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Duckett S. The problematic place of private payment for healthcare in Australia. Healthc Manage Forum 2021; 34:225-228. [PMID: 33622082 DOI: 10.1177/0840470421994139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Private funding and private hospital provision play a key role in Australian healthcare. However, this role is inherently inequitable, creating a two-speed health system. Canada should avoid expanding private involvement in paying for healthcare.
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Affiliation(s)
- Stephen Duckett
- Health Program, Grattan Institute, Carlton, AU-VIC Victoria, Australia
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McGee BT, Parikh R, Phillips V. Cost implications of patient spending on heart failure medications in the US Medicare program. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2021. [DOI: 10.1093/jphsr/rmaa018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Objectives
The aim of this study was to model the associations between patient spending on heart failure (HF) medications and Medicare and all-payer expenditures on health care services for participants in the Medicare prescription drug (Part D) program.
Methods
Correlational analysis of pooled 2011–12 data from the Medicare Current Beneficiary Survey. Analysis was restricted to community-dwelling beneficiaries with self-reported HF at baseline, continuous Part D coverage, and no Low-Income Subsidy (LIS). The main predictor was mean patient expenditure on a HF-related prescription per 30-day supply. The outcomes were all-payer and Medicare-specific payments for inpatient and total health care services during the observation year.
Key findings
Mean patient drug expenditure was not statistically associated with Medicare or all-payer inpatient payments or (after covariate adjustment) with total health care payments. However, patient expenditure was statistically associated with total Medicare payments, eγ = 1.022, 95% CI [1.004 to 1.041]. Marginal effects analysis predicted an average rise in total Medicare payments of $190.32, 95% CI [$40.54 to $341.10], for each additional $1 of patient spending per prescription, P = 0.013. Given an average 2.4 HF-indicated drug classes per participant and assuming 12.2 copays per year, a hypothetical $1 increase in prescription copay predicted a net loss to Medicare of $160.90 per participant.
Conclusion
Prescription drug spending by Medicare beneficiaries with HF was not associated with higher inpatient or all-payer costs. A modest association between patient drug spending and total Medicare costs was observed, but longitudinal and cost-effectiveness analyses are needed to support causal inference.
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Affiliation(s)
- Blake Tyler McGee
- Georgia State University Byrdine F. Lewis College of Nursing and Health Professions, Atlanta, GA, USA
| | - Rishika Parikh
- Department of Population Health Sciences, Georgia State University School of Public Health, Atlanta, GA, USA
| | - Victoria Phillips
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, GA, USA
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McGee BT, Higgins MK, Phillips V, Butler J. Prescription drug spending and hospital use among Medicare beneficiaries with heart failure. Res Social Adm Pharm 2020; 16:1452-1458. [PMID: 31953113 DOI: 10.1016/j.sapharm.2019.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 12/20/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Heart failure (HF) is a common cause of hospitalization in Medicare. Optimal medication adherence lowers hospitalization risk in HF patients. Although out-of-pocket spending can adversely affect adherence to HF medications, it is unknown whether medication spending ultimately increases hospital use for Medicare beneficiaries with HF. OBJECTIVE To examine the association between out-of-pocket medication payments and HF-related hospital use among Medicare Part D subscribers. METHODS Retrospective analysis of the 2010-12 Medicare Current Beneficiary Survey. The sample comprised community-dwelling respondents with fee-for-service Medicare, continuous Part D coverage, and self-reported HF (n = 819 participant-year records). The effects of average out-of-pocket payment for a 30-day HF-related prescription on odds and frequency of hospitalization and total inpatient days attributable to HF were estimated. Design-adjusted models adjusted for sociodemographic and health status variables, survey year and censoring, and included a pre-specified interaction of out-of-pocket payment with Medicaid co-eligibility. RESULTS The interaction term was statistically significant in all the models. For beneficiaries without Medicaid, average out-of-pocket payment per prescription was not significantly associated with odds of HF-related hospitalization (odds ratio = 1.01, 95% CI = 0.98-1.05, P = .399). The association between out-of-pocket payment and hospitalization frequency was statistically significant (incidence rate ratio [IRR] = 1.02, 95% CI = 1.00-1.05, P = .048), as was the association between out-of-pocket payment and total inpatient days (IRR = 1.04, 95% CI = 1.00-1.08, P = .041). For Medicaid co-eligible beneficiaries, the validity of model estimates is limited, because the range of actual out-of-pocket payments was negligible. CONCLUSIONS Fee-for-service Medicare beneficiaries with Part D, self-reported HF, and no supplemental Medicaid tolerated out-of-pocket medication payments without elevated risk of HF-related hospital use, but medication spending modestly increased hospital use intensity. Therefore, Part D plans with higher out-of-pocket requirements for essential HF medications may warrant additional scrutiny.
