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Maciejewski ML, Greene L, Grubber JM, Blalock DV, Jacobs J, Rao M, Zulman DM, Smith VA. Association between patient-reported social and behavioral risks and health care costs in high-risk Veterans health administration patients. Health Serv Res 2024; 59:e14243. [PMID: 37767603 PMCID: PMC10771909 DOI: 10.1111/1475-6773.14243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE Social risks complicate patients' ability to manage their conditions and access healthcare, but their association with health expenditures is not well established. To identify patient-reported social risk, behavioral, and health factors associated with health expenditures in Veterans Affairs (VA) patients at high risk for hospitalization or death. DATA SOURCES, STUDY SETTING, AND STUDY DESIGN Prospective cohort study among high-risk Veterans obtaining VA care. Patient-reported social risk, function, and other measures derived from a 2018 survey sent to 10,000 VA patients were linked to clinical and demographic characteristics extracted from VA data. Response-weighted generalized linear and marginalized two-part models were used to examine VA expenditures (total, outpatient, medication, inpatient) 1 year after survey completion in adjusted models. PRINCIPAL FINDINGS Among 4680 survey respondents, the average age was 70.9 years, 6.3% were female, 16.7% were African American, 20% had body mass index ≥35, 42.4% had difficulty with two or more basic or instrumental activities of daily living, 19.3% reported transportation barriers, 12.5% reported medication insecurity and 21.8% reported food insecurity. Medication insecurity was associated with lower outpatient expenditures (-$1859.51 per patient per year, 95% confidence interval [CI]: -3200.77 to -518.25) and lower total expenditures (-$4304.99 per patient per year, 95% CI: -7564.87 to -1045.10). Transportation barriers were negatively associated with medication expenditures (-$558.42, 95% CI: -1087.93 to -31.91). Patients with one functional impairment had higher outpatient expenditures ($2997.59 per patient year, 95% CI: 1185.81-4809.36) than patients without functional impairments. No social risks were associated with inpatient expenditures. CONCLUSIONS In this study of VA patients at high risk for hospitalization and mortality, few social and functional measures were independently associated with the costs of VA care. Individuals with functional limitations and those with barriers to accessing medications and transportation may benefit from targeted interventions to ensure that they are receiving the services that they need.
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Affiliation(s)
- Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Liberty Greene
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Janet M. Grubber
- Cooperative Studies Program Coordinating CenterBoston Veterans Affairs Health Care SystemBostonMassachusettsUSA
| | - Dan V. Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Josephine Jacobs
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Health Economics Resource CenterVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
| | - Mayuree Rao
- Seattle‐Denver Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWashingtonUSA
| | - Donna M. Zulman
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
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Jiang L, Qiu Q, Zhu L, Wang Z. Identifying Characteristics Associated with the Concentration and Persistence of Medical Expenses among Middle-Aged and Elderly Adults: Findings from the China Health and Retirement Longitudinal Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12843. [PMID: 36232143 PMCID: PMC9564963 DOI: 10.3390/ijerph191912843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
Medical expenses, especially among middle-aged and elderly people, have increased in China over recent decades. However, few studies have analyzed the concentration or persistence of medical expenses among Chinese residents or vulnerable groups with longitudinal survey data. Based on the data of CHARLS (China Health and Retirement Longitudinal Study), this study sought to identify characteristics associated with the concentration and persistence of medical expenses among Chinese middle-aged and elderly adults and to help alleviate medical spending and the operational risk of social medical insurance. Concentration was measured using the cumulative percentages of ranked annual medical expenses and descriptive statistics were used to define the characteristics of individuals with high medical expenses. The persistence of medical expenses and associated factors were estimated using transfer rate calculations and Heckman selection modeling. The results show that total medical expenses were concentrated among a few adults and the concentration increased over time. People in the high medical expense group were more likely to be older, live in urban areas, be less wealthy, have chronic diseases, and attend higher-ranking medical institutions. Lagged medical expenses had a persistent positive effect on current medical expenses and the effect of a one-period lag was strongest. Individuals with chronic diseases during the lagged period had a higher likelihood of experiencing persistent medical expenses. Policy efforts should focus on preventive management, more efficient care systems, improvement of serious illness insurance level, and strengthening the persistent protection effect of social medical insurance to reduce the high medical financial risk and long-term financial healthcare burden in China.
