Patient cost-sharing and healthcare spending growth

Leadership to Accelerate Healthcare's Digital Transformation: Evidence From 33 Health Systems

GOAL

The COVID-19 pandemic, healthcare market disruptors, and new digital healthcare technologies have made a substantial impact on the delivery of healthcare services, highlighting the critical roles of leaders in hospitals and health systems. This study sought to understand the evolving roles of CEOs, CIOs, and other executive leaders in the postpandemic era and highlight the adaptability and strategic vision of executives in shaping the future of healthcare delivery.

METHODS

Between October 2022 and May 2023, 51 interviews were conducted with CEOs, CIOs, and other executives responsible for delivering technology solutions for 33 nonprofit health systems in the United States. They were asked to describe their backgrounds; how information solutions and technologies were viewed within their organizations' strategy, operations, and governance; and the key characteristics of executive leaders.

PRINCIPAL FINDINGS

The study has found that effective CEOs have an authentic belief in technology's role in achieving their organization's mission and that contemporary CIOs are strategic executive partners who align strategy with culture to improve care. This study examines how healthcare systems are creating digitally savvy executive leadership teams that operate in a new, integrated model that unites previously siloed functions.

PRACTICAL APPLICATIONS

Some healthcare CIOs are unprepared for current and future business challenges, and some CEOs are unsure how to leverage digital technologies and C-suite expertise to transform their organizations. This research provides insights into how the nation's health systems are building and sustaining leadership teams capable of adapting to the healthcare environment and accelerating organizational transformation.

Total and Out-of-Pocket Costs Surrounding Emergency Department Care Among Older Adults Enrolled in Traditional Medicare and Medicare Advantage

STUDY OBJECTIVE

We sought to quantify differences in total and out-of-pocket health care costs associated with treat-and-release emergency department (ED) visits among older adults with traditional Medicare and Medicare Advantage.

METHODS

We conducted a repeated cross-sectional analysis of treat-and-release ED visits using 2015 to 2020 data from the Medicare Current Beneficiary Survey. We measured total and out-of-pocket health care spending during 3 time periods: the 30 days prior to the ED visit, the treat-and-release ED visit itself, and the 30 days after the ED visit. Stratified by traditional Medicare or Medicare Advantage status, we determined median total costs and the proportion of costs that were out-of-pocket.

RESULTS

Among the 5,011 ED visits by those enrolled in traditional Medicare, the weighted median total (and % out-of-pocket) costs were $881.95 (13.3%) for the 30 days prior to the ED visit, $419.70 (10.1%) for the ED visit, and $809.00 (13.8%) for the 30 days after the ED visit. For the 2,595 ED visits by those enrolled in Medicare Advantage, the weighted median total (and % out-of-pocket) costs were $484.92 (24.0%) for the 30 days prior to the ED visit, $216.66 (21.9%) for the ED visit, and $439.13 (22.4%) for the 30 days after the ED visit.

CONCLUSION

Older adults insured by Medicare Advantage incur lower total health care costs and face similar overall out-of-pocket expenses in the time period surrounding emergency care. However, a higher proportion of expenses are out-of-pocket compared with those insured by traditional Medicare, providing evidence of greater cost sharing for Medicare Advantage plan enrollees.

Painless cost control as a central strategy for universal oral health coverage: A critical review with policy guide

AIM

This study aimed to critically review the methods used to control the significantly increasing costs of dental care.

METHODS

Through a comprehensive search of the available literature, the cost control (CC) mechanisms for health services were identified from a healthcare system perspective. The probable applicability of each CC method was evaluated mainly based on its potential contribution to oral health promotion. Each mechanism was then classified and discussed under any of the two headings of financing and service provision. An operational guide was finally presented for policy-making in each of the three main models of healthcare systems, including National Health Services, social/public health insurance and private insurance.

RESULTS

From a total of 142 articles/reports retrieved in PubMed, 73 in Scopus and 791 in Google Scholar, 35 were included in the final review after eliminating the duplicates and screening process. Totally ten mechanisms were identified for CC of dental care. Seven were discussed under the financing function, including cost sharing, preauthorization, mixed payment method and an evidence-based approach to benefit package definition, among others. Three further methods were classified under the service provision function, including workforce skill mix with emphasis on primary oral healthcare providers, development of primary healthcare (PHC) network and an appropriate use of tele-dentistry.

CONCLUSION

Painless control of dental expenditures requires a smart integration of prevention into the CC plans. The suggested policy guide emphasizes organizational factors; particularly including the development of PHC-based networks with midlevel providers (desirably extended-duty dental hygienists) as the frontline oral healthcare providers.

Effect of no cost sharing for paediatric care on healthcare usage by household income levels: regression discontinuity design

OBJECTIVES

To investigate the impact of no cost sharing on paediatric care on usage and health outcomes, and whether the effect varies by household income levels.

DESIGN

Regression discontinuity design.

SETTING

Nationwide medical claims database in Japan.

PARTICIPANTS

Children aged younger than 20 years from April 2018 to March 2022.

EXPOSURE

Co-insurance rate that increases sharply from 0% to 30% at a certain age threshold (the threshold age varies between 6 and 20 years depending on region).

PRIMARY OUTCOME MEASURES

The outpatient care usage (outpatient visit days and healthcare spending for outpatient care) and inpatient care (experience of any hospitalisation and healthcare spending for inpatient care).

RESULTS

Of 244 549 children, 49 556 participants were in the bandwidth and thus included in our analyses. Results from the regression discontinuity analysis indicate that no cost sharing was associated with a significant increase in the number of outpatient visit days (+5.26 days; 95% CI, +4.89 to +5.82; p<0.01; estimated arc price elasticity, -0.45) and in outpatient healthcare spending (+US$369; 95% CI, +US$344 to +US$406; p<0.01; arc price elasticity, -0.55). We found no evidence that no cost sharing was associated with changes in inpatient care usage. Notably, the effect of no cost-sharing policy on outpatient healthcare usage was larger among children from high-income households (visit days +5.96 days; 95% CI, +4.88 to +7.64, spending +US$511; 95% CI, +US$440 to +US$627) compared with children from low-income households (visit days +2.64 days; 95% CI, +1.54 to +4.23, spending +US$154; 95% CI, +US$80 to +US$249).

CONCLUSIONS

No cost sharing for paediatric care was associated with a greater usage of outpatient care services, but did not affect inpatient care usage. The study found that this effect was more pronounced among children from high-income households, indicating that the no cost sharing disproportionately benefits high-income households and may contribute to larger disparities.

