had sought medical care (the extremely high-risk group; n = 809). There were 1343 employees in the high-risk group and 650 employees in the no-risk group. The diagnosed group had much higher chances of incurring medical care costs at or above the 90th percentile than did any other risk or no-risk group. No difference among the three risk or no-risk groups was found in mean medical care costs or in the likelihood of any use of medical care services after controlling for the effect of diagnosis. In a Japanese employee population, the diagnosis status of diabetes mellitus, hyperlipidemia, and hypertension was found to be associated with higher medical care costs while risk levels for the diseases were not in a 1-year time period.

A National Profile of Health Care Utilization and Expenditures for Children With Special Health Care Needs

To provide the first nationally representative data on total health care expenses, out-of-pocket health care expenses, and information on the extent to which out-of-pocket expenses are financially burdensome for families of children with special health care needs (CSHCN). To also compare utilization and expenditure patterns for children with and without special health care needs. We used data from the 2000 Medical Expenditure Panel Survey (MEPS). We present univariate, bivariate, and multivariate statistics on utilization and expenditures adjusted for the complex sample design. The 2000 MEPS data set contains 6965 children younger than 18 years. Using the CSHCN definition adopted by the federal Maternal and Child Health Bureau and operationalized using the CSHCN Screener, 949 children (15.6%) were identified as children with special health care needs. Compared with other children, CSHCN had 3 times higher health care expenditures (2099 dollars vs 628 dollars; P<.01). The 15.6% of CSHCN accounted for 42.1% of total medical care costs (excluding dental costs) and 33.6% of total health care costs (including dental costs) attributed to children in 2000. Families of CSHCN were best protected against inpatient hospital care expenses and most exposed to dental care expenses. Families of CSHCN experiencing high out-of-pocket expenses (exceeding 5% of family income) were approximately 11 times more likely to be from households with incomes below 200% of the federal poverty level (odds ratio, 10.9; 95% confidence interval, 3.55-33.76) than to be from families with incomes at or above 400% of the federal poverty level. Families with CSHCN experience much higher expenditures, including out-of-pocket expenditures, than other children. Insurance plays an important protective role for families of CSHCN, but it still provides incomplete protection. Health policy changes that would extend the breadth and depth of insurance coverage are needed to ensure that all families of CSHCN are protected against burdensome expenses.

Cost of care for patients treated with lipid-lowering drugs

To investigate the relationship between attainment of treatment goals with lipid-lowering therapy and healthcare costs. 9789 patients who received treatment with a lipid-lowering agent at any time between 1 January 1993 and 14 April 2003. A cohort study using linkage of patient medical records from 29 Swedish primary care centres and the Swedish national inpatient register. The primary outcomes of interest were the total costs of medical care and costs of cardiovascular-related inpatient care during the year before treatment initiation and during years 1, 2 and 3 of treatment. The cost data were analysed with a two-part random-effects regression model. Of the 9789 patients identified in the database for the study, 6316 had at least one cholesterol measurement during the year after the index prescription and were included in the analysis. 37% of the patients attained the goal of low-density lipoprotein cholesterol < 3.0 mmol/L and total cholesterol < 5.0 mmol/L. Patients who attained treatment goal had 44% higher pre-treatment costs of care. During the first year of treatment, patients who attained treatment goal had 28% higher costs of care. After the first year, costs for goal-attaining patients were 17% higher. However, the cost of cardiovascular-related inpatient care in patients attaining cholesterol treatment goal was twice as high as in patients not achieving goal before treatment start and 40% lower 2-3 years after treatment start. Patients reaching target cholesterol levels showed a trend of cost reductions over time, whereas no such trend could be found for patients not reaching goal levels. Reductions in costs were substantial for cardiovascular-related inpatient care for patients attaining cholesterol goals compared with patients not attaining cholesterol goals.

Medical Care Costs Associated with Postmenopausal Estrogen Plus Progestogen Therapy

Objective To investigate the medical management costs of estrogen plus progestogen hormone therapy (HT) among postmenopausal women taking HT primarily as a preventive treatment for osteoporosis. Design Retrospective longitudinal comparative analysis of HT users and demographically matched nonusers using administrative databases on physician services, hospital stays and prescription medications. Setting: Saskatchewan, Canada. Patients: a total of 5762 women aged 55 years or more who took HT sometime between 1990 and 1997 and 5762 demographically matched controls who did not take HT from 1990 to 1997. Main outcome measures: total medical care expenditures and apparent costs of managing adverse events associated with HT. Results Excluding drug acquisition costs for HT and costs of care for osteoporosis, women in their first year of postmenopausal HT had total medical care costs about $400 greater than women who had never used HT (1997 Canadian dollars). This total medical care cost differential falls to about $90 to $120 per annum after the first year of therapy. If osteoporosis-related medical care costs are not excluded, the cost differential is about $390 during the first year of therapy and $80 to $110 per annum after the first year of therapy. These excess costs primarily are the result of excess rates of resource utilization for uterine- and breast-related diagnostic and treatment procedures. Conclusion Medical management costs for HT may be substantial during the first year of therapy, and some medical management costs may persist over several years. These short-term management costs, combined with recent data about the long-term safety of HT as a preventive therapy, reinforce the importance of considering therapeutic alternatives to HT.