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Affiliation(s)
- Luyan Jiang
- School of Health Policy & Management, Nanjing Medical University, Nanjing 211166, China
| | - Qianqian Qiu
- School of Health Policy & Management, Nanjing Medical University, Nanjing 211166, China
| | - Lin Zhu
- School of Health Policy & Management, Nanjing Medical University, Nanjing 211166, China
| | - Zhonghua Wang
- School of Health Policy & Management, Nanjing Medical University, Nanjing 211166, China
- Public Health Policy and Management Innovation Research Group, Nanjing Medical University, Nanjing 211166, China
- Center for Global Health, Nanjing Medical University, Nanjing 211166, China
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Rodriguez Santana I, Aragón MJ, Rice N, Mason AR. Trends in and drivers of healthcare expenditure in the English NHS: a retrospective analysis. HEALTH ECONOMICS REVIEW 2020; 10:20. [PMID: 32607791 PMCID: PMC7325682 DOI: 10.1186/s13561-020-00278-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/23/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND In England, rises in healthcare expenditure consistently outpace growth in both GDP and total public expenditure. To ensure the National Health Service (NHS) remains financially sustainable, relevant data on healthcare expenditure are needed to inform decisions about which services should be delivered, by whom and in which settings. METHODS We analyse routine data on NHS expenditure in England over 9 years (2008/09 to 2016/17). To quantify the relative contribution of the different care settings to overall healthcare expenditure, we analyse trends in 14 healthcare settings under three broad categories: Hospital Based Care (HBC), Diagnostics and Therapeutics (D&T) and Community Care (CC). We exclude primary care and community mental health services settings due to a lack of consistent data. We employ a set of indices to aggregate diverse outputs and to disentangle growth in healthcare expenditure that is driven by activity from that due to cost pressures. We identify potential drivers of the observed trends from published studies. RESULTS Over the 9-year study period, combined NHS expenditure on HBC, D&T and CC rose by 50.2%. Expenditure on HBC rose by 54.1%, corresponding to increases in both activity (29.2%) and cost (15.7%). Rises in expenditure in inpatient (38.5%), outpatient (57.2%), and A&E (59.5%) settings were driven predominately by higher activity. Emergency admissions rose for both short-stay (45.6%) and long-stay cases (26.2%). There was a switch away from inpatient elective care (which fell by 5.1%) and towards day case care (34.8% rise), likely reflecting financial incentives for same-day discharges. Growth in expenditure on D&T (155.2%) was driven by rises in the volume of high cost drugs (270.5%) and chemotherapy (110.2%). Community prescribing grew by 45.2%, with costs falling by 24.4%. Evidence on the relationship between new technologies and healthcare expenditure is mixed, but the fall in drug costs could reflect low generic prices, and the use of health technology assessment or commercial arrangements to inform pricing of new medicines. CONCLUSIONS Aggregate trends in HCE mask enormous variation across healthcare settings. Understanding variation in activity and cost across settings is an important initial step towards ensuring the long-term sustainability of the NHS.
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Affiliation(s)
| | - María José Aragón
- Centre for Health Economics, Alcuin A Block, University of York, York, YO10 5DD, UK
| | - Nigel Rice
- Centre for Health Economics, Alcuin A Block, University of York, York, YO10 5DD, UK
| | - Anne Rosemary Mason
- Centre for Health Economics, Alcuin A Block, University of York, York, YO10 5DD, UK.
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Krämer J, Schreyögg J. Demand-side determinants of rising hospital admissions in Germany: the role of ageing. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:715-728. [PMID: 30739296 PMCID: PMC6602979 DOI: 10.1007/s10198-019-01033-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 01/24/2019] [Indexed: 06/09/2023]
Abstract
In this study, we investigated the relationship between changes in demand-side determinants and changes in hospital admissions. We used longitudinal market-wide data, including a novel detailed measure of population morbidity. To assess the effect of ageing, we interacted age with shifts in the population structure for both the surviving population and the population in their last year of life. We used fixed effects models and addressed the endogeneity of morbidity with instrumental variables. We found that changes in morbidity had the largest impact on changes in hospital admissions. Changes in the size of the surviving population had the second largest impact, which differed substantially across the age spectrum. There was a large response in admissions to changes in the size of the population aged 60-79 years. The end-of-life effect had the smallest impact and began to play a greater role only in the population aged 80 years and older. In many studies, end of life presumably approximates high morbidity. Our results demonstrated robustness in several tests. We performed estimations in separate major diagnostic categories and included changes in personal preferences. We argue that the determinants included in our estimations capture the vast majority of change on the demand side. Taken together, our findings provide evidence that these determinants explain one-fifth of changes in hospital admissions.