The Associations of Prescription Drug Insurance and Cost-Sharing With Drug Use, Health Services Use, and Health: A Systematic Review of Canadian Studies

OBJECTIVES

In Canada, public insurance for physician and hospital services, without cost-sharing, is provided to all residents. Outpatient prescription drug coverage, however, is provided through a patchwork system of public and private plans, often with substantial cost-sharing, which leaves many underinsured or uninsured.

METHODS

We conducted a systematic review to examine the association of drug insurance and cost-sharing with drug use, health services use, and health in Canada. We searched 4 electronic databases, 2 grey literature databases, 5 specialty journals, and 2 working paper repositories. At least 2 reviewers independently screened articles for inclusion, extracted characteristics, and assessed risk of bias.

RESULTS

The expansion of drug insurance was associated with increases in drug use, individuals who reported drug insurance generally reported higher drug use, and increases in and higher levels of drug cost-sharing were associated with lower drug use. Although a number of studies found statistically significant associations between drug insurance or cost-sharing and health services use, the magnitudes of these associations were generally fairly small. Among 5 studies that examined the association of drug insurance and cost-sharing with health outcomes, 1 found a statistically significant and clinically meaningful association. We did not find that socioeconomic status or sex were effect modifiers; there was some evidence that health modified the association between drug insurance and cost-sharing and drug use.

CONCLUSIONS

Increased cost-sharing is likely to reduce drug use. Universal pharmacare without cost-sharing may reduce inequities because it would likely increase drug use among lower-income populations relative to higher-income populations.

Does Maintained Medical Aid Coverage Affect Healthy Lifestyle Factors, Metabolic Syndrome-Related Health Status, and Individuals' Use of Healthcare Services?

Concerns about the moral hazards and usage of universal health insurance require examination. This study aimed to analyze changes in lifestyle, metabolic syndrome-related health status, and individuals' tendency to use healthcare services according to changes in the eligibility status of medical aid recipients. This paper reports a retrospective cohort study that involved analyzing data from 2366 medical aid recipients aged 40 years or older who underwent national health screenings in 2012 and 2014. Of the recipients, 1606 participants continued to be eligible for medical aid (the "maintained" group) and 760 changed from being medical aid recipients to National Health Insurance (NHI) enrollees (the "changed" group). Compared to the "changed" group, the "maintained" group was less likely to quit smoking, more likely to begin smoking, less likely to reduce binge drinking to moderate drinking, and had a significant increase in blood glucose and waist circumference. Annual total medical expenses also increased significantly in the "maintained" group. Since the mere strengthening of healthcare coverage may lead to moral hazards and the failure to link individuals' tendency to use healthcare services and outcomes, establishing mechanisms is necessary to educate people about the health-related outcomes of maintaining a healthy lifestyle and ensure the appropriate use of healthcare services.

Minimum generosity levels in a competitive health insurance market

An important condition for optimal health insurance is that the level of health care coverage is inversely related to the elasticity of demand. We show that this condition is not satisfied for voluntary deductibles in the Netherlands, which are optional deductibles on top of the mandatory deductible introduced by the Dutch government. We find that low-risk types, that mainly choose voluntary deductibles, have a lower elasticity of demand than high-risk types. Moreover, we show that voluntary deductibles introduce equity problems as it results in non-trivial cross subsidies from high-risk to low-risk types. Capping the level of voluntary deductibles (imposing minimum generosity) is likely to be welfare enhancing in the Netherlands.

The short-term effects of fixed copayment policy on elderly health spending and service utilization: evidence from South Korea's age-based policy using exact date of birth

A large number of the poor elderly in Korea have been exposed to the risk of insufficient proper medical treatments because of financial restrictions. South Korea launched policies to reduce the cost-sharing burden on the elderly, including one compelling the elderly to pay a fixed out-of-pocket amount for outpatient treatments. The impacts of such policies, however, have yet to be elucidated. In this paper, we estimate the short-term effects of the fixed outpatient copayment policy on the health-related behavior of the elderly. We employed a regression discontinuity design by using the exact days before and after the sample's 65th birthdate as the assignment variable, along with the restricted individual-level 2012 and 2013 National Health Insurance claims data. Results show that the policy increased the elderly's health service utilization numbers and reduced out-of-pocket spending for insured services. Moreover, the effects on prescription spending and the insurer's burden differed depending on beneficiaries' characteristics.

Health insurance, endogenous medical progress, health expenditure growth, and welfare

We study the impact of health insurance expansion on medical spending, longevity and welfare in an OLG economy in which individuals purchase health care to lower mortality and medical progress is profit-driven. Three sectors are considered: final goods production; a health care sector, selling medical services to individuals; and an R&D sector, selling increasingly effective medical technology to the health care sector. We calibrate the model to the development of the US economy/health care system from 1965 to 2005 and study numerically the impact of the insurance expansion. We find that more extensive health insurance accounts for a large share of the rise in US health spending but also boosts the rate of medical progress. A welfare analysis shows that while the subsidization of health care through health insurance creates excessive health care spending, the gains in life expectancy brought about by induced medical progress more than compensate for this.

The impact of cost-sharing on prescription drug demand: evidence from a double-difference regression kink design

Pharmaceuticals represent the third-largest expenditure item in health care spending in the OECD countries, and cost growth is around 5% per year in many OECD countries. One possible way to contain the rise in pharmaceutical spending is the use of cost-sharing schemes that makes insured individuals directly bear parts of the cost of a drug. This study estimates the price sensitivity of demand for prescription drugs using data on all prescription drug purchases from a random sample of 400,000 Swedes followed from 2010 to 2013. We use a regression kink design (RKD) by exploiting the kinked Swedish cost-sharing scheme to assess the price elasticity. Further, since the cost-sharing scheme has changed over time, we also use a double-difference RKD to account for potential confounding nonlinearities around the kink. Our results indicate that the standard RKD results are biased and exaggerate the price sensitivity. Our preferred double-difference RKD specifications show no or minor price sensitivity (95% CI price elasticity from - 0.12 to 0.02). The results are similar in several sub-group analyses across age groups, sexes, and income quartiles.

Understanding patient and physician responses to various cost-sharing programs for prescription drugs in South Korea: A multilevel analysis

Introduction

Patient and/or physician responses are a pivotal issue in designing rational cost-sharing programs under health insurance systems.

Objectives

This study aims to understand patient and/or physician responses to cost-sharing programs designed for prescription drugs in South Korea.

Methods

As a framework, we took advantage of a tiered cost-sharing program, including from copayment to coinsurance (threshold 1) and reduced coinsurance (threshold 2). Given the hierarchical structure of prescriptions nested within patients, we utilized a multilevel analysis to assess effects of various cost-sharing programs on patient and/or physician responses using National Health Insurance claims data from 2018.

