Cross-country comparisons in health price growth over time

OBJECTIVE

To examine how the United States compares in terms of health price growth relative to four other countries - Australia, Canada, France, and the Netherlands.

DATA SOURCES AND STUDY SETTING

Secondary data on health expenditure were extracted from international and national agencies spanning the years 2000-2020.

STUDY DESIGN

International price indices specific to health were constructed using available international expenditure data and compared to existing health-specific national and general international price indices.

DATA COLLECTION/EXTRACTION METHODS

Health expenditure data were extracted from the Organization for Economic Cooperation and Development (OECD) database. We obtained a time series of health price indices from the national agencies in each of the study countries.

PRINCIPAL FINDINGS

We find meaningful variation across countries in the rate at which health prices grow relative to general prices. The United States had the highest cumulative health price growth compared to general price growth over the years 2000-2020 at 14%, followed by Canada and the Netherlands. Unlike the other study countries, health prices in France grew consistently in line with general prices. Price growth for health care paid for by public funds and households grew at different rates across countries, where price growth was higher for public payers. US households faced the greatest mean annual price growth.

CONCLUSIONS

The choice of price index has major implications for comparative analysis. Despite their widespread use internationally, general price indices likely underestimate the contribution of price growth to overall health expenditure growth. We find that in addition to its reputation for having high health price levels compared to other high-income countries, the United States also faces health price growth for goods and services paid for by government and households in excess of general price growth. Furthermore, US households are exposed to greater health price growth than households in comparator countries.

Investor-owned Health Care: The Hidden Blight on America's "System"

Investor ownership of US health care has grown exponentially in the past 50 years through ever closer ties with Wall Street corporate interests. More recently, private equity firms have accelerated this process, invariably with harmful impacts on access to affordable care, its quality, and profiteering, with little accountability. These impacts are fueled by several concurrent trends: (1) increasing privatization, (2) consolidation and mergers, (3) increasing bureaucracy and waste, and (4) profiteering that may bleed into outright fraud. This article traces the uncontrolled growth of health care costs and prices in recent decades, together with documented examples across the health care delivery system whereby profit-driven, investor-owned interests have compromised patient care. These include hospitals, emergency care, nursing homes, mental health, and practices of such specialities as obstetrics-gynecology and ophthalmology. These practices have compromised patient care in the midst of a pandemic and economic downturn, as reflected by markers of a system needing reform. A larger role of government is called for, together with the advantages of Medicare for All in establishing health care as a human right, not a privilege based on ability to pay.

Evaluation of a Clinical Pharmacist-Led Automated Dispensing Cabinet Stewardship Program at a Tertiary Academic Medical Center

BACKGROUND

There is little guidance regarding the best methodology or frequency to optimize automated dispensing cabinets. Clinical pharmacists are in the unique position to make decisions regarding automated dispensing cabinet inventory to best serve their specific patient population.

OBJECTIVE

The purpose of this evaluation was to determine if automated dispensing cabinet optimization by clinical pharmacists would affect the number of dispenses from central pharmacy, number of stockouts, and inventory cost.

METHODS

A retrospective analysis was completed to evaluate the quantity of medications dispensed from a central pharmacy department over 2 separate 2-month periods, with optimization of automated dispensing cabinets occurring in between. The differences in quantity of medications dispensed and redispensed, as well as the number of stockouts and inventory cost on all automated dispensing cabinets, were compared pre- and postintervention.

RESULTS

There were 1132 medication additions, 262 medication removals, and 167 medication par level adjustments. Medications dispensed from central pharmacy were decreased by 12% from the preintervention group to the postintervention group. The number of stockouts per cabinet per day also decreased from 0.75 to 0.61 in the pre- and postintervention groups, respectively. The inventory-at-par cost level was decreased by 15%.

CONCLUSION AND RELEVANCE

Automated dispensing cabinet optimization by clinical pharmacists led to increased medication availability on inpatient units and decreased the number of dispenses from central pharmacy. Simple yet meaningful interventions can be taken to improve multiple medication distribution metrics simultaneously.