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Affiliation(s)
- Blake Tyler McGee
- Laney Graduate School, Emory University, 201 Dowman Dr. NW, Atlanta, GA, 30322, USA.
| | - Melinda K Higgins
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd. NW, Atlanta, GA, 30322, USA.
| | - Victoria Phillips
- Rollins School of Public Health, Emory University, 1518 Clifton Rd. NW, Atlanta, GA, 30322, USA.
| | - Javed Butler
- Department of Medicine, University of Mississippi, 2500 N State St. Jackson, MS, 39216, USA.
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Gaffney A, McCormick D, Bor DH, Goldman A, Woolhandler S, Himmelstein DU. The Effects on Hospital Utilization of the 1966 and 2014 Health Insurance Coverage Expansions in the United States. Ann Intern Med 2019; 171:172-180. [PMID: 31330539 DOI: 10.7326/m18-2806] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Persons with comprehensive health insurance use more hospital care than those who are uninsured or have high-deductible plans. Consequently, analysts generally assume that expanding coverage will increase society-wide use of inpatient services. However, a limited supply of beds might constrain this growth. OBJECTIVE To determine how the implementations of Medicare and Medicaid (1966) and the Patient Protection and Affordable Care Act (ACA) (2014) affected hospital use. DESIGN Repeated cross-sectional study. SETTING Nationally representative surveys. PARTICIPANTS Respondents to the National Health Interview Survey (1962 to 1970) and Medical Expenditure Panel Survey (2008 to 2015). MEASUREMENTS Mean hospital discharges and days were measured, both society-wide and among subgroups defined by income, age, and health status. Changes between preexpansion and postexpansion periods were analyzed using multivariable negative binomial regression. RESULTS Overall hospital discharges averaged 12.8 per 100 persons in the 3 years before implementation of Medicare and Medicaid and 12.7 per 100 persons in the 4 years after (adjusted difference, 0.2 discharges [95% CI, -0.1 to 0.4 discharges] per 100 persons; P = 0.26). Hospital days did not change in the first 2 years after implementation but increased later. Effects differed by subpopulation: Adjusted discharges increased by 2.4 (CI, 1.7 to 3.1) per 100 persons among elderly compared with nonelderly persons (P < 0.001) and also increased among those with low incomes compared with high-income populations. For younger and higher-income persons, use decreased. Similarly, after the ACA's implementation, overall hospital use did not change: Society-wide rates of discharge were 9.4 per 100 persons before the ACA and 9.0 per 100 persons after the ACA (adjusted difference, -0.6 discharges [CI, -1.3 to 0.2 discharges] per 100 persons; P = 0.133), and hospital days were also stable. Trends differed for some subgroups, and rates decreased significantly in unadjusted (but not adjusted) analyses among persons reporting good or better health status and increased nonsignificantly among those in worse health. LIMITATION Data sources relied on participant recall, surveys excluded institutionalized persons, and follow-up after the ACA was limited. CONCLUSION Past coverage expansions were associated with little or no change in society-wide hospital use; increases in groups who gained coverage were offset by reductions among others, suggesting that bed supply limited increases in use. Reducing coverage may merely shift care toward wealthier and healthier persons. Conversely, universal coverage is unlikely to cause a surge in hospital use if growth in hospital capacity is carefully constrained. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Adam Gaffney
- Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts (A.G., D.M., D.H.B.)
| | - Danny McCormick
- Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts (A.G., D.M., D.H.B.)
| | - David H Bor
- Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts (A.G., D.M., D.H.B.)
| | - Anna Goldman
- Harvard T.H. Chan School of Public Health, Boston, and Cambridge Health Alliance, Cambridge, Massachusetts (A.G.)
| | - Steffie Woolhandler
- Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts, and City University of New York at Hunter College, New York, New York (S.W., D.U.H.)
| | - David U Himmelstein
- Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts, and City University of New York at Hunter College, New York, New York (S.W., D.U.H.)
