Health spending growth up in 1999; faster growth expected in the future

An investigation into the pharmaceutical advertising in Iranian medical journals

Background

Pharmaceutical advertising is not only considered a key factor in the successful launch of pharmaceutical products, but is also an important source of public health information with a significant impact on consumer choice and behavior. Nowadays, advertising has become the broadest dissemination channel for various products, including medicines, which may ultimately lead to the generalization of self-treatment or mistreatment. Improper drug promotion can exacerbate unhealthy outcomes by making false or misleading claims, using inferior references, and failing to meet international standards. This study aimed to examine the requirements for pharmaceutical advertising from regulatory perspective and the compliance of Iranian pharmaceutical advertisements to related standards and guidelines. It is limited to print advertisements in Iranian national medical journals and magazines.

Method

The present study is a descriptive–analytical study using bibliometric methods. As a first step, a comprehensive review of the national and international regulations on drug advertising was conducted and a comparison of different regulations was provided. In the second step, a checklist was created to evaluate the compliance of drug advertising with the extracted regulations.

Result

The results of the present study show that the claims made in Iranian drug advertisements are 29.10% valid, 27.67% exaggerated, 23.10% controversial, 12.62% misleading, and 6.8% invalid. In general, we found that most medical advertisements in Iranian journals and magazines comply with national laws and regulations. However, many international requirements are not met in these advertisements.

Conclusions

Although we found that printed medical advertisements in Iran are roughly compliant with national regulations, there is still a long way to achieve full compliance. Monitoring processes should be improved and clearly defined penalties should be set to avoid misleading claims and their likely health consequences. It is very important in Iran to update the existing rules and regulations for medical advertisements according to international guidelines. More careful monitoring of the content of advertising and the accuracy of claims are also needed.

Oncologists' Views on Using Value to Guide Cancer Treatment Decisions

OBJECTIVES

Cancer costs have increased substantially in the past decades, prompting specialty societies to urge oncologists to consider value in clinical decision making. Despite oncologists' crucial role in guiding cancer care, current literature is sparse with respect to the oncologists' views on value. Here, we evaluated oncologists perceptions of the use and measurement of value in cancer care.

METHODS

We conducted in-depth, open-ended interviews with 31 US oncologists practicing nationwide in various environments. Oncologists discussed the definition, measurement, and implementation of value. Transcripts were analyzed using matrix and thematic analysis.

RESULTS

Oncologists' definitions of value varied greatly. Some described versions of the standard health economic definition of value, that is, cost relative to health outcomes. Many others did not include cost in their definition of value. Oncologists considered patient goals and quality of life as important components of value that they perceived were missing from current value measurement. Oncologists prioritized a patient-centric view of value over societal or other perspectives. Oncologists were inclined to consider the value of a treatment only if they perceived treatment would pose a financial burden to patients. Oncologists had differing opinions regarding who should be responsible for determining whether care is low value but generally felt this should remain within the purview of the oncology community.

CONCLUSIONS

Oncologists agreed that cost was an important issue, but disagreed about whether cost was involved in value as well as the role of value in guiding treatment. Better clarity and alignment on the definition of and appropriate way to measure value is critical to the success of efforts to improve value in cancer care.

Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicentre cohort study

OBJECTIVE

We aim to determine the incidence of delirium and describe its impacts on hospital length of stay (LOS) among non-delirious community-dwelling older adults with an 8-hour exposure to the emergency department (ED) environment.

DESIGN

This is a prospective observational multicentre cohort study (March-July 2015). Patients were assessed two times per day during their entire ED stay and up to 24 hours on hospital ward.

SETTING

The study took place in four Canadian EDs.

PARTICIPANTS

338 included patients: (1) aged ≥65 years; (2) who had an ED stay ≥8 hours; (3) were admitted to hospital ward and (4) were independent/semi-independent.

MAIN OUTCOMES AND MEASURES

The primary outcomes of this study were incident delirium in the ED or within 24 hours of ward admission and ED and hospital LOS. Functional and cognitive status were assessed using validated Older Americans Resources and Services and the modified Telephone Interview for Cognitive Status tools. The Confusion Assessment Method was used to detect incident delirium. Univariate and multivariate analyses were conducted to evaluate outcomes.

RESULTS

Mean age was 76.8 (±8.1), 17.7% were aged >85 years old and 48.8% were men. The mean incidence of delirium was 12.1% (n=41). Median IQR ED LOS was 32.4 (24.5-47.9) hours and hospital LOS was 146.6 (75.2-267.8) hours. Adjusted mean hospital LOS was increased by 105.4 hours (4.4 days) (95% CI 25.1 to 162.0, P<0.001) for patients who developed an episode of delirium compared with non-delirious patient.

CONCLUSIONS

An incident delirium was observed in one of eight independent/semi-independent older adults after an 8-hour ED exposure. An episode of delirium increases hospital LOS by 4 days and therefore has important implications for patients and could contribute to ED overcrowding through a deleterious feedback loop.

A New Paradigm in Gallstones Diseases and Marked Elevation of Transaminases: An Observational Study

BACKGROUND

In clinical practice, it is assumed that a severe rise in transaminases is caused by ischemic, viral or toxic hepatitis. Nevertheless, cases of biliary obstruction have increasingly been associated with significant hypertransaminemia. With this study, we sought to determine the true etiology of marked rise in transaminases levels, in the context of an emergency department.

MATERIAL AND METHODS

We retrospectively identified all patients admitted to the emergency unit at Centro Hospitalar e Universitário de Coimbra between 1st January 2010 and 31st December 2010, displaying an increase of at least one of the transaminases by more than 15 times. All patient records were analyzed in order to determine the cause of hypertransaminemia.

RESULTS

We analyzed 273 patients - 146 males, mean age 65.1 ± 19.4 years. The most frequently etiology found for marked hypertransaminemia was pancreaticobiliary acute disease (n = 142;39.4%), mostly lithiasic (n = 113;79.6%), followed by malignancy (n = 74;20.6%), ischemic hepatitis (n = 61;17.0%), acute primary hepatocellular disease (n = 50;13.9%) and muscle damage (n = 23;6.4%). We were not able to determine a diagnosis for 10 cases. There were 27 cases of recurrence in the lithiasic pancreaticobiliary pathology group. Recurrence was more frequent in the group of patients who had not been submitted to early cholecystectomy after the first episode of biliary obstruction (p = 0.014). The etiology of hypertransaminemia varied according to age, cholestasis and glutamic-pyruvic transaminase values.