The rise of hospitalists: an opportunity for infectious diseases investigators

INTRODUCTION

Despite the essential role played by infectious diseases specialists in patient care, public health, cost-containment, and biomedical research, the field has a substantially higher percentage of vacant positions than other medicine sub-specialties. While much has been written about what this disturbing trend means for patient care, comparatively little attention has been focused on the dire implications for clinical research and the development of novel anti-infective therapy. Areas covered: We examine the ways that hospitalists and infectious disease specialists might collaborate to study emerging diagnostic platforms, novel antimicrobial agents, and strengthen antimicrobial stewardship programs to improve the delivery of high-quality health care. Through the use of PubMed, the manuscript reviews existing collaborations as well as those that might develop in the years to come. Expert commentary: In this paper, we propose potential strategies to confront this emerging problem, focusing on novel collaborations with the hospitalist - the specialist in inpatient medicine - to bolster the pipeline of funding for clinical infectious diseases investigators.

Standardized Review and Approval Process for High-Cost Medication Use Promotes Value-Based Care in a Large Academic Medical System

BACKGROUND

As healthcare costs rise and reimbursements decrease, healthcare organization leadership and clinical providers must collaborate to provide high-value healthcare. Medications are a key driver of the increasing cost of healthcare, largely as a result of the proliferation of expensive specialty drugs, including biologic agents. Such medications contribute significantly to the inpatient diagnosis-related group payment system, often with minimal or unproved benefit over less-expensive therapies.

OBJECTIVE

To describe a systematic review process to reduce non-evidence-based inpatient use of high-cost medications across a large multihospital academic health system.

METHODS

We created a Pharmacy & Therapeutics subcommittee consisting of clinicians, pharmacists, and an ethics representative. This committee developed a standardized process for a timely review (<48 hours) and approval of high-cost medications based on their clinical effectiveness, safety, and appropriateness. The engagement of clinical experts in the development of the consensus-based guidelines for the use of specific medications facilitated the clinicians' acceptance of the review process.

RESULTS

Over a 2-year period, a total of 85 patient-specific requests underwent formal review. All reviews were conducted within 48 hours. This review process has reduced the non-evidence-based use of specialty medications and has resulted in a pharmacy savings of $491,000 in fiscal year 2016, with almost 80% of the savings occurring in the last 2 quarters, because our process has matured.

CONCLUSION

The creation of a collaborative review process to ensure consistent, evidence-based utilization of high-cost medications provides value-based care, while minimizing unnecessary practice variation and reducing the cost of inpatient care.

A narrative synthesis of illustrative evidence on effects of capitation payment for primary care: lessons for Ghana and other low/middle-income countries

OBJECTIVE

To analyse and synthesize available international experiences and information on the motivation for, and effects of using capitation as provider payment method in country health systems and lessons and implications for low/middle-income countries.

METHODS

We did narrative review and synthesis of the literature on the effects of capitation payment on primary care.

RESULTS

Eleven articles were reviewed. Capitation payment encourages efficiency: drives down cost, serves as critical source of income for providers, promotes adherence to guidelines and policies, encourages providers to work better and give health education to patients. It, however, induces reduction in the quantity and quality of care provided and encourages skimming on inputs, underserving of patients in bad state of health, "dumping" of high risk patients and negatively affect patient-provider relationship.

CONCLUSION

The illustrative evidence adduced from the review demonstrates that capitation payment in primary care can create positive incentives but could also elicit un-intended effects. However, due to differences in country context, policy makers in Ghana and other low/middle-income countries may only be guided by the illustrative evidence in their design of a context-specific capitation payment for primary care.

FUNDING

Netherlands Fellowship Programme (NFP), Fellowship number: NFP-PhD.12/352.