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Nyman JA, Koc C, Dowd BE, McCreedy E, Trenz HM. Decomposition of moral hazard. JOURNAL OF HEALTH ECONOMICS 2018; 57:168-178. [PMID: 29275240 DOI: 10.1016/j.jhealeco.2017.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 09/25/2017] [Accepted: 12/07/2017] [Indexed: 06/07/2023]
Abstract
This study seeks to simulate the portion of moral hazard that is due to the income transfer contained in the coinsurance price reduction. Healthcare spending of uninsured individuals from the MEPS with a priority health condition is compared with the predicted counterfactual spending of those same individuals if they were insured with either (1) a conventional policy that paid off with a coinsurance rate or (2) a contingent claims policy that paid off by a lump sum payment upon becoming ill. The lump sum payment is set to be equal to the insurer's predicted spending under the coinsurance policy. The proportion of moral hazard that is efficient is calculated as the proportion of total moral hazard that is generated by this lump sum payment. We find that the efficient proportion of moral hazard varies from disease to disease, but is the highest for those with diabetes and cancer.
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Affiliation(s)
- John A Nyman
- Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware St. SE, Box 729, Minneapolis, MN, 55455-0392, United States.
| | - Cagatay Koc
- Cornerstone Research, 1919 Pennsylvania Avenue, N.W., Suite 600, Washington, D.C., 20006-3420, United States
| | - Bryan E Dowd
- Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware St. SE, Box 729, Minneapolis, MN, 55455-0392, United States
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, Brown University, School of Public Health, 121 South Main Street, Suite 6, Providence, RI, 02903, United States
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Affiliation(s)
- Joseph P Newhouse
- From the Departments of Health Care Policy (J.P.N., S-L.T.N.) and Biostatistics (S.-L.T.N.), Harvard Medical School, Boston
| | - Sharon-Lise T Normand
- From the Departments of Health Care Policy (J.P.N., S-L.T.N.) and Biostatistics (S.-L.T.N.), Harvard Medical School, Boston
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Jing L, Bai J, Sun X, Zakus D, Lou J, Li M, Zhang Q, Zhuang Y. NRCMS capitation reform and effect evaluation in Pudong New Area of Shanghai. Int J Health Plann Manage 2015; 31:e131-57. [DOI: 10.1002/hpm.2302] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/30/2015] [Accepted: 05/05/2015] [Indexed: 11/11/2022] Open
Affiliation(s)
- Limei Jing
- Pudong Institute for Health Development; Shanghai 200129 China
| | - Jie Bai
- Pudong Institute for Health Development; Shanghai 200129 China
- School of Public Health; Fudan University; Shanghai 200031 China
| | - Xiaoming Sun
- Pudong Institute for Health Development; Shanghai 200129 China
- Pudong New Area Health and Family Planning Commission; Shanghai 200125 China
| | - David Zakus
- Global Health, Community Engagement; University of Alberta; Edmonton Alberta T6G 1C9 Canada
| | - Jiquan Lou
- School of Public Health; Fudan University; Shanghai 200031 China
| | - Ming Li
- Pudong New Area Health and Family Planning Commission; Shanghai 200125 China
| | - Qunfang Zhang
- Pudong New Area New Rural Cooperative Medical Scheme Management Office; Shanghai 201300 China
| | - Yuehong Zhuang
- Pudong New Area Health and Family Planning Commission; Shanghai 200125 China
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Abstract
Overutilization is commonly blamed for escalating costs, compromising quality, and limiting access to the US health care system. Recent estimates suggest that nearly one-third of health care spending in the United States is a result of unnecessary care. Despite the surge of exposés that purport to uncover this "new" problem, narratives about overutilization have been circulating in health policy debates since the beginnings of the health insurance industry. This article traces how the term overutilization has spread in popularity from a relatively small community of mid-twentieth-century insurance experts to economists, physicians, epidemiologists, and eventually the news media of the early twenty-first century. A quick glimpse at the history of the term reveals that there has been constant disagreement and debate over the meaning and impact of overutilization. Moreover, the term has been put to very different uses, from keeping socialism at bay to preserving the fiscal integrity of Medicare to protecting the health of patients. The overutilization narrative, seductive in its promise of cutting costs without sacrificing access to quality care, too often drowns out other difficult conversations about social welfare, health equity, prices, and universal coverage.