Results

We found that a tiered cost-sharing program was effective in changing the behaviors of patients and/or physicians. Threshold 1 was found to be more effective than threshold 2 in changing their behaviors. At the prescription level, sensitivity to cost-sharing programs was associated with prescribed days of treatment and locations of prescription. In a similar vein, sensitivity to cost-sharing programs was associated with gender and age group of patients.

Conclusion

A simplified cost-sharing program with extended intervals should be considered to rationalize cost-sharing programs. Specifically, a cost-sharing program designed for long-term prescriptions for chronic diseases together with an emphasis on cost transparency is required to better guide price-conscious decisions by patients and/or physicians.

The effects of patient cost-sharing on health expenditure and health among older people: Heterogeneity across income groups

Despite rapidly rising health expenditure associated with population aging, empirical evidence on the effects of cost-sharing on older people is still limited. This study estimated the effects of cost-sharing on the utilization of healthcare and health among older people, the most intensive users of healthcare. We employed a regression discontinuity design by exploiting a drastic reduction in the coinsurance rate from 30 to 10% at age 70 in Japan. We used large administrative claims data as well as income information at the individual level provided by a municipality. Using the claims data with 1,420,252 person-month observations for health expenditure, we found that reduced cost-sharing modestly increased outpatient expenditure, with an implied price elasticity of  - 0.07. When examining the effects of reduced cost-sharing by income, we found that the price elasticities for outpatient expenditure were almost zero,  - 0.08, and  - 0.11 for lower-, middle-, and higher-income individuals, respectively, suggesting that lower-income individuals do not have more elastic demand for outpatient care compared with other income groups. Using large-scale mail survey data with 3404 observations for self-reported health, we found that the cost-sharing reduction significantly improved self-reported health only among lower-income individuals, but drawing clear conclusions about health outcomes is difficult because of a lack of strong graphical evidence to support health improvement. Our results suggest that varying cost-sharing by income for older people (i.e., smaller cost-sharing for lower-income individuals and larger cost-sharing for higher-income individuals) may reduce health expenditure without compromising health.

The Impact of Cost-Containment Schemes on Outpatient Services for Schoolchildren with Refractive Errors in Taiwan—A Population-Based Study

Objectives: Extant research on cost-sharing finds no impact on health care utilization when the amount is insubstantial. This research investigates the effects on nonacute outpatient services for schoolchildren with refractive errors in Taiwan and discusses the potential harm caused by cost sharing and relevant cost containment policies. Methods: Longitudinal claims data from the National Health Insurance database are employed. District demographic information is also used for aggregate-level analyses. Interventional modeling is conducted on pooled individual-level data with a Poisson model and negative binomial models. Generalized least square modeling is performed on aggregate district-level data to elucidate the impacts of cost sharing and the reimbursement rate with controls for patient and institutional characteristics, district socioeconomic factors, and competitiveness among institutions. Results: The findings of this study show that cost sharing does not significantly affect children’s utilization of outpatient services in the patient-level analyses. However, it significantly decreases the service volume based on the results of district aggregate analyses. There are potentially marginal patients in society, and they are more likely to be girls in poorer families, whose chances of seeking medical care significantly decrease when cost sharing increases. Conclusions: The gap in health inequity can be widened when stringent cost-containment policies are implemented. The offset effect caused by delayed care may also result in higher health care expenditures later. Cost sharing for children should be separately and prudently designed to better protect them from deprivations caused by changes in health policies.

Multidisciplinary Firms and the Treatment of Chronic Pain: A Case Study of Low Back Pain

Sixteen million people suffer with chronic low back pain and related healthcare expenditures can be as high as $USD 635 billion. Current pain treatments help a significant number of acute pain patients, allowing them to obtain various treatments and then “exit the market for pain services” quickly. However, chronic patients remain in pain and need multiple, varying treatments over time. Often, a single pain provider does not oversee their care. Here, we analyze the current pain market and suggest ways to establish a new treatment paradigm. We posit that more cost effective treatment and better pain relief can be achieved with multi-disciplinary care with a provider team overseeing care.

A systematic umbrella review of the association of prescription drug insurance and cost-sharing with drug use, health services use, and health

BACKGROUND

Increasing spending and use of prescription drugs pose an important challenge to governments that seek to expand health insurance coverage to improve population health while controlling public expenditures. Patient cost-sharing such as deductibles and coinsurance is widely used with aim to control healthcare expenditures without adversely affecting health.

METHODS

We conducted a systematic umbrella review with a quality assessment of included studies to examine the association of prescription drug insurance and cost-sharing with drug use, health services use, and health. We searched five electronic bibliographic databases, hand-searched eight specialty journals and two working paper repositories, and examined references of relevant reviews. At least two reviewers independently screened the articles, extracted the characteristics, methods, and main results, and assessed the quality of each included study.

RESULTS

We identified 38 reviews. We found consistent evidence that having drug insurance and lower cost-sharing among the insured were associated with increased drug use while the lack or loss of drug insurance and higher drug cost-sharing were associated with decreased drug use. We also found consistent evidence that the poor, the chronically ill, seniors and children were similarly responsive to changes in insurance and cost-sharing. We found that drug insurance and lower drug cost-sharing were associated with lower healthcare services utilization including emergency room visits, hospitalizations, and outpatient visits. We did not find consistent evidence of an association between drug insurance or cost-sharing and health. Lastly, we did not find any evidence that the association between drug insurance or cost-sharing and drug use, health services use or health differed by socioeconomic status, health status, age or sex.

CONCLUSIONS

Given that the poor or near-poor often report substantially lower drug insurance coverage, universal pharmacare would likely increase drug use among lower-income populations relative to higher-income populations. On net, it is probable that health services use could decrease with universal pharmacare among those who gain drug insurance. Such cross-price effects of extending drug coverage should be included in costing simulations.

How important is income in explaining individuals having forgone healthcare due to cost-sharing payments? Results from a mixed methods sequential explanatory study

Background

Patients having forgone healthcare because of the costs involved has become more prevalent in recent years. Certain patient characteristics, such as income, are known to be associated with a stronger demand-response to cost-sharing. In this study, we first assess the relative importance of patient characteristics with regard to having forgone healthcare due to cost-sharing payments, and then employ qualitative methods in order to understand these findings better.

Methods

Survey data was collected from a Dutch panel of regular users of healthcare. Logistic regression models and dominance analyses were performed to assess the relative importance of patient characteristics, i.e., personal characteristics, health, educational level, sense of mastery and financial situation. Semi-structured interviews (n = 5) were conducted with those who had forgone healthcare. The verbatim transcribed interviews were thematically analyzed.

