A structural microsimulation model for demand-side cost-sharing in healthcare

From Oral to Subcutaneous Furosemide: The Road to Novel Opportunities to Manage Congestion

Background: Smoking, unhealthy alcohol consumption, poor diet and physical inactivity are leading risk factors for morbidity and mortality, and contribute substantially to overall healthcare costs. The availability of health surveys linked to health care provides population-based estimates of direct healthcare costs. We estimated health behaviour and socioeconomic-attribute healthcare costs, and how these have changed during a period when government policies have aimed to reduce their burden. Methods: The Ontario samples of the Canadian Community Health Surveys (conducted in 2003, 2005, and 2007-2008) were linked at the individual level to all records of health care use of publicly funded healthcare. Generalized linear models were estimated with a negative binomial distribution to ascertain the relationship of health behaviours and socioeconomic risk factors on health care costs. The multivariable cost model was applied to unlinked, Ontario CCHS samples for each year from 2004 to 2013 to examine the evolution of health behaviour and socioeconomic-attributable direct health care expenditures over a 10-year period. Results: We included 80,749 respondents, aged 25 years and older, and 312,952 person-years of follow-up. The cost model was applied to 200,324 respondents aged 25 years and older (CCHS 2004 to 2013). During the 10-year period from 2004 to 2013, smoking, unhealthy alcohol consumption, poor diet and physical inactivity attributed to 22% of Ontario's direct health care costs. Ontarians in the most disadvantaged socioeconomic position contributed to 15% of the province's direct health care costs. Combined, these health behaviour and socioeconomic risk factors were associated with 34% ($134 billion) of direct health care costs (2004 to 2013). Over this time period, we estimated a 1.9% reduction in health care expenditure ($5.0 billion) attributable to improvements in some health behaviours, most importantly reduced rates of smoking. Conclusions: Adverse health behaviours and socioeconomic position cause a large direct health care system cost burden.

To assess the impact of a collaborative cardiovascular risk reduction service (Collaborative Cardiac Care Service [CCCS]) on total health care expenditures after an incident acute coronary event. Matched, retrospective cohort study. Kaiser Permanente Colorado (KPCO) databases. Patients who had an incident coronary event between January 1999 and June 2004 and were either enrolled (CCCS group) or never enrolled in the CCCS (No CCCS group). Patients in the CCCS group (628 patients) were matched in a 1:1 ratio to patients in the No CCCS group (628 patients) by Chronic Disease Score (CDS) and total health care expenditures in the 180 days before the index coronary event (baseline). Drug purchases and medical utilization encounters were extracted from the KPCO administrative and claims databases after the incident coronary event until death, KPCO plan termination, 3 years later, or December 31, 2005, whichever came first (follow-up). Expenditure estimates from the plan's decision support system (in 2007 U.S. dollars) were applied to each utilization encounter. A $1/follow-up day cost was applied to all patients in the CCCS group. Expenditures/follow-up day were modeled with adjustment for matching variables, patient characteristics, baseline expenditures, and intracorrelations of matched patients. Patients in the No CCCS group were slightly older and were more likely to be female and have had a myocardial infarction as their incident event compared with those in the CCCS group. During follow-up, there were 12 and 98 cardiac-related deaths and 16 and 188 all-cause deaths for the CCCS and No CCCS groups, respectively; mean and median total health care expenditures/day were $39 and $20, respectively, for the CCCS group, and $108 and $45, respectively, for the No CCCS group (all p<0.001). After adjustment, total health care expenditures for patients in the CCCS group were approximately $60/day ($21,900/yr) lower than those for patients in the No CCCS group (p<0.001; adjusted R(2)=0.29 with log-transformed expenditures). The comprehensive and aggressive implementation of secondary cardiac prevention strategies and close monitoring and follow-up of patients with coronary artery disease provided by the CCCS were associated with reduced health care expenditures.

To determine the effectiveness of the University of Minnesota's worksite health promotion program in reducing health care expenditures during the first 2 years of the program; to investigate the program's effect on absenteeism; and to study the effect of specific disease- or lifestyle-management programs on both health care expenditures and absenteeism. Health care expenditures and absenteeism of program participants were compared with those who were eligible but did not participate. Differences-in-differences regression equations with random effects were used to account for selection. Participation in the general disease management program over 2 years was associated with significant reductions in expenditures, as was participation in programs for certain specific diseases. No consistently significant absenteeism or lifestyle management effects were found. : Although the program significantly reduced expenditures, it did not generate a positive return on investment.

