Economic grand rounds: The myth of medical cost offset

Hospitalizations Among Children and Youth With Autism in the United States: Frequency, Characteristics, and Costs

National estimates of hospitalization diagnoses and costs were determined using the 2016 HCUP Kids' Inpatient Database. Children and youth with autism were hospitalized over 45,000 times at over $560 million in costs and 260,000 inpatient days. The most frequent principal diagnoses for hospitalizations of children and youth with autism were epilepsy, mental health conditions, pneumonia, asthma, and gastrointestinal disorders, which resulted in almost $200 million in costs and 150,000 inpatient days. Mental health diagnoses accounted for 24.8% of hospitalizations, an estimated $82 million in costs, and approximately 94,000 inpatient days. Children and youth with autism were more likely hospitalized for epilepsy, mental health diagnoses, and gastrointestinal disorders, and less likely for pneumonia and asthma compared to other children and youth.

Cost-effectiveness of the Self-Help Plus Intervention for Adult Syrian Refugees Hosted in Turkey

Importance

The cost-effectiveness of the Self-Help Plus (SH+) program, a group-based, guided, self-help psychological intervention developed by the World Health Organization for people affected by adversity, is unclear.

Objective

To investigate the cost-utility of providing the SH+ intervention combined with enhanced usual care vs enhanced usual care alone for Syrian refugees or asylum seekers hosted in Turkey.

Design, Setting, and Participants

This economic evaluation was performed as a prespecified part of an assessor-blinded randomized clinical trial conducted between October 1, 2018, and November 30, 2019, with 6-month follow-up. A total of 627 adults with psychological distress but no diagnosed psychiatric disorder were randomly assigned to the intervention group or the enhanced usual care group.

Interventions

The SH+ program was a 5-session (2 hours each), group-based, stress management course in which participants learned self-help skills for managing stress by listening to audio sessions. The SH+ sessions were facilitated by briefly trained, nonspecialist individuals, and an illustrated book was provided to group members. Th intervention group received the SH+ intervention plus enhanced usual care; the control group received only enhanced usual care from the local health care system. Enhanced usual care included access to free health care services provided by primary and secondary institutions plus details on nongovernmental organizations and freely available mental health services, social services, and community networks for people under temporary protection of Turkey and refugees.

Main Outcomes and Measures

The primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the Turkish health care system. An intention-to-treat analysis was used including all participants who were randomized and for whom baseline data on costs and QALYs were available. Data were analyzed September 30, 2020, to July 30, 2021.

Results

Of 627 participants (mean [SD] age, 31.3 [9.0] years; 393 [62.9%] women), 313 were included in the analysis for the SH+ group and 314 in the analysis for the enhanced usual care group. An incremental cost-utility ratio estimate of T£6068 ($1147) per QALY gained was found when the SH+ intervention was provided to groups of 10 Syrian refugees. At a willingness to pay per QALY gained of T£14 831 ($2802), the SH+ intervention had a 97.5% chance of being cost-effective compared with enhanced usual care alone.

Conclusions and Relevance

This economic evaluation suggests that implementation of the SH+ intervention compared with enhanced usual care alone for adult Syrian refugees or asylum seekers hosted in Turkey is cost-effective from the perspective of the Turkish health care system when both international and country-specific willingness-to-pay thresholds were applied.

Cost Analysis of Integrated Behavioral Health in a Large Primary Care Practice

A residency-based Family Medicine outpatient clinic chose to implement an integrated behavioral health care program in a large primary care clinic in the Southeast to improve patient access to behavioral health care. We hypothesized that embedding a BHP in a primary care setting would be a cost neutral intervention. We implemented a prospective cohort design and included expenses from both inpatient and outpatient visits. We implemented a mixed effects linear regression model to evaluate pre- and post-BHP exposure costs. A total of 1256 patients were identified in the post-BHP exposure period that had more than one-year post-exposure. After applying exclusion criteria, there were 926 patients included in analysis. These patient had an average total cost during the one-year pre-BHP exposure period of $5113 (SD = 7712) and one-year post-BHP exposure period of $5462 (SD = 7813). Our analysis shows a relatively cost neutral impact following the introduction of BHPs in a primary care setting. The results of this study provide a gauge for future planning of services.

Cost-Effectiveness of Collaborative Care for Depression in HIV Clinics

OBJECTIVE

To examine the cost-effectiveness of the HIV Translating Initiatives for Depression Into Effective Solutions (HITIDES) intervention.

DESIGN

Randomized controlled effectiveness and implementation trial comparing depression collaborative care with enhanced usual care.

SETTING

Three Veterans Health Administration HIV clinics in the Southern United States.

