Total Medical Expenditures Research Articles

Association between reduction in copayment and gastric cancer patient concentration to the capital area in South Korea: NHI cohort 2003–2013

Since 2004, the South Korean government has introduced a policy that decreases copayment for cancer patients by strengthening public coverage in the National Health Insurance (NHI) system (first phase=copayment for outpatient care from 30% to 20%; second phase=copayment for total medical expenditures from 20% to 10%; third phase=copayment for total medical expenditures from 10% to 5%). We aimed to investigate the relationship between the policy introduction and patient visits to hospitals in the capital area. We used data from the NHI Cohort 2003–2013, which included all medical claims (7193 cases) filed for 2124 patients who visited the hospital due to stomach cancer, and performed a segmented Poisson regression analysis. Of all hospital visits, 40.6% of patients were from the capital area. After the introduction of the second phase of the policy, there was an increase in patient concentration in the capital area, although there were no significant effects on patient concentration during the first and third phases of the policy. In conclusion, our findings suggest that the introduction of a policy that reduces copayment for cancer patients had a substantial impact on patient concentration in the capital area. Therefore, health policymakers should consider effective alternatives including efficient allocation of medical resources or support for the more vulnerable population as flexible benefit plans to aid healthcare utilization by cancer patients.

PCN153 - Quantifying the Association between Health-Related Quality of Life Scores and Subsequent Health Resource Utilization in Oncology

Although HRQL scores have been linked to HCRU in the general population, this link has not been clearly demonstrated in oncology. We quantified the association between differences in scores from the SF-12v2 Health Survey (SF-12v2) and subsequent HCRU among noninstitutionalized US adults with cancer. We analyzed the Medical Expenditure Panel Survey (MEPS) data, including patients 18 years of age or older with a completed SF-12v2, 6 months of subsequent HCRU data, and a reported diagnosis of cancer not in remission (n=647). HCRU included total medical expenditures (MEs) and number of medical events (EVs). We modeled the effect of physical (PCS) and mental (MCS) component summary scores on MEs using a gamma-log generalized linear model (GLM) controlling for demographics and comorbidities. A Poisson-log GLM was used for EVs. Estimates were obtained for the total sample and major cancer subgroups: breast, prostate, skin and lung. A one-point higher (better) PCS score was associated with 2% lower MEs (P<0.001); a one-point higher MCS score was associated with 2.5% lower MEs (P=0.015). A 3-point higher PCS or MCS score (proposed MID for these scores) was associated with 6% and 7.5% lower MEs respectively. Within the cancer subgroups, a 1-point higher PCS score was most strongly associated with MEs for patients with prostate cancer (7% lower MEs; P=0.009) followed by patients with skin cancer (5% lower MEs; P=0.019). We found less association between PCS and EVs, and no evidence that this association varied by cancer group. We showed that differences in PCS and MCS scores from the SF-12v2 are significantly associated with differences in subsequent HCRU in a national oncology sample. The key role of HRQL in oncology makes these findings a potential guide in health policy and decisions on the evaluation of outcomes.

The Impacts of Breakthrough Drug Classes on Total Healthcare Expenditures

Background: Pharmaceutical firms spend billions of dollars developing new therapies, which are often sold at a substantial premium over older therapies. The costs and benefits of these newer and more expensive drugs, however, are controversial. The empirical evidence on whether newer drugs can decrease overall healthcare expenditures may enable private and public health policymakers to develop new drug benefit structures. Objective: This paper investigates the impact of new drugs and drug classes on overall healthcare expenditures. The paper focuses on the level of reductions in total healthcare expenditures drawn from the replacement of other drugs with breakthrough drug classes. Methods: We used the Medical Expenditure Panel Survey (MEPS) data sets from 1996 to 2001. To measure the effect of important drugs prescribed for a given condition on the expenditures, we developed a model that captures the effect of important drugs on expenditures in a less restrictive way than the extant literature. Our analysis of these drug groupings offers several improvements over prior work. First, we treated all drugs with a similar pharmacology as the same, rather than assigning their therapeutic value based on year of introduction. Second, our approach recognizes that innovations emerge in waves and that drugs within a particular group are more similar therapeutically to each other than to other existing drugs, or other drugs introduced in the same or different years. Third, we separately estimated the effects of each of these groups of drugs on drug and non-drug expenditures. Finally, we measured the cost impact of drug use in a more general way than in the existing literature. We examined six different groups of breakthrough drugs, selective serotonin reuptake inhibitors, statins, angiotensin-converting-enzyme (ACE) inhibitors, histamine type 2 antagonists, proton pump inhibitors, calcium channel blockers and fluoroquinolones. Results: Our results demonstrate that drugs from breakthrough classes - except ACE inhibitors - are more expensive than other drugs. Next, we measured the impact of breakthrough drug classes and other drugs on total non-drug medical expenditures. The results indicate that important drugs significantly decrease total non-drug expenditures for all breakthrough classes, except fluoroquinolones. In general, the reduction in non-drug expenditures is many times larger than the increased drug expenditures. Conclusion: Breakthrough drug classes, with the exception of fluoroquinolones, substantially reduce overall healthcare expenditures.