The efficient planning and programming of human resources has a number of benefits for the organization, such as improved workforce management policies. Indeed, maintaining a healthy population has a positive impact on the productivity and competiveness of a country but it very much depends on the sustainability of the health care system and hence on the efficiency and effectiveness of its health care units. Health workforce planning and programming is a challenge for health care decisions makers as they aim to satisfy the needs of the system and secure a sufficiently sizeable health care workforce (medical doctors and nurses) in every geographical area and type of hospital. In the last five years, due to the severe economic crisis, the public health care sector in Greece has experienced a number of negative implications such as a freeze on the recruitment of health care employees, workforce imbalances, a reduction in health care expenditures and the merging of health care units. Based on the above, this study investigates the level of satisfaction of the health care workforce regarding human resource planning and programming in Greek health care units. Moreover, this study examines whether or not the personal characteristics (such as age, etc.) of medical doctors and nurses have any impact on their attitude. Based on the findings, recommendations are made to policy makers for possible improvements to the system.

Health care in the United States is among the most technologically advanced in the world, but it is largely failing to meet the needs of the nation. The US can claim international excellence in important areas of care, such as cancer treatment, and it leads the world in biomedical innovation and building a well-prepared and dedicated clinical workforce. The Affordable Care Act was a major step forward in expanding access to health care in the US. However, Americans are faced with staggering health costs, inadequate access to care, pervasive health inequities, and lagging life expectancy compared with other developed nations. In this article, part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2025 initiative, we present a partial road map for transforming the US health care system. We propose bold national goals: affordable and equitable care for all, an additional decade of healthy birthdays after retirement, elimination of racial and ethnic disparities in health, substantial reduction in health care expenditures, and, most important, improved health outcomes. To achieve these goals, we recommend changes to ensure coverage for all, invest in primary care and social determinants of health, create financing to incentivize population health, and improve transparency and accountability. Major systemic transformation of the US health care system is not just required; it is a moral and economic imperative.

Cirrhosis is the most important risk factor for hepatocellular carcinoma (HCC) regardless of the etiology of cirrhosis. Compared to individuals who are anti-hepatitis C virus (HCV) seronegative, anti-HCV seropositive individuals have a greater mortality from both hepatic as well as nonhepatic disease processes. The aim of this paper is do describe the burden of HCV infection and consider treatment strategies to reduce HCV-related morbidity and mortality. The newly developed direct acting antiviral (DAA) therapies are associated with greater rates of drug compliance, fewer adverse effects, and appear not to be limited by the presence of a variety of factors that adversely affect the outcome of interferon-based therapies. Because of the cost of the current DAA, their use has been severely rationed by insurers as well as state and federal agencies to those with advanced fibrotic liver disease (Metavir fibrosis stage F3-F4). The rationale for such rationing is that many of those recognized as having the disease progress slowly over many years and will not develop advanced liver disease manifested as chronic hepatitis C, cirrhosis, and experience any of the multiple complications of liver disease to include HCC. This mitigation has a short sided view of the cost of treatment of hepatitis C related disease processes and ignores the long-term expenses of hepatitis C treatment consisting of the cost of treatment of hepatitis C, the management of cirrhosis with or without decompensation as well as the cost of treatment of HCC and liver transplantation. We believe that treatment should include all HCV infected patients including those with stage F0-F2 fibrosis with or without evidence of coexisting liver disease. Specifically, interferon (IFN)-free regimens with the current effective DAAs without liver staging requirements and including those without evidence of hepatic diseases but having recognized extrahepatic manifestations of HCV infection is projected to be the most cost-effective approach for treating HCV in all of its varied presentations. Early rather than later therapy of HCV infected individuals would be even more efficacious than waiting particularly if it includes all cases from F0-F4 hepatic disease. Timely therapy will reduce the number of individuals developing advanced liver disease, reduce the cost of treating these cases and more importantly, reduce the lifetime cost of treatment of those with any form of HCV related disease as well as HCV associated all - cause mortality. Importantly, HCV treatment regimens without any restrictions would result in a substantial reduction in health care expenditure and simultaneously reduce the number of infected individuals who are infecting others.

