Showing papers by "Dana P. Goldman published in 2003"
TL;DR: The elderly are underrepresented in cancer clinical trials relative to their disease burden, and older patients are more likely to have medical histories that make them ineligible for clinical trials because of protocol exclusions.
Abstract: Purpose: Although 61% of new cases of cancer occur among the elderly, recent studies indicate that the elderly comprise only 25% of participants in cancer clinical trials. Further investigation into the reasons for low elderly participation is warranted. Our objective was to evaluate the participation of the elderly in clinical trials sponsored by the National Cancer Institute (NCI) and assess the impact of protocol exclusion criteria on elderly participation. Patients and Methods: We conducted a retrospective analysis using NCI data, analyzing patient and trial characteristics for 59,300 patients enrolled onto 495 NCI-sponsored, cooperative group trials, active from 1997 through 2000. Our main outcome measure was the proportion of elderly patients enrolled onto cancer clinical trials compared with the proportion of incident cancer patients who are elderly. Results: Overall, 32% of participants in phase II and III clinical trials were elderly, compared with 61% of patients with incident cancers in the Uni...
957 citations
TL;DR: It is predicted that this trend will reverse itself within the next decade, and that the nursing home population is likely to be 10–25% higher than would be suggested by a simple extrapolation of past declines in disability.
Abstract: Objective. To forecast growth in the US nursing home population, as a function of trends in disability and marriage.Methods. Nursing home residence is modeled as a function of disability status, marital status, and other demographic covariates. Our predictions for nursing home residence are built up
106 citations
TL;DR: In this paper, the impact of different types of insurance on mortality in the human immunodeficiency virus (HIV+) population was investigated and it was shown that, after accounting for observed and unobserved heterogeneity, private insurance is more effective than public insurance in preventing premature death.
104 citations
01 Jan 2003
TL;DR: It is found that Medicare HMOs, employer supplements, and Medicaid effectively insulate against the risk of high expenditures, and among the near-poor elderly, there is little employer coverage, so Medicare H MOs provide most of the protection against financial risk.
Abstract: We use data from the Health and Retirement Study to examine the elderly's out-of-pocket health care spending. We find that Medicare HMOs, employer supplements, and Medicaid effectively insulate against the risk of high expenditures. At the ninetieth per- centile, Medicare beneficiaries with employer supplements or enrolled in Medicare HMOs spend $1,600 less out of pocket than beneficiaries with traditional Medicare spend. For the poor elderly, Medicaid offers similar protection. Among the near-poor elderly, there is lit- tle employer coverage, so Medicare HMOs provide most of the protection against financial risk. There is evidence that Medicare HMO benefits have eroded since 1998, raising the question of whether the near-poor have lost financial protection since then.
80 citations
TL;DR: In this article, the authors examined the elderly's out-of-pocket health care spending and found that Medicare HMOs, employer supplements, and Medicaid effectively insulate against the risk of high expenditures.
Abstract: We use data from the Health and Retirement Study to examine the elderly’s out-of-pocket health care spending. We find that Medicare HMOs, employer supplements, and Medicaid effectively insulate against the risk of high expenditures. At the ninetieth percentile, Medicare beneficiaries with employer supplements or enrolled in Medicare HMOs spend $1,600 less out of pocket than beneficiaries with traditional Medicare spend. For the poor elderly, Medicaid offers similar protection. Among the near-poor elderly, there is little employer coverage, so Medicare HMOs provide most of the protection against financial risk. There is evidence that Medicare HMO benefits have eroded since 1998, raising the question of whether the near-poor have lost financial protection since then.
73 citations
TL;DR: The additional treatment costs of an open reimbursement policy for government-sponsored cancer clinical trials appear minimal and were higher for patients who died and who were in early phase studies, although these findings deserve further scrutiny.
