Showing papers in "Health Economics in 1992"

Discounting and health benefits.

Abstract: This paper argues that non-monetary health benefits should not be discounted at the same rate as variables expressed in monetary terms. It argues instead that the appropriate discount rate should be at or close to zero. It explores the various influences of rising income, age and pure time preference on the relative value of current and future health states. It examines various arguments advanced to justify the current practice of discounting health benefits at the same rate as monetary costs. These include uncertainty and delay. The article concludes with an analysis of the likely impact of adopting a zero discount rate on the ranking of health interventions.

Discounting and health benefits: another perspective.

Abstract: This paper reviews the argument advanced by Parsonage and Neuburger that the non-monetary benefits of health programmes should be discounted at a lower rate than that used for financial flows. The conceptual issues raised in that paper are discussed and others, such as the tradability of non-monetary benefits and the link between individual and social discount rates, are introduced. The collection and assessment of more evidence is needed before Parsonage and Neuburger's proposition can be supported.

Pooling international health care expenditure data

Abstract: The purpose of this paper is twofold. The first is to analyse the statistical relationship between real health care expenditure per capita and aggregate income, public share in finance, age-dependency ratio and inflation. The second purpose deals with methodological problems involved in pooling health care expenditure data. The empirical work is based on pooled cross-sectional, time-series data for 22 OECD countries from 1972 to 1987. Public finance share and inflation were found to be associated with lower per capita health care expenditure. No consistent correlation was found between the age-dependency ratio and health care expenditure. Contrary to results of earlier studies, we found that health care expenditure does not appear to be income (GDP) elastic. However, the results do not appear to be robust to changes in the time periods and countries included.

The morality of efficiency in health care--some uncomfortable implications.

Abstract: There are some general considerations which have implications for the delivery and finance of health care in all countries, not only Canada and the USA. Beginning with two propositions: that access to health care is a right of citizenship, which should not depend on individual income and wealth; and that the objective of health services is to maximise the impact on the nation's health of the resources available; the paper examines the ethical justification for pursuing efficiency in health care provision. The different meanings of efficiency are discussed in detail, and the use of quantitative indicators of health benefit, such as the QALY, placed in context. It is argued that the determination of health care resource allocations should take account of costs at both the macro planning level and the micro level of the individual doctor-patient relationship. Given the starting points the overall conclusion is that it is ethical to be efficient, since to be inefficient implies failure to achieve the ethical objective of maximising health benefits from available resources.

Screening for diabetic retinopathy: a relative cost-effectiveness analysis of alternative modalities and strategies.

Abstract: Diabetic retinopathy is the most common cause of blindness among adults of working age in the UK. If the disease is detected early effective treatment can be provided and this has resulted in calls for a systematic national screening programme. Using data on the screening of 3423 diabetics collected as part of an experimental programme in three UK centres, the relative cost-effectiveness of various screening options is assessed. The paper utilises direct evidence on a number of single modality screening options, including ophthalmoscopy undertaken by general practitioners or ophthalmic opticians, and non-mydriatic photography. With the objective of increasing the sensitivity of screening and using data collected in the study, options based on two further potential screening strategies are modelled and evaluated: combined screening using both ophthalmoscopy and non-mydriatic photography; and selective screening where high-risk diabetics are directly referred to an ophthalmologist and low-risk cases are either left unscreened or are screened by one of the single or combined modality screening options. Given the objective of early detection, effectiveness is assessed in terms of the sensitivity and specificity of the referral decisions of screening options. Both health service and private resource costs of the various screening options are estimated, the latter in terms of travel and the opportunity cost of time. Cost effectiveness is evaluated in terms of the expected cost per true positive case of diabetic retinopathy referred by the screening options. To narrow the choice between the options, those subject to three-way domination with respect to the three choice variables of sensitivity, specificity and expected cost per true positive are excluded. Amongst the remaining options, the choice is dependent on the trade-off between the higher specifics of unselective single modality screening options and the higher sensitivities and lower expected costs per true positive case detected of combined modality and selective screening options.

Appraising the use of contingent valuation.

Abstract: The valuation of treatments and health states has been pursued in a number of ways. Most predominant are contingent valuation (CV), QALYs, and HYEs. CV--that is, willingness to pay and willingness to accept--is the only one of these methods that can be consistent with welfare economic theory, but, as discussed by Gafni (1990), in order to do so three criteria must be met. This article argues that the fulfilment of these criteria is not sufficient to obtain useful results, and some additional criteria are suggested. Several CV studies carried out in the area of health are reviewed, and their compliance or non-compliance, with both sets of criteria, is discussed. Finally, it is argued that, although CV is the more theoretically correct method, it is not a superior tool to QALYs and HYEs, and that the decision as to which is the appropriate valuation method depends on the policy issue at hand.