The impact of consumer-driven health plans (CDHPs) on utilization and expenditures for members with chronic diseases. Analyzed claims data from a national employer who switched from a preferred provider organization (PPO) plan to offering only CDHPs in 2005. A matched comparison group of PPO members was used. Analysis was conducted using generalized estimating equations for repeated measures. Compared with the PPO group, the CDHP group had lower: outpatient visits (-36% vs -22%), laboratory services (-34.3% vs -19%), emergency room (odds ratio [OR]: 0.1 vs 0.6), and inpatient visits (OR: 0.35 vs 0.68), and medication adherence (OR: 0.7 vs 1.0). Reductions in health care expenditures were not statistically different between the groups (-28% vs -15%, P = 0.5). Switching to a CDHP resulted in lower utilization and adherence. Potential underutilization of necessary services should be addressed in future research.

Hospice care ensures better end-of-life quality by relieving terminal symptoms. Prior research has indicated that hospice care could prolong survival and reduce end-of-life medical expenditures among patients with cancer. However, the dearth of studies on the effects of hospice care type and use sequence on survival time and end-of-life medical expenditures substantiates the need for investigation. Two million random records were obtained from the National Health Insurance Research Database. We estimated the effects of the type and sequence of hospice care use on survival time and medical expenditures among advanced cancer patients. This was a cross-sectional study. Patient data were collected from 2 million random records provided by the National Health Insurance Research Database of Taiwan. We included people with cancer and excluded patients under 20years of age; 2860 patients remained after matching. The results indicated that the average survival time of patients who received inpatient palliative care (1022days) was significantly shorter than that of patients who did not receive palliative care (P < 0.001), but the health care expenditure during the entire course of cancer therapy was not the lowest. Interestingly, patients who received inpatient palliative care had the lowest health care expenditure at 1year or month before the end of life (P < 0.001). The type and sequence of palliative care affected the survival time and health care expenditures of cancer patients. Receiving palliative care did not prolong survival but rather reduced health care expenditures. The sequence of receiving palliative care significantly affected health care expenditures.

Depression is associated with high healthcare expenditures, and depression treatment may reduce healthcare expenditures. However, to date, there have not been any studies on the effect of depression treatment on healthcare expenditures among cancer survivors. Therefore, this study examined the association between depression treatment and healthcare expenditures among elderly with depression and incident cancer. The current study used a retrospective longitudinal study design, the linked Surveillance, Epidemiology, and End Results-Medicare database. Elderly (≥66years) fee-for-service Medicare beneficiaries with newly diagnosed depression and incident breast, colorectal, or prostate cancer (N=1502) were followed for a period of 12months after depression diagnosis. Healthcare expenditures were measured every month for a period of 12-month follow-up period. Depression treatment was identified during the 6-month follow-up period. The adjusted associations between depression treatment and healthcare expenditures were analyzed with generalized linear mixed model regressions with gamma distribution and log link after controlling for other factors. The average 1-year total healthcare expenditures after depression diagnosis were $38219 for those who did not receive depression treatment; $42090 for those treated with antidepressants only; $46913 for those treated with psychotherapy only; and $51008 for those treated with a combination of antidepressants and psychotherapy. As compared to no depression treatment, those who received antidepressants only, psychotherapy only, or a combination of antidepressants and psychotherapy had higher healthcare expenditures. However, second-year expenditures did not significantly differ among depression treatment categories. Among cancer survivors with newly diagnosed depression, depression treatment did not have a significant effect on expenditures in the long term.

To determine whether bariatric surgery is associated with reduced health care expenditures in a multisite cohort of predominantly older male patients with a substantial disease burden. Retrospective cohort study of bariatric surgery. Outpatient, inpatient, and overall health care expenditures within Department of Veterans Affairs (VA) medical centers were examined via generalized estimating equations in the propensity-matched cohorts. Bariatric surgery programs in VA medical centers. Eight hundred forty-seven veterans who were propensity matched to 847 nonsurgical control subjects from the same 12 VA medical centers. Bariatric surgical procedures. Health expenditures through December 2006. Outpatient, inpatient, and total expenditures trended higher for bariatric surgical cases in the 3 years leading up to the procedure and then converged back to the lower expenditure levels of nonsurgical controls in the 3 years after the procedure. Based on analyses of a cohort of predominantly older men, bariatric surgery does not appear to be associated with reduced health care expenditures 3 years after the procedure.