Results

Of the 7,339 respondents who completed the questionnaire, 1,048 respondents (14.3%) had forgone healthcare because of the deductible requirement. The regression model indicated that having a higher income reduced the odds of having forgone recommended healthcare due to the deductible (odds ratios of higher income categories relative to the lowest income category (reference): 0.29–0.49). However, dominance analyses revealed that financial leeway was more important than income: financial leeway contributed the most (34.8%) to the model’s overall McFadden’s pseudo-R2 (i.e., 0.123), followed by income (25.6%). Similar results were observed in stratified models and in population weighted models. Qualitative analyses distinguished four main themes that affected the patient’s decision whether to use healthcare: financial barriers, structural barriers related to the complex design of cost-sharing programs, individual considerations of the patient, and the perceived lack of control regarding treatment choices within a given treatment trajectory. Furthermore, “having forgone healthcare” seemed to have a negative connotation.

Conclusion

Our findings show that financial leeway is more important than income with respect to having forgone recommended healthcare due to cost-sharing payments, and that other factors such as the perceived necessity of healthcare also matter. Our findings imply that solely adapting cost-sharing programs to income levels will only get one so far. Our study underlines the need for a broader perspective in the design of cost-sharing programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07527-z.

Cost sharing: implications of a well-intended benefits strategy

DISCLOSURES: The thoughts and opinions expressed in this article are those of the author only and are not the thoughts and opinions of any current or former employer of the author. Nor is this publication made by, on behalf of, or endorsed or approved by any current or former employer of the author.

Medicare Must Provide Additional Cost and Access Information to Enhance Decision Making Around Trade Offs Between Medicare Advantage and Medigap

Health insurance coverage options are complicated and often leave Medicare beneficiaries, families, advocates, and brokers confused. Medicare should make small changes to its existing “Compare Coverage Options” tool that would enhance the public’s understanding of the trade-offs between Medicare Advantage and supplemental Medigap with Fee-for-Service Medicare. For cost considerations, Medicare should include a projection of annual out-of-pocket (OOP) spending, whether an OOP cap applies and whether the ability to alter OOP for additional clinical benefit is offered. For access considerations, Medicare should provide access to information to educate the public on coverage and costs associated with dental, vision, and hearing benefits, network adequacy, prior authorization, and supplemental benefits. These changes will enhance transparency and decision making.

Medicaid Coverage 'Cliff' Increases Expenses And Decreases Care For Near-Poor Medicare Beneficiaries

Cost sharing in traditional Medicare can consume a substantial portion of the income of beneficiaries who do not have supplemental insurance from Medicaid, an employer, or a Medigap plan. Near-poor Medicare beneficiaries (with incomes more than 100 percent but less than 200 percent of the federal poverty level) are ineligible for Medicaid but frequently lack alternative supplemental coverage, resulting in a supplemental coverage "cliff" of 25.8 percentage points just above the eligibility threshold for Medicaid (100 percent of poverty). We estimated that beneficiaries affected by this supplemental coverage cliff incurred an additional $2,288 in out-of-pocket spending over the course of two years, used 55 percent fewer outpatient evaluation and management services per year, and filled fewer prescriptions. Lower prescription drug use was partly driven by low take-up of Part D subsidies, which Medicare beneficiaries automatically receive if they have Medicaid. Expanding eligibility for Medicaid supplemental coverage and increasing take-up of Part D subsidies would lessen cost-related barriers to health care among near-poor Medicare beneficiaries.

The effects of health insurance on the choice of medical procedures: Evidence from heart attacks and childbirths

This paper investigates the effect of health insurance on the use of alternative procedures to treat a given medical condition. In particular, we estimate the effect of health insurance on the use of bypass surgery after a heart attack and on the use of a C-section after a normal pregnancy. These procedures are the most expensive, compared to the alternatives. Theoretically, the demand for some procedures like bypass surgery is likely to be inelastic. In this situation, health insurance should have no effect on the use of the procedure. For other procedures such as C-section, demand may be more elastic, especially after a normal pregnancy without complications. We use a nationally representative dataset of inpatient hospital admissions from the United States and control for individual and hospital characteristics. The results from our empirical analysis support our predictions. For patients admitted to a hospital because of a heart attack, being uninsured has no effect on the probability of bypass surgery. However, for patients admitted for childbirth, the uninsured have a substantially lower probability of a C-section delivery.

Disentangling Moral Hazard and Adverse Selection in Private Health Insurance

Moral hazard and adverse selection create inefficiencies in private health insurance markets and understanding the relative importance of each factor is critical for addressing these inefficiencies. We use claims data from a large firm which changed health insurance plan options to isolate moral hazard from plan selection, estimating a discrete choice model to predict household plan preferences and attrition. Variation in plan preferences identifies the differential causal impact of each health insurance plan on the entire distribution of medical expenditures. Our estimates imply that 53% of the additional medical spending observed in the most generous plan in our data relative to the least generous is due to adverse selection. We find that quantifying adverse selection by using prior medical expenditures overstates the true magnitude of selection due to mean reversion. We also statistically reject that individual health care consumption responds solely to the end-of-the-year marginal price.

Noninvasive Real-Time Mortality Prediction in Intensive Care Units Based on Gradient Boosting Method: Model Development and Validation Study

BACKGROUND

Monitoring critically ill patients in intensive care units (ICUs) in real time is vitally important. Although scoring systems are most often used in risk prediction of mortality, they are usually not highly precise, and the clinical data are often simply weighted. This method is inefficient and time-consuming in the clinical setting.

OBJECTIVE

The objective of this study was to integrate all medical data and noninvasively predict the real-time mortality of ICU patients using a gradient boosting method. Specifically, our goal was to predict mortality using a noninvasive method to minimize the discomfort to patients.

METHODS

In this study, we established five models to predict mortality in real time based on different features. According to the monitoring, laboratory, and scoring data, we constructed the feature engineering. The five real-time mortality prediction models were RMM (based on monitoring features), RMA (based on monitoring features and the Acute Physiology and Chronic Health Evaluation [APACHE]), RMS (based on monitoring features and Sequential Organ Failure Assessment [SOFA]), RMML (based on monitoring and laboratory features), and RM (based on all monitoring, laboratory, and scoring features). All models were built using LightGBM and tested with XGBoost. We then compared the performance of all models, with particular focus on the noninvasive method, the RMM model.