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Affiliation(s)
- Jonas Krämer
- Hamburg Center for Health Economics, Universität Hamburg, 20354, Hamburg, Germany
| | - Jonas Schreyögg
- Hamburg Center for Health Economics, Universität Hamburg, 20354, Hamburg, Germany.
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Wouterse B, Huisman M, Meijboom BR, Deeg DJH, Polder JJ. The effect of trends in health and longevity on health services use by older adults. BMC Health Serv Res 2015; 15:574. [PMID: 26704342 PMCID: PMC4690430 DOI: 10.1186/s12913-015-1239-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Indexed: 11/23/2022] Open
Abstract
Background The effect of population aging on future health services use depends on the relationship between longevity gains and health. Whether further gains in life expectancy will be paired by improvements in health is uncertain. We therefore analyze the effect of population ageing on health services use under different health scenarios. We focus on the possibly diverging trends between different dimensions of health and their effect on health services use. Methods Using longitudinal data on health and health services use, a latent Markov model has been estimated that includes different dimensions of health. We use this model to perform a simulation study and analyze the health dynamics that drive the effect of population aging. We simulate three health scenarios on the relationship between longevity and health (expansion of morbidity, compression of morbidity, and the dynamic equilibrium scenario). We use the scenarios to predict costs of health services use in the Netherlands between 2010 and 2050. Results Hospital use is predicted to decline after 2040, whereas long-term care will continue to rise up to 2050. Considerable differences in expenditure growth rates between scenarios with the same life expectancy but different trends in health are found. Compression of morbidity generally leads to the lowest growth. The effect of additional life expectancy gains within the same health scenario is relatively small for hospital care, but considerable for long-term care. Conclusions By comparing different health scenarios resulting in the same life expectancy, we show that health improvements do contain costs when they decrease morbidity but not mortality. This suggests that investing in healthy aging can contribute to containing health expenditure growth.
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Affiliation(s)
- Bram Wouterse
- Tranzo Scientific Center for Care and Welfare, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands. .,Center for Public Health Forecasting, National Institute for Public Health and the Environment, Bilthoven, >The Netherlands. .,CPB Netherlands Bureau for Economic Policy Analysis, P.O. Box 80510, The Hague, 2508 GM, >The Netherlands.
| | - Martijn Huisman
- EMGO + Institute on Health and Care Research, Department of Epidemiology & Biostatistics, VU University Medical Center, Amsterdam, >The Netherlands. .,Department of Sociology, VU University, Amsterdam, >The Netherlands.
| | - Bert R Meijboom
- Tranzo Scientific Center for Care and Welfare, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands.
| | - Dorly J H Deeg
- EMGO + Institute on Health and Care Research, Department of Epidemiology & Biostatistics, VU University Medical Center, Amsterdam, >The Netherlands. .,Department of Psychiatry, VU University Medical Center, Amsterdam, >The Netherlands.
| | - Johan J Polder
- Tranzo Scientific Center for Care and Welfare, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands. .,Center for Public Health Forecasting, National Institute for Public Health and the Environment, Bilthoven, >The Netherlands.