Abstract: ContextConcern about additional costs for direct patient care impedes efforts
to enroll patients in clinical trials. But generalizable evidence substantiating
these concerns is lacking.ObjectiveTo assess the additional cost of treating cancer patients in the National
Cancer Institute (NCI)–sponsored clinical trials in the United States
across a range of trial phases, treatment modalities, and patient care settings.DesignRetrospective cost study using a multistage, stratified, random sample
of patients enrolled in 1 of 35 active phase 3 trials or phase 1 or any phase
2 trials between October 1, 1998, and December 31, 1999. Unadjusted and adjusted
costs were compared and related to trial phase, institution type, and vital
status.Setting and ParticipantsA representative sample of 932 cancer patients enrolled in nonpediatric,
NCI-sponsored clinical trials and 696 nonparticipants with a similar stage
of disease not enrolled in a research protocol from 83 cancer clinical research
institutions across the United States.Main Outcome MeasuresDirect treatment costs as measured using a combination of medical records,
telephone survey, and Medicare claims data. Administrative and other research
costs were excluded.ResultsThe incremental costs of direct care in trials were modest. Over approximately
a 2.5-year period, adjusted costs were 6.5% higher for trial participants
than nonparticipants ($35 418 vs $33 248; P =
.11). Cost differences for phase 3 studies were 3.5% (P = .22), lower than for phase 1 or 2 trials (12.8%; P = .20). Trial participants who died had higher costs than nonparticipants
who died (17.9%; $39 420 vs $33 432, respectively; P = .15).ConclusionsTreatment costs for nonpediatric clinical trial participants are on
average 6.5% higher than what they would be if patients did not enroll. This
implies total incremental treatment costs for NCI–sponsored trials of
$16 million in 1999. Incremental costs were higher for patients who died and
who were in early phase studies although these findings deserve further scrutiny.
Overall, the additional treatment costs of an open reimbursement policy for
government-sponsored cancer clinical trials appear minimal.
71 citations
Journal Article•
TL;DR: It is found that public insurance is the predominant source of coverage for those in care for HIV, and that coverage increases as disease progresses, suggesting that reforms allowing HIV positive (+) patients to maintain public coverage while returning to work could increase employment and earnings significantly.
Abstract: This paper uses data from a unique, nationally representative sample of HIV-infected adults receiving medical care, to describe the relationship between disease progression and insurance coverage in the United States. The authors find that public insurance is the predominant source of coverage for those in care for HIV, and that coverage increases as disease progresses.
22 citations
TL;DR: In this paper, the authors construct and implement a test of rational consumer behavior in a high-stakes financial market and test whether consumers make systematic mistakes in perceiving their mortality risks.
Abstract: We construct and implement a test of rational consumer behavior in a highstakes financial market In particular, we test whether consumers make systematic mistakes in perceiving their mortality risks We implement this test using data from secondary life insurance markets where consumers with a lifethreatening illness sell their life insurance policies to firms in return for an up-front payment We compare predictions from two models: one with consumers who correctly perceive their mortality risk, and one with consumers who are misguided about their life expectancy, and find that our data are most consistent with the predictions made by the second model
8 citations
TL;DR: Commentaries by Williamson1 and Manton2 clarify two opposing forces in the determination of future trends in disability and nursing home use by focusing on the potential development of medical technologies and federal policies that will limit disability and release the elderly from nursing homes in the coming decades.
Abstract: The authors respond to comments on their work that highlights divergent trends that influence the course of disability and nursing home use: improving medical technology and worsening health behavior.
5 citations
Journal Article•
TL;DR: It is predicted that this trend will reverse itself within the next decade, and that the nursing home population is likely to be 10-25% higher than would be suggested by a simple extrapolation of past declines in disability.
Abstract: OBJECTIVE. To forecast growth in the US nursing home population, as a function of trends in disability and marriage. METHODS. Nursing home residence is modeled as a function of disability status, marital status, and otherdemographic covariates. Our predictions for nursing home residence are built upon joint forecasts of marriage and disability. We use data from the 1992 to 1996 Medicare Current Beneficiary Surveys, which are individual-level data sets designed to be representative of the US population older than the age of 65. RESULTS. Today's young cohorts will have higher rates and levels of institutionalization than their older counterparts. This will reverse several decades of decline in rates of disability and institutionalization. The nursing home population is likely to be 10-25% higher than would be suggested by a simple extrapolation of past declines in disability. CONCLUSIONS. In recent years, the rate of institutionalization among the elderly has been falling. It is predicted that this trend will reverse itself within the next decade, and that we will see substantial increases in the incidence of institutionalization among the elderly. This result is generated by our prediction of rising disability among the younger cohorts that are beginning to approach old age.