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Abstract
In 2003, John Nyman published The Theory of Demand for Health Insurance. His principal contributions are (1) to replace the previously unexamined axiom of risk avoidance with the axiom of welfare maximization; (2) to uncover a misinterpretation in the literature on moral hazard, namely, the insurance payoff as a price reduction, rather than as an income transfer. The immediate consequence of these reformulations is to recognize insurance-induced health care utilization as resulting in an increase in social welfare. Despite its evident validity and enormous implications, Nyman’s work has received very little attention or recognition in the health economics literature.
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Aron-Dine A, Einav L, Finkelstein A. The RAND Health Insurance Experiment, three decades later. THE JOURNAL OF ECONOMIC PERSPECTIVES : A JOURNAL OF THE AMERICAN ECONOMIC ASSOCIATION 2013; 27:197-222. [PMID: 24610973 PMCID: PMC3943162 DOI: 10.1257/jep.27.1.197] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
We re-present and re-examine the analysis from the famous RAND Health Insurance Experiment from the 1970s on the impact of consumer cost sharing in health insurance on medical spending. We begin by summarizing the experiment and its core findings in a manner that would be standard in the current age. We then examine potential threats to the validity of a causal interpretation of the experimental treatment effects stemming from different study participation and differential reporting of outcomes across treatment arms. Finally, we re-consider the famous RAND estimate that the elasticity of medical spending with respect to its out-of-pocket price is −0.2, emphasizing the challenges associated with summarizing the experimental treatment effects from non-linear health insurance contracts using a single price elasticity.
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Cogan JA. The Affordable Care Act's preventive services mandate: breaking down the barriers to nationwide access to preventive services. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2011; 39:355-365. [PMID: 21871033 DOI: 10.1111/j.1748-720x.2011.00605.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The Affordable Care Act (ACA) transforms the U.S.'s public and private health care financing systems into vehicles for promoting public health by making evidence-based preventive services available nationwide through individual and group health plans, Medicare, and Medicaid. The ACA accomplishes this transformation by breaking down two barriers: (1) the public health-health care divide, which led to a dominance of curative medicine over preventive health measures and (2) ERISA preemption, which created an obstacle to the provision of a uniform set of evidence-based preventive services that could be made available to the U.S. population through individual and group health plans. As a result, prevention measures with proven effectiveness will now be provided on a national and uniform basis to a majority of Americans, with the potential to improve health outcomes and reduce costs.
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Moral hazard and modern health care. Plast Reconstr Surg 2010; 126:280e-281e. [PMID: 21042096 DOI: 10.1097/prs.0b013e3181ef94f4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rosenau PV, Lal LS, Glasser JH. U.S. pharmacy policy: a public health perspective on safety and cost. SOCIAL WORK IN PUBLIC HEALTH 2009; 24:543-567. [PMID: 19821192 DOI: 10.1080/19371910802679457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A public health perspective based on social justice and a population health point of view emphasizes pharmacy policy innovations regarding safety and costs. Such policies that effectively reduce costs include controlling profits, establishing profit targets, extending prescription providers, revising prescription classification schemes, emphasizing generic medications, and establishing formularies. Public education and universal programs may reduce costs, but co-pays and "cost-sharing" do not. Switching medications to over-the-counter (OTC) status, pill splitting, and importing medication from abroad are poor substitutes for authentic public health pharmacy policy. Where policy changes yield savings, public health insists that these savings should be used to increase access and improve population health. In the future, pharmacy policies may emphasize public health accountability more than individual liberty because of potential cost savings to society. Fear of litigation, as an informal mechanism of focusing manufacturer's attention on safety, is inefficient; public health pharmacy policy regarding safety looks toward a more active regulatory role on the part of government. A case study of direct-to-consumer advertising illustrates the complexity of public health pharmacy policy.
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Affiliation(s)
- Pauline Vaillancourt Rosenau
- Division of Management, Policy, and Community Health, School of Public Health, University of Texas, Houston, Texas 77030, USA.
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Affiliation(s)
- Dahlia K. Remler
- School of Public Affairs, Baruch College, City University of New York, New York, NY, 10010, and Economics Department, The Graduate Center of the City University of New York and National Bureau of Economic Research, New York, NY 10016;
| | - Jessica Greene
- Department of Planning, Public Policy, and Management, University of Oregon, Eugene, Oregon, 97403
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