CONCLUSION

Pancreaticobiliary lithiasis is the main cause of marked hypertransaminemia. Hence, it must be considered when dealing with such situations. Not performing cholecystectomy early on, after the first episode of biliary obstruction, may lead to recurrence.

Emergency Department Stay Associated Delirium in Older Patients

BACKGROUND

Caring for older patients can be challenging in the Emergency Department (ED). A > 12 hr ED stay could lead to incident episodes of delirium in those patients. The aim of this study was to assess the incidence and impacts of ED-stay associated delirium.

METHODS

A historical cohort of patients who presented to a Canadian ED in 2009 and 2011 was randomly constituted. Included patients were aged ≥ 65 years old, admitted to any hospital ward, non-delirious upon arrival and had at least a 12-hour ED stay. Delirium was detected using a modified chart-based Confusion Assessment Method (CAM) tool. Hospital length of stay (LOS) was log-transformed and linear regression assessed differences between groups. Adjustments were made for age and comorbidity profile.

RESULTS

200 records were reviewed, 55.5% were female, median age was 78.9 yrs (SD:7.3). 36(18%) patients experienced ED-stay associated delirium. Nearly 50% of episodes started in the ED and within 36 hours of arrival. Comorbidity profile was similar between the positive CAM group and the negative CAM group. Mean adjusted hospital LOS were 20.5 days and 11.9 days respectively (p<.03).

CONCLUSIONS

1 older adult out of 5 became delirious after a 12 hr ED stay. Since delirium increases hospital LOS by more than a week, better screening and implementation of preventing measures for delirium could reduce LOS and overcrowding in the ED.

Medicaid Community-Based Programs: A Longitudinal Analysis of State Variation in Expenditures and Utilization

As states face challenges posed by budget crises and pressures to develop Medicaid home and community-based services (HCBS), this paper provides a longitudinal analysis of state variation in expenditures and utilization for three HCBS programs (waivers, home health and personal care), and for total Medicaid HCBS. The first part of the analysis describes the nature and scope of state variation for each program in 1999, using such measures as participants per 1,000 population and expenditures per capita. The second part of the analysis presents time-series regression models that estimate sociodemographic, state policy, and market factors associated with intra-state variation in waiver participants and expenditures, and home health, personal care and total HCBS expenditures for the period 1992–99. Among the results, positive state-level factors related to HCBS participants and expenditures include: higher percentages of aged people, greater incomes per capita, and a larger supply of home health agencies.

Smoke without Fire: Nursing Facility Closures in California, 1997–2001

This paper draws from a rich longitudinal California data set to analyze the scope and nature of nursing home closures between 1997 and 2001, and to present a Cox proportionate hazards model of the risks of closure that arise from a range of facility and market characteristics. When compared with the sample total of 1,482 facilities operating in the baseline year of 1997, only 56 facilities closed through 2001, involving the loss of 3.8% of facilities and 2,915 beds (2.3%). The multivariate Cox model of factors associated with closure reports that: 1) hospital-based facilities are 600% more likely to close than are free-standing homes; 2) reducing bed size by one standard deviation (52 beds) increases the risk of closure by 460%; 3) facilities with losses of 5% or worse are more than twice as likely to close; and 4) a one-standard deviation increase in the spare bed capacity measure of county competition raises the risk of facility closure by 140%.

State Policy Choices and Medicaid Long-Term Care Expenditures

State long-term care policies are directed toward a variety of goals. Concerns with expenditure control are primary. Certain states are also seeking to increase the availability of community-based care. A more balanced system would assist consumers in attaining valued goals, while being consonant with federal policy initiatives and legal rulings. The authors examine the relationship between state policies and Medicaid long-term care expenditures. These relationships are tested by multiple regression analysis, using a random effects model for 1991 through 1997. Prospective payment may moderate nursing facility expenditure growth and total long-term care expenditures. Institutional supply constraints demonstrated a positive relationship to both forms of community-based care expenditures. The authors found no evidence of Medicare maximization as a policy to constrain Medicaid expenditure growth. Finally, the authors note the importance of additional work in exploring the dynamics between state long-term care policies and expenditures for individuals with differing disabilities.

The Economies of Scale for Nursing Home Care

Using a modified hybrid short-term operating cost function and a national sample of nursing homes in 1994, the authors examined the scale economies of nursing home care. The results show that scale economies exist for Medicare postacute care, with an elasticity of –0.15 and an optimal scale of around 4,000 patient days annually. However, more than 68 percent of nursing homes in the analytic sample produced Medicare days at a level below the optimal scale. The financial pressures resulting from the implementation of a prospective payment system for Medicare skilled nursing facilities may further reduce the quantity of Medicare days served by nursing homes. In addition, the results show that chain-owned nursing homes do not have lower short-term operating costs than do independent facilities. This indicates that the rationale behind recent increasing horizontal integration among nursing homes may not be seeking greater cost efficiency but some other consideration.

A paradigm shift in the outpatient approach to liver function tests

The American Gastroenterological Association (2002), Canadian Medical Association (2005), and the Centers for Disease Control and Prevention (2006) released guidelines to screen patients with mild elevations of liver enzymes for hepatitis B and hepatitis C. Mildly elevated liver enzymes were defined as less than five times the upper limit of normal, but above the normal reference range. The rationale for this recommendation was based on many factors including cost effectiveness, lab variation, and ultimately, for better patient care.Chronic hepatitis B and C have values of transaminases that fluctuate between normal and mildly abnormal. Screening patients with even mild elevations of transaminases allows many chronic hepatitis patients to be diagnosed early in the course of their disease. Diagnosing these patients early in their disease course leads to better treatment response, decreased progression to cirrhosis, lower viral loads leading to decreased incidence of extrahepatic manifestations, prevention of hepatocellular carcinoma, and decreased likelihood of liver transplantation.There are organizations which recommend discontinuing hepatotoxic medications such as acetaminophen or nonsteroidal anti-inflammatory drugs and reevaluating the patient in three months. However, this recommendation misses a number of hepatitis patients for the reasons aforementioned. The obesity epidemic has clouded the diagnosis of hepatitis B/C as patients that have obesity, diabetes mellitus, and metabolic syndrome are not being screened due the presumptive diagnosis of nonalcoholic fatty liver disease.Not screening patients in the setting of obesity is not cost-effective and also leads to increased morbidity, as we will discuss in this manuscript. Additionally, it has been proven in the literature that it is more cost-effective to screen for hepatitis B/C in high-prevalence areas, than to reassess the patient months later, and potentially miss a diagnosis of hepatitis B/C. The overall goal of this study is to increase screening awareness of patients with mild transaminitis elevations through publication in order to diagnose patients with hepatitis B and C prior to the development of chronic liver disease.