Drug Policy in Hungary

We present a brief overview of the health care system in Hungary, focusing particularly on the pricing and reimbursement procedures of medicines. The National Institute of Health Insurance Fund Management is responsible for the administration of the health insurance system and public reimbursement of health technologies. There are two major types of reimbursement techniques in the outpatient care: the normative reimbursement is applied to all physicians and may be used for all indications listed in the Summary of Product Characteristics, and the indication-linked reimbursement is applied only to specialists who are authorized to prescribe the drug. Pharmaceuticals used in the inpatient care are fully reimbursed and are financed through diagnosis-related groups. Several cost-containment measures such as external price referencing and internal price referencing with blind bidding are applied. Proposing managed entry agreements is a mandatory condition for reimbursing innovative pharmaceuticals. Compared with other countries in the region, the implementation of health technology assessment has a relatively long history in Hungary. The health technology assessment body critically evaluates reimbursement submissions of pharmaceuticals, simple medical devices, and complex medical devices such as hospital technologies.

Prediction of Change in Prescription Ingredient Costs and Co-payment Rates under a Reference Pricing System in South Korea

BACKGROUND

The reference pricing system (RPS) establishes reference prices within interchangeable reference groupings. For drugs priced higher than the reference point, patients pay the difference between the reference price and the total price.

OBJECTIVES

To predict potential changes in prescription ingredient costs and co-payment rates after implementation of an RPS in South Korea.

METHODS

Korean National Health Insurance claims data were used as a baseline to develop possible RPS models. Five components of a potential RPS policy were varied: reference groupings, reference pricing methods, co-pay reduction programs, manufacturer price reductions, and increased drug substitutions. The potential changes for prescription ingredient costs and co-payment rates were predicted for the various scenarios.

RESULTS

It was predicted that transferring the difference (total price minus reference price) from the insurer to patients would reduce ingredient costs from 1.4% to 22.8% for the third-party payer (government), but patient co-payment rates would increase from a baseline of 20.4% to 22.0% using chemical groupings and to 25.0% using therapeutic groupings. Savings rates in prescription ingredient costs (government and patient combined) were predicted to range from 1.6% to 13.7% depending on various scenarios. Although the co-payment rate would increase, a 15% price reduction by manufacturers coupled with a substitution rate of 30% would result in a decrease in the co-payment amount (change in absolute dollars vs. change in rates).

CONCLUSIONS

Our models predicted that the implementation of RPS in South Korea would lead to savings in ingredient costs for the third-party payer and co-payments for patients with potential scenarios.

Anticipated Changes in Spine Practice with Advancing Center for Medicare and Medicaid Services-Required Changes

In providing spinal care to neurosurgical patients, cost and quality metrics are areas of interest to many. The federal government has legislated changes mandated for Centers for Medicare and Medicaid Services-enrolled patient care. The ever-changing administrative and patient-care challenges and opportunities are explored in this article, highlighting the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act of 2015 (MACRA), in the context of the Affordable Care Act. Trends in contemporary spinal care, addressing bundling, patient satisfaction, and ambulatory surgical centers are featured.

Pharmacy-Driven Dexmedetomidine Stewardship and Appropriate Use Guidelines in a Community Hospital Setting

BACKGROUND

Dexmedetomidine is a widely utilized agent in the intensive care unit (ICU) because it does not suppress respiratory drive and may be associated with less delirium than midazolam or propofol. Cost of dexmedetomidine therapy and debate as to the proper duration of use has brought its use to the forefront of discussion.

OBJECTIVE

To validate the efficacy and cost savings associated with pharmacy-driven dexmedetomidine appropriate use guidelines and stewardship in mechanically ventilated patients.

METHODS

This was a retrospective cohort study of adult patients who received dexmedetomidine for ICU sedation while on mechanical ventilation at a 433-bed not-for-profit community hospital. Included patients were divided into pre-enactment (PRE) and postenactment (POST) of dexmedetomidine guideline groups.

RESULTS

A total of 100 patients (50 PRE and 50 POST) were included in the analysis. A significant difference in duration of mechanical ventilation (11.1 vs 6.2 days, P = 0.006) and incidence of reintubation (36% vs 18% of patients, P = 0.043) was seen in the POST group. Aggregate use of dexmedetomidine 200-µg vials (37.1 vs 18.4 vials, P = 0.010) and infusion days (5.4 vs 2.5 days, P = 0.006) were significantly lower in the POST group. Dexmedetomidine acquisition cost savings were calculated at $374 456.15 in the POST group. There was no difference between the PRE and POST groups with regard to ICU length of stay, expected mortality, and observed mortality.

