Getting The Price Right: How Some Countries Control Spending In A Fee-For-Service System

Although the US has the highest health care prices in the world, the specific mechanisms commonly used by other countries to set and update prices are often overlooked, with a tendency to favor strategies such as reducing the use of fee-for-service reimbursement. Comparing policies in three high-income countries (France, Germany, and Japan), we describe how payers and physicians engage in structured fee negotiations and standardize prices in systems where fee-for-service is the main model of outpatient physician reimbursement. The parties involved, the frequency of fee schedule updates, and the scope of the negotiations vary, but all three countries attempt to balance the interests of payers with those of physician associations. Instead of looking for policy importation, this analysis demonstrates the benefits of structuring negotiations and standardizing fee-for-service payments independent of any specific reform proposal, such as single-payer reform and public insurance buy-ins.

Billing Codes Determine Lower Physician Income for Primary Care and Non-Procedural Specialties

The income gap between specialists and primary care physicians and among specialists is well established, but the drivers of this difference are not well delineated. Using the Community Tracking Study (CTS) Physician Survey, we sought to isolate and compare premiums paid to physicians for specialization and the proportion of time spent on offices visit rather than procedures. We divided medical subspecialties according the proportion of Medicare billing for Evaluation and Management (E&M) codes for the specialty as a whole. We report substantial differences in income across physician specialty, and over 70 percent of the difference in income remained controlling for factors that may confound the relationship between income and specialty including gender, location and type of practice, and hours. We note a large variation in premiums for specialization: 11.3-46.8 percent above family medicine after controlling for confounders. Classifying medical subspecialties by E&M billing as procedural versus non-procedural specialties revealed clear income differences. Controlling for confounders, procedural medical specialties earned 37.5 percent more than family medicine, as compared with 15.3 percent for non-procedural medical specialties. This analysis suggests that differences in physician income and resulting incentives are a direct consequence of the payment structure itself, rather than compensation for additional years of training or a reflection of different underlying demographics.

Precision lattice parameter determination from transmission diffraction of thick specimens with irregular cross sections

Accurate determination of lattice parameters from X-ray diffraction requires that the diffraction angles be measured very precisely, and significant errors result if the sample–detector separation differs from that assumed. Transmission diffraction from bones, which have a complex cross section and must be left intact, is a situation where this separation is difficult to measure and it may differ from position to position across the specimen. This article describes a method for eliminating the effect of variable sample cross section. Diffraction patterns for each position on the specimen are collected before and after 180° rotation about an axis normal to the cross section of interest. This places the centroid of the diffracting mass at the center of rotation and provides the absolute lattice parameters from the average apparent lattice parameters at the two rotation angles. Diffraction patterns were collected across the cross section of three specimens: a 3D-printed elliptical cylinder of Hyperelastic Bone (HB), which is composed primarily of synthetic hydroxyapatite (hAp), a 3D-printed HB model of the second metacarpal bone (Mc2), and a modern human Mc2 containing nanocrystalline carbonated apatite (cAp). Rietveld refinement was used to determine precise unit-cell parameters a apparent and c apparent for each pattern of each scan, and these values determined the actual average 〈a〉 and 〈c〉 for each sample. The results indicate that the 0°/180° rotation method works well enough to uncover variations approaching 1 × 10−3 Å in cAp unit-cell parameters in intact bones with irregular cross sections.

Take-up of public insurance and crowd-out of private insurance under recent CHIP expansions to higher income children

OBJECTIVE

To analyze the effects of states' expansions of Children's Health Insurance Program (CHIP) eligibility to children in higher income families on health insurance coverage outcomes.

DATA SOURCES

2002-2009 Current Population Survey linked to multiple secondary data sources.

STUDY DESIGN

Instrumental variables estimation of linear probability models. Outcomes are whether the child had any public insurance, any private insurance, or no insurance coverage during the year.

PRINCIPAL FINDINGS

Among children in families with incomes between two and four times the federal poverty line (FPL), four enrolled in CHIP for every 100 who became eligible. Roughly half of the newly eligible children who took up public insurance were previously uninsured. The upper bound "crowd-out" rate was estimated to be 46 percent.

CONCLUSIONS

The CHIP expansions to children in higher income families were associated with limited uptake of public coverage. Our results additionally suggest that there was crowd-out of private insurance coverage.