Nudging (i.e. behavioural change programmes involving subtle environmental modifications (nudges) aimed at influencing lifestyle choices and behaviour) has been advocated as an efficient and cost-effective way to achieve public health objectives. Research shows that well-calibrated nudges can result in healthier dietary and nutritional choices, higher vaccination compliance, reduction in health-care expenditures, and other positive public health outcomes. In spite of these findings, nudging has been criticized for its possible impact on fundamental ethical notions such as personal autonomy and freedom of choice. This stems from the fact that nudging, unlike other public health strategies for lifestyle modification such as education and financial inducements, is characterized by a higher reliance on non-rational influence. With the advent of digital technology and online spaces, nudges are being increasingly administered in digital format. These ‘digital nudges’ include influencing lifestyle habits via wearable devices, predetermining choices via predictive analytics, segmenting user groups by psychometric variables, hijacking human attention through addictive user interfaces, and enabling surveillance and behavioural compliance via ubiquitous computing. While the ethics of analogue nudging has been largely debated in public health ethics, the ethical implications of non-rational behavioural change via digital technology have often eluded scrutiny. This chapter explores the ethical boundaries of digital nudging. It discusses the core features of digital nudges and their impact on the principle of autonomy and reviews emerging normative accounts of autonomy that may enable a greater degree of normative protection from non-rational influence via digital technology, namely, freedom of thought, mental integrity, and cognitive liberty.

Diabetes mellitus imposes significant costs both on individuals and on healthcare delivery systems. Chronic diseases such as diabetes mellitus have lifetime costs, and so resources spent on interventions now may not bring benefits, in terms of reduced complications, for many years. In Europe, the St Vincent Declaration, which includes targets for the reduction of diabetes mellitus-related complications, is an important initiative set up to address quality and education issues relevant to people with diabetes mellitus. The Declaration is to be welcomed as focusing attention on diabetes mellitus, and its implementation may lead to a reduction in healthcare expenditure on complications in future years. The aims of the St Vincent Declaration are to set goals and 5-year targets to improve quality of life and life expectancy for people with diabetes mellitus and to reduce the serious complications associated with the disease. Achievement of these targets will depend on good organisation and management of services to people with diabetes mellitus, but the aims are a clear signal that the importance of prevention and education have been recognised. A major barrier to the implementation of the Declaration is financial. If more people are diagnosed and treated, more services will be required. This will incur costs, although future benefits will be gained in terms of a reduction in complications.

This study evaluates the impact of the Affordable Care Act (ACA) preexisting conditions provision on mental health. The 2014 policy ensured individuals with preexisting health conditions the right to obtain insurance coverage. Using longitudinal data from the Panel Study of Income Dynamics between 2007 and 2017 and estimating difference-in-differences models, our study provides evidence that the policy reduced severe mental distress by 1.44 percentage points (baseline mean: 8.09%) among individuals with preexisting physical health conditions. Exploiting pre-ACA, state-level variation in policies providing insurance coverage options to people with preexisting conditions, we find that this improvement in mental well-being is highly associated with the presence of high-risk pools before 2014, which provided individuals with prior health conditions access to coverage. Specifically, we show that our main results are driven by individuals with preexisting health conditions living in the 16 states that did not have high-risk pools. Furthermore, gender-specific analysis shows that the reduction in mental distress is primarily observable among women. When examining potential mechanisms, our analysis provides evidence that increases in insurance coverage, reductions in healthcare expenditures, and improvements in physical health can explain the positive effects of the provision on mental well-being.

Long-term care needs have grown with population aging. This study explores the relationships among health status, healthcare expenditure, and long-term care insurance (LTCI) among the older adults. Using data from the China Health and Retirement Longitudinal Study (CHARLS 2011, 2013, 2015, 2018, and 2020) and based on the demand model for healthcare services, this study employed the difference-in-difference (DID) method to assess how the implementation of LTCI contributed to the health status and healthcare expenditures of the older adults. The propensity score matching DID method (PSM-DID) and other tests were used to conduct further robustness checks. The findings demonstrate a significant positive impact of LTCI on improving the health status and reducing healthcare expenditures in the elderly population. The PSM-DID indicates that LTCI can effectively improve the health status of the elderly population and reduce their healthcare spending. Based on the findings, the development of relevant policy frameworks for LTCI in China is recommended. These include consider the differences among the various pilot cities and social strata to allow policy adjustments and improvements in a timely, establish a dynamic and diversified long-term care insurance financing mechanism, encourage collaboration between medical institutions and elder care facilities, establish effective contact between LTCI and medical institutions, and use incentive policies such as tax relief to provide financial support and subsidies.