Abstract

Abstract

The Technological Change in Health Care Research Network collected unique patient-level data on three procedures for treatment of heart attack patients (catheterization, coronary artery bypass grafts and percutaneous transluminal coronary angioplasty) for 17 countries over a 15-year period to examine the impact of economic and institutional factors on technology adoption. Specific institutional factors are shown to be important to the uptake of these technologies. Health-care systems characterized as public contract systems and reimbursement systems have higher adoption rates than public-integrated health-care systems. Central control of funding of investments is negatively associated with adoption rates and the impact is of the same magnitude as the overall health-care system classification. GDP per capita also has a strong role in initial adoption. The impact of income and institutional characteristics on the utilization rates of the three procedures diminishes over time.

The incidence of obesity has increased dramatically in the U.S. Obese individuals tend to be sicker and spend more on health care, raising the question of who bears the incidence of obesity-related health care costs. This question is particularly interesting among those with group coverage through an employer given the lack of explicit risk adjustment of individual health insurance premiums in the group market. In this paper, we examine the incidence of the healthcare costs of obesity among full time workers. We find that the incremental healthcare costs associated with obesity are passed on to obese workers with employer-sponsored health insurance in the form of lower cash wages. Obese workers in firms without employer-sponsored insurance do not have a wage offset relative to their non-obese counterparts. Our estimate of the wage offset exceeds estimates of the expected incremental health care costs of these individuals for obese women, but not for men. We find that a substantial part of the lower wages among obese women attributed to labor market discrimination can be explained by the higher health insurance premiums required to cover them.

ABSTRACT

OBJECTIVE: To assess the health literacy of US parents and explore the role of health literacy in mediating child health disparities.

METHODS: A cross-sectional study was performed for a nationally representative sample of US parents from the 2003 National Assessment of Adult Literacy. Parent performance on 13 child health-related tasks was assessed by simple weighted analyses. Logistic regression analyses were performed to describe factors associated with low parent health literacy and to explore the relationship between health literacy and self-reported child health insurance status, difficulty understanding over-the-counter medication labeling, and use of food labels.

RESULTS: More than 6100 parents made up the sample (representing 72600098 US parents); 28.7% of the parents had below-basic/basic health literacy, 68.4% were unable to enter names and birth dates correctly on a health insurance form, 65.9% were unable to calculate the annual cost of a health insurance policy on the basis of family size, and 46.4% were unable to perform at least 1 of 2 medication-related tasks. Parents with below-basic health literacy were more likely to have a child without health insurance in their household (adjusted odds ratio: 2.4 [95% confidence interval: 1.1–4.9]) compared with parents with proficient health literacy. Parents with below-basic health literacy had 3.4 times the odds (95% confidence interval: 1.6–7.4) of reporting difficulty understanding over-the-counter medication labels. Parent health literacy was associated with nutrition label use in unadjusted analyses but did not retain significance in multivariate analyses. Health literacy accounted for some of the effect of education, racial/ethnic, immigrant-status, linguistic, and income-related disparities.

CONCLUSIONS: A large proportion of US parents have limited health-literacy skills. Decreasing literacy demands on parents, including simplification of health insurance and other medical forms, as well as medication and food labels, is needed to decrease health care access barriers for children and allow for informed parent decision-making. Addressing low parent health literacy may ameliorate existing child health disparities.

Objective

To determine whether eligible extremely-low-birth-weight children (<1000g) were enrolled in the federally enacted, state-coordinated Early Intervention (EI) program intended to help children with developmental delay or disability regardless of parental income, and the factors associated with enrollment.

Methods

Retrospective analysis of 884 EI-eligible ELBW children born in South Carolina with birth weight 401 to 999g, gestation ≥24 weeks, and survival for the first 120 days of life. We created a linked data set with data from Early Intervention (1996–2001), Vital Records (1996–1998), death certificates, and Medicaid. Each child was followed from birth to 3 years old, the program eligibility period.

Results

A total of 54% of ELBW children were enrolled in EI at any time from birth to 36 months. Even among children ever enrolled in Medicaid (83% of all ELBW children), only 63% were enrolled in EI. Being born in a multiple gestational birth, having heavier birth weight (750 to 999g), and having ever enrolled in Medicaid were positively associated with EI enrollment. Among Medicaid patients for whom perinatal data were available, additional risk adjustment showed that EI enrollment was more likely with birth in level 3 hospitals, birth weight 750 to 999g, Neonatal Medical Index severity level V (most severe), and longer initial length of hospital stay.