United States-Mexico cross-border health insurance initiatives: Salud Migrante and Medicare in Mexico

While U.S. health care reform will most likely reduce the overall number of uninsured Mexican-Americans, it does not address challenges related to health care coverage for undocumented Mexican immigrants, who will remain uninsured under the measures of the reform; documented low-income Mexican immigrants who have not met the five-year waiting period required for Medicaid benefits; or the growing number of retired U.S. citizens living in Mexico, who lack easy access to Medicare-supported services. This article reviews two promising binational initiatives that could help address these challenges-Salud Migrante and Medicare in Mexico; discusses their prospective applications within the context of U.S. health care reform; and identifies potential challenges to their implementation (legal, political, and regulatory), as well as the possible benefits, including coverage of uninsured Mexican immigrants, and their integration into the U.S. health care system (through Salud Migrante), and access to lower-cost Medicare-supported health care for U.S. retirees in Mexico (Medicare in Mexico).

Niche players in health policy: medical specialty societies in Congress 1969-2002

Scholars and commentators alike have long used 'organized medicine' as shorthand for the American Medical Association (AMA). However, organized medicine has increasingly shown signs of fragmentation into specialty societies over the last two decades. While the AMA remains the largest association of physicians, and wields a great deal of influence in political circles, its use as a proxy for organized medicine may warrant reevaluation due to the changing political organization of medicine. We developed a unique database of specialty medical society appearances before all Congressional committees by combining records from Lexis-Nexis Congressional and the Policy Agendas database. Descriptive statistics were used to evaluate the participation of specialty societies by committee and by hearing type. The Herfindahl-Hirschman Index (HHI) was used to measure whether specialty societies develop niche roles with specific committees, and the Chi-Square Goodness of Fit test was used to study the distribution of specialty society testimonies in health hearings more formally. We found that although the AMA participates in Congressional hearings at a higher rate than any other individual medical specialty society, it accounts for a decreasing percentage of all specialty society appearances over time. In addition, specialty societies have developed niche and monopoly roles in health policymaking as well as relationships with particular congressional committees over time. We conclude that the increasing participation of specialty medical societies in the policymaking process is important because medical societies do not testify solely to promote the economic self-interest of their members. Specialization in medicine has segmented lobbying roles, such that specialty societies have a different focus than the AMA. Thus, 'organized medicine' and the AMA are no longer synonymous.

Why some market reforms lack legitimacy in health care

Market-oriented health policy reforms in the 1980s and 1990s generally included five kinds of proposals: increased cost sharing for patients through user fees, the separation of purchaser-provider functions, management reforms of hospitals, provider competition, and vouchers for purchasing health insurance. These policies are partly derived from agency theory and a model of managed competition in health insurance. The essay reviews the course of reform in five countries that had a national health service model in place in the late 1980s: Italy, New Zealand, Spain, Sweden, and the United Kingdom. Special consideration is given to New Zealand, where the market model was extensively adopted but short lived. In New Zealand, surveys and polls are compared to archival records of reformers' deliberations. Voters saw health care differently from elites, and voters particularly felt that health care was ill suited to commercialization. There are similarities across all five countries in what has been adopted and rejected. Some market reforms are more legitimate than others. Reforms based on resolving principal-agent problems, including purchaser-provider splits and managerial reforms, have been more successful, although cost sharing has not. Competition-based reforms in financing and to a lesser extent in provision have not gained legitimacy. Most voters in these countries see health care as different from other parts of the economy and view managerial reforms differently from policies that try to make health care more like other sectors.

How many deaths are caused by second hand cigarette smoke?

OBJECTIVES

To estimate the number of deaths attributable to second hand smoke (SHS), to distinguish attributable and potentially avoidable burdens of mortality, and to identify the most important sources of uncertainty in these estimates.

METHOD

A case study approach, using exposure and mortality data for New Zealand.

RESULTS

In New Zealand, deaths caused by past exposures to second hand smoke currently number about 347 per year. On the basis of present exposures, we estimate there will be about 325 potentially avoidable deaths caused by SHS in New Zealand each year in the future. We have explored the effect of varying certain assumptions on which the calculations are based, and suggest a plausible range (174-490 avoidable deaths per year).

CONCLUSION

Attributable risk estimates provide an indication for policy makers and health educators of the magnitude of a health problem; they are not precise predictions. As a cause of death in New Zealand, we estimate that second hand smoke lies between melanoma of the skin (200 deaths per year) and road crashes (about 500 deaths per year).