Effects of weight gain on medical care costs.

To examine in middle-aged adults the effect of medical care costs of large, rapid weight gain compared to weight maintenance. : Retrospective cohort study for a 3-y time period. Population-based sample (N=15174) of men and women members of a large managed care organization, aged 35-65 y, with a body mass index (BMI) >25 kg/m(2) at baseline. Health-care utilization and costs were measured at baseline and over the 3-y follow-up period. Mean age at baseline was 49.7 y and mean BMI was 31.5 kg/m(2). During the 3-y follow-up period, 40.8% were classified as weight maintainers (+/-4 pounds), 45.3% gained 5-19 pounds, and 13.9% gained >/=20 pounds. A weight gain of >/=20 pounds was significantly associated with increased total medical care costs in all subgroups evaluated. Among all subjects, for those who gained >/=20 pounds compared to those who maintained weight, the adjusted 3-y increase in costs was 561 dollars. Among the subgroup with baseline comorbidities, the adjusted 3-y change in total medical care costs was 711 dollars. Multivariate analyses showed no significant differences between those who gained 5-19 pounds and those who maintained weight. Baseline BMI and comorbidities were also significant predictors of change in medical care costs, independent of weight gain. A large 3-y weight gain (>/=20 lb) in middle-aged overweight and obese adults is associated with a correspondingly larger increase in total medical care costs compared to weight maintainers. The prevention of large weight gains holds promise for significantly reducing future medical care costs. Future studies should examine the causes of rapid weight gain and evaluate approaches to prevent and reverse such weight gain.

Impact of skeletal complications on total medical care costs in prostate cancer patients with bone metastases

6057 Background: Prostate cancer patients with bone metastases often experience skeletal-related events (SREs) including pathological fracture, spinal cord compression, or pain requiring surgery, radiotherapy, or opioid analgesics. Previous studies have estimated the costs of SREs by tallying costs for services specifically attributable to these events. This approach may underestimate costs if SREs have effects on other services. Methods: We used a large US health insurance claims database (7/94 - 6/02) to quantify impact of SREs on total medical care costs in patients with bone metastases of prostate cancer. Subjects included in this analysis had ≥2 encounters with a diagnosis of primary prostate cancer and ≥2 encounters with a diagnosis of metastases to bone. Expected total medical care costs were compared for propensity-matched samples of patients with SREs versus patients without SREs. SREs were identified based on the occurrence on or after the date of first diagnosis of bone metastases, of (1) ≥1 encounter with a diagnosis of pathological fracture or spinal cord compression, or (2) ≥1 bone surgery or radiotherapy procedure, or (3) initiation of opioid analgesic therapy. Results: We identified 542 prostate cancer patients with bone metastases, including 282 (52%) with ≥1 SRE. After matching, there were 181 patients each in the SRE and no-SRE groups with mean follow-up of 13 and 10 months respectively. In the SRE group, expected costs of care directly attributable to SREs were $9,783 per patient. Expected total medical-care costs were $20,484 greater in SRE patients ($59,522 vs $39,038 in the no-SRE group) Conclusions: The costs of SREs in patients with prostate cancer and bone metastases are substantial and potentially greater than previously estimated. Treatments which prevent SREs, such as the intravenous bisphosphonate zoledronic acid, may reduce these costs. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Novartis Novartis Novartis Aventis Oncology

Impact of skeletal complications on total medical care costs in prostate cancer patients with bone metastases