CONCLUSIONS

Pharmacy-driven dexmedetomidine appropriate use guidelines decreased the use of dexmedetomidine and increased cost savings at a community hospital without adversely affecting clinical outcomes.

Do the current performance-based schemes in Italy really work? "Success fee": a novel measure for cost-containment of drug expenditure

BACKGROUND

Drug costs have risen rapidly in the last decade, driving third-party payers to adopt performance-based agreements that provide either a discount before payment or an ex post reimbursement on the basis of treatments' effectiveness and/or safety issues.

OBJECTIVES

This article analyses the strategies currently approved in Italy and proposes a novel model called "success fee" to improve payment-by-result schemes and to guarantee patients rapid access to novel therapies.

METHODS

A review of the existing risk-sharing schemes in Italy has been performed, and data provided by the Italian National report (2012) on drug use have been analyzed to assess the impact on drug expenditure deriving from the application of "traditional" performance-based strategies since their introduction in 2006.

RESULTS

Such schemes have poorly contributed to the fulfillment of the purpose in Italy, producing a trifling refund, compared with relevant drugs costs for the National Health System : €121 million out of a total of €3696 million paid. The novel risk-sharing agreement called "success fee" has been adopted for a new high-cost therapy approved for idiopathic pulmonary fibrosis, pirfenidone, and consists of an ex post payment made by the National Health System to the manufacturer for those patients who received a real benefit from treatment.

CONCLUSIONS

"Success fee" represents an effective strategy to promote value-based pricing, making available to patients a rapid access to innovative and expensive therapies, with an affordable impact on drug expenditure and, simultaneously, ensuring third-party payers to share with manufacturers the risk deriving from uncertain safety and effectiveness.

Implementation of an Automated Dispensing Cabinet Stewardship Program at a Tertiary Academic Medical Center

Automated dispensing cabinet (ADC) use within hospitals is designed to replace or partially replace medication cabinets or carts to allow for a more decentralized model of medication distribution. This project was designed to improve medication delivery by decreasing the burden of dispensing patient-specific medications from a centralized inpatient pharmacy while decreasing overall inventory cost. This single-center pilot analysis evaluated ADC inventory optimization in a mixed medical population. Data collected included inventory cost on ADC, medications removed from or added to ADC, patient-specific medications sent from central pharmacy, and the rate of medication stock outs on ADC.

Clinical and economic impact of a quality improvement initiative to enhance early recognition and treatment of sepsis

BACKGROUND

Studies evaluating the clinical effectiveness of sepsis screening tools and methods to improve the time from diagnosis to antibiotic administration are needed to improve sepsis-related outcomes.

OBJECTIVE

To evaluate the clinical and economic impact of a sepsis quality improvement initiative to improve early recognition and treatment of sepsis.

METHODS

A retrospective observational study of adults with sepsis was performed in a 433-bed tertiary medical center. Baseline data were collected for 181 patients with sepsis diagnosis-related group (DRG) coding assignments from July through September 2013. The intervnetion group included 216 patients from October through December 2013. A First-Dose STAT Antibiotic policy was developed, and nurses were instructed to complete an electronic sepsis screening tool once per shift. Primary outcomes included in-hospital mortality and intensive care unit (ICU) length of stay (LOS). Secondary outcomes included overall LOS and cost per case.

RESULTS

Nonsignificant decreases in overall LOS (7.43 ± 5.68 days vs 6.77 ± 5 days; P = 0.138) and in-hospital mortality (13.8% vs 8.8%; P = 0.113) were observed in patients with sepsis DRGs. Early recognition and treatment contributed to significant reductions in ICU LOS (5.85 ± 4.38 days vs 4.21 ± 3.64 days; P = 0.003) and total cost per case ($14 378 vs $12 311; P = 0.033). The percentage of highest disease-severity DRG coding assignments decreased from 7.9% to 0%.

CONCLUSIONS

Strategies to improve early recognition and treatment of sepsis, including routine use of an electronic sepsis screening tool and implementation of a First-Dose STAT Antibiotic policy, contributed to significant reductions in ICU LOS and cost per case.