The New Zealand food supply and diet--trends 1961-95 and comparison with other OECD countries. Organisatioin for Economic Co-operation and Development

AIMS

To compare the New Zealand food supply and trends from 1961 to 1995 with other Organisation for Economic Co-operation and Development (OECD) countries, with an emphasis on foods linked with coronary heart disease (CHD).

METHOD

Food and Agricultural Organization per capita food supply statistics for 24 OECD countries were converted to nutritional supply values and adjusted for edible portion.

RESULTS

In 1995, New Zealand had the highest supply per capita of butter and meat fats among OECD countries, ranking its food supply highest for thrombogenicity and third for atherogenicity. Seafood and alcohol supply were average and vitamin E supply was high compared with other OECD countries. Beneficial trends have occurred with increases in fruit consumption, vegetable consumption and fibre intake between 1961 and 1995. While total fat intake has not changed appreciably, the fatty acid profile has shifted and is now less likely to promote CHD.

CONCLUSIONS

The New Zealand diet's tendency to promote CHD has decreased, particularly since 1985. The diet's fatty acid profile, however, remains highly atherogenic and thrombogenic, predisposing to CHD, and the fat content of the food supply remains high, predisposing to obesity. Continued efforts are needed to improve the diet of New Zealanders and to maintain food supply data collection for long term monitoring of these changes.

New Zealand's tobacco control programme 1985-1998

OBJECTIVE

To review the impact of New Zealand's tobacco control programme from 1985 to 1998 on smoking prevalence and tobacco consumption, and to estimate the scope for further reduction.

DESIGN

Country case study; interventions, with outcomes ranked internationally across time.

SETTING

New Zealand 1985-98; for 1985-95, 23 OECD countries.

INTERVENTIONS

Between 1985 and 1998, New Zealand eliminated tobacco advertising, halved the affordability of cigarettes, and reduced smoke exposure in work time by 39%.

MAIN OUTCOME MEASURE

Reduction in adult smoking prevalence and in tobacco products consumption per adult.

RESULTS

Changes in prevalence 1985-98: in adults (aged 15+ years), -17% (from 30% to 25%) but short of the 20% target for 2000; in youth (aged 15-24 years), -20% (from 35% to 28%); and in Maori adults (aged 15+ years), -17% (from 56% in 1981 to 46% in 1996). Changes in consumption 1985-98: tobacco products per adult aged 15+ years, -45% (2493 to 1377 cigarette equivalents); cigarettes smoked per smoker, -34% (22. 7 to 15.0 per day). Between 1985 and 1995 New Zealand reduced tobacco products consumption per adult more rapidly than any other OECD country, and reduced youth prevalence more rapidly than most. The acceleration of the decline in cigarette attributable mortality rates in men and in women age 35-69 years averted an additional 1400 deaths between 1985 and 1996. Between 1981 and 1996 smoking prevalence among blue collar workers decreased only marginally, and in 14-15 year olds, rose by one third between 1992 and 1997.

CONCLUSION

In 13 years, New Zealand's tobacco control programme has been successful in almost halving tobacco products consumption, particularly by lowering consumption per smoker. With strong political support for quit campaigns, increased taxation, and the elimination of displays of tobacco products on sale, the consumption could theoretically be halved again in as little as 3-6 years.

Changes in cigarette purchasing by fourth form students in New Zealand 1992-1997

AIM

To determine recent changes in cigarette purchasing behaviour of 14- and 15-year-old students in New Zealand.

METHOD

Nationwide cross-sectional surveys of fourth form students in 85 schools in New Zealand by means of an anonymous self-administered questionnaire collected in November 1992 and in November 1997.

RESULTS

Analyses were restricted to 4198 out of 11 824 total students in 1992, and 4526 out of a total of 11 350 in 1997, who were current smokers aged 14 and 15 years. Self-purchasing of cigarettes decreased by 37% (95% CI: -40, -34) from 1992 to 1997, adjusting for age, sex and ethnicity, while acquiring cigarettes from other people increased. There was decreased purchasing from dairies (-6%; 95% CI: -8, -4) and supermarkets (-9%; 95% CI: -16, -1) but increases from other sources such as take-away shops, tobacconists and vending machines. From 1992 to 1997, weekly buying increased by 23% (95% CI 16, 32), students who were refused a sale increased by 153% (95% CI 139, 169) and students who had difficulty in buying increased by 324% (95% CI 276, 379). The latter were less likely to buy weekly than students who did not have difficulty (31.1% vs 41.4%). Students who smoked < or =5 cigarettes per week were 32% (95% CI 13, 53) more likely to have difficulty in buying than students smoking >20 per week.