RESULTS

After extensive experiments, the area under the curve of the RMM model was 0.8264, which was superior to that of the RMA and RMS models. Therefore, predicting mortality using the noninvasive method was both efficient and practical, as it eliminated the need for extra physical interventions on patients, such as the drawing of blood. In addition, we explored the top nine features relevant to real-time mortality prediction: invasive mean blood pressure, heart rate, invasive systolic blood pressure, oxygen concentration, oxygen saturation, balance of input and output, total input, invasive diastolic blood pressure, and noninvasive mean blood pressure. These nine features should be given more focus in routine clinical practice.

CONCLUSIONS

The results of this study may be helpful in real-time mortality prediction in patients in the ICU, especially the noninvasive method. It is efficient and favorable to patients, which offers a strong practical significance.

Free GP care and psychological health: Quasi-experimental evidence from Ireland

There is considerable ambiguity in the literature on the effect of health insurance on health. While the majority of previous analyses have examined physical health outcomes, analyses of the broader dimensions of health such as psychological health and wellbeing have been less frequent. Using data from the Irish Longitudinal Study on Ageing (TILDA) and a difference-in-differences research design, we examine the impact of free general practitioner (GP) care on psychological health among the older population and explore potential mechanisms. While we find no impact of public health insurance expansions on quality of life, life satisfaction, depression, and worry, the removal of GP fees for all those 70+ leads to a significantly lower level of perceived stress. The impact is mainly driven by poorer, sicker and single individuals. Further analyses show that removing GP fees leads to greater access to GP services and lower levels of financial stress.

Effects of primary care cost-sharing among young adults: varying impact across income groups and gender

We estimate the price sensitivity in health care among adolescents and young adults, and assess how it varies across income groups and gender, using a regression discontinuity design. We use the age differential cost-sharing in Swedish primary care as our identification strategy. At the 20th birthday, the copayment increases from €0 to approx. €10 per primary care physician visit and close to this threshold the copayment faced by each person is distributed almost as good as if randomized. The analysis is performed using high-quality health care and economic register data of 73,000 individuals aged 18-22. Our results show that the copayment decreases the average number of visits by 7%. Among women visits are reduced by 9%, for low-income individuals by 11%, and for low-income women by 14%. In conclusion, modest copayments have significant utilization effects, and even in a policy context with relatively low income inequalities, the effect is substantially larger in low-income groups and among women.

US Growth Hormone Use in the Idiopathic Short Stature Era: Trends in Insurer Payments and Patient Financial Burden

Objective

To investigate trends in prevalence and expenditures of growth hormone (GH) use by US youth in the last 15 years, a period during which the US Food and Drug Administration (FDA) approved GH treatment of idiopathic short stature (ISS), and insurers imposed greater barriers to GH treatment reimbursements.

Design

With the use of 2001 to 2016 OptumInsight commercial claims data, we analyzed trends in claims of GH drugs among beneficiaries aged 0 to 18 years (n = 38,857 beneficiaries receiving GH). Outcome measures included annual prevalence of GH claims and annual total insurer and total patient payments for GH claims. t Tests were used for linear time trends in outcomes. The percentage of beneficiaries switching GH brands also was calculated.

Results

The number of members with GH claims per 10,000 beneficiaries under age 18 rose steadily from 5.1 in 2001 to 14.6 in 2016, without a dramatic change around 2003, the ISS approval date. Mean total GH expenditures decreased (−26% in constant dollars), as did the estimated insurance paid amount (−28%). However, mean total patient spending increased by 163%. Beneficiaries switching GH brands in the year ranged from 1.4% to 3.6% in 2001 to 2007 and from 5.1% to 8.8% after, with 25.6% switching in 2009 and 13.9% switching in 2015.

Conclusions

The FDA ISS approval was not a watershed event in the steady increase in GH use by US youth. Progressive restrictions on coverage and formulary preference coverage strategies appear to have succeeded in lowering total expenditures and insurer burden of GH treatment per beneficiary. However, those savings were not passed on to patients who bore greater burdens financially and from brand switches.

Drivers of hospital expenditure and length of stay in an academic medical centre: a retrospective cross-sectional study

BACKGROUND

As healthcare expenditure and utilization continue to rise, understanding key drivers of hospital expenditure and utilization is crucial in policy development and service planning. This study aims to investigate micro drivers of hospital expenditure and length of stay (LOS) in an Academic Medical Centre.

METHODS

Data corresponding to 285,767 patients and 207,426 inpatient visits was extracted from electronic medical records of the National University of Hospital in Singapore between 2005 to 2013. Generalized linear models and generalized estimating equations were employed to build patient and inpatient visit models respectively. The patient models provide insight on the factors affecting overall expenditure and LOS, whereas the inpatient visit models provide insight on how expenditure and LOS accumulate longitudinally.

RESULTS

Although adjusted expenditure and LOS per inpatient visit were largely similar across socio-economic status (SES) groups, patients of lower SES groups accumulated greater expenditure and LOS over time due to more frequent visits. Admission to a ward class with greater government subsidies was associated with higher expenditure and LOS per inpatient visit. Inpatient death was also associated with higher expenditure per inpatient visit. Conditions that drove patient expenditure and LOS were largely similar, with mental illnesses affecting LOS to a larger extent. These observations on condition drivers largely held true at visit-level.

CONCLUSIONS

The findings highlight the importance of distinguishing the drivers of patient expenditure and inpatient utilization at the patient-level from those at the visit-level. This allows better understanding of the drivers of healthcare utilization and how utilization accumulates longitudinally, important for health policy and service planning.

Emergency Department Out-of-Pocket Expenditures by Insurance, 1999 to 2016

STUDY OBJECTIVE

Per visit, emergency department (ED) expenditures have increased more for private insurance than Medicare and Medicaid during the past 20 years, but it is unknown whether ED out-of-pocket expenditures show a similar pattern of increase. We compare increases in per-visit ED out-of-pocket expenditures over time for visits that did not result in hospitalization or observation admissions for private insurance, Medicare, and Medicaid.

METHODS

This repeated cross-sectional analysis of out-of-pocket expenditures used data from the 1999 to 2016 Medical Expenditure Panel Survey, a nationally representative survey of the noninstitutionalized US civilian population. We used 2-part models-logistic regression followed by a generalized linear model with a γ distribution and a log link function-to compare per-visit out-of-pocket expenditures over time among different payers. Models contained insurance type, year, an interaction between year and insurance type, region of country, sex, and 5 visit-level variables (magnetic resonance imaging/computed tomography scans, ultrasonography, surgical procedures, radiographs, and ECGs).

