Money,Case Complexity,and Wait Lists: Perspectives on Problems and Solutions at Children’s Mental Health Centers in Ontario

Senior managers of children’s mental health centers across Ontario, Canada were interviewed regarding the challenges and solutions of access and delivery of care. The central challenges—funding, case complexity, waitlists, staffing, and system integration—revealed a complex interplay between the policies and financing of children’s mental health services and the provision of clinical services at the agency level and within the community. The desire for integration and collaboration was countered by competition for funding and service demands. A need for policies that allow for local solutions while providing leadership for sustained improvements in the ease and timeliness of access to care and effective clinical services emerged.

Are physician and non-physician providers of outpatient mental healthcare substitutes or complements? a conceptual clarification

Solving the health care consumers’ (producers’) utility maximization (cost minimization) problem could entail the substitution of alternative care providers (factor inputs) when the relative out-of-pocket costs (factor prices) change, ceteris paribus. The conceptual advancement in this contribution is illustrated with an earlier paper (P. Deb and A. Holmes, Health Economics 7(4):347–362, 1998) on the economic relationship of physicians (M.D.s) and ‘other providers’ (Ph.D.s, other) in the US outpatient demand for mental health care services. Many aspects of our conceptual progress are insightful. Foremost, our conclusion on whether M.D. and non-M.D. providers of outpatient mental health care are economic complements or substitutes depends on the alternative measure of the substitution elasticity used. Second, when correctly measured the expenditure-minimizing substitutions among mental health providers can be useful policy decision guides for consumers covered under traditional indemnity insurance with deductibles or managed care plans with user co-payments. Finally, our conceptual clarification should motivate future investigators of health services demand (or use) and cost models to consider a wider conceptual foundation for assessing the structure and implications of provider relationships.

Waiting times and hospitalizations for ambulatory care sensitive conditions

Long waits for health care are hypothesized to cause negative health outcomes due to delays in diagnosis and treatment. This study uses administrative data to examine the relationship between time spent waiting for outpatient care and the risk of hospitalization for an ambulatory care sensitive condition (ACSC). Data on the number of days until the next available appointment were extracted from Veterans Affairs (VA) medical centers. Two methodological issues arose. First, the simultaneous determination of individual health status and wait times due to medical triage was overcome by developing an exogenous wait time measure. Second, selection bias due to unobserved case mix differences was minimized by separating in time the sample selection period from the period when wait times and outcomes were measured. Exogenous facility-level wait time was the main variable of interest in a fixed effects stacked heteroskedastic probit regression model that predicted the probability of ACSC hospitalization in each month of a six-month period. There was a significant and positive relationship between facility-level wait times and the probability of experiencing an ACSC hospitalization, especially for facility-level wait times of 29 days or more. Further research is needed to replicate these findings in other populations and among those with different clinical histories. As well, policymakers and researchers need an improved understanding of the causes of long wait times and interventions to decrease wait times.

Inter-DRG resource dynamics in a prospective payment system: a stochastic kernel approach

This paper empirically investigates the resource distribution dynamics across Diagnosis Related Groups (DRGs) of elective surgery patients, in a continuing Prospective Payment System (PPS). Existing econometric literature has mainly focussed on the impact of PPS on average Length of Stay (LOS) concluding that the average LOS has declined post PPS. There is little literature on the distribution of this decline across DRGs, in a PPS. The present paper helps fill this gap. It models the evolution over time of the empirical distribution of LOS across DRGs. The empirical distributions are estimated using a non parametric “stochastic kernel approach” based on Markov Chain theory. The results for inlier episodes suggest that resource redistribution will increase capacity and expected number of admissions for DRGs having increasing waiting times. In addition, adjustments in relative cost weights are perceived as price signals by hospitals leading to a change in their casemix. The results for high outlier patients reveal that improved quality of care is one of the factors causing reduction in high outlier episodes.

CAPTA and the Residential Placement: A Survey of State Policy and Practice

Children in out-of-home care due to familial maltreatment and other developmental and behavioral problems remain at risk for abuse and neglect in the very placements designed for care and treatment. The background of federal involvement in Child Abuse Prevention and Treatment Act (CAPTA) requirements, as well as the states’ responses for addressing protective service responsibilities for residential care, is overviewed. The shift away from direct federal oversight of eligibility standards for child protective systems mandated by CAPTA has apparently contributed to a double standard in protective service activities. The purpose of this study was to provide knowledge of current state child protective services policies and practice regarding out-of-home care through a national survey of state child protective services. Findings of the study suggest that out-of-home protective services would benefit from renewed awareness from social work and child welfare professionals. Calling on states to review their systems for protective services of out-of-home care, the authors recommend collaborative system review between state protective services and the federally funded protection and advocacy programs.

A deterministic model of home and community care client counts in British Columbia

In British Columbia (BC) Home and Community Care (HCC) services provide a range of health care and support services for British Columbians with acute, chronic, palliative or rehabilitative health care needs. Although it is not surprising that almost 80% of HCC clients are senior citizens (aged 65 and older), this does lead to some concern. In particular, the most recent population projections suggest that the senior population of BC will double in the next twenty years. Predicting how this will impact HCC is of high importance in preparing for future years. In this paper we discuss the development of a deterministic multi-state Markov model of the HCC system, its validation, and its predictions for future client counts for various HCC client groupings. This model was originally developed for the BC Ministry of Health Services, and is currently being used as a first step to developing a strategic direction plan for BC’s HCC sector. The model makes several notable steps forward in terms of research and modelling of HCC. First, past literature regarding models of HCC appears to be only concerned with publicly funded (government run) residential care environments. Our model advances this in two directions by including at home care and non-publicly funded care. Second, our model considers both the predicted changes in the age demographics of British Columbia, as well as the predicted changes in the relationship between age and health status.