3 citations
Posted Content•
TL;DR: In this article, the authors examined how compensation packages change when health insurance premiums rise and found that a $1 increase in the price of health insurance leads to a 52-cent increase in expenditures on health insurance.
Abstract: This paper examines how compensation packages change when health insurance premiums rise. We use data on employee choices within a single large firm with a flexible benefits plan; an increasingly common arrangement among medium and large firms. In these companies, employees explicitly choose how to allocate compensation between cash and various benefits such as retirement, medical insurance, life insurance, and dental benefits. We find that a $1 increase in the price of health insurance leads to 52-cent increase in expenditures on health insurance. Approximately 2/3 of this increase is financed through reduced wages and 1/3 through other benefits
TL;DR: It is found that the inpatient DCG model does not adequately adjust for biased selection into Medicare HMOs, and new HMO enrollees are healthier than FFS beneficiaries even after adjustment for the included PIP-DCG risk factors.
Abstract: The study assesses unobserved selection bias in an inpatient diagnostic cost group (DCG) model similar to Medicare's Principal Inpatient Diagnostic Cost Group (PIP-DCG) risk adjustment model using a unique data set that contains hospital discharge records for both FFS and HMO Medicare beneficiaries in California from 1994 to 1996. We use a simultaneous equations model that jointly estimates HMO enrollment and subsequent hospital use to test the existence of unobserved selection and estimate the true HMO effect. It is found that the inpatient DCG model does not adequately adjust for biased selection into Medicare HMOs. New HMO enrollees are healthier than FFS beneficiaries even after adjustment for the included PIP-DCG risk factors. A model developed over an FFS sample ignoring unobserved selection overestimates hospital use of new HMO enrollees by 28 percent compared to their use if they had remained in FFS. Models that better captures selection bias are needed to reduce overestimation of Medicare HMO enrollees' resource use.
TL;DR: A simulation-based approach for designing complex multi-stage samples that explores the tradeoff between competing design goals such as precision of estimates, coverage of the target population and cost and identifies the design that is the best compromise among all goals.
Abstract: In order to better inform study design decisions when sampling patients within and across health care providers we develop a simulation-based approach for designing complex multi-stage samples. The approach explores the tradeoff between competing design goals such as precision of estimates, coverage of the target population and cost.
Posted Content•
TL;DR: In this article, the authors construct and implement a test of rational consumer behavior in a high-stakes financial market and test whether consumers make systematic mistakes in perceiving their mortality risks.
Abstract: We construct and implement a test of rational consumer behavior in a highstakes financial market. In particular, we test whether consumers make systematic mistakes in perceiving their mortality risks. We implement this test using data from secondary life insurance markets where consumers with a lifethreatening illness sell their life insurance policies to firms in return for an up-front payment. We compare predictions from two models: one with consumers who correctly perceive their mortality risk, and one with consumers who are misguided about their life expectancy, and find that our data are most consistent with the predictions made by the second model.
01 Jan 2003
TL;DR: In this paper, a simulation-based approach for designing complex multi-stage samples was developed to explore the tradeoff between competing design goals such as precision of estimates, coverage of the target population and cost, and identify the design that is the best compromise among all goals.
Abstract: In order to better inform study design decisions when sampling patients within and across health care providers we develop a simulation-based approach for designing complex multi-stage samples. The approach explores the tradeoff between competing design goals such as precision of estimates, coverage of the target population and cost.We elicit a number of sensible candidate designs, evaluate these designs with respect to multiple sampling goals, investigate their tradeoffs, and identify the design that is the best compromise among all goals. This approach recognizes that, in the practice of sampling, precision of the estimates is not the only important goal, and that there are tradeoffs with coverage and cost that should be explicitly considered. One can easily add other goals. We construct a sample frame with all phase III clinical cancer treatment trials that are conducted by cooperative oncology groups of the National Cancer Institute from October 1, 1998 through December 31, 1999. Simulation results for our study suggest sampling a different number of trials and institutions than initially considered.Simulations of different study designs can uncover efficiency gains both in terms of improved precision of the estimates and in terms of improved coverage of the target population. Simulations enable us to explore the tradeoffs between competing sampling goals and to quantify these efficiency gains. This is true even for complex designs where the stages are not strictly nested in one another.