SUBJECTS

Two hundred forty-nine HIV-infected patients completed the baseline interview; 123 were randomized to the intervention and 126 to usual care.

INTERVENTION

HITIDES consisted of an offsite HIV depression care team that delivered up to 12 months of collaborative care. The intervention used a stepped-care model for depression treatment, and specific recommendations were based on the Texas Medication Algorithm Project and the VA/Department of Defense Depression Treatment Guidelines.

MAIN OUTCOME MEASURES

Quality-adjusted life years (QALYs) were calculated using the 12-Item Short Form Health Survey, the Quality of Well Being Scale, and by converting depression-free days to QALYs. The base case analysis used outpatient, pharmacy, patient, and intervention costs. Cost-effectiveness was calculated using incremental cost-effectiveness ratios (ICERs) and net health benefit. ICER distributions were generated using nonparametric bootstrap with replacement sampling.

RESULTS

The HITIDES intervention was more effective and cost saving compared with usual care in 78% of bootstrapped samples. The intervention net health benefit was positive and therefore deemed cost-effective using an ICER threshold of $50,000/QALY.

CONCLUSIONS

In HIV clinic settings, this intervention was more effective and cost saving compared with usual care. Implementation of offsite depression collaborative care programs in specialty care settings may be a strategy that not only improves outcomes for patients but also maximizes the efficient use of limited health care resources.

The interplay of outpatient services and psychiatric hospitalization among Medicaid-enrolled children with autism spectrum disorders

OBJECTIVE

To examine whether increased provision of community-based services is associated with decreased psychiatric hospitalizations among children with autism spectrum disorders (ASDs).

DESIGN

Retrospective cohort study using discrete-time logistic regression to examine the association of service use in the preceding 60 days with the risk of hospitalization.

SETTING

The Medicaid-reimbursed health care system in the continental United States.

PARTICIPANTS

Medicaid-enrolled children with an ASD diagnosis in 2004 (N = 28 428).

MAIN EXPOSURES

Use of respite care and therapeutic services, based on procedure codes.

MAIN OUTCOME MEASURES

Hospitalizations associated with a diagnosis of ASD (International Classification of Diseases, 10th Revision, codes 299.0, 299.8, and 299.9).

RESULTS

Each $1000 increase in spending on respite care during the preceding 60 days resulted in an 8% decrease in the odds of hospitalization in adjusted analysis. Use of therapeutic services was not associated with reduced risk of hospitalization.

CONCLUSIONS

Respite care is not universally available through Medicaid. It may represent a critical type of service for supporting families in addressing challenging child behaviors. States should increase the availability of respite care for Medicaid-enrolled children with ASDs. The lack of association between therapeutic services and hospitalization raises concerns regarding the effectiveness of these services.

Medical utilization among wellness consumers

This study investigates conventional medicine utilization by wellness-motivated, complementary and alternative medicine (CAM) consumers. While CAM consumers are typically characterized as high health care utilizers, negative correlations have been found between CAM-based wellness programs and the consumption of conventional medical care. We use a nationally representative sample to analyze both illness- and wellness-motivated CAM users, with an interest in whether CAM therapies used for wellness replace conventional medicine, thus potentially offering cost offsets. Results indicate that motivation for CAM use is neither associated with a lower probability nor a lower rate of conventional medicine utilization. Increasingly, individuals, workplaces, and governments incorporate wellness programs involving CAM modalities into health care and policy; as the conventional and unconventional medical spheres begin to integrate and influence one another, understanding our pluralistic medical environment and its consumers will better enable policy makers to balance health and wellness initiatives with economic imperatives.

Medicare mental health parity: a high potential change that is long overdue

Recent changes in legislation regarding mental health parity in Medicare will revolutionize payment for mental health care and delivery systems. This commentary discusses why this policy change was essential to promote adequate care for populations served by Medicare and to address expected changes in beneficiary, provider, and plan behavior as more equitable payments by Medicare are implemented.

Helping smokers quit: understanding the barriers to utilization of smoking cessation services

CONTEXT

Counseling smokers to quit smoking and providing them with pharmaceutical cessation aides are among the most beneficial and cost-effective interventions that clinicians can offer patients. Yet assistance with quitting is not universally covered by health plans or offered by all clinicians. Analysis of stakeholders' perspectives and interests can identify the barriers to more widespread provision of cessation services and suggest strategies for the public policy agenda to advance smoking cessation.

METHODS

Review of literature and discussions with representatives of stakeholders.