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Cangelosi MJ, Rodday AM, Saunders T, Cohen JT. Evaluation of the Economic Burden of Diseases Associated With Poor Nutrition Status. JPEN J Parenter Enteral Nutr 2013; 38:35S-41S. [DOI: 10.1177/0148607113514612] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Michael J. Cangelosi
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, Massachusetts
| | - Angie Mae Rodday
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Tully Saunders
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, Massachusetts
| | - Joshua T. Cohen
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, Massachusetts
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Smits FT, Brouwer HJ, Zwinderman AH, Mohrs J, Smeets HM, Bosmans JE, Schene AH, Van Weert HC, ter Riet G. Morbidity and doctor characteristics only partly explain the substantial healthcare expenditures of frequent attenders: a record linkage study between patient data and reimbursements data. BMC FAMILY PRACTICE 2013; 14:138. [PMID: 24044374 PMCID: PMC3851974 DOI: 10.1186/1471-2296-14-138] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 09/06/2013] [Indexed: 11/29/2022]
Abstract
Background Frequently attending patients to primary care (FA) are likely to cost more in primary care than their non-frequently attending counterparts. But how much is spent on specialist care of FAs? We describe the healthcare expenditures of frequently attending patients during 1, 2 or 3 years and test the hypothesis that additional costs can be explained by FAs’ combined morbidity and primary care physicians’ characteristics. Methods Record linkage study. Pseudonymised clinical data from the medical records of 16 531 patients from 39 general practices were linked to healthcare insurer’s reimbursements data. Main outcome measures were all reimbursed primary and specialist healthcare costs between 2007 and 2009. Multilevel linear regression analysis was used to quantify the effects of the different durations of frequent attendance on three-year total healthcare expenditures in primary and specialist care, while adjusting for age, sex, morbidities and for primary care physicians characteristics. Primary care physicians’ characteristics were collected through administrative data and a questionnaire. Results Unadjusted mean 3-year expenditures were 5044 and 15 824 Euros for non-FAs and three-year-FAs, respectively. After adjustment for all other included confounders, costs both in primary and specialist care remained substantially higher and increased with longer duration of frequent attendance. As compared to non-FAs, adjusted mean expenditures were 1723 and 5293 Euros higher for one-year and three-year FAs, respectively. Conclusions FAs of primary care give rise to substantial costs not only in primary, but also in specialist care that cannot be explained by their multimorbidity. Primary care physicians’ working styles appear not to explain these excess costs. The mechanisms behind this excess expenditure remain to be elucidated.
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Affiliation(s)
- Frans T Smits
- Department of General Practice - Academic Medical Center, University of Amsterdam, Amsterdam 1105 AZ, The Netherlands.
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Abstract
Although the consequences of population aging for growth in health expenditures have been widely investigated, research on this topic is rather fragmented. Therefore, these consequences are not fully understood. This paper reviews the consequences of population aging for health expenditure growth in Western countries by combining insights from epidemiological and health economics research. Based on a conceptual model of health care use, we first review evidence on the relationship between age and health expenditures to provide insight into the direct effect of aging on health expenditure growth. Second, we discuss the interaction between aging and the main societal drivers of health expenditures. Aging most likely influences growth in health expenditures indirectly, through its influence on these societal factors. The literature shows that the direct effect of aging depends strongly on underlying health and disability. Commonly used approximations of health, like age or mortality, insufficiently capture complex dynamics in health. Population aging moderately increases expenditures on acute care and strongly increases expenditures on long-term care. The evidence further shows that the most important driver of health expenditure growth, medical technology, interacts strongly with age and health, i.e., population aging reinforces the influence of medical technology on health expenditure growth and vice versa. We therefore conclude that population aging will remain in the centre of policy debate. Further research should focus on the changes in health that explain the effect of longevity gains on health expenditures, and on the interactions between aging and other societal factors driving expenditure growth.
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Wouterse B, Huisman M, Meijboom BR, Deeg DJH, Polder JJ. Modeling the relationship between health and health care expenditures using a latent Markov model. JOURNAL OF HEALTH ECONOMICS 2013; 32:423-439. [PMID: 23353134 DOI: 10.1016/j.jhealeco.2012.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 11/08/2012] [Accepted: 11/16/2012] [Indexed: 06/01/2023]
Abstract
We investigate the dynamic relationship between several dimensions of health and health care expenditures for older individuals. Health data from the Longitudinal Aging Survey Amsterdam is combined with data on hospital and long term care use. We estimate a latent variable based jointly on observed health indicators and expenditures. Annual transition probabilities between states of the latent variable are estimated using a Markov model. States associated with good current health and low annual health care expenditures are not associated with lower cumulative health care expenditures over remaining lifetime. We conclude that, although the direct health care cost saving effect is limited, the considerable gain in healthy lifeyears can make investing in the improvement of health of the older population worthwhile.
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Affiliation(s)
- Bram Wouterse
- Tranzo Scientific Center for Care and Welfare, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands.
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