Impact of direct-to-consumer advertising (DTCA) on patient health-related behaviors and issues

The pharmaceutical industry spends billions of dollars annually on direct-to-consumer advertising (DTCA). Patient perspectives on the impact of televised DTCA on health-related behaviors and issues were assessed by means of a 68-question survey. 58.6% of respondents believed that DTCA allowed consumers to have a more active role in managing their health. However, 27.6% felt DTCA caused confusion, and an alarming 17.8% of respondents stopped taking their medication because of concerns about serious side effects mentioned in DTCA. Overall, participants believed DTCA plays a useful role in health self-management; however, a considerable percentage thought that the cost outweighs the benefits.

US health care: single-payer or market reform

The authors advocate a fundamental change in health care financing-national health insurance (NHI). NHI would reorient the way we pay for care, bringing the hundreds of billions now squandered on malignant bureaucracy back to the bedside. NHI could restore the physician-patient relationship, offer patients a free choice of physicians and hospitals, and free physicians from the hassles of insurance paperwork.

Trends in State Certificate of Need and Moratoria Programs for Long-Term Care Providers

This study examined state policies for certificate of need or moratoria for new building, renovation, and remodeling of long-term care (LTC) providers, using a telephone survey of state officials in between 1990 and 2002. In 2002, the vast majority of states still continue to regulate the supply of nursing homes, hospital-based nursing homes, and facilities for the mentally retarded/developmentally disabled. Surprisingly, 18 percent of states regulate the supply of residential care facilities, 35 percent regulate home health agencies, and 37 percent regulate hospices. These state efforts to control supply are primarily based on cost containment strategies and assuring the appropriate distribution of LTC services. Where limits are placed on home and community service providers, however, access could be negatively impacted.

National health insurance or incremental reform: aim high, or at our feet?

Single-payer national health insurance could cover the uninsured and upgrade coverage for most Americans without increasing costs; savings on insurance overhead and other bureaucracy would fully offset the costs of improved care. In contrast, proposed incremental reforms are projected to cover a fraction of the uninsured, at great cost. Moreover, even these projections are suspect; reforms of the past quarter century have not stemmed the erosion of coverage. Despite incrementalists' claims of pragmatism, they have proven unable to shepherd meaningful reform through the political system. While national health insurance is often dismissed as ultra left by the policy community, it is dead center in public opinion. Polls have consistently shown that at least 40%, and perhaps 60%, of Americans favor such reform.

Patient, physician, pharmacy, and pharmacy benefit design factors related to generic medication use

BACKGROUND

Increased use of generic medications conserves insurer and patient financial resources and may increase patient adherence.

OBJECTIVE

The objective of the study is to evaluate whether physician, patient, pharmacy benefit design, or pharmacy characteristics influence the likelihood that patients will use generic drugs

DESIGN, SETTING, AND PARTICIPANTS

Observational analysis of 2001-2003 pharmacy claims from a large health plan in the Western United States. We evaluated claims for 5,399 patients who filled a new prescription in at least 1 of 5 classes of chronic medications with generic alternatives. We identified patients initiated on generic drugs and those started on branded medications who switched to generic drugs in the subsequent year. We used generalized estimating equations to perform separate analyses assessing the relationship between independent variables and the probability that patients were initiated on or switched to generic drugs.

RESULTS

Of the 5,399 new prescriptions filled, 1,262 (23.4%) were generics. Of those initiated on branded medications, 606 (14.9%) switched to a generic drug in the same class in the subsequent year. After regression adjustment, patients residing in high-income zip codes were more likely to initiate treatment with a generic than patients in low-income regions (RR = 1.29; 95% C.I. 1.04-1.60); medical subspecialists (RR = 0.82; 0.69-0.95) and obstetrician/gynecologists (RR = 0.81; 0.69-0.98) were less likely than generalist physicians to initiate generics. Pharmacy benefit design and pharmacy type were not associated with initiation of generic medications. However, patients were over 2.5 times more likely to switch from branded to generic medications if they were enrolled in 3-tier pharmacy plans (95% C.I. 1.12-6.09), and patients who used mail-order pharmacies were 60% more likely to switch to a generic (95% C.I. 1.18-2.30) after initiating treatment with a branded drug.

CONCLUSIONS

Physician and patient factors have an important influence on generic drug initiation, with the patients who live in the poorest zip codes paradoxically receiving generic drugs least often. While tiered pharmacy benefit designs and mail-order pharmacies helped steer patients towards generic medications once the first prescription has been filled, they had little effect on initial prescriptions. Providing patients and physicians with information about generic alternatives may reduce costs and lead to more equitable care.

The quality of pharmacologic care for adults in the United States

BACKGROUND

Despite rising annual expenditures for prescription drugs, little systematic information is available concerning the quality of pharmacologic care for adults in the United States. We evaluated how frequently appropriate pharmacologic care is ordered in a national sample of U.S. residents.

METHODS

The RAND/UCLA Modified Delphi process was used to select quality-of-care indicators for adults across 30 chronic and acute conditions and preventive care. One hundred thirty-three pharmacologic quality-of-care indicators were identified. We interviewed a random sample of adults living in 12 metropolitan areas in the United States by telephone and received consent to obtain copies of their medical records for the most recent 2-year period. We abstracted patient medical records and evaluated 4 domains of the prescribing process that encompassed the entire pharmacologic care experience: appropriate medication prescribing (underuse), avoidance of inappropriate medications (overuse), medication monitoring, and medication education and documentation. A total of 3,457 participants were eligible for at least 1 quality indicator, and 10,739 eligible events were evaluated. We constructed aggregate scores and studied whether patient, insurance, and community factors impact quality.

RESULTS

Participants received 61.9% of recommended pharmacologic care overall (95% confidence interval 60.3-63.5%). Performance was lowest in education and documentation (46.2%); medication monitoring (54.7%) and underuse of appropriate medications (62.6%) performance were higher. Performance was best for avoiding inappropriate medications (83.5%). Patient race and health services utilization were associated with modest quality differences, while insurance status was not.

CONCLUSIONS

Significant deficits in the quality of pharmacologic care were seen for adults in the United States, with large shortfalls associated with underuse of appropriate medications. Strategies to measure and improve pharmacologic care quality ought to be considered, especially as we initiate a prescription drug benefit for seniors.