Effects of a Lifestyle-Based Physical Activity Intervention on Medical Expenditure in Japanese Adults: A Community-Based Retrospective Study.

Background. This study aimed to investigate whether a lifestyle-based physical activity program could contribute to reduced medical expenditure. Methods. The study participants were 60 adults aged 63.1 (standard deviation, 4.4) years in the intervention group; the case-control group consisted of 300 adults who were randomly selected from Japan's national health insurance system. This community-based retrospective study incorporated a 3-year follow-up. Results. The total and outpatient medical expenditure in the intervention group were significantly lower than in the control group: total expenditure, $US640.4/year; outpatient expenditure, $369.1/year. The odds ratio for outpatient visiting was 6.47-fold higher in the control than in the intervention group. Conclusion. Our study suggests that a health program to promote physical activity can result in reduced total medical expenditure, outpatient medical expenditure, and possibly also inpatient medical expenditure.

Insurance-Induced Moral Hazard: A Dynamic Model of Within-Year Medical Care Decision Making Under Uncertainty

Existing studies estimate health insurance-induced increases in medical care expenditure by examining medical care decisions that are aggregated to the annual level. Using employer-employee matched data from the Medical Expenditure Panel Survey, I quantify the moral hazard effect of insurance on medical care expenditure by estimating a dynamic model of within-year medical care consumption that allows for insurance selection, endogenous health transitions, and individual uncertainty about medical care prices in an environment where insurance has non-linear cost-sharing features. The results suggest that the additional consumption induced by moral hazard amounts to 53.1 percent, on average, of total annual medical care expenditure when insured. In order to understand the relationship between the dynamic features of the model and the estimated moral hazard effects, I estimate a second model that is representative of the annual decision-making models found in the literature. The within-year decision-making model produces a moral hazard effect that is significantly different, and generally larger, than the alternative model. To illustrate the importance of the within-year decision-making model, I quantify the welfare and spending implications of health insurance alternative sets with more and less generous options.

Healthcare Utilization and Expenditures for Persons with Diabetes Comorbid with Mental Illnesses.

The aim of this study was to investigate healthcare utilization and expenditure for patients with diabetes comorbid with and without mental illnesses in Taiwan. People with diabetes comorbid with and without mental illnesses in 2000 were identified and followed up to 2004 to explore the healthcare utilization and expenditure. Healthcare utilization included outpatient visits and use of hospital inpatient services, and expenditure included outpatient, inpatient and total medical expenditure. General estimation equation models were used to explore the factors associated with outpatient visits and expenditure. To identify the factors associated with hospitalization, multiple logistic regressions were applied. The average number of annual outpatient visits of the patients with mental illnesses ranged from 37.01 to 41.91, and 28.83 to 31.79 times for the patients without mental illnesses from 2000 to 2004. The average annual total expenditure for patients with mental illnesses during this period ranged from NT$77,123-NT$90,790, and NT$60,793- NT$84,984 for those without mental illnesses. After controlling for covariates, the results indicated that gender, age, mental illness and time factor were associated with outpatient visits. Gender, age, and time factor were associated with total expenditure. Age and mental illness were associated with hospitalization in logistic regression. The healthcare utilization and expenditure for patients with mental illnesses was significantly higher than for patients without mental illnesses. The factors associated with healthcare utilization and expenditure included gender, age, mental illness and time trends.