CONCLUSION

These results indicate major changes in cigarette purchasing behaviour between 1992 and 1997, when there was increased enforcement against underage sales of tobacco.

Trends in cigarette smoking in fourth-form students in New Zealand, 1992-1997

AIMS

To determine trends in the cigarette smoking behaviour of 14- and 15-year-old students in New Zealand.

METHODS

Nationwide cross-sectional surveys of fourth-form students in New Zealand in 85 schools by anonymous self-administered questionnaire in 1992 and 1997. In 1992, 79% of schools and 70% of students responded; in 1997, 88% and 72%, respectively.

RESULTS

Responses were analysed from 11,824 14- and 15 year-old fourth formers in 1992 and from 11,350 in 1997. Daily, weekly or monthly combined smoking prevalence increased by 27% (95% confidence interval (CI) 21-32), adjusting for age, sex and ethnicity, from 23.4% in 1992 to 28.5% in 1997. Daily smoking increased from 11.6% in 1992 to 15.5% in 1997 - an adjusted 37% (95% CI = 24-47) increase. The increase in daily smoking was: greater in girls (44%, 95% CI = 33-57) than boys (28%, 95% CI = 16-42), adjusting for age and ethnicity; unrelated to the socioeconomic decile of schools; and greatest in Auckland and Northland.

CONCLUSION

This increase in smoking is large, 27-37% over five years, of uncertain cause, affects both sexes, all regions, ethnic and socio-economic groups, and certain cigarette brands. Regular school smoking surveys and more smokefree youth venues are recommended. Addiction and nicotine absorption merit monitoring. Legislation can require disclosure of manufacturing recipes used for youth-popular cigarette brands. On 1960-97 trends it would take 100 years to reduce fourth-form smoking to 5% prevalence. The proposed gradual denicotinisation of all cigarettes would allow smoking but prevent addiction, within ten years.

Emigration of New Zealand and Australian physicians to the United States and the international flow of medical personnel

One in five physicians practising in the US received their initial medical qualifications in another country. Contrary to expectations, a large cadre come from developed nations such as New Zealand and Australia. In particular, these two countries provide a unique prism with which to view the international flow of medical talent. While they differ from developing nations that primarily export physicians without attracting others in return, they are distinguished from importing nations such as the US which rarely export. Our analysis is based on a unique dataset collected from three cross-sectional sources. We found that, compared to post-resident physicians remaining at home, New Zealand medical graduates (NZMGs) and Australian medical graduates (AMGs) in the US are typically older, more likely to be male, more likely to have received their initial medical qualifications from certain schools, less likely to be employed in a public hospital setting, more likely to work in a medical school and more likely to practice in a specialty than primary care. Additional findings show that NZMGs and AMGs in the US are more likely than other US physicians to have established themselves in areas with 50,000 or more people and are therefore more likely to serve a population with sociodemographic characteristics typical of the nation's urban centers. It appears then, that NZMGs and AMGs may be emigrating to the US for educational and professional opportunities that may be unavailable at home. In short, the emigration of NZMGs and AMGs may be an instance of what has come to be called the 'international equity problem' or 'brain drain'. However, losses resulting from the disproportionate migration of New Zealand and Australian physicians to the US may be compensated for by the importation of foreign trained physicians from other nations. Future analysis must be extended to take this facet of the international flow phenomena into account.

New Zealand health care: a background

New Zealand, its people and health care services are described, followed by a discussion of (i) the role of government and non-government agencies in the funding, provision and purchasing of health care and (ii) persistent problems in the health care system. The authors argue that recent New Zealand health care reforms represent a significant deviation from past policies. However, to have any prospect of being judged as successful, the reforms must address difficulties in the funding, purchasing and provision of health care that are not new but have been features of New Zealand health care over many years.