Leisure-Time Physical Activity and Health-Care Utilization in Older Adults

This study examined whether leisure-time physical activity (LTPA) was associated with health-care utilization in a racially diverse sample of rural and urban older adults. Community-dwelling adults (N= 1,000, 75.32 ± 6.72 years old) self-reported participating in LTPA and their use of the health-care system (physician visits, number and length of hospitalizations, and emergency-room visits). After controlling for variables associated with health and health-care utilization, older adults who reported lower levels of LTPA also reported a greater number of nights in the hospital in the preceding year. There was no support, however, for a relationship between LTPA and the other indicators of health-care utilization. Our findings suggest that being physically active might translate to a quicker recovery for older adults who are hospitalized. Being physically active might not only have health benefits for older persons but also lead to lower health-care costs.

OBRA 1987 and the quality of nursing home care

Because minimum government standards for quality regulate only part of the market failure, they may have unintended effects. We present a general theory of how government regulation of quality of care may affect different market segments, and test the hypotheses for the nursing home market. OBRA 1987 was a sweeping government reform to improve the quality of nursing home care. We study how the effect of OBRA on the quality of nursing home care, measured by resident outcomes, varied with nursing home profitability. Using a semi-parametric method to control for the endogenous effects of regulation, we found that this landmark legislation had a negative effect on the quality of care in less profitable nursing homes, but improved the quality in more profitable nursing homes during the initial period after OBRA. But, this legislation had no statistically significant effect in the later period when the regulation was weakly enforced.

Do oncologists believe new cancer drugs offer good value?

BACKGROUND

Substantial debate centers on the high cost and relative value of new cancer therapies. Oncologists play a pivotal role in treatment decisions, yet it is unclear whether they perceive high-cost new treatments to offer good value or how therapeutic costs factor into their treatment recommendations.

METHODS

We surveyed 139 academic medical oncologists at two academic hospitals in Boston. We asked respondents to provide estimates for the cost and effectiveness of bevacizumab and whether they believed the treatment offered "good value." We also asked respondents to judge how large a gain in life expectancy would justify a hypothetical cancer drug that costs $70,000 a year. Using this information, we calculated implied cost-effectiveness thresholds. Finally, we explored respondents' views on the role of cost in treatment decisions.

RESULTS

Ninety academic oncologists (65%) completed the survey. Seventy-eight percent stated that patients should have access to "effective" care regardless of cost. Implied cost-effectiveness thresholds, derived from the bevacizumab and hypothetical scenarios, averaged roughly $300,000 per quality-adjusted-life-year (QALY). Only 25% of oncologists felt that bevacizumab offered "good value."

CONCLUSIONS

A majority of academic oncologists stated that cost does not influence their clinical practice, nor should it limit access to "effective" care. Yet respondents did not consider all effective drugs to be of good value. Implied cost-effectiveness thresholds were $300,000/QALY--a value higher than the $50,000 standard often cited. A subset of oncologists were sensitive to cost, believing it should factor into clinical decisions. These findings reflect the ongoing controversies within the medical community as expensive new therapies enter the system.

Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews

OBJECTIVES

The objective of physician continuing medical education (CME) is to help them keep abreast of advances in patient care, to accept new more-beneficial care, and discontinue use of existing lower-benefit diagnostic and therapeutic interventions. The goal of this review was to examine effectiveness of current CME tools and techniques in changing physician clinical practices and improving patient health outcomes.

METHODS

Results of published systematic reviews were examined to determine the spectrum from most- to least-effective CME techniques. We searched multiple databases, from 1 January 1984 to 30 October 2004, for English-language, peer-reviewed meta-analyses and other systematic reviews of CME programs that alter physician behavior and/or patient outcomes.

RESULTS

Twenty-six reviews met inclusion criteria, that is, were either formal meta-analyses or other systematic reviews. Interactive techniques (audit/feedback, academic detailing/outreach, and reminders) are the most effective at simultaneously changing physician care and patient outcomes. Clinical practice guidelines and opinion leaders are less effective. Didactic presentations and distributing printed information only have little or no beneficial effect in changing physician practice.

CONCLUSIONS

Even though the most-effective CME techniques have been proven, use of least-effective ones predominates. Such use of ineffective CME likely reduces patient care quality and raises costs for all, the worst of both worlds.

Unmet patient need in home care under managed care

Social workers in home care agencies obtained through a national random sample responded to a mail questionnaire that examined the relationship between the frequency of discharge with unmet patient need and patient/family characteristics, agency auspice, and practice activities when social workers' assessment of patient needs and managed care payment limits conflict. Regression analysis found that the importance of social work financial planning with clients and intra-agency advocacy were significant negative contributors, and patient cognitive impairment, inadequate family care, and agency auspice were significant positive contributors to a regression model explaining 31 percent of the variance in the frequency of discharge with unmet need. Implications for practice, education, and research are discussed.

The Effect of Direct-to-Consumer Advertising on Prescription Drug Use by Older Adults

BACKGROUND AND OBJECTIVE

Although older adults are frequent consumers of prescription drugs and increasingly the intended audience of direct-to-consumer advertising (DTCA) marketing efforts, little is known about the effect of DTCA on older adults' prescription drug-seeking behaviour. In response, the objective of this study is to examine factors associated with requesting a prescription drug from a physician following exposure to DTCA among older adults, and whether the drug or other medical treatment was prescribed during the encounter.

METHODS

A secondary data analysis of the "Public Health Impact of Direct-to-Consumer Advertising of Prescription Drugs", a data set publicly available through the Inter-university Consortium for Political and Social Research (ICPSR 3687), was conducted. For the purposes of this study, only those respondents who indicated that they had been exposed to DTCA (n = 2601) were included in the study sample. Using a two-step weighted logistic regression approach, separate models were estimated to examine first, whether a request for the advertised drug was made following exposure to DTCA and secondly, the outcomes of any patient-physician encounters that occurred following exposure to DTCA.

RESULTS

Descriptive analysis of the outcome variables revealed that, among respondents exposed to DTCA, 31% (n = 801) requested a prescription drug from their physician. Approximately 5% of those who made a request were > or =75 years of age. Among respondents requesting a prescription drug, 69% (n = 556) received a prescription in response to their request, of whom, approximately 5% were > or =75 years of age. Multivariate findings suggest that although adults > or =75 years of age are less likely to request a prescription drug following exposure to DTCA (odds ratio [OR] = 0.58; p = 0.032), when they do approach their physicians, they are more likely to receive recommendations for further treatment, with ORs indicating a 250% (OR = 3.507; p = 0.002) increase in the odds of further referral among adults > or =75 years of age.