Impact of the Pharma Economic Act on Diffusion of Innovation and Reduction of Costs in the Hungarian Prescription Drug Market (2007-2010)

OBJECTIVE

In this study, we examined the impact of the Pharma Economic Act, which was introduced in Hungary in 2007.

METHODS

We used detailed data on the Hungarian prescription drug market, which had been made publicly available by the authorities. We evaluated the effect of the Pharma Economic Act on both dynamic and static efficiencies and also on equity, which has been historically a controversial issue in Hungary. We analyzed the overall prescription drug market and statin and atorvastatin markets; as a proxy for determining dynamic efficiency, we examined the oncology drug market for some specific products (e.g., bortezomib) and the long-acting atypical antipsychotic drugs market.

RESULTS

There is no denying that the authorities managed to control the overall prescription drug costs; however, they were still paying excessive rents for off-patent drugs. Examples of oncology and long-acting atypical antipsychotic drugs showed that the diffusion of innovation was on per-capita basis at least comparable to G-5 countries. While the share of out-of-pocket co-payments markedly increased and the reimbursement was lowered, the concurrent price decreases often meant that the co-payment per milligram of a given dispensed drug was actually lower than that before the Act, thereby benefiting the patient.

CONCLUSIONS

It appears that strong mechanisms to control volume rather than price on the supply side (marketing authorization holders) contained the drug expenditure, while offering enough room to strive for innovation. Making data on prescription drug expenditures and associated co-payments publicly available is an item that should be definitely followed by the surrounding jurisdictions.

The moral psychology of rationing among physicians: the role of harm and fairness intuitions in physician objections to cost-effectiveness and cost-containment

INTRODUCTION

Physicians vary in their moral judgments about health care costs. Social intuitionism posits that moral judgments arise from gut instincts, called "moral foundations." The objective of this study was to determine if "harm" and "fairness" intuitions can explain physicians' judgments about cost-containment in U.S. health care and using cost-effectiveness data in practice, as well as the relative importance of those intuitions compared to "purity", "authority" and "ingroup" in cost-related judgments.

METHODS

We mailed an 8-page survey to a random sample of 2000 practicing U.S. physicians. The survey included the MFQ30 and items assessing agreement/disagreement with cost-containment and degree of objection to using cost-effectiveness data to guide care. We used t-tests for pairwise subscale mean comparisons and logistic regression to assess associations with agreement with cost-containment and objection to using cost-effectiveness analysis to guide care.

RESULTS

1032 of 1895 physicians (54%) responded. Most (67%) supported cost-containment, while 54% expressed a strong or moderate objection to the use of cost-effectiveness data in clinical decisions. Physicians who strongly objected to the use of cost-effectiveness data had similar scores in all five of the foundations (all p-values > 0.05). Agreement with cost-containment was associated with higher mean "harm" (3.6) and "fairness" (3.5) intuitions compared to "in-group" (2.8), "authority" (3.0), and "purity" (2.4) (p < 0.05). In multivariate models adjusted for age, sex, region, and specialty, both "harm" and "fairness" were significantly associated with judgments about cost-containment (OR = 1.2 [1.0-1.5]; OR = 1.7 [1.4-2.1], respectively) but were not associated with degree of objection to cost-effectiveness (OR = 1.2 [1.0-1.4]; OR = 0.9 [0.7-1.0]).

CONCLUSIONS

Moral intuitions shed light on variation in physician judgments about cost issues in health care.

Using electronic health records to save money

OBJECTIVES

Health information technology, especially electronic health records (EHRs), can be used to improve the efficiency and effectiveness of healthcare providers. This study assessed the cost-savings of incorporating a list of preferred specialty care providers into the EHRs used by all primary care physicians (PCPs), accompanied by a comprehensive implementation plan.

METHODS

On January 1, 2005, all specialty clinic providers at the Israeli Defense Forces were divided into one of four financial classes based on their charges, class 1, the least expensive, being the most preferred, followed by classes 2-4. This list was incorporated into the EHRs used by all PCPs in primary care clinics. PCPs received comprehensive training. Target referral goals were determined for each class and measured for 4 years, together with the total cost of all specialist visits in the first year compared to the following years. Quality assessment (QA) scores were used as a measure of the program's effect on the quality of patient care.