Are increases in cigarette taxation regressive

Abstract: Using the latest published data from Tobacco Advisory Council surveys, this paper re-evaluates the question of whether or not increases in cigarette taxation are regressive in the United Kingdom. The extended data set shows no evidence of increasing price-elasticity by social class as found in a major previous study. To the contrary, there appears to be no clear pattern in the price responsiveness of smoking behaviour across different social classes. Increases in cigarette taxation, while reducing smoking levels in all groups, fall most heavily on men and women in the lowest social class. Men and women in social class five can expect to pay eight and eleven times more of a tax increase respectively, than their social class one counterparts. Taken as a proportion of relative incomes, the regressive nature of increases in cigarette taxation is even more pronounced.

The Canadian health care system: A model for America to emulate?

Abstract: The American health care system has the world's highest per capita costs and over 30 million citizens uninsured. The neighbouring Canadian system provides coverage for all basic medical and hospital services, at costs per capita that are about US$700 lower. Single-agency public funding allows tighter control of Canadian expenditures, and reduces administrative overheads. Hospitals are run as non-profit private corporations, funded primarily by a fixed annual allocation for operating costs. Most physicians are in private fee-for-service practice, but cannot charge more than the insured tariff negotiated between their provincial government and medical association. This approach, while attractive in its decentralization, tends to separate the funding and management of clinical services. Thus, hospital information systems lag a decade behind the USA, managed care initiatives are few, health maintenance organisations do not exist, and experimentation with alternative funding or delivery systems has been sporadic. Strengths of the system compared to the USA include: higher patient satisfaction, universal coverage, slightly better cost containment, higher hospital occupancy rates, and reduction in income-related rationing with more equitable distribution of services. Weaknesses in common with the United States are: cost escalation consistently outstripping the consumer price index with costs per capita second highest in the world, ever rising consumption of services per capita, inadequate manpower planning and physician maldistribution, poor regional co-ordination of services, inadequate quality assurance and provider frustration. Additional weaknesses include: an emerging funding crisis caused by the massive federal deficit, less innovation in management and delivery of care as compared to the USA, implicit rationing with long waiting lists for some services, and recurrent provider-government conflicts that have reduced goodwill among stakeholders. Thus, while the Canadian model has important advantages, it does not offer a panacea for American health care woes.

Cost savings in mass population screening for colorectal cancer resulting from the early detection and excision of adenomas.

Abstract: The widely-accepted hypothesis of a development sequence from colorectal adenoma to carcinoma is felt by clinicians to legitimate adenoma excision during routine colonoscopic investigation. Using published data on adenoma development, and adenoma prevalence data derived from the Nottingham colorectal cancer screening trial, the number of carcinomas prevented by early excision as a result of screening is predicted. The cost-effectiveness of early excision is then evaluated with reference to the expected treatment costs saved. These cost savings are found to represent a discount on the overall costs of mass population screening for colorectal cancer.

Management of human resources in health care: the Canadian experience.

Abstract: Each of Canada's ten provinces has a publicly administered system of health insurance, funded by provincial and federal taxes, that is accessible to all citizens and covers all medically necessary services provided by physicians and hospitals. Canadians spend an estimated 9.2 percent of their gross national product on health care (about 2.8 percentage points below US spending), of which three quarters is public-sector spending. According to the Organization for Economic Cooperation and Development, Canada's health status is equal to or better than that of the United States, despite lower per capita health spending. About seven percent of the Canadian labour force works in health care, and attempts to introduce coordinated planning of human resources in health care have not as yet proceeded far. The predominant policy issue here is the supply and the role of physicians. It has been argued that entrenching within the system the fee-for-service method of paying physicians has created a disincentive to the delegation of responsibility to health personnel other than doctors. It is also argued that introduction of government-run health insurance provided the opportunity for human resource planning, but that the decision by governments to act only as the payer resulted in ad-hoc planning approaches. However, governments' concern over health care costs has led to a more direct role by them in the planning of the human resources in health. They are re-examining the autonomy and jurisdictional rights of the professions that deliver health care to Canadians.

Fairness and feasibility in national health care systems.