FINDINGS

All stakeholders-health plans, employers, clinicians, smokers, and the government-face barriers to broader smoking cessation activities. These range from health plans' perceiving that covering counseling and pharmacotherapy will increase costs without producing commensurate health care savings, to clinicians' feeling unprepared and uncompensated for counseling. Like other preventive measures aimed at behavior, efforts directed at smoking cessation have marginal status among health care interventions. State governments can help correct this status by increasing Medicaid coverage of treatment and expanding coverage for state employees. The federal government can promote the adoption of six initiatives recommended by a government subcommittee on cessation: set up a national quit line, develop a media campaign to encourage cessation, include cessation benefits in all federally funded insurance plans, create a research infrastructure to improve cessation rates, develop a clinician training agenda, and create a fund to increase cessation activities through a new $2 per pack cigarette excise tax. Both the federal and state governments can increase cessation by adopting policies such as the higher cigarette tax and laws prohibiting smoking in workplaces and public places.

CONCLUSIONS

Public policy efforts should assume greater social responsibility for smoking cessation, including more aggressive leadership at the state and federal levels, as well as through advocacy, public health, and clinician organizations.

Making the business case for enhanced depression care: the National Institute of Mental Health-harvard Work Outcomes Research and Cost-effectiveness Study

OBJECTIVE

Explore the business case for enhanced depression care and establish a return on investment rationale for increased organizational involvement by employer-purchasers.

METHOD

Literature review, focused on the National Institute of Mental Health-sponsored Work Outcomes Research and Cost-effectiveness Study.

RESULTS

This randomized controlled trial compared telephone outreach, care management, and optional psychotherapy to usual care among depressed workers in large national corporations. By 12 months, the intervention significantly improved depression outcomes, work retention, and hours worked among the employed.

CONCLUSION

Results of the Work Outcomes Research and Cost-effectiveness Study trial and other studies suggest that enhanced depression care programs represent a human capital investment opportunity for employers.

Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: a randomized controlled trial

CONTEXT

Although guideline-concordant depression treatment is clearly effective, treatment often falls short of evidence-based recommendations. Organized depression care programs significantly improve treatment quality, but employer purchasers have been slow to adopt these programs based on lack of evidence for cost-effectiveness from their perspective.

OBJECTIVE

To evaluate the effects of a depression outreach-treatment program on workplace outcomes, a concern to employers.

DESIGN, SETTING, AND PARTICIPANTS

A randomized controlled trial involving 604 employees covered by a managed behavioral health plan were identified in a 2-stage screening process as having significant depression. Patient treatment allocation was concealed and assessment of depression severity and work performance at months 6 and 12 was blinded. Employees with lifetime bipolar disorder, substance disorder, recent mental health specialty care, or suicidality were excluded.

INTERVENTION

A telephonic outreach and care management program encouraged workers to enter outpatient treatment (psychotherapy and/or antidepressant medication), monitored treatment quality continuity, and attempted to improve treatment by giving recommendations to providers. Participants reluctant to enter treatment were offered a structured telephone cognitive behavioral psychotherapy.

MAIN OUTCOME MEASURES

Depression severity (Quick Inventory of Depressive Symptomatology, QIDS) and work performance (World Health Organization Health and Productivity Questionnaire [HPQ], a validated self-report instrument assessing job retention, time missed from work, work performance, and critical workplace incidents).

RESULTS

Combining data across 6- and 12-month assessments, the intervention group had significantly lower QIDS self-report scores (relative odds of recovery, 1.4; 95% confidence interval, 1.1-2.0; P = .009), significantly higher job retention (relative odds, 1.7; 95% confidence interval, 1.1-3.3; P = .02), and significantly more hours worked among the intervention (beta=2.0; P=.02; equivalent to an annualized effect of 2 weeks of work) than the usual care groups that were employed.

CONCLUSIONS

A systematic program to identify depression and promote effective treatment significantly improves not only clinical outcomes but also workplace outcomes. The financial value of the latter to employers in terms of recovered hiring, training, and salary costs suggests that many employers would experience a positive return on investment from outreach and enhanced treatment of depressed workers.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00057590.

Family history of mental illness and frequent mental distress in community clinic patients

OBJECTIVE

The objective of this study was to investigate the importance of family history of mental illness as a risk factor for self-reported frequent mental distress among patients who use community-based clinics.

DESIGN

A cross-sectional survey was distributed to a convenience sample in three community clinics serving largely low-income patients. Forms were completed by 793 clinic patients. Multiple logistic regression analysis was to control for the effects of demographic variables.

RESULTS

In this sample of primary care patients, 27.1% had frequent mental distress. Having a family history of mental illness or substance abuse was found to be associated with frequent mental distress in this population [adjusted odds ratio (OR) = 2.24, P = 0.000]. Also associated with increased odds of frequent mental distress were avoiding medical care owing to cost (OR = 1.86, P = 0.003) and obesity (OR = 1.73, P = 0.006).