6057 Background: Prostate cancer patients with bone metastases often experience skeletal-related events (SREs) including pathological fracture, spinal cord compression, or pain requiring surgery, radiotherapy, or opioid analgesics. Previous studies have estimated the costs of SREs by tallying costs for services specifically attributable to these events. This approach may underestimate costs if SREs have effects on other services. Methods: We used a large US health insurance claims database (7/94 - 6/02) to quantify impact of SREs on total medical care costs in patients with bone metastases of prostate cancer. Subjects included in this analysis had ≥2 encounters with a diagnosis of primary prostate cancer and ≥2 encounters with a diagnosis of metastases to bone. Expected total medical care costs were compared for propensity-matched samples of patients with SREs versus patients without SREs. SREs were identified based on the occurrence on or after the date of first diagnosis of bone metastases, of (1) ≥1 encounter with a diagnosis of pathological fracture or spinal cord compression, or (2) ≥1 bone surgery or radiotherapy procedure, or (3) initiation of opioid analgesic therapy. Results: We identified 542 prostate cancer patients with bone metastases, including 282 (52%) with ≥1 SRE. After matching, there were 181 patients each in the SRE and no-SRE groups with mean follow-up of 13 and 10 months respectively. In the SRE group, expected costs of care directly attributable to SREs were $9,783 per patient. Expected total medical-care costs were $20,484 greater in SRE patients ($59,522 vs $39,038 in the no-SRE group) Conclusions: The costs of SREs in patients with prostate cancer and bone metastases are substantial and potentially greater than previously estimated. Treatments which prevent SREs, such as the intravenous bisphosphonate zoledronic acid, may reduce these costs. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Novartis Novartis Novartis Aventis Oncology

Impact of skeletal complications on total medical care costs in lung cancer patients with bone metastases

6064 Background: Lung cancer patients with bone metastases often experience skeletal-related events (SREs) including pathological fracture, spinal cord compression, hypercalcemia, or pain requiring surgery, radiotherapy, or opioid analgesics . Previous studies have estimated the costs of SREs by tallying costs for services specifically attributable to these events. This approach may underestimate costs if SREs have effects on other services. Methods: We used a large US health insurance claims database (7/94 - 6/02) to quantify impact of SREs on total medical care costs in patients with bone metastases of lung cancer. Subjects included in this analysis had ≥2 encounters with a diagnosis of primary lung cancer and ≥2 encounters with a diagnosis of metastases to bone. Expected total medical care costs were compared for propensity-matched samples of patients with SREs versus patients without SREs. SREs were identified based on the occurrence on or after the date of first diagnosis of bone metastases, of (1) ≥1 encounter with a diagnosis of pathological fracture, spinal cord compression, or hypercalcemia, or (2) ≥1 bone surgery or radiotherapy procedure, or (3) initiation of opioid analgesic therapy. Results: We identified 534 lung cancer patients with bone metastases, including 295 (55%) with ≥1 SRE. After matching, there were 162 patients each in the SRE and no-SRE groups with mean follow-up of 6.3 and 4.5 months respectively. In the SRE group, expected costs of care directly attributable to SREs were $9,494 per patient. Expected total medical-care costs were $28,223 greater in SRE versus no-SRE patients ($59,926 vs $31,704 in the no-SRE group). Conclusions: The costs of SREs in patients with lung cancer and bone metastases are substantial and potentially greater than previously estimated. Treatments which prevent SREs, such as the intravenous bisphosphonate zoledronic acid, may reduce these costs. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Novartis Pharmaceuticals Corp. Novartis Pharmaceutical Corp. Novartis Aventis Oncology Aventis Oncology

Impact of skeletal complications on total medical care costs in lung cancer patients with bone metastases

6064 Background: Lung cancer patients with bone metastases often experience skeletal-related events (SREs) including pathological fracture, spinal cord compression, hypercalcemia, or pain requiring surgery, radiotherapy, or opioid analgesics . Previous studies have estimated the costs of SREs by tallying costs for services specifically attributable to these events. This approach may underestimate costs if SREs have effects on other services. Methods: We used a large US health insurance claims database (7/94 - 6/02) to quantify impact of SREs on total medical care costs in patients with bone metastases of lung cancer. Subjects included in this analysis had ≥2 encounters with a diagnosis of primary lung cancer and ≥2 encounters with a diagnosis of metastases to bone. Expected total medical care costs were compared for propensity-matched samples of patients with SREs versus patients without SREs. SREs were identified based on the occurrence on or after the date of first diagnosis of bone metastases, of (1) ≥1 encounter with a diagnosis of pathological fracture, spinal cord compression, or hypercalcemia, or (2) ≥1 bone surgery or radiotherapy procedure, or (3) initiation of opioid analgesic therapy. Results: We identified 534 lung cancer patients with bone metastases, including 295 (55%) with ≥1 SRE. After matching, there were 162 patients each in the SRE and no-SRE groups with mean follow-up of 6.3 and 4.5 months respectively. In the SRE group, expected costs of care directly attributable to SREs were $9,494 per patient. Expected total medical-care costs were $28,223 greater in SRE versus no-SRE patients ($59,926 vs $31,704 in the no-SRE group). Conclusions: The costs of SREs in patients with lung cancer and bone metastases are substantial and potentially greater than previously estimated. Treatments which prevent SREs, such as the intravenous bisphosphonate zoledronic acid, may reduce these costs. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Novartis Pharmaceuticals Corp. Novartis Pharmaceutical Corp. Novartis Aventis Oncology Aventis Oncology

Direct medical costs and their predictors in patients with rheumatoid arthritis: a three-year study of 7,527 patients.