RESULTS

In our sample of 107,519 ED visits, mean annual per-visit out-of-pocket expenditures increased $7.31 a year (95% confidence interval $6.22 to $8.41) for private insurance and did not increase for Medicare or Medicaid. Most private insurance and Medicare visits had out-of-pocket expenditures less than $100 and nearly all Medicaid visits had no out-of-pocket expenditures. There was no strong evidence suggesting that out-of-pocket expenditures at different total expenditure amounts increased appreciably for private insurance.

CONCLUSION

Per-visit out-of-pocket expenditure increases for private insurance ED visits were predominantly related to overall increases in per-visit total expenditure.

Consumers' Perceptions And Choices Related To Three Value-Based Insurance Design Approaches

The burden of rising health care costs is being shifted to consumers, and 30 percent of health care costs are attributed to wasteful spending on low- or no-value services. Value-based insurance design (VBID) is intended to encourage the use of high-value services or discourage the use of low-value services by aligning cost with quality. During the summer and fall of 2016, this mixed-methods study used focus groups and a quantitative analysis of survey data to explore consumer decision making in Northern California. When presented with three common VBID approaches, the focus groups favored value-based benefit design the most (41 percent), followed by reference pricing (28 percent) and narrow networks (21 percent). When presented with VBID scenarios, participants were skeptical of the value-based trade-offs and reported seeking information they wanted instead of relying on information that health plans provide. Engaging consumers to successfully reduce waste through VBID will require clarifying trade-offs to support consumers' processes for arriving at high-value decisions as well as reaching out to consumers through trusted sources and networks.

Patient cost-sharing, socioeconomic status, and children's health care utilization

This paper estimates the effect of cost-sharing on the demand for children's and adolescents' use of medical care. We use a large population-wide registry dataset including detailed information on contacts with the health care system as well as family income. Two different estimation strategies are used: regression discontinuity design exploiting age thresholds above which fees are charged, and difference-in-differences models exploiting policy changes. We also estimate combined regression discontinuity difference-in-differences models that take into account discontinuities around age thresholds caused by factors other than cost-sharing. We find that when care is free of charge, individuals increase their number of doctor visits by 5-10%. Effects are similar in middle childhood and adolescence, and are driven by those from low-income families. The differences across income groups cannot be explained by other factors that correlate with income, such as maternal education.

The moral hazard effects of consumer responses to targeted cost-sharing

This paper examines the effects of the reference pricing program implemented by the California Public Employees Retirement System (CalPERS) in 2012. The program uses targeted cost-sharing to incentivize patient price shopping. We find that the program leads to a 10.3% increase in the use of low-price providers and reduces the average cost per procedure by 12.5%. We further estimate that the program reduces medical spending by $218.8 per procedure, which we estimate is approximately 53.7% of the excessive spending that is due to patient choice of higher price providers caused by insurance coverage, at the expense of a $94.3 (or 12.5%) reduction in consumer surplus. The cost savings from the reference pricing program is about two to three times as large as the reduction from implementing a high-deductible health plan, while the accompanying consumer surplus reduction is much smaller under reference pricing.

Tiered co-payments, pricing, and demand in reference price markets for pharmaceuticals

Health insurance companies curb price-insensitive behavior and the moral hazard of insureds by means of cost-sharing, such as tiered co-payments or reference pricing in drug markets. This paper evaluates the effect of price limits - below which drugs are exempt from co-payments - on prices and on demand. First, using a difference-in-differences estimation strategy, we find that the new policy decreases prices by 5 percent for generics and increases prices by 4 percent for brand-name drugs in the German reference price market. Second, estimating a nested-logit demand model, we show that consumers appreciate co-payment exempt drugs and calculate lower price elasticities for brand-name drugs than for generics. This explains the different price responses of brand-name and generic drugs and shows that price-related co-payment tiers are an effective tool to steer demand to low-priced drugs.

Public Healthcare Entitlements and Healthcare Utilisation among the Older Population in Ireland

The use of direct out-of-pocket payments to finance general practitioner (GP) care by the majority of the population in Ireland is unusual in a European context. Currently, approximately 40% of the population have means-tested access to free GP care, while the remainder must pay the full out-of-pocket cost. In this paper, we use data from The Irish Longitudinal Study on Ageing (TILDA) to examine the impact of the current system of public healthcare entitlements on GP utilisation among the older population. Using difference-in-difference propensity score matching methods, we find significant effects of changes in public healthcare entitlements on GP utilisation (i.e. introducing user fees reduces utilisation, while removing them increases utilisation). There is limited evidence of offset effects on other types of healthcare utilisation. The results have direct implications for current Irish health policy, and add to the international literature on the effects of insurance on healthcare utilisation. Copyright © 2016 John Wiley & Sons, Ltd.

A method to simulate incentives for cost containment under various cost sharing designs: an application to a first-euro deductible and a doughnut hole

Many health insurance schemes include deductibles to provide consumers with cost containment incentives (CCI) and to counteract moral hazard. Policymakers are faced with choices on the implementation of a specific cost sharing design. One of the guiding principles in this decision process could be which design leads to the strongest CCI. Despite the vast amount of literature on the effects of cost sharing, the relative effects of specific cost sharing designs-e.g., a traditional deductible versus a doughnut hole-will mostly be absent for a certain context. This papers aims at developing a simulation model to approximate the relative effects of different deductible modalities on the CCI. We argue that the CCI depends on the probability that healthcare expenses end up in the deductible range and the expected healthcare expenses given that they end up in the deductible range. Our empirical application shows that different deductible modalities result in different CCIs and that the CCI under a certain modality differs across risk-groups.

Association of Cost Sharing With Mental Health Care Use, Involuntary Commitment, and Acute Care

IMPORTANCE

A higher out-of-pocket price for mental health care may lead not only to cost savings but also to negative downstream consequences.

OBJECTIVE

To examine the association of higher patient cost sharing with mental health care use and downstream effects, such as involuntary commitment and acute mental health care use.

DESIGN, SETTING, AND PARTICIPANTS

This difference-in-differences study compared changes in mental health care use by adults, who experienced an increase in cost sharing, with changes in youths, who did not experience the increase and thus formed a control group. The study examined all 2 780 558 treatment records opened from January 1, 2010, through December 31, 2012, by 110 organizations that provide specialist mental health care in the Netherlands. Data analysis was performed from January 18, 2016, to May 9, 2017.

EXPOSURES

On January 1, 2012, the Dutch national government increased the out-of-pocket price of mental health services for adults by up to €200 (US$226) per year for outpatient treatment and €150 (US$169) per month for inpatient treatment.