Influenza Antiviral Expenditures and Outpatient Prescriptions in the United States, 2003-2012.

The clinical efficacy and cost-effectiveness of influenza antiviral use are controversial, with recent analyses suggesting potentially limited value. Thus, the objectives of this study were to describe influenza antiviral expenditures overall and by health care setting over a 10-year period (2003-2012) and to assess the correlation between outpatient influenza antiviral prescription use and influenza-like illness (ILI) outpatient visits. Retrospective, cross-sectional study. IMS Health National Sales Perspectives and Xponent databases and Centers for Disease Control and Prevention ILINet national influenza surveillance system database. All prescriptions for oseltamivir, rimantadine, or zanamivir from community pharmacies, mail order pharmacies, clinics, nonfederal hospitals, and other health care settings (federal hospitals, military facilities, jails and prisons, universities, staff-model health maintenance organizations, veterinary hospitals and clinics, and long-term care facilities) between January 1, 2003, and December 31, 2012. Prescribing rates were calculated (prescriptions/1000persons) for each year from 2003 to 2012 by using U.S. Census Bureau data. Influenza season was defined as July 1-June 30 of each calendar year. Linear regression assessed the correlation between influenza antiviral expenditures, prescription use, and ILI diagnoses. From 2003 to 2012, influenza antiviral drug expenditures accounted for $3.74 billion, with the majority from community pharmacies. After adjusting for inflation, no growth was observed for expenditures. A total of 32.8 million influenza antiviral prescriptions were dispensed from community pharmacies during the study period, and these prescriptions experienced 133.2% growth from 2003 to 2012. One third of expenditures and one quarter of dispensed prescriptions were in 2009. Influenza seasons were correlated with ILI and antiviral prescriptions. Annual community pharmacy expenditures were also associated with influenza antiviral prescriptions dispensed over the 10-year period. Influenza antivirals totaled $3.74 billion in the United States from 2003 to 2012, with the majority in 2009 and from community pharmacies. Influenza antivirals constituted a small proportion of total medication expenditures, but unforeseen pandemics resulted in unusually high use and expenditures. Influenza antiviral prescriptions dispensed from community pharmacies were associated with ILI and drug expenditures.

Comparisons of annual health care utilization, drug consumption, and medical expenditure between the elderly and general population in Taiwan

Background/PurposeThe aim of this study was to present an overview of health care utilization (outpatient, inpatient, and emergency visits), total medical expenditure, and drug consumption between the elderly and general population under Taiwan's National Health Insurance program. MethodsWe conducted a cross-sectional analysis using the 2010 Taiwan's Longitudinal Health Insurance Database. Our analysis included 999,418 beneficiaries with eligible records under the National Health Insurance system. Among them, 10.43% (n=104,273) were elderly (65 years and older). Health care utilization [including outpatient, emergency department (ED), and inpatient visits], medical expenditure, as well as drug consumption for the entire study cohort (“the general population”) and the elderly were estimated using patient-level data from the Longitudinal Health Insurance Database. Specifically, “polypharmacy” and “excessive polypharmacy” defined as the concomitant use of five or more drugs and 10 or more drugs, respectively, were used to quantify drug consumption. ResultsThe annual use of outpatient visits [mean (standard deviation): elderly 26.7 (21.5) vs. 12.2 (14.5)] per elderly individual doubled that of the general population. Approximately one-in-five of the elderly were admitted to hospital (20.9%) and went to ED (22.6%) at least once annually. Only 7.7% and 14.0% of the general public were admitted to hospital and went to ER at least once annually. The elderly had higher drug consumption and were more likely to be users of polypharmacy than the general population (elderly 15.5% vs. 3.7%). The annual medical expenditure per elderly individual tripled that of the general population (elderly 1846 US$ vs. 554 US$). ConclusionElderly people had higher medical utilization than the general population, which may contribute to a fragmented health care system. Strategies to integrate health care for older people would be considered a first priority task of policymakers and health professionals.

NRCMS capitation reform and effect evaluation in Pudong New Area of Shanghai.