To estimate total direct medical costs in persons with rheumatoid arthritis (RA) and to characterize predictors of these costs. Patients (n = 7,527) participating in a longitudinal study of outcome in RA completed 25,050 semiannual questionnaires from January 1999 through December 2001. From these we determined direct medical care costs converted to 2001 US dollars using the consumer price index. We used generalized estimating equations to examine potential predictors of the costs. Monte Carlo simulations and sensitivity analyses were performed to evaluate the varying prevalence and cost of biologic therapy. The mean total annual direct medical care cost in 2001 for a patient with RA was 9,519 US dollars. Drug costs were 6,324 US dollars (66% of the total), while hospitalization costs were only 1,573 US dollars (17%). Approximately 25% of patients received biologic therapy. The mean total annual direct cost for patients receiving biologic agents was 19,016 US dollars per year, while the cost for those not receiving biologic therapy was 6,164 US dollars. RA patients who were in the worst quartile of functional status, as measured by the Health Assessment Questionnaire, experienced direct medical costs for the subsequent year that were 5,022 US dollars more than the costs incurred by those in the best quartile. Physical status as determined by the Short Form 36 physical component scale had a similar large effect on RA costs, as did comorbidity. Medical insurance type played a more limited role. However, those without insurance had substantially lower service utilization and costs, and health maintenance organization patients had lower drug costs and total medical costs. Increased years of education, increased income, and majority ethnic status were all associated with increased drug costs but not hospitalization costs. Costs in all categories decreased after age 65 years. Estimates of direct medical costs for patients with RA are substantially higher than cost estimates before the biologic therapy era, and costs are now driven predominantly by the cost of drugs, primarily biologic agents. RA patients with poor function continue to incur substantially higher costs, as do those with comorbid conditions, and sociodemographic characteristics also play an important role in determination of costs.

Physician Financial Incentives in Managed Care

Patients with health insurance do not make the most cost conscious healthcare decisions since they bear only a fraction of the total cost of medical care. Managed care advocates point to financial incentives as a way to reduce wasteful resource use. However, physicians with managed care contracts feel financial pressures designed to reduce waste may also limit medically necessary services and adversely impact the quality of patient care. In light of a growing public and professional distrust of the motives behind offering financial incentives, the economic theory of agency is used to illustrate how financial contracts designed to reduce wasteful resource use influence physician behavior. A review of the literature was conducted to determine the effects of financial incentives on resource use, cost and the quality of medical care. The method used to undertake this literature review followed the approach set forth in the Cochrane Collaboration handbook. This review revealed that much of the empirical evidence on the effect of managed care on physician behavior compared the experiences of traditional indemnity plan enrollees with health maintenance organization enrollees. Published studies are outdated and are influenced by statistical problems including both patient and physician selection bias. With respect to the newer types of managed care organizations, there is a paucity of information on the effects of financial incentives on physician behavior. Despite the lack of empirical evidence, the perception remains that managed care financial incentives are perverse in that they induce physicians to take actions that compromise quality of care. To evaluate the legitimacy of these concerns, research on how physician contractual arrangements influence the cost and quality of care in the newer types of plans is needed. In the absence of such research, political rhetoric bent by anecdotal evidence will continue to influence public policy and undermine managed care.

Estimating the costs and benefits of new drug therapies: atypical antipsychotic drugs for schizophrenia.

This article presents an analytic tool populated with data from published studies to illustrate the likely impacts of a switch from typical to atypical antipsychotic drugs over a 3-year period on individual, family, and societal outcomes for a U.S. schizophrenia population. Data taken from clinical trials and observational data studies are used. Changes in annual health care costs, schizophrenia symptom days, extrapyramidal symptom (EPS) days, suicide rates, and employment days are estimated. For each 1,000 people treated with typical drugs, the base case scenario gives estimates of annual medical care costs of dollar 28.9 million with 80,253 moderate/severe schizophrenia symptom days and 92,006 EPS days. In the base case scenario, after switching to atypical drugs, schizophrenia symptom days are estimated to decrease up to 33 percent, EPS days up to 50 percent, and total medical care costs up to 19 percent over the 3-year period. Suicide rates fall and employment rates increase. The direction of the impacts remain the same for a wide range of input parameter values used in sensitivity analyses. Thus, switching to atypical drugs will likely reduce total medical care costs and decrease other disease burdens for people with schizophrenia, their families, and society.