CONCLUSIONS

Having a family history of mental illness or substance abuse is independently associated with increased odds of frequent mental distress among primary care patients seen in community clinics. Three strategies are suggested for using this information to prevent frequent mental distress: health education via mass communication to the general population of primary care patients being followed in a clinic, health education to at-risk patients, and targeted screening of clinic patients who have the risk factor.

Reducing the societal burden of depression: a review of economic costs, quality of care and effects of treatment

Depression is a highly prevalent condition that results in substantial functional impairment. Advocates have attempted in recent years to make the 'business case' for investing in quality improvement efforts in depression care, particularly in primary care settings. The business case suggests that the costs of depression treatment may be offset by gains in worker productivity and/or reductions in other healthcare spending. In this paper, we review the evidence in support of this argument for improving the quality of depression treatment. We examined the impact of depression on two of the primary drivers of the societal burden of depression: healthcare utilisation and worker productivity. Depression leads to higher healthcare utilisation and spending, most of which is not the result of depression treatment costs. Depression is also a leading cause of absenteeism and reduced productivity at work. It is clear that the economic burden of depression is substantial; however, critical gaps in the literature remain and need to be addressed. For instance, we do not know the economic burden of untreated and/or inappropriately treated versus appropriately treated depression. There remain considerable problems with access to and quality of depression treatment. Progress has been made in terms of access to care, but quality of care is seldom consistent with national treatment guidelines. A wide range of effective treatments and care programmes for depression are available, yet rigorously tested clinical models to improve depression care have not been widely adopted by healthcare systems. Barriers to improving depression care exist at the patient, healthcare provider, practice, plan and purchaser levels, and may be both economic and non-economic. Studies evaluating interventions to improve the quality of depression treatment have found that the cost per QALY associated with improved depression care ranges from a low of 2519 US dollars to a high of 49,500 US dollars. We conclude from our review of the literature that effective treatment of depression is cost effective, but that evidence of a medical or productivity cost offset for depression treatment remains equivocal, and this points to the need for further research in this area.

Medical cost-offset following treatment referral for alcohol and other drug use disorders in a group model HMO

The purpose of this study was to determine whether specialty alcohol and other drug (AOD) treatment is associated with reduced subsequent medical care costs. AOD treatment costs and medical costs in a group model health maintenance organization (HMO) were collected for up to 6 years on 1,472 HMO members who were recommended for specialty AOD treatment, and on 738 members without AOD diagnoses or treatment. Addiction Severity Index measures were also obtained from a sample of 293 of those recommended for treatment. Changes in medical costs did not differ between treatment and comparison groups. Nor did individuals with improved treatment outcomes have greater reductions in medical costs. AOD treatment costs were not inversely related to subsequent medical costs, except for a subgroup with recent AOD treatment. In the interviewed sample, better treatment outcomes did not predict lower subsequent medical costs. Multiple treatment episodes may hold promise for producing cost-offsets.

Rural residence is not a risk factor for frequent mental distress: a behavioral risk factor surveillance survey

BACKGROUND

Residents of rural areas may be at increased risk of mental health problems. If so, public health programs aimed at preventing poor mental health may have to be customized for delivery to rural areas. The purpose of this study was to examine the relationship between residing in a rural area and frequent mental distress, which is one indicator of poor mental health.

METHODS

The Behavioral Risk Factor Surveillance System (BRFSS) survey for the state of Texas was the source of information about obesity, demographic characteristics, and frequent mental distress (FMD). FMD was defined as poor self-rated mental health during at least half of the days in the last month. Adjusted odds for FMD were computed for rural and suburban respondents relative to urban respondents.

RESULTS

FMD was found to be independently associated with lower education, being younger, being non-Hispanic, being unmarried, and being female. FMD also was associated with being obese or underweight and suburban residence (relative to metro-central city). FMD was not more common among rural respondents than in the metro-central city.

CONCLUSION

Rural respondents were not at greater risk of frequent mental distress than urban respondents in this sample. Programs seeking to improve community mental health should target persons with less education and extremes in body weight, along with women and single persons, regardless of whether they live in rural or urban areas.

An introduction to economic evaluation: what's in a name?

OBJECTIVE

This paper describes the main types of economic evaluation techniques.

METHOD

To examine the strengths and limitations of different types of economic evaluations, we used a hypothetical example to review the reasoning underlying each method and to illustrate when it is appropriate to use each method.