The Rural Cooperative Medical Scheme (RCMS) had played an important role in guaranteeing the acquisition of basic medical healthcare of China's rural populations, being an innovative model of the medical insurance system for so many years here in China. Following the boom and bust of RCMS, the central government rebuilt the New Rural Cooperative Medical Scheme (NRCMS) in 2003 across the whole country. Shanghai, one of the developed cities in China, has developed its RCMS and NRCMS as an advanced and exemplary representative of Chinese rural health insurance. But in the past 10 years, its NRCMS has encountered such challenges as a spiral of medical expenditures and a decrease of insurance participants. Previous investigations showed that the capitation and general practitioner (GP) system had great effect on medical cost containment. Thus, the capitation reform combined with GP system reform of NRCMS, based on a system design, was implemented in Pudong New Area of Shanghai as of 1 August 2012. The aim of the current investigation was to present how the reform was designed and implemented, evaluating its effect by analyzing the data acquired from 12 months before and after the reform. This was an empirical study; we made a conceptual design of the reform to be implemented in Pudong New Area. Most data were derived from the institution-based surveys and supplemented by a questionnaire survey, qualitative interviews and policy document analysis. We found that most respondents held an optimistic attitude towards the reform. We employed a structure-process-outcome evaluation index system to evaluate the effect of the reform, finding that the growth rate of the insured population's total medical costs and NRCMS funds slowed down significantly after the reform; that the total medical expenditure of the insured rural population decreased by 3.60%; and that the total expenditure of NRCMS decreased by 3.99%. The capitation was found to help the medical staff build active cost control consciousness. Approximately 2.3% of the outpatients flowed to the primary hospitals from the secondary hospitals; and farmers' annual medical burden was relieved to a certain degree. Meanwhile, it did not affect farmers' utilization and benefits of healthcare. However, further reform still faces new challenges: The capitation reform should be well combined with the primary healthcare system to realize the "dual gatekeeper" of GPs; a variety of payment methods should be mixed on the basis of capitation to avoid possible mistakes by one single approach; and the supervision of medical institutions should be strengthened. A long-term follow-up study need to be carried out to evaluate the effects of the capitation reform so as to improve the design of the program. Copyright © 2015 John Wiley & Sons, Ltd.

Association between periodontitis and medical expenditure in older adults: A 33-month follow-up study.

Along with rapid aging, medical expenditure for older adults has been increasing in Japan. Research has shown that periodontitis is a useful predictor for excess medical expenditure; however, limited information is available on the elderly population after adequately considering confounding factors. The aim of the present study was to evaluate the association between periodontitis and long-term medical expenditure in elderly Japanese. Baseline health and periodontal examinations were carried out in June 2008. Japanese adults (n = 245) aged 80 years were classified into quartiles based on periodontal inflamed surface area (PISA), which quantifies the degree of periodontal inflammation. Medical care use and costs were monitored by assessment of the National Health Insurance claim files from the baseline survey through the end of February 2011. Multivariable analysis of the differences in medical expenditure among PISA quartiles was carried out using linear regression with robust standard errors. The participants in the fourth (with the largest PISA) and third quartiles had significantly higher inpatient medical expenditure compared with those of the first quartile (P < 0.01 and = 0.04, respectively). Participants in the fourth quartile had significantly higher total medical expenditure (P < 0.01) compared with the first quartile. A trend was observed of higher inpatient and total medical expenditure with increasing PISA. A significant association was found between periodontitis and future increase in medical expenditure, suggesting that periodontitis might be a modifiable factor for the reduction of excess medical expenditure among elderly Japanese. Geriatr Gerontol Int 2016; 16: 856-864.

Abstract 830: Gene-specific promoter methylation is related to micronuclei frequency in urothelial cells from individuals exposed to organic solvents and paints