MAIN OUTCOMES AND MEASURES

The number of treatment records opened each day in regular specialist mental health care, involuntary commitment, and acute mental health care, and annual specialist mental health care spending.

RESULTS

This study included 1 448 541 treatment records opened from 2010 to 2012 (mean [SD] age, 41.4 [16.7] years; 712 999 men and 735 542 women). The number of regular mental health care records opened for adults decreased abruptly and persistently by 13.4% (95% CI, -16.0% to -10.8%; P < .001) per day when cost sharing was increased in 2012. The decrease was substantial and significant for severe and mild disorders and larger in low-income than in high-income neighborhoods. Simultaneously, in 2012, daily record openings increased for involuntary commitment by 96.8% (95% CI, 87.7%-105.9%; P < .001) and for acute mental health care by 25.1% (95% CI, 20.8%-29.4%; P < .001). In contrast to our findings for adults, the use of regular care among youths increased slightly and the use of involuntary commitment and acute care decreased slightly after the reform. Overall, the cost-sharing reform was associated with estimated savings of €13.4 million (US$15.1 million). However, for adults with psychotic disorder or bipolar disorder, the additional costs of involuntary commitment and acute mental health care exceeded savings by €25.5 million (US$28.8 million).

CONCLUSIONS AND RELEVANCE

Higher cost sharing for seriously ill and low-income patients could discourage treatment of vulnerable populations and create substantial downstream costs.

Chronic Health Outcomes and Prescription Drug Copayments in Medicaid

BACKGROUND

Prescription drug copayments and cost-sharing have been linked to reductions in prescription drug use and expenditures. However, little is known about their effect on specific health outcomes.

OBJECTIVE

To evaluate the association between prescription drug copayments and uncontrolled hypertension, uncontrolled hypercholesterolemia, and prescription drug utilization among Medicaid beneficiaries with these conditions.

SUBJECTS

Select adults aged 20-64 from NHANES 1999-2012 in 18 states.

MEASURES

Uncontrolled hypertension, uncontrolled hypercholesterolemia, and taking medication for each of these conditions.

RESEARCH DESIGN

A differencing regression model was used to evaluate health outcomes among Medicaid beneficiaries in 4 states that introduced copayments during the study period, relative to 2 comparison groups-Medicaid beneficiaries in 14 states unaffected by shifts in copayment policy, and a within-state counterfactual group of low-income adults not on Medicaid, while controlling for individual demographic factors and unobserved state-level characteristics.

RESULTS

Although uncontrolled hypertension and hypercholesterolemia declined among all low-income persons during the study period, the trend was less pronounced in Medicaid beneficiaries affected by copayments. After netting out concurrent trends in health outcomes of low-income persons unaffected by Medicaid copayment changes, we estimated that introduction of drug copayments in Medicaid was associated with an average rise in uncontrolled hypertension and uncontrolled hypercholesterolemia of 7.7 and 13.2 percentage points, respectively, and with reduced drug utilization for hypercholesterolemia.

CONCLUSIONS

As Medicaid programs change in the years following the Affordable Care Act, prescription drug copayments may play a role as a lever for controlling hypertension and hypercholesterolemia at the population level.

Smoking Response to Health and Medical Spending Changes and the Role of Insurance

Severe health shocks provide new information about one's personal health and have been shown to influence smoking behaviors. In this paper, we suggest that they may also convey information about the hard to predict financial consequences of illnesses. Relevant financial risk information is idiosyncratic and unavailable to the consumer preceding illness, and the information search costs are high. However, new and salient information about the health as well as financial consequences of smoking after a health shock may impact smoking responses. Using variation in the timing of health shocks and two features of the US health care system (uninsured spells and aging into the Medicare program at 65), we test for heterogeneity in the post-shock smoking decision according to plausibly exogenous changes in financial risk exposure to medical spending. We also explore the relationship between smoking and the evolution of out-of-pocket costs. Individuals experiencing a cardiovascular health shock during an uninsured spell have more than twice the cessation effect of those receiving the illness while insured. For those uninsured prior to age 65 years, experiencing a cardiovascular shock post Medicare eligibility completely offsets the cessation effect. We also find that older adults' medical spending changes separate from health shocks influence their smoking behavior. Copyright © 2016 John Wiley & Sons, Ltd.

The Effects of Introducing Mixed Payment Systems for Physicians: Experimental Evidence

Mixed payment systems have become a prominent alternative to paying physicians through fee-for-service and capitation. While theory shows mixed payment systems to be superior, causal effects on physicians' behavior when introducing mixed systems are not well understood empirically. We systematically analyze the influence of fee-for-service, capitation, and mixed payment systems on physicians' service provision. In a controlled laboratory setting, we implement an exogenous variation of the payment method. Medical and non-medical students in the role of physicians in the lab (N = 213) choose quantities of medical services affecting patients' health outside the lab. Behavioral data reveal significant overprovision of medical services under fee-for-service and significant underprovision under capitation, although less than predicted when assuming profit maximization. Introducing mixed payment systems significantly reduces deviations from patient-optimal treatment. Although medical students tend to be more patient regarding, our results hold for both medical and non-medical students. Responses to incentive systems can be explained by a behavioral model capturing individual altruism. In particular, we find support that altruism plays a role in service provision and can partially mitigate agency problems, but altruism is heterogeneous in the population. Copyright © 2015 John Wiley & Sons, Ltd.

In the Shadow of a Giant: Medicare's Influence on Private Physician Payments

We analyze Medicare's influence on private insurers' payments for physicians' services. Using a large administrative change in reimbursements for surgical versus medical care, we find that private prices follow Medicare's lead. A $1.00 increase in Medicare's fees increases corresponding private prices by $1.16. A second set of Medicare fee changes, which generates area-specific payment shocks, has a similar effect on private reimbursements. Medicare's influence is strongest in areas with concentrated insurers and competitive physician markets, consistent with insurer-doctor bargaining. By echoing Medicare's pricing changes, these payment spillovers amplify Medicare's impact on specialty choice and other welfare-relevant aspects of physician practices.

The Impacts of China's Urban Employee Basic Medical Insurance on Healthcare Expenditures and Health Outcomes

At the end of 1998, China launched a government-run mandatory insurance program, the urban employee basic medical insurance (UEBMI), to replace the previous medical insurance system. Using the UEBMI reform in China as a natural experiment, this study identifies variations in patient cost sharing that were imposed by the UEBMI reform and examines their effects on the demand for healthcare services. Using data from the 1991-2006 waves of the China Health and Nutrition Survey, we find that increased cost sharing is associated with decreased outpatient medical care utilization and expenditures but not with decreased inpatient care utilization and expenditures. Patients from low-income and middle-income households or with less severe medical conditions are more sensitive to prices. We observe little impact on patient's health, as measured by self-reported health status. Copyright © 2015 John Wiley & Sons, Ltd.