CONCLUSION

Overall, results from the study suggest that DTCA influences the patient-doctor relationship and prescription drug acquisition behaviour of patients; however, the nature of the effect of DTCA on older adults is complex. Because future cohorts of older adults may be more comfortable about requesting prescription drugs and the consumer-driven approach to obtaining medical care, understanding the impact of DTCA on older consumers represents an important area for further inquiry.

Health expenditures for privately insured adults enrolled in managed care gatekeeping vs indemnity plans

OBJECTIVES

We assessed the ability of managed care gatekeeping strategies (i.e., requiring a designated primary care provider to authorize referrals) to control health care costs in the mid-1990s.

METHODS

We analyzed expenditure data from 8195 privately insured adults sampled in the nationally representative 1996 Medical Expenditure Panel Survey. Managed care gatekeeping plan enrollees included those in health maintenance organizations and other plans requiring a primary care gatekeeper. All others were considered indemnity plan enrollees.

RESULTS

In 1996, total per capita annual health expenditures for adult gatekeeping enrollees were about $50 less than those of indemnity enrollees, primarily owing to lower out-of-pocket expenditures. After multivariate adjustment, mean per capita expenditures were approximately 6% lower for gatekeeping enrollees than for indemnity enrollees.

CONCLUSIONS

In the private sector, gatekeeping strategies resulted in modest cost savings over indemnity plans.

Elders who delay medication because of cost: health insurance, demographic, health, and financial correlates

PURPOSE

Prescription medication use is essential to the health and well-being of many elderly persons. However, the cost of medications may be prohibitive and contribute to noncompliance with medical recommendations. This study identifies community-dwelling elders who reported a delay in medication use because of prescription medication cost.

DESIGN AND METHODS

This was a cross-sectional study of a nationwide sample of 6,535 elders participating in the Asset and Health Dynamics Among the Oldest Old (AHEAD) study. Participants reported if they had taken less medication than prescribed or if they had not filled prescriptions because of cost in the past 2 years. This response was then compared with the self-report of multiple variables, including demographic, health status, health insurance coverage, and financial variables.

RESULTS

Elders who were most vulnerable to medication delay as a result of cost included those with Medicare coverage only, low income, high out-of-pocket prescription costs, and poor health as well as African American elders and those aged 65-80 years.

IMPLICATIONS

This study provides important information about community-dwelling elders that reported a delay in medication use because of cost. As a Medicare prescription benefit has been passed, it will be important to monitor how these changes affect the elders identified at risk for medication delay.

Managed care in home health: social work practice and unmet client needs

Findings from a sample (n = 117) obtained through a survey mailed to a random sampling of social workers in home health agencies nation-wide suggest that the characteristics of patients discharged with unmet needs were psychosocial. Social work practice activities targeted transferring responsibility for care for patients from agencies and government/commercial third party payers to informal caregivers and community resources. Desired continuing education topics evidence the emphasis on effective interventions that facilitate discharge, interdisciplinary collaboration and practice evaluation.

Comparisons of Estimated Economic Burdens due to Insufficient Solar Ultraviolet Irradiance and Vitamin D and Excess Solar UV Irradiance for the United States

Vitamin D sufficiency is required for optimal health, and solar ultraviolet B (UVB) irradiance is an important source of vitamin D. UVB and/or vitamin D have been found in observational studies to be associated with reduced risk for over a dozen forms of cancer, multiple sclerosis, osteoporotic fractures, and several other diseases. On the other hand, excess UV irradiance is associated with adverse health outcomes such as cataracts, melanoma, and nonmelanoma skin cancer. Ecologic analyses are used to estimate the fraction of cancer mortality, multiple sclerosis prevalence, and cataract formation that can be prevented or delayed. Estimates from the literature are used for other diseases attributed to excess UV irradiation, additional cancer estimates, and osteoporotic fractures. These results are used to estimate the economic burdens of insufficient UVB irradiation and vitamin D insufficiency as well as excess UV irradiation in the United States for these diseases and conditions. We estimate that 50,000-63,000 individuals in the United States and 19,000-25,000 in the UK die prematurely from cancer annually due to insufficient vitamin D. The U.S. economic burden due to vitamin D insufficiency from inadequate exposure to solar UVB irradiance, diet, and supplements was estimated at $40-56 billion in 2004, whereas the economic burden for excess UV irradiance was estimated at $6-7 billion. These results suggest that increased vitamin D through UVB irradiance, fortification of food, and supplementation could reduce the health care burden in the United States, UK, and elsewhere. Further research is required to confirm these estimates.

Prescription Drug Coverage, Health, and Medication Acquisition Among Seniors With One or More Chronic Conditions

BACKGROUND

The unabated rise in medication costs particularly affects older persons with chronic conditions that require long-term medication use, but how prescription benefits affect medication adherence for such persons has received limited study.

OBJECTIVE

We sought to study the relationship among prescription benefit status, health, and medication acquisition in a sample of elderly HMO enrollees with 1 or more common, chronic conditions.

RESEARCH DESIGN

We implemented a cross-sectional cohort study using primary survey data collected in 2000 and administrative data from the previous 2 years.

SUBJECTS

Subjects were aged 67 years of age and older, continuously enrolled in a Medicare + Choice program for at least 2 years, and diagnosed with 1 or more of hypertension, diabetes, congestive heart failure, and coronary artery disease (n = 3073).

MEASURES

Outcomes were the mean daily number of essential therapeutic drug classes and refill adherence.

RESULTS

In multivariate models, persons without a prescription benefit acquired medications in 0.15 fewer therapeutic classes daily and experienced lower refill adherence (approximately 7 fewer days of necessary medications during the course of 2 years) than those with a prescription benefit. A significant interaction revealed that, among those without a benefit, persons in poor health acquired medications in 0.73 more therapeutic classes daily than persons in excellent health; health status did not significantly influence medication acquisition for those with a benefit.

CONCLUSIONS

Coverage of prescription drugs is important for improving access to essential medications for persons with the studied chronic conditions. A Medicare drug benefit that provides unimpeded access to medications needed to treat such conditions may improve medication acquisition and, ultimately, health.