Abstract Bladder cancer is the 9th most common cancer worldwide and patients often receive late diagnosis. Due to its high recurrence (50-80%) this malignancy is the fifth most expensive cancer in terms of total medical care expenditures. Even though epidemiologic evidence shows the etiologic link between occupational exposure to organic solvents and bladder cancer, not all exposed individuals develop such disease, making it an attractive target for prevention and risk stratification. Previously, we reported the association between multiple polymorphisms in DNA-repair and metabolism genes and an increase in chromosome instability in workers exposed to organic solvents; however, it is still unclear whether gene-specific promoter methylation contributes to chromosome breakage or loss, as an intermediate end point of disease. Here, we investigated the effect of chronic exposure to organic solvents and paints on DNA-methylation profiles and micronuclei frequency in non-smoking, car painter compared to age matched referents (non-exposed). Micronucleus frequency and methylation profiles in gene promoters of E-cadherin (CDH-1), p16INK4a, Glutathione S-transferase P (GSTP1), and Adenomatous polyposis coli (APC), were assessed in exfoliated urothelial cells from voided urine. Poisson regression analysis indicated a significant increase in micronuclei frequency in all individuals with CDH-1- (RR 16.91, 95% CI 8.2-35.76, p&amp;lt; 0.001) and GSTP1- (RR 2.23, 95% CI 1.58-3.12, p&amp;lt; 0.001) promoter methylation. In addition, exposed workers with methylated p16INK4a promoter had an increased micronuclei frequency in relation to the matched referents (RR 1.93, 95% CI 1.45-2.55, p&amp;lt; 0.001). In contrast, methylation in the APC promoter was associated with decreased micronuclei frequency in all individuals (RR 0.11, 95% CI 0.7-0.19, p&amp;lt; 0.001). Finally, overall the exposed group had a higher percentage of individuals with &amp;gt; 2 micronuclei/2000 cells compared to the referent group (p = 0.04). These results support the conclusion that gene-specific promoter methylation may increase micronuclei frequency in a dependent or independent interaction with occupational exposure to organic solvents. The present and other studies might be used in the primary prevention of bladder cancer to encourage preventive measures at the work place and lifestyle changes in those at highest risk of developing the disease. Citation Format: Luz S. Hoyos-Giraldo, Luisa F. Escobar-Hoyos, Diana Saavedra-Trujillo, Ingrid Reyes-Carvajal, Adriana Muñoz, Elizabeth Londoño-Velasco, Angela Tello, Silvio Carvajal, Regina Santella. Gene-specific promoter methylation is related to micronuclei frequency in urothelial cells from individuals exposed to organic solvents and paints. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 830. doi:10.1158/1538-7445.AM2015-830

The Medical Cost Attributable to Obesity and Overweight in China: Estimation Based on Longitudinal Surveys

With its rapid economic growth and fast changing lifestyle, China witnessed expansionary prevalence of obesity and overweight during the recent decades. This paper provides the first nationally representative estimate of the medical cost attributable to obesity and overweight in China. We improve upon the traditional estimation methodology (two-part model) by jointly adopting the instrumental variable approach and the panel data methods in order to correct for the potential endogeneity of body size and the individual heterogeneity in medical expenditure. Using longitudinal data from 2000-2009 China Health and Nutrition Surveys, we find that body size has a significant impact on the individual expected medical expenditure and the per capita medical cost attributable to obesity and overweight in a single medical event is estimated to be 6.18 Yuan, or 5.29% of the total personal medical expenditure. This translates to 24.35 billion Yuan annual cost on the national scale, accounting for 2.46% of China's national health care expenditure. The subsample analyses also show that such cost is higher for the urban, women, and better educated people and increases over time. Our results contribute to the literature on the economic impact of obesity in developing countries and bear policy implications on controlling the rising health care costs in China. Copyright © 2015 John Wiley & Sons, Ltd.

Comment on “How does the Price Regulation Policy Impact on Patient–Nurse Ratios and the Length of Hospital Stays in Japanese Hospitals?”