Abstract: The issue of National Health Care reform has been discussed from many different perspectives. One of the most fundamental justifications for such reform is based on the notion of horizontal equity. The motivation for equity in medical services use contrasts with the seeming lack of concern for equity in financing. Proposed policy remedies often involve transfers through taxation, though the effects of government taxation often reduce the efficiency of publicly financed health insurance. Further, the effects of heterogeneous preferences complicate the assessment of optimal medical service consumption levels. Ethical justification aside, this paper addresses the notion of fairness in the provision of medical care from an economic perspective. It suggests policies which might be most suitable in achieving such a goal. A paradoxical result of these considerations of fairness is that unequal insurance coverage is requisite to ensure more equal utilization of medical services by the population. The concept of fairness is then developed into a bottom up system of equity in the medical market.

Editorial. Which medical therapies are proven

Abstract: This paper examines the factors that influence the voluntary dissemination of performance information by health care organizations. A model of information dissemination is developed and tested using data on Health Maintenance Organizations. The empirical findings suggest that health care organizations disseminate information on their performance because there are collective-good benefits resulting from dissemination, particularly when the product or organizational innovation is unfamiliar to some purchasers. The findings also suggest that the competitive structure of the local health care market influences the dissemination decision, with health care organizations more likely to disseminate information about their performance in relatively competitive markets.

Forces for reforming the U.S. health care system: a review of the cost and access issues.

Abstract: In recent years, a spate of health care reform proposals have emerged on the American agenda. Although the elements of the reform proposals often vary substantially, most of the initiatives are fuelled by two common concerns: rising health care expenditures and a growing uninsured population. National health spending, for example, commands an increasing share of U.S. gross national product despite numerous cost-containment efforts initiated by public and private payers throughout the 1980s. And the uninsured population continues to grow--by an estimated 30 percent between 1978 and 1989. To facilitate understanding of the public policy options being considered to address these concerns, the article examines U.S. health care expenditure data and some of the causes of rising health care costs. The article also discusses the demographic characteristics of the uninsured population, the reasons why they lack health coverage, and the health consequences associated with being uninsured.

Quality assurance in Canada: what are the health professions doing?

Abstract: Although quality assurance (QA) programming in Canada is still at an early stage of development, health professionals are increasingly being called upon to substantiate the value of the services they provide. A body of research showing wide variations in the rates of service provision and significant amounts of inappropriate care have convinced many policy makers about the need to improve quality in the Canadian health system. Recent and severe economic pressures on provincial government funders could foster a more rational approach to resource allocation, including the consideration that better quality care is more efficient care. The bulk of health care in Canada is delivered in the private offices of practitioners, where quality assurance programming is relatively undeveloped. Although some licensing organizations do conduct proactive routine audits of their members' practices, a national survey, based on self-report, indicated that most of these programmes do not conform to recommendations found in the quality assurance literature. Although there have been some new initiatives in Canadian QA, it remains to be seen how these will influence the evolution of quality assurance programming conducted by Canada's health professions.

Public hospital systems in New York and Paris. Edited by V. G. Rodwin, C. Brecher, D. Jolly and R. J. Baxter. New York university press, New York and London, 1992. No. of pages: 266. ISBN 0‐8147‐7422‐9

Abstract: Interestingly, public hospital systems in new york and paris that you really wait for now is coming. It's significant to wait for the representative and beneficial books to read. Every book that is provided in better way and utterance will be expected by many peoples. Even you are a good reader or not, feeling to read this book will always appear when you find it. But, when you feel hard to find it as yours, what to do? Borrow to your friends and don't know when to give back it to her or him.

Lessons in long-term care: the benefits of a northern exposure.

Abstract: Canada stands as an important lesson for the United States. At the very minimum it represents the art of the possible. For those interested in long-term care, it suggests that it is possible to include long-term care in a programme of universally accessible care without national bankruptcy. Although Canada has brought medical and social services closer together and has brought acute and chronic care under the same aegis, not all the problems of coordinating such efforts have been solved. For others, the Canadian example shows that care can be provided to all persons who need it without creating uncontrollable expenses or removing families' motivations to care for their own. In so doing, universal coverage creates the opportunity for better coordination of services and ultimately for more efficient care.

Proposals to reform the U.S. health care system: a critical review.

Abstract: The objective is to provide an overview and analysis of the current discussion of ways to reform the U.S. health care system. A common analytic framework is needed to evaluate the alternative approaches that are being advocated. Such a framework, organized around seven general questions, is developed and discussed. The analytic framework is then applied to five specific reform proposals, selected to be representative of the range of options being considered. The results are used to identify the basic choices that are inherent in the current discussion of health system reform. A discussion of the political realities of the health system reform movement in the U.S. concludes that an incremental reform measure will be implemented at the federal level in the near future and that the reform measure will give the federal government increased control over the health care sector. However, the pressure for more fundamental reform will continue to grow.