Health care administration in the United States and Canada: micromanagement, macro costs

A decade ago, U.S. health administration costs greatly exceeded Canada's. Have the computerization of billing and the adoption of a more business-like approach to care cut administrative costs? For the United States and Canada, the authors calculated the 1999 administrative costs of health insurers, employers' health benefit programs, hospitals, practitioners' offices, nursing homes, and home care agencies; they analyzed published data, surveys of physicians, employment data, and detailed cost reports filed by hospitals, nursing homes, and home care agencies; they used census surveys to explore time trends in administrative employment in health care settings. Health administration costs totaled at least dollar 294.3 billion, dollar 1,059 per capita, in the United States vs. dollar 9.4 billion, dollar 307 per capita, in Canada. After exclusions, health administration accounted for 31.0 percent of U.S. health expenditures vs. 16.7 percent of Canadian. Canada's national health insurance program had an overhead of 1.3 percent, but overhead among Canada's private insurers was higher than in the U.S.: 13.2 vs. 11.7 percent. Providers' administrative costs were far lower in Canada. Between 1969 and 1999 administrative workers' share of the U.S. health labor force grew from 18.2 to 27.3 percent; in Canada it grew from 16.0 percent in 1971 to 19.1 percent in 1996. Reducing U.S. administrative costs to Canadian levels would save at least dollar 209 billion annually, enough to fund universal coverage.

A randomized intervention to improve heart failure outcomes in community-based home health care

This study examines the effects of a home health intervention designed to standardize nursing care, strengthen nurses' support for patient self-management and yield better CHF patient outcomes. Participants were 371 Medicare CHF patients served by 205 nurses randomized to intervention and control groups in a large urban home healthcare agency (HHA). The intervention consisted of an evidence-based nursing protocol, patient self-care guide, and training to improve nurses'teaching and support skills. Outcome measures included home care,physician and emergency department (ED) use, hospital admission, condition-specific quality of life (QoL), satisfaction with home care services and survival at 90 days. The intervention was associated with a marginally significant reduction in the volume of skilled nursing visits (p = .074), and a reduction variation in the typical number of visits provided (p < .05), without a significant increase in physician or ED use or patient mortality. Hypothesized improvement in other outcomes did not occur.

Seniors with chronic health conditions and prescription drugs: benefits, wealth, and health

OBJECTIVES

The objectives of this study were to examine the relationship between prescription benefit status and access to medications among Medicare beneficiaries with hypertension, congestive heart failure, coronary artery disease, and diabetes and to determine how income, wealth, and health status influence this relationship.

METHODS

We analyzed survey and administrative data for 4492 Medicare + Choice enrollees aged 67 and above enrolled in a predominantly group-model health maintenance organization in 2000. Outcome measures included difficulty affording medications, methods of coping with medication costs including obtaining medicines from another country, using free samples, and stretching out medications to make them last longer. Independent variables included prescription benefit status, income, wealth measures, health status, and out-of-pocket prescription drug spending.

RESULTS

Lacking a prescription benefit was independently associated with difficulty affording medications (25% of those without a benefit vs. 17% with a benefit) and coping methods such as stretching out medications. Lower income, lower assets, and worse health status also independently predicted greater difficulty as measured by these outcomes; there was no effect modification between these factors and benefit status. Relative to national figures, out-of-pocket spending in this setting was quite low, with only 0.2 and 13% of those with and without a benefit, respectively, spending over 100 dollars per month. Higher out-of-pocket spending predicted greater difficulty affording medications but not stretching out medications.

CONCLUSIONS

Efforts to improve medication accessibility for older Americans with chronic conditions need to address not only insurance coverage but also barriers related to socioeconomic status and health status.

Collaborative drug therapy management by pharmacists--2003

Since publication of the initial ACCP position statement on CDTM by pharmacists in 1997, the public, government, and much of the health care community at large have come to better appreciate the growing complexity of providing effective and safe drug therapy in today's health care environment. Increased interest in the issues of cost and quality of drug use is evident in the increasing coverage of the issue in the lay press and professional literature. This represents real progress, as well as real opportunity, for pharmacists. It also heightens the potential for a better understanding of the vital role that pharmacists can play in addressing these concerns. The percentage of patients who take several drugs for chronic diseases will continue to increase. Based on current trends, the number of patients who lack adequate access to care, or who receive either suboptimal, inappropriate, or unnecessarily expensive drug therapy for their acute and chronic diseases, will increase. Even as financial and human resources are increasingly strained within the current health care system, costs will continue to rise unless changes are made. Fortunately, qualified pharmacists are prepared, capable, and willing to help address a significant portion of these challenges. The public, many health care providers, some legislators, and a few insurers now recognize that pharmacists, because of their education and training in drug therapy, are well positioned both to accept additional responsibility for patient care and to provide services that make a real difference in health care quality and outcomes. The health care programs administered by the U.S. Public Health Service, the armed forces, and the Veterans Health Administration, as well as 38 states, now support pharmacist participation in CDTM. Pharmacists, working in an interdisciplinary structure with physicians and other health care providers, have demonstrated that they can improve the effectiveness, efficiency, and safety of drug therapy by providing CDTM. It is time to incorporate this valuable professional skill of the contemporary pharmacist as a core component of the delivery of health care services.

State nursing home enforcement systems

This study presents interview and statistical data from a telephone and fax survey of state agency officials and statistical data from the Centers for Medicare & Medicaid Services' Online Survey Certification and Reporting (OSCAR) system. State survey activities for nursing facilities were reviewed and the number and types of intermediate sanctions issued by states in 1999 were reported, along with barriers to the use of such sanctions. Using five selected enforcement measures to create a summary score, states were classified by quartiles based on the stringency of their nursing facility enforcement activities. Controlling for the number of complaints as a proxy for quality, the predictors of a summary of state enforcement actions were: percentage of population at age eighty-five and above. Democratic governors, higher percentages of chain facilities, and lower facility occupancy rates. Regional differences in enforcement patterns also were shown. Many federal policies and resource constraints were identitied as barriers to effective regulation. The findings identified nursing facility survey and enforcement issues that need to be addressed by policy makers.

How state-funded home care programs respond to changes in Medicare home health care: resource allocation decisions on the front line

OBJECTIVE

To examine how case managers in a state-funded home care program allocate home care services in response to information about a client's Medicare home health care status, with particular attention to the influence of work environment.

DATA SOURCES/STUDY SETTING

Primary data collected on 355 case managers and 26 agency directors employed in June 1999 by 26 of the 27 regional agencies administering the Massachusetts Home Care Program for low-income elders.

STUDY DESIGN

Data were collected in a cross-sectional survey study design. A case manager survey included measures of work environment, demographics, and factorial survey vignette clients (N = 2,054), for which case managers assessed service eligibility levels. An agency director survey included measures of management practices.

DATA COLLECTION/EXTRACTION METHODS

Hierarchical linear models estimated the effects of work environment on the relationship between client receipt of Medicare home health care and care plan levels while controlling for case-mix differences in agencies' clients.