It has been said that the fee-for-service (FFS) system in Japan's public health insurance system is a major contributor to Japan's relatively low national medical expenditures. Basically, this system allows the central government to almost fully control the prices of medical services through the reimbursement system of public health insurance, which covers most of the medical usage in Japan. This price control has been used for not only suppressing total medical expenditures, but also for balancing the allocations of medical resources by making higher rewards for services in short supply. Noguchi (2015), however, reveals the limitations of this approach by showing the “overreaction” of patient–nurse ratio (PNR) to changes in the FFS criteria. I have four major comments on Noguchi's (2015) paper. First, I would have liked to have seen a more detailed description about the reasons why the government wanted to lower PNR at the particular times it did. In particular, since the abstract and conclusion read as if the main policy implication of Noguchi (2015) is that the changes in the FFS caused an undesired outcome (an increase in beds for acute care), Noguchi should explain why the government, which wanted to reallocate health-care resources toward subacute and long-term care, also aimed to lower the PNR at the same time. As mentioned in Noguchi's paper, the changes in FFS intended to lower PNR and shorten the length of hospital stays (LHS), and the empirical results suggest that both PNR and LHS actually decreased in response to the changes. That is, the revision achieved its primary objectives. If the final goal of this fee revision is to expedite the treatment of acute diseases through the provision of more intensive human resources, I feel it is off the point to accuse hospitals of inducing more resources toward acute care. A second and related comment relates to the overall goals of the series of FFS revisions in Japan. In the concluding section, Noguchi argues that “[a] series of revisions of FSS aim to clarify and differentiate the roles and functions of medical facilities with various characteristics” (p. 318), and this argument seems to be the basis for the rather negative tone of Noguchi's overall evaluation of the FFS revision in 2000 and 2006. However, non-experts (like me) cannot see how the government actually planned to achieve such a differentiation by the FFS revisions. Were there any revisions other than the ones examined in this paper to focus on the differentiation, or were the policymakers just saying that the roles and functions of medical facilities should be differentiated? If the latter is the case, I think the problem is more on the self-inconsistency of the policy rather than the overreaction of the hospitals. Third, to me it was not very clear why the effect of the revisions on LHS is larger for small hospitals, whereas the effect on PNR is small and statistically insignificant for them. It is not surprising that small hospitals cannot recruit as many nurses as they want, and thus they cannot lower PNR as much as larger hospitals. Then, however, the effect on LHS should be smaller for them if the FFS revision affects LHS through a lower PNR. Even if the FFS revision has a direct effect on LHS through the price change, unless it differentiates hospitals by its size, it is not clear why small hospitals respond more. Fourth, it would be very informative if Noguchi provided further evidence on the heterogeneous effects across different types of hospitals other than those related to hospital size. For example, hospitals in underpopulated area may have difficulties in recruiting nurses because they are less attractive workplace for nurses and are more financially stressed than other types of hospitals. If so, the effects on PNR should be smaller for such hospitals. Also, the ownership of hospitals may affect hospital compliance. I believe such information should be available from the data used in this study, so it could be a good extension for future research.

Analysis of Medical Care Expenditure by Japanese Prefecture using Fuzzy Robust Regression Model.

In 2012, 15.13% of the total fiscal medical care expenditure was for lifestyle-related health care costs, which was approximately 179 billion yen. Lifestyle-related diseases are not only the biggest factor in reducing healthy life expectancy but also have the most significant impact on the national medical care expenditure. In addition, lifestyle-related diseases can be prevented by moderate daily exercise, a well-balanced diet, and not smoking. Our fuzzy robust regression model is a controllable model describing a target system. Therefore, our model is used to analyze the relation between medical care expenditure and selected lifestyle factors.

Direct medical costs of hospitalizations for cardiovascular diseases in Shanghai, China: trends and projections.

Few studies in China have focused on direct expenditures for cardiovascular diseases (CVDs), making cost trends for CVDs uncertain. Epidemic modeling and forecasting may be essential for health workers and policy makers to reduce the cost burden of CVDs.To develop a time series model using Box–Jenkins methodology for a 15-year forecasting of CVD hospitalization costs in Shanghai.Daily visits and medical expenditures for CVD hospitalizations between January 1, 2008 and December 31, 2012 were analyzed. Data from 2012 were used for further analyses, including yearly total health expenditures and expenditures per visit for each disease, as well as per-visit-per-year medical costs of each service for CVD hospitalizations. Time series analyses were performed to determine the long-time trend of total direct medical expenditures for CVDs and specific expenditures for each disease, which were used to forecast expenditures until December 31, 2030.From 2008 to 2012, there were increased yearly trends for both hospitalizations (from 250,354 to 322,676) and total costs (from US $ 388.52 to 721.58 million per year in 2014 currency) in Shanghai. Cost per CVD hospitalization in 2012 averaged US $ 2236.29, with the highest being for chronic rheumatic heart diseases (US $ 4710.78). Most direct medical costs were spent on medication. By the end of 2030, the average cost per visit per month for all CVDs was estimated to be US $ 4042.68 (95% CI: US $ 3795.04–4290.31) for all CVDs, and the total health expenditure for CVDs would reach over US $1.12 billion (95% CI: US $ 1.05–1.19 billion) without additional government interventions.Total health expenditures for CVDs in Shanghai are estimated to be higher in the future. These results should be a valuable future resource for both researchers on the economic effects of CVDs and for policy makers.