RESULTS

The choice of economic evaluation method reflects a decision about what should represent "success" and how success should be valued. Measures of benefit and cost must be considered systematically and simultaneously. Claiming that a new treatment is cost-effective requires making a value judgment based on the personal beliefs of the claimant. Even when cost and effect data are objective, a verdict of cost-effective is subjective. The conclusions of an economic study can change significantly, depending on which patient outcome is used to measure success.

CONCLUSIONS

Clinicians must be sure that important patient outcomes are not excluded from economic evaluations. Economic evaluation is a process designed to produce an estimate rather than a decision. New treatment can be more costly and still be cost-effective (if the extra benefit is valued more than the extra cost to produce it). However, since economic evaluation does not explicitly consider a decision maker's available budget, a new treatment can be deemed cost-effective but too expensive to approve.

Economics and physical activity: a research agenda

Both economic and public health/medical perspectives play an important role in the policy process, but often approach policy questions in an incompatible way. Economics and public health perspectives can complement each other, although harnessing any synergy requires an understanding of the other perspective. This article contrasts the two perspectives and reviews existing economic research in physical activity. Much effort has gone into producing cost-of-illness numbers or cost-offset claims with limited value from an economic perspective, although some simple steps could make them more informative. A more notable advance for active living research would be the adoption of standardized cost-effectiveness analysis methods, even just as an add-on to ongoing intervention trials. Probably the most challenging and exciting area, however, is the emerging research on the interaction between environmental incentives and physical activity. An economic perspective with its explicit focus on market failures is an important complement to ongoing active living research as policymakers in the United States are more likely to rely on the market to solve policy problems than on regulation. It is imperative to understand how the market works in actuality, not in the abstract, an area wide open for empirical research.

Medical care usage and self-rated mental health

Background

Population studies frequently employ a single item dependent variable for overall health. Self-rated mental health has been the focus of attention less often. The purpose of this project was to investigate the relationship between use of medical care and poor mental health in an elderly population.

Methods

This study involved a cross-sectional telephone survey of persons over 65 years of age in West Texas, a sparsely-populated 108-county region. Independent variables included number of medical visits, race/ethnicity, age, gender and ability to pay for care. Mental health was measured by asking subjects how often they felt downhearted or blue.

Results

Multiple logistic regression analysis revealed that more medical visits were made by persons who were downhearted or blue. Females, persons who had difficulty paying for care, Hispanic respondents, and older persons were more likely to report poor mental health.

Conclusions

Elderly persons in this region who use more medical care are at greater risk of being in poor mental health. Public health agencies that are planning population-based approaches to improving mental health should consider targeting persons who are high users of medical care as well as those of limited means, women, persons of Hispanic ethnicity, and people who are of greater age.

Patterns of medical resource and psychotropic medicine use among adult depressed managed behavioral health patients

Medical and pharmacy utilization patterns were examined among 782 depressed patients seen by independent clinicians through a Managed Behavioral Health Organization using behavioral, medical and pharmacy claims spanning 2 years. Two-thirds received psychiatric care in the medical and mental health sector concurrently, 43% had comorbid medical disorders, 61% received psychotropic medications, and 54% were on antidepressants. Fewer depressed medically comorbid patients used medical services while in mental health treatment than before or after treatment, while the per patient costs remained the same. For those with chronic conditions, medical utilization and costs remained the same. A quarter of depressed patients received mental health treatment before seeing a mental health specialist, and a quarter remained in treatment in the medical sector after treatment in the mental health sector. Despite increases in mental health services access made available through managed behavioral health organizations, patients continue receiving mental health treatment in the medical sector.

The value of the periodic executive health examination: experience at Bank One and summary of the literature

The executive physical examination has been advocated in the United States for almost 100 years. A MEDLINE search of the literature found very few studies that document the potential impact of a worksite physical examination program on medical and disability costs. Bank One has performed executive physical examinations at its corporate headquarters' medical department since 1983. Approximately 65% of eligible executives voluntarily participate in the program annually. Medical claims and short term disability data were available for a total of 1773 executives who were eligible for a physical examination for a consecutive 3-year period. For three consecutive years after the initial physical examination, the Bank paid a total of $5361 for medical claims for periodic health examination participants (PHE) in contrast to $6426 paid for medical claims for non-periodic health examination participants (NPHE). PHE participants experienced an average 0.93 (or 2.78 for 3 years) short-term disability days absent per year in comparison with an average of 1.34 (or 4.02 for 3 years) short-term disability days absent for NPHE. The net return on investment for a worksite-based executive health examination which cost approximately $400 per executive whose total compensation (salary and benefits) is at least $125,000 is estimated to be 2.3:1, which compares favorably with other preventive health programs.