High Out-of-Pocket Medical Spending among the Poor and Elderly in Nine Developed Countries

OBJECTIVE

The design of health insurance, and the role out-of-pocket (OOP) payments play in it, is a key policy issue as rising health costs have encouraged greater cost-sharing measures. This paper compares the percentage of Americans spending large amounts OOP to meet their health needs with percentages in eight other developed countries. By disaggregating by age and income, the paper focuses on the poor and elderly populations within each.

DATA SOURCE

The study uses nationally representative household survey data made available through the Luxembourg Income Study. It includes nations with high, medium, and low levels of OOP spending.

STUDY DESIGN

Households have high medical spending when their OOP expenditures exceed a threshold share of income. I calculate the share of each nation's population, as well as subpopulations within it, with high OOP expenditures.

PRINCIPAL FINDINGS

The United States is not alone in exposing large numbers of citizens to high OOP expenses. In six of the other eight countries, one-quarter or more of low-income citizens devoted at least 5 percent of their income to OOP expenses, and in all but two countries, more than 1 in 10 elderly citizens had high medical expenses.

CONCLUSIONS

For some populations in the sample nations, health insurance does not provide adequate financial protection and likely contributes to inequities in health care delivery and outcomes.

Cost Sharing in Medicaid: Assumptions, Evidence, and Future Directions

Several states have received waivers to expand Medicaid to poor adults under the Affordable Care Act using more cost sharing than the program traditionally allows. We synthesize literature on the effects of cost sharing, focusing on studies of low-income U.S. populations from 1995 to 2014. Literature suggests that cost sharing has a deterrent effect on initiation of treatments, and can reduce utilization of ongoing treatments. Furthermore, cost sharing may be difficult for low-income populations to understand, patients often lack sufficient information to choose medical treatment, and cost sharing may be difficult to balance within the budgets of poor adults. Gaps in the literature include evidence of long-term effects of cost sharing on health and financial well-being, evidence related to effectiveness of cost sharing combined with patient education, and evidence related to targeted programs that use financial incentives for wellness. Literature underscores the need for evaluation of the effects of cost sharing on health status and spending, particularly among the poorest adults.

How Low-Income Subsidy Recipients Respond to Medicare Part D Cost Sharing

OBJECTIVES

To determine the magnitude and mechanisms of response to Medicare Part D cost sharing by low-income subsidy (LIS) recipients using oral hypoglycemic agents (OHAs) and statins.

DATA SOURCES

Medicare data for a 5 percent random sample of beneficiaries with diabetes enrolled in fee-for-service Part D drug plans in 2008.

STUDY DESIGN

We evaluated the impact of differences between generic and brand cost sharing rates among cohorts of LIS and non-LIS recipients to determine if wider price spreads increased the generic dispensing rate (GDR) and reduced total drug use and cost.

PRINCIPAL FINDINGS

We found little association between cost sharing and aggregate OHA and statin use. In adjusted analyses, non-LIS beneficiaries who paid 46 percent of total OHA costs had 2.5 percent fewer OHA days supply than full benefit dual eligibles who paid just 5 percent of their therapy costs. For statins, the difference in days supply between those facing the lowest and highest cost sharing was 4.6 percent. Higher cost sharing was associated with filling fewer but larger prescriptions for both generics and brands.

CONCLUSIONS

Higher generic and brand copays had little association with OHA and statin use among LIS recipients. This implies that modest changes in required cost sharing for these medicines would have very little substantive impact on generic dispensing or utilization patterns among LIS recipients and thus would have little effect on total program spending. At the same time, any increases in out-of-pocket costs would be expected to shift costs and place greater financial burden on low-income beneficiaries, particularly those in poor health.

Behavioral Health Services in the Changing Landscape of Private Health Plans

OBJECTIVE

Health plans play a key role in facilitating improvements in population health and may engage in activities that have an impact on access, cost, and quality of behavioral health care. Although behavioral health care is becoming more integrated with general medical care, its delivery system has unique aspects. The study examined how health plans deliver and manage behavioral health care in the context of the Affordable Care Act (ACA) and the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA). This is a critical time to examine how health plans manage behavioral health care.

METHODS

A nationally representative survey of private health plans (weighted N=8,431 products; 89% response rate) was conducted in 2010 during the first year of MHPAEA, when plans were subject to the law but before final regulations, and just before the ACA went into effect. The survey addressed behavioral health coverage, cost-sharing, contracting arrangements, medical home innovations, support for technology, and financial incentives to improve behavioral health care.

RESULTS

Coverage for inpatient and outpatient behavioral health services was stable between 2003 and 2010. In 2010, health plans were more likely than in 2003 to manage behavioral health care through internal arrangements and to contract for other services. Medical home initiatives were common and almost always included behavioral health, but financial incentives did not. Some plans facilitated providers' use of technology to improve care delivery, but this was not the norm.

CONCLUSIONS

Health plans are key to mainstreaming and supporting delivery of high-quality behavioral health services. Since 2003, plans have made changes to support delivery of behavioral health services in the context of a rapidly changing environment.

Free Medicines Thanks to Retirement: Impact of Coinsurance Exemption on Pharmaceutical Expenditures and Hospitalization Offsets in a national health service

This paper examines the impact of coinsurance exemption for prescription medicines applied to elderly individuals in Spain after retirement. We use a rich administrative dataset that links pharmaceutical consumption and hospital discharge records for the full population aged 58 to 65 years in January 2004 covered by the public insurer in a Spanish region, and we follow them until December 2006. We use a difference-in-differences strategy and exploit the eligibility age for Social Security to control for the endogeneity of the retirement decision. Our results show that this uniform exemption increases the consumption of prescription medicines on average by 17.5%, total pharmaceutical expenditure by 25% and the costs borne by the insurer by 60.4%, without evidence of any offset effect in the form of lower short term probability of hospitalization. The impact is concentrated among consumers of medicines for acute and other non-chronic diseases whose previous coinsurance rate was 30% to 40%. Copyright © 2015 John Wiley & Sons, Ltd.

Growth and welfare effects of health care in knowledge-based economies

We study the effects of labor intensive health care within a research and development (R&D) driven growth model with overlapping generations. Health care increases longevity, labor participation, and productivity, while it also diverts labor away from production and R&D. We examine under which conditions expanding health care enhances growth and welfare and establish mild conditions under which the provision of health care beyond the growth-maximizing level is Pareto superior.