Tobacco advertising restrictions, price, income and tobacco consumption in OECD countries, 1960-1986

Factors affecting tobacco consumption per adult in 22 countries of the OECD between 1960 and 1986, were studied using pooled cross-section time-series analysis. The resulting log-linear model was estimated using Generalized Least Squares. The severity of tobacco advertising restrictions in each country and year was scored from published legislation and information from health agencies. Tobacco advertising restrictions have since 1973 increasingly been associated with lower tobacco consumption. Lower consumption levels were also associated with higher real tobacco prices, and with increased female labour force participation. Higher levels of consumption were associated with higher per capita real income and with a larger fraction of tobacco consumed as manufactured cigarettes. The model explains 99.5% of the variance in the average annual level of tobacco consumption across these countries. Ten-fold differences in purchasing power for tobacco products were found across the countries and years studied. In all countries tobacco products became more affordable between 1960 and 1986. In 1986 either a 36% inflation-indexed increase in real tobacco prices, or legislation to end tobacco promotion in those countries without a total ban, would have lowered average consumption by 6.8% and both together, by 13.5%. Across the OECD, if in 1986 all governments had raised tobacco product prices relative to income to Irish levels, and had banned all tobacco promotion, tobacco products consumption per adult would have fallen by 40% in that year.

Advertising, price, income and publicity effects on weekly cigarette sales in New Zealand supermarkets

Total cigarettes (all brands) sold weekly by a panel of 60 New Zealand supermarkets were monitored electronically for 42 weeks, a period when cigarette advertisements were in plain format with strong, varied disease warnings. Real cigarette price, newspaper advertising of old, regular and upmarket brands, and the number of newspaper news items on smoking issues were inversely associated with cigarette sales. Tending to increase total sales (all brands) were: more non-shopping days in the current week, and in the week following; volume of grocery items purchased, to indicate income and store traffic; and real advertising expenditure in newspapers for new downmarket cigarette brands, particularly one heavily-advertised brand (Peter Jackson) which was in late 1989 smoked by 4% of teenage smokers. All factors when interacting, explained 93% of changes in weekly cigarette sales. Most of the change occurred in the same week, and was 90% in place after a further 3 weeks. Newspapers, by doubling news coverage of smoking issues or by banning cigarette advertisements, can lower cigarette consumption as much as can a 10% price increase.

The cost of cigarette smoking in New Zealand

Attributable risks of mortality and morbidity occasioned by current or past cigarette smoking are applied to recent mortality and hospital morbidity data. The 1981 census data on smoking, the hospital discharge data from 1984 and mortality since 1980 are analysed showing that 1 in 5 deaths of men aged 15 to 60 can be attributed to smoking, as can 1 in 9 deaths of women 15 to 60. In all 4137 deaths per year are attributable to smoking. Each year 4815 years of working life (15 to 60) are lost due to cigarette smoking induced premature mortality. Excess hospital use caused by cigarette smoking is estimated to cost more than $81 million (in 1986 dollars).

The prevalence of retained testes in Dunedin

A cohort of approximately 500 boys was screened for retained testes at ages five and seven years and when the boys were aged three, five, seven and nine years, their parents were questioned about hospitalisation for surgery. Orchidopexy for retained testes had been performed on 15 of the 536 boys (2.8%) while one other had orchidopexy for high retractile testes (0.2%). Eighty-one percent of this surgery was performed between the seventh and ninth years of age.

Computer assessment of alternative rubella vaccination strategies in New Zealand

Results from a dynamic computer model of rubella vaccination programmes indicate that consideration should be given to vaccinating all one-year-old girls and boys and revaccinating all girls at about 11 years of age, as well as continuing with the programme for susceptible women in the childbearing age group. With vaccine-induced immunity decaying at about 1% annually, the vaccination of 80 to 95% of all one-year-olds, 95% of 11 year old girls, and 5% of women aged 15 to 33 annually is expected to reduce congenital rubella syndrome deformities to less than 5% of the 1980 incidence by 1994, and to negligible levels thereafter. In comparison, continuation of the present scheme may reduce deformities to only 69% of 1980 levels by 1994 with a slow decline to 25% in 2010. (The 1980 levels used were computer generated to eliminate short-term fluctuations, and do not apply to actual figures from that year.) For convenience and better compliance, measles vaccine and the initial rubella vaccine may be given in combined form at 15 months without altering the effect of either. The rate of decay of immunity after vaccination is critically important in congenital rubella syndrome prediction, so that further accurate monitoring of immune status and congenital rubella incidence is essential.