PRINCIPAL FINDINGS

Case managers did not supplement extant Medicare home health services, but did allocate more generous service plans to clients who have had Medicare home health care services recently terminated. This finding persisted when controlling for case mix and did not vary by work environment. Work environment affected overall care plan levels.

CONCLUSIONS

Study findings indicate systematic patterns of frontline resource allocation shaping the relationships among community-based long-term care payment sources. Further, results illustrate how nonuniform implementation of upper-level initiatives may be partially attributed to work environment characteristics.

Urologists on a tightrope--do we have a net?

PURPOSE

The purpose of this review is to analyze the current health care environment and its impact on urological practice.

MATERIALS AND METHODS

The medical and lay literature as it pertains to the socioeconomics of health care was reviewed.

RESULTS

Analysis of the political and economic factors that influence the delivery of health care today reveals alarming realities. More than 40 million Americans remain uninsured, and with a retrenched economy that number is likely to increase. Neither government nor the private sector has been either willing or able to address the health care problem in a coherent or comprehensive way. As the population ages, the Medicare and Medicaid programs will become further stressed. Employers are increasingly unwilling to finance the health care expenses of their employees. Academic medical centers are facing unique exigencies that, if left uncorrected, will jeopardize the future training of physicians.

CONCLUSIONS

In the current environment of a depressed economy, further proposed tax cuts and increased military spending it appears inevitable that the economic restraints on medical care will increase substantially in the foreseeable future.

Costs of health care administration in the United States and Canada

BACKGROUND

A decade ago, the administrative costs of health care in the United States greatly exceeded those in Canada. We investigated whether the ascendancy of computerization, managed care, and the adoption of more businesslike approaches to health care have decreased administrative costs.

METHODS

For the United States and Canada, we calculated the administrative costs of health insurers, employers' health benefit programs, hospitals, practitioners' offices, nursing homes, and home care agencies in 1999. We analyzed published data, surveys of physicians, employment data, and detailed cost reports filed by hospitals, nursing homes, and home care agencies. In calculating the administrative share of health care spending, we excluded retail pharmacy sales and a few other categories for which data on administrative costs were unavailable. We used census surveys to explore trends over time in administrative employment in health care settings. Costs are reported in U.S. dollars.

RESULTS

In 1999, health administration costs totaled at least 294.3 billion dollars in the United States, or 1,059 dollars per capita, as compared with 307 dollars per capita in Canada. After exclusions, administration accounted for 31.0 percent of health care expenditures in the United States and 16.7 percent of health care expenditures in Canada. Canada's national health insurance program had overhead of 1.3 percent; the overhead among Canada's private insurers was higher than that in the United States (13.2 percent vs. 11.7 percent). Providers' administrative costs were far lower in Canada. Between 1969 and 1999, the share of the U.S. health care labor force accounted for by administrative workers grew from 18.2 percent to 27.3 percent. In Canada, it grew from 16.0 percent in 1971 to 19.1 percent in 1996. (Both nations' figures exclude insurance-industry personnel.)

CONCLUSIONS

The gap between U.S. and Canadian spending on health care administration has grown to 752 dollars per capita. A large sum might be saved in the United States if administrative costs could be trimmed by implementing a Canadian-style health care system.

Cost of pharmacological care of the elderly: implications for healthcare resources

Expenditures on prescribed medicines are significantly higher among those aged 65 years and over than among younger people. As populations in developed countries age so the cost of pharmacological care associated with the older population can be expected to increase. While pharmacological care represents only one component of healthcare, its costs are increasing rapidly because of advances in technology and increasing use. However, such costs should be considered within a context of decreasing disability in the elderly population, improving economic conditions among seniors and the relationship of these costs with those in other aspects of healthcare. Where medications have been demonstrated to be cost-effective, attempts to curtail expenditure growth may prove a false economy resulting in significantly higher growth elsewhere such as in the hospital and long-term care sectors. Policy responses to this issue should encompass the inclusion of elderly patients in clinical trials, the use of evidence-based principles of practice and strategies to ensure that this population obtain maximum benefit from medication through education and counselling.

Patterns of health care and disability for Medicare beneficiaries under 65

Disabled people under age 65 are a vulnerable and growing segment of the Medicare population, yet Medicare reform has focused on the needs of the aged. This study linked the Medicare Current Beneficiary Survey to Social Security Administration records to analyze patterns of health care for disabled beneficiaries by reason for disability. We found substantial variation in average health care costs by type of service, including prescription drugs, and in sources of payment. Rates of institutionalization were high among some disability categories and there was heavy reliance on Medicaid and other public programs for payment. It is essential that the special needs of the disabled not be overlooked as policymakers consider fundamental modifications to Medicare and Medicaid.

Investing in Oregon's expanded food and nutrition education program (EFNEP): documenting costs and benefits

OBJECTIVES

To apply Virginia's cost-benefit analysis (CBA) model developed for a large Expanded Food and Nutrition Education Program (EFNEP) to Oregon's small EFNEP. To estimate a cost-benefit ratio for Oregon's EFNEP based on retrospective analysis of program costs and optimal nutrition behaviors (ONBs) in relation to potential health-related savings for diet-related chronic diseases/conditions.

DESIGN

Standard components of a CBA.

SUBJECTS/SETTINGS

368 adult graduates of Oregon State University's Extension Service EFNEP during the 1999-2000 program year.

INTERVENTION

Prior participation in the EFNEP with a mean of 10.4 lessons.

MAIN OUTCOME MEASURES

Cost-benefit ratio and several sensitivity analyses.

ANALYSIS

EFNEP program graduates practicing ONBs related to prevention/delay of diet-related chronic diseases/conditions were determined using SPSS (Base 10 computer program). Cost-benefit ratios were computed using Microsoft Excel.

RESULTS

CBA determined a 1:3.63 cost-benefit ratio (in 1999 dollars).

CONCLUSIONS AND IMPLICATIONS

Virginia's CBA model was useful in the retrospective evaluation of Oregon's small EFNEP. With Oregon's benefits exceeding costs, CBA provides evidence for resource allocation and justification for program continuation.

Hospital economics of the hospitalist

OBJECTIVE

To determine the economic impact on the hospital of a hospitalist program and to develop insights into the relative economic importance of variables such as reductions in mean length of stay and cost, improvements in throughput (patients discharged per unit time), payer methods of reimbursement, and the cost of the hospitalist program.

DATA SOURCES

The primary data source was Tufts-New England Medical Center in Boston. Patient demographics, utilization, cost, and revenue data were obtained from the hospital's cost accounting system and medical records.