Posted Content•
TL;DR: In this paper, the authors examined how compensation packages change when health insurance premiums rise and found that a $1 increase in the price of health insurance leads to a 52-cent increase in expenditures on health insurance.
Abstract: This paper examines how compensation packages change when health insurance premiums rise. We use data on employee choices within a single large firm with a flexible benefits plan; an increasingly common arrangement among medium and large firms. In these companies, employees explicitly choose how to allocate compensation between cash and various benefits such as retirement, medical insurance, life insurance, and dental benefits. We find that a $1 increase in the price of health insurance leads to 52-cent increase in expenditures on health insurance. Approximately 2/3 of this increase is financed through reduced wages and 1/3 through other benefits
01 Jan 2003
TL;DR: The elderly are underrepresented in cancer clinical trials relative to their disease burden and older patients are more likely to have medical histories that make them ineligible for clinical trials because of protocol exclusions.
Abstract: Purpose: Although 61% of new cases of cancer occur among the elderly, recent studies indicate that the elderly comprise only 25% of participants in cancer clinical trials. Further investigation into the reasons for low elderly participation is warranted. Our objective was to evaluate the participation of the elderly in clinical trials sponsored by the National Cancer Institute (NCI) and assess the impact of protocol exclusion criteria on elderly participation. Patients and Methods: We conducted a retrospective analysis using NCI data, analyzing patient and trial characteristics for 59,300 patients enrolled onto 495 NCI-sponsored, cooperative group trials, active from 1997 through 2000. Our main outcome measure was the proportion of elderly patients enrolled onto cancer clinical trials compared with the proportion of incident cancer patients who are elderly. Results: Overall, 32% of participants in phase II and III clinical trials were elderly, compared with 61% of patients with incident cancers in the United States who are elderly. The degree of underrepresentation was more pronounced in trials for early-stage cancers than in trials for late-stage cancers (P < .001). Furthermore, protocol exclusion criteria on the basis of organ-system abnormalities and functional status limitations were associated with lower elderly participation. We estimate that if protocol exclusions were relaxed, elderly participation in cancer trials would be 60%. Conclusion: The elderly are underrepresented in cancer clinical trials relative to their disease burden. Older patients are more likely to have medical histories that make them ineligible for clinical trials because of protocol exclusions. Insurance coverage for clinical trials is one step toward improvement of elderly access to clinical trials. Without a change in study design or requirements, this step may not be sufficient. J Clin Oncol 21:1383-1389. © 2003 by American Society of Clinical Oncology.
01 Jan 2003
TL;DR: In this article, the technical appendix to an article being published in the journal Health Affairs, Vol 23, No 1, January/February 2004 is presented, along with the corresponding abstract.
Abstract: This is the technical appendix to an article being published in the journal Health Affairs, Vol 23, No 1, January/February 2004
01 Jan 2003
TL;DR: In this article, the authors used data from a unique, nationally representative sample of HIV-infected adults receiving medical care, to describe the relationship between disease progression and insurance coverage in the United States.
Abstract: In the United States, universal public insurance is only available for the elderly. But unlike most other major diseases, HIV/AIDS predominantly affects the nonelderly. The result is that insurance availability and public programme participation are linked to disease progression in a complicated way. This paper uses data from a unique, nationally representative sample of HIV-infected adults receiving medical care, to describe the relationship between disease progression and insurance coverage in the United States. We find that public insurance is the predominant source of coverage for those in care for HIV, and that coverage increases as disease progresses. Those with public coverage have substantial work experience and earnings capacity, but do not work. This suggests that reforms allowing HIV positive (+) patients to maintain public coverage while returning to work could increase employment and earnings significantly. More speculatively, it suggests that the United States system for financing health care is not well-equipped to deal with epidemics that afflict a population in its prime work years.