RESULTS

During 2005-2008, a marginally significant decline in referrals to class 1 was observed (r=-0.254, p=0.078), however a significant increase in referral rates to class 2 was observed (r=0.957, p=0.042), concurrent with a decrease in referral rates to classes 3 and 4 (r=-0.312, p=0.024). An inverse correlation was observed between year and total costs for all visits to specialists (2008 prices; r=-0.96, p=0.04), and between the mean cost of one specialist visit over the 4 years, indicating a significant reduction in real costs (2008 prices; r=-0.995, p=0.005). QA was not affected by these changes (r=0.94, p=0.016).

CONCLUSIONS

From a policy perspective, our data suggest that EHR can facilitate effective utilization of healthcare providers and decrease costs.

Discounts and rebates granted to public payers for medicines in European countries

OBJECTIVE

The objective of this study was to provide an overview about the existence and types of discounts and rebates granted to public payers by the pharmaceutical industry in European countries.

METHODS

Data were collected via a questionnaire in spring 2011. Officials from public authorities for pharmaceutical pricing and reimbursement represented in the PPRI (Pharmaceutical Pricing and Reimbursement Information) network provided the information and reviewed the compilation.

RESULTS

Information is available from 31 European countries. Discounts and rebates granted to public payers by pharmaceutical industry were reported for 25 European countries. Such discounts exist both in the in- and out-patient sectors in 21 countries and in the in-patient sector only in four countries. Six countries reported not having any regulations or agreements regarding the discounts and rebates granted by industry. The most common discounts and rebates are price reductions and refunds linked to sales volume but types such as in-kind support, price-volume and risk-sharing agreements are also in place. A mix of various types of discounts and rebates is common. Many of these arrangements are confidential. Differences regarding types, the organizational and legal framework, validity and frequency of updates and the amount of the discounts and rebates granted exist among the surveyed countries.

CONCLUSIONS

In Europe, discounts and rebates on medicines granted by pharmaceutical industry to public payers are common tools to contain public pharmaceutical expenditure. They appear to be used as a complimentary measure when price regulation does not achieve the desired results and in the few European countries with no or limited price regulation. The confidential character of many of these arrangements impedes transparency and may lead to a distortion of medicines prices. An analysis of the impact on these measures is recommended.

Pharmaceutical policies in European countries in response to the global financial crisis

OBJECTIVE

The objective of this paper is to analyze which pharmaceutical policies European countries applied during the global financial crisis.

METHODS

We undertook a survey with officials from public authorities for pharmaceutical pricing and reimbursement of 33 European countries represented in the PPRI (Pharmaceutical Pricing and Reimbursement Information) network based on a questionnaire. The survey was launched in September 2010 and repeated in February 2011 to obtain updated information.

RESULTS

During the survey period from January 2010 to February 2011, 89 measures were identified in 23 of the 33 countries surveyed which were implemented to contain public medicines expenditure. Price reductions, changes in the co-payments, in the VAT rates on medicines and in the distribution margins were among the most common measures. More than a dozen countries reported measures under discussion or planned, for the remaining year 2011 and beyond. The largest number of measures were implemented in Iceland, the Baltic states (Estonia, Latvia, Lithuania), Greece, Spain and Portugal, which were hit by the crisis at different times.

CONCLUSIONS

Cost-containment has been an issue for high-income countries in Europe - no matter if hit by the crisis or not. In recent months, changes in pharmaceutical policies were reported from 23 European countries. Measures which can be implemented rather swiftly (e.g. price cuts, changes in co-payments and VAT rates on medicines) were among the most frequent measures. While the "crisis countries" (e.g. Baltic states, Greece, Spain) reacted with a bundle of measures, reforms in other countries (e.g. Poland, Germany) were not directly linked to the crisis, but also aimed at containing public spending. Since further reforms are under way, we recommend that the monitoring exercise is continued.