Medical care expenditures associated with chronic kidney disease in adults with diabetes: United States 2011

ObjectiveApproximately 1 in 3 adults with diabetes have CKD. However, there are no recent national estimates of the association of CKD with medical care expenditures in individuals with diabetes. Our aim is to assess the association of CKD with total medical expenditures in US adults with diabetes using a national sample and novel cost estimation methodology. Research design and methodsData on 2,053 adults with diabetes in the 2011 Medical Expenditure Panel Survey (MEPS) was analyzed. Individuals with CKD were identified based on self-report. Adjusted mean health services expenditures per person in 2011 were estimated using a two-part model after adjusting for demographic and clinical covariates. ResultsOf the 2,053 individuals with diabetes, approximately 9.7% had self-reported CKD. Unadjusted mean expenditures for individuals with CKD were $20,726 relative to $9,689.49 for no CKD. Adjusted mean expenditures from the 2-part model for individuals with CKD were $8473 higher relative to individuals without CKD. Additional significant covariates were Hispanic/other race, uninsured, urban dwellers, CVD, stroke, high cholesterol, arthritis, and asthma. The estimated unadjusted total expenditures for individuals with CKD were estimated to be in excess of $43 billion in 2011. ConclusionsWe showed that CKD is a significant contributor to the financial burden among individuals with diabetes, and that minorities and the uninsured with CKD may experience barriers in access to care. Our study also provides a baseline national estimate of CKD cost in Diabetes by which future studies can be used for comparison.

Health care utilization and expenditures of persons with diabetes comorbid with anxiety disorder: a national population-based cohort study

ObjectiveThe aim of this study was to investigate and compare health care utilization and expenditures between persons with diabetes comorbid with and without anxiety disorder in Taiwan. MethodsHealth care utilization and expenditures among persons with diabetes with and without comorbid anxiety disorder in the period 2000–2004 were examined using the Taiwan's National Health Insurance claims data. Health care utilization included outpatient visits and use of hospital inpatient services, while expenditures included outpatient, inpatient and total medical expenditures. General estimation equation (GEE) models were used to analyze the factors associated with outpatient visits and expenditures, and multiple logistic regression analysis was applied to identify factors associated with hospitalization. ResultsIn the study period, the average number of annual outpatient visits was 43.11–50.37 and 29.82–31.42 for persons with diabetes comorbid with anxiety disorder and for those without anxiety disorder, respectively. The average annual total expenditure was NT$74,875–92,781 and NT$63,764–81,667, respectively. Controlling for covariates, the GEE models revealed that age and time were associated with outpatient visits. Income and time factor were associated with total expenditure. ConclusionsHealth care utilization and expenditures for persons with diabetes with comorbid anxiety disorder are significantly higher than those without anxiety disorder. The factors associated with health care utilization and expenditures are age, income and time.

Evaluation of different revascularization strategies for patients with acute myocardial infarction with lesions of multiple coronary arteries after primary percutaneous coronary intervention and its economic evaluation