Conclusions

Only about half of eligible ELBW children in South Carolina were enrolled—much lower than reported elsewhere. Efforts are needed to understand why eligible infants are not being enrolled and to develop strategies to remedy the situation.

This issue of the International Journal of Healthcare Finance and Economics features eight
articles evaluating different provider payment methods in comparative international perspective, with authors from Hungary, China, Thailand, the US, Switzerland, and Canada. These contributions illustrate how the array of incentives facing providers shapes their interpersonal, clinical, administrative, and investment decisions in ways that profoundly impact the performance of health care systems. Taken as a whole, the articles show that in addition to the specifics of the reimbursement or remuneration scheme for individual providers and provider organizations, other factors matter—including ownership, allocation of control rights (such as in public-private partnerships), and expectation of a bail-out (soft budget constraints). All of these facets of payment and accountability systems shape the quality and efficiency of service delivery.

Given an increasingly complex web of financial pressures on providers, studies have examined how hospitals’ overall financial health affects different aspects of hospital operations. In our study, we develop an empirical proxy for the concept of soft budget constraint (SBC, Kornai, Kyklos 39:3–30, 1986) as an alternative financialmeasure of a hospital’s overall financial health and offer an initial estimate of the effect of SBCs on hospital access and quality. An organization has a SBC if it can expect to be bailed out rather than shut down. Our conceptual model predicts that hospitals facing softer budget constraints will be associated with less aggressive cost control, and their quality may be better or worse, depending on the scope for damage to quality from noncontractible aspects of cost control. We find that hospitals with softer budget constraints are less likely to shut down safety net services. In addition, hospitals with softer budget constraints appear to have better mortality outcomes for elderly heart attack patients.

Using data from 276 general acute hospitals in the Pearl River Delta region of Guangdong Province from 2002 and 2004, we construct a preliminary metric of budget constraint softness. We find that, controlling for hospital size, ownership, and other factors, a Chinese hospital’s probability of receiving government financial support is inversely associated with the hospital’s previous net revenue, an association consistent with soft budget constraints.

A variety of recent theoretical and empirical advances have renewed interest in monopsonistic models of the labor market. However, there is little direct empirical support for these models, even in labor markets that are textbook examples of monopsony. We use an exogenous change in wages at Veterans Affairs hospitals as a natural experiment to investigate the extent of monopsony in the nurse labor market. In contrast to much of the prior literature, we estimate that labor supply to individual hospitals is quite inelastic, with short-run elasticity around 0.1. We also find that non-VA hospitals responded to the VA wage change by changing their own wages.

Background.  The net value of increased health care spending remains unclear, especially for chronic diseases.

Objective. To assess value for money spent on medical care for patients with type 2 diabetes, using a “cost-of-living” approach.

Setting. Mayo Clinic Rochester, a not-for-profit integrated health care delivery system. 

Patients. 613 patients with type 2 diabetes: 36 diagnosed before 1985; 186 in 1985-96; 181 in 1997-99; and 210 in 2000-02.

Design. We compare the increase in inflation-adjusted annual health care spending with the value of changes in health status between 1997 and 2005.

Measurements. Measures of health status are (1) cardiovascular risk based on the United Kingdom Prospective Diabetes Study (UKPDS) equations, holding age and diabetes duration constant (“modifiable risk”); and (2) simulated outcomes for all diabetes complications using the UKPDS Outcomes Model. The present discounted value of improved survival and avoided treatment spending for coronary heart disease (CHD), net of the increase in annual spending per patient, yields net value.

Results. We estimate a total value of $20,824 per patient for quality improvement ($17,392 from reduction in modifiable risk of fatal CHD and fatal stroke, $3,432 from avoided CHD treatment spending), and a value net of cost of $10,911 per patient (95% confidence interval -$8,480, $33,402). A second approach to assessing value, using the UKPDS Outcomes Model, yields a net value of $6,931 per patient.

Conclusions. Our estimates of net value are positive, indicating that value for money has improved, although confidence intervals bracket zero. The increase in spending thus appears “worth it” on average, but there remains considerable room for enhancing value for money in care for patients with diabetes.