STUDY DESIGN

The hospitalist admitted and managed all patients during a six-week period on the general medical unit of Tufts-New England Medical Center. Reimbursement, cost, length of stay, and throughput outcomes during this period were contrasted with patients admitted to the unit in the same period in the prior year, in the preceding period, and in the following period.

PRINCIPAL FINDINGS

The hospitalist group compared with the control group demonstrated: length of stay reduced to 2.19 days from 3.45 days (p<.001); total hospital costs per admission reduced to 1,775 dollars from 2,332 dollars (p<.001); costs per day increased to 811 dollars from 679 dollars (p<.001); no differences for readmission within 30 days of discharge to extended care facilities. The hospital's expected incremental profitability with the hospitalist was -1.44 dollars per admission excluding incremental throughput effects, and it was most sensitive to changes in the ratio of per diem to case rate reimbursement. Incremental throughput with the hospitalist was estimated at 266 patients annually with an associated incremental profitability of 1.3 million dollars.

CONCLUSION

Hospital interventions designed to reduce length of stay, such as the hospitalist, should be evaluated in terms of cost, throughput, and reimbursement effects. Excluding throughput effects, the hospitalist program was not economically viable due to the influence of per diem reimbursement. Throughput improvements occasioned by the hospitalist program with high baseline occupancy levels are substantial and tend to favor a hospitalist program.

A statistical analysis of the magnitude and composition of drug promotion in the United States in 1998

BACKGROUND

Although pharmaceutical industry marketing and other factors may influence physician decisions regarding medication prescribing in the United States, little information is available about the composition of promotional efforts by promotional mode and medication class.

OBJECTIVES

The aims of this study were to determine the magnitude of expenditures for common modes of promotion and to delineate patterns of promotional strategies for particular classes of medications.

METHODS

Nationally representative data on expenditures (in US $) for the 250 most promoted medications in the United States in 1998 were available from an independent pharmaceutical market research company for the 5 most commonly used modes of promotion. Key patterns of drug promotion were identified by descriptive statistics, a cluster analysis of expenditures by class, and an analysis of expenditure concentration.

RESULTS

In 1998, the pharmaceutical industry spent $12,724 million promoting its products in the United States, of which 85.9% was accounted for by the top 250 drugs and 51.6% by the top 50 drugs. Direct-to-consumer (DTC) advertising was more concentrated on a small subset of medications than was promotion to professionals. Overall, 1998 expenditures were dominated by free drug samples provided to physicians (equivalent retail cost of $6602 million) and office promotion ($3537 million), followed by DTC advertising ($1337 million), hospital promotion ($705 million), and advertising in medical journals ($540 million). Four distinct patterns of expenditures were observed: promotion to office physicians with little consumer promotion (14 drug classes); dual focus on office physicians and consumer advertising (4 drug classes); predominant DTC advertising (1 class: smoking-cessation products); and promotion to office- and hospital-based professionals without consumer advertising (1 class: narcotic analgesics).

CONCLUSIONS

The present findings reinforce the perception that the pharmaceutical industry invests heavily in promoting its products and demonstrates that promotional expenditures are concentrated on a small number of medications. Although promotion to professionals remains dominant, DTC advertising has become key for a subset of common medications

The end of an era: what became of the "managed care revolution" in 2001?

OBJECTIVE

To describe how the organization and dynamics of health systems changed between 1999 and 2001, in the context of expectations from the mid-1990s when managed care was in ascendance, and assess the implications for consumers and policymakers.

DATA SOURCES/STUDY SETTING

Data are from the Community Tracking Study site visits to 12 communities that were randomly selected to be nationally representative of metropolitan areas with 200,000 people or more. The Community Tracking Study is an ongoing effort that began in 1996 and is fielded every two years.

STUDY DESIGN

Semistructured interviews were conducted with 50-90 stakeholders and observers of the local health care market in each of the 12 communities every two years. Respondents include leaders of local hospitals, health plans, and physician organizations and representatives of major employers, state and local governments, and consumer groups. First round interviews were conducted in 1996-1997 and subsequent rounds of interviews were conducted in 1998-1999 and 2000-2001. A total of 1,690 interviews were conducted between 1996 and 2001. DATA ANALYSIS METHODS: Interview information was stored and coded in qualitative data analysis software. Data were analyzed to identify patterns and themes within and across study sites and conclusions were verified by triangulating responses from different respondent types, examining outliers, searching for disconfirming evidence, and testing rival explanations.

PRINCIPAL FINDINGS

Since the mid-1990s, managed care has developed differently than expected in local health care markets nationally. Three key developments shaped health care markets between 1999 and 2001: (1) unprecedented, sustained economic growth that resulted in extremely tight labor markets and made employers highly responsive to employee demands for even fewer restrictions on access to care; (2) health plans increasingly moved away from core strategies in the "managed care toolbox"; and (3) providers gained leverage relative to managed care plans and reverted to more traditional strategies of competing for patients based on services and amenities.

CONCLUSIONS

Changes in local health care markets have contributed to rising costs and created new access problems for consumers. Moreover, the trajectory of change promises to make the goals of cost-control and quality improvement more difficult to achieve in the future.

Managing costs, managing benefits: employer decisions in local health care markets

OBJECTIVES

To better understand employer health benefit decision making, how employer health benefits strategies evolve over time, and the impact of employer decisions on local health care systems.

DATA SOURCES/STUDY SETTING

Data were collected as part of the Community Tracking Study (CTS), a longitudinal analysis of health system change in 12 randomly selected communities.

STUDY DESIGN

This is an observational study with data collection over a six-year period.

DATA COLLECTION/EXTRACTION METHODS

The study used semistructured interviews with local respondents, combined with monitoring of local media, to track changes in health care systems over time and their impact on community residents. Interviewing began in 1996 and was carried out at two-year intervals, with a total of approximately 2,200 interviews. The interviews provided a variety of perspectives on employer decision making concerning health benefits; these perspectives were triangulated to reach conclusions.

PRINCIPAL FINDINGS

The tight labor market during the study period was the dominant consideration in employer decision making regarding health benefits. Employers, in managing employee compensation, made independent decisions in pursuit of individual goals, but these decisions were shaped by similar labor market conditions. As a result, within and across our study sites, employer decisions in aggregate had an important impact on local health care systems, although employers' more highly visible public efforts to bring about health system change often met with disappointing results.

CONCLUSIONS

General economic conditions in the 1990s had an important impact on the configuration of local health systems through their effect on employer decision making regarding health benefits offered to employees, and the responses of health plans and providers to those decisions.