To investigate the effect and medical cost of different revascularization strategies for acute myocardial infarction (AMI) patients with multi-vessel disease (MVD). A prospective randomized controlled trial (RCT) was conducted. From January 2009 to June 2012, patients with AMI and MVD undergoing primary percutaneous coronary intervention (PCI) were enrolled. They were randomly assigned to group A [staged PCI for non-infarction related artery (non-IRA) within 7-10 days after AMI] and group B (subsequent PCI for non-IRA recommended only for those with evidence of ischemia). All of patients were given optimized medical therapy according to clinical guideline, and they were followed up for 24 months at regular intervals. Major adverse cardiovascular events (MACE) including recurrence of myocardial infarction and death due to cardiac ailments were recorded. Meanwhile, re-hospitalization from cardiac causes, recurrence of angina, heart failure, and re-PCI, number of stents, total hospital stay days, and total medical expenditure were recorded. A total of 428 patients accomplished the 24-month follow up. All the patients underwent PCI for non-IRA in group A (215 patients), while 62 patients in group B (213 patients) undergone PCI for myocardial ischemia, and 51 patients received non-IRA treatment. There was no significant difference in MACE incidence between group A and group B [8.4% (18/215) vs. 10.8% (23/213), χ² = 0.727, P = 0.394]. The difference of death rate due to cardiac causes (5.1% vs. 6.6%), recurrence of myocardial infarction (4.2% vs. 6.6%), and heart failure (4.2% vs. 7.0%) were not significantly different between groups A and B (all P > 0.05). The rate of recurrence of angina (14.4 % vs. 32.9%), re-hospitalization from cardiac causes (14.4% vs. 33.8%), and re-treatment of implanting stents (12.6% vs. 29.1%) were significantly lower in group A than group B (all P < 0.01), and the rate of revascularization was significantly higher in group A than group B (10.7% vs. 5.2%, P < 0.05). The total number of stents (610 vs. 366), mean number of stents per patient (2.83 ± 0.91 vs. 1.72 ± 0.91, t = 12.725, P = 0.000), and total cost per patient (kRMB: 63.7 ± 12.6 vs. 51.5 ± 1 2.3, t = 10.107, P = 0.000) in group A were significantly higher than those in group B. Total hospital stay days in group A was significantly less than group B (days: 8.21 ± 2.45 vs. 9.89 ± .23, t = 6.071, P = 0.000). Because non-IRA-vascular reconstruction rate was low in group B, the rate of using β-blocker and anti-anginal agents during the 24-month follow up in group B was significantly higher than group A [59.2% (126/213) vs. 47.0% (101/215), χ² = 6.371, P = 0.012; 56.3% (112/213) vs. 17.6% (36/215), χ² = 64.704, P = 0.000]. In patients with AMI and MVD undergone emergency PCI, staged PCI within 7-10 days for non-IRA cannot decrease the incidence of myocardial infarction and death due to cardiac causes, recurrence of angina and rehospitalization for cardiac causes was diminished, and it may increase the number of stents and medical cost significantly.

Diabetes and medical expenditures among non-institutionalized U.S. adults

AimsThis research presents a comprehensive picture of medical spending associated with diabetes in the United States, accounting for important population characteristics. MethodsThe Household Component (HC) of the 2010 Medical Expenditure Panel Survey (MEPS) was used for this study. Regression analysis was used to compare medical spending between individuals with and without diabetes. The dependent variables of interest were total and out-of-pocket expenditures related to medical care, hospital use, physician office visits, and prescription drug use. ResultsThis study reveals that individuals with diabetes experience significantly greater medical, hospital, physician office, and prescription drug expenditures compared to those without diabetes. Even after controlling for predisposing, enabling, and need factors, adults with diabetes spent $1843 more on total medical expenditures and $353 more on out-of-pocket medical expenditures than those without diabetes. Significant disparities were found in total and out-of-pocket expenditures by age, gender, education, race/ethnicity, and insurance status. ConclusionsComprehensive interventions that focus on education and prevention should target individuals and communities at high-risk for diabetes and its complications. Our findings suggest that programs should focus on older Americans and those with poor health and mental health status.

Corruption in the Health Sector: Evidence from Unofficial Consultation Fees in Bangladesh

We study the incidence and extent of bribes paid to the doctors in the public health facilities which are cleverly identified using a nationally representative survey. The survey asks households about the fees paid to public doctors, not about the bribe, which makes it less prone to reporting bias. We find that though consultations are free in the public health facilities, 41% of the patients who visited them paid about US$2 as a consultation fee, which is about 16% of their total medical expenditure. Three interesting generalized results that we find on the determinants of incidence and extent of bribe payment are: First, bribe givers and non-givers are different in terms of observed characteristics. Second, the same doctors, when sit in a private facility, charge more, setting an upper limit of bribes at public facilities. Third, travel time of the service seekers is used as a price discriminating device by the public service providers. Results have important implications for combating corruption, especially in developing countries.