Emergency department visits: the cost of trauma centers

Crowded emergency departments (EDs) have become a serious problem in the current U.S. healthcare system. Patient wait times and periods of ED diversion have increased, raising concerns about the timeliness, efficiency, and quality of ED treatment. This study addresses the question of whether there are economies of scale (EOS) in ED care, and the extent to which such economies vary across different types of EDs. A hospital cost function approach is taken to evaluate average and marginal costs of EDs designated as trauma centers. Data comes from acute care hospitals in Texas for the period 1998–2004. Cost functions corresponding to four different levels of ED trauma care are estimated using a translog panel data model with hospital fixed effects. The marginal costs (in 2004 dollars) of each trauma center level are: $53 (Level I), $177 (Level II), $119 (Level III), and $258 (Level IV). Average cost per ED visit for trauma centers exceeds marginal cost at all Levels, indicating the presence of EOS. The results support a possible expansion of ED size policy in order to improve the cost efficiency of ED services.

Choice determinants of the mobility in the Dutch health insurance market

We estimate a Logit model for the choice determinants of the mobility in the Dutch market for health insurance in 2006. The results highlight that socio-economic, geographical, and health-related factors matter in the decision to switch health care insurer. Moreover, previous contact with the insurer and the former type of health policy are also of influence.

Dying in Germany - consequences of societal changes for palliative care and the health care system

The changes in the way people die and the new challenges in dealing with dying and death have not been realized to their full extent or discussed in respect to their implications and consequences for end-of-life care in Germany. The purpose of this problem analysis paper is to provide an overview of the most important societal changes and to address the consequences for end-of-life care in the German Health Care System from a public health nursing point of view. It will be demonstrated that an exclusive focus on fostering the development of palliative care as a form of specialized health care and thereby allowing only a few people access to qualified care at the end of life is not a sufficient approach. It will be rather necessary to make broad changes in all areas of health care in order to achieve a level of end-of-life care that is of high quality and appropriate to match people’s needs. The most important challenges to be managed in the German health care system will be presented and discussed.

Total costs of injury from accidents in the home and during education, sports and leisure activities: estimates for Norway with assessment of uncertainty

Injury accidents occurring in the home, during educational, sports or leisure activities were estimated from samples of hospital data, combined with fatality data from vital statistics. Uncertainty of estimated figures was assessed in simulation-based analysis. Total economic costs to society from injuries and fatalities due to such accidents were estimated at approximately NOK 150 billion per year. The estimated costs reveal the scale of the public health problem and lead to arguments for the establishment of a proper injury register for the identification of preventive measures to reduce the costs to society.

Redistributive effects in public health care financing

This article focuses on the redistributive effects of different measures to finance public health insurance. We analyse the implications of different financing options for public health insurance on the redistribution of income from good to bad health risks and from high-income to low-income individuals. The financing options considered are either income-related (namely income taxes, payroll taxes, and indirect taxes), health-related (co-insurance, deductibles, and no-claim), or neither (flat fee). We show that governments who treat access to health care as a basic right for everyone should consider redistributive effects when reforming health care financing.

The public funding of abortion in Canada: going beyond the concept of medical necessity

This article defends the public funding of abortion in the Canadian health care system in light of objections by opponents of abortion that the procedure should be denied public funding. Abortion opponents point out that women terminate their pregnancies most often for social reasons, that the Canadian health care system only requires funding for medically necessary procedures, and that abortion for social reasons is not medically necessary care. I offer two lines of response. First, I briefly present an argument that characterizes abortion sought for social reasons as medically necessary care, directly contesting the anti-abortion position. Second, and more substantially, I present a justice argument that shows that even if abortion is not regarded as medically necessary care, the reasons that typically motivate women to seek abortion are sufficiently weighty from the moral perspective that it would be unjust to deny them public funding. I finish by drawing the more general conclusion that health care funding decisions should be guided by a broader concept of necessary care, rather than by a narrow concept of specifically medical necessity. A broad concept of necessary care has been debated in health care policy in the Netherlands, and I suggest that such a concept would be a more just and defensible guide for funding decisions than the concept of medical necessity.

Why U.S. health care expenditure and ranking on health care indicators are so different from Canada’s

Compared to other industrialized countries, the U.S. spends most of all on health care. Nonetheless, the U.S. ranks relatively low on health care indicators. This paradox has been already known for decades. For example, the turning point comparing the U.S. and Canada was in 1972. Health expenditure as a percentage of GDP was higher in Canada than in the USA from 1960 until 1972. Since 1972 expenditure on health care has been higher in the U.S. than in Canada (OECD 2005a, Health data 2005, fourteenth OECD electronic database on health systems, date of release June 2005, last update 04/26/2005). The present study integrates the dispersed literature on spending and health care rankings and adds some statistical analysis to these studies. The evaluation of different factors influencing health care expenditure in the U.S. relative to other countries is restricted to a comparison with Canada. The U.S. and Canada are two countries that are sufficiently similar to make comparisons useful. The comparison of factors influencing health care expenditure in the U.S. and Canada in 2002 reveals that health care expenditure in the U.S. is higher than in Canada mainly due to administration costs, Baumol’s cost disease and pharmaceutical prices. It is not primarily inefficiency in health care production but the dominant prevalence for free choice and own responsibility that explains the paradox of high expenditure on health care and low ranking on health care indicators.

Effects of Integrated Trauma Treatment on Outcomes in a Racially/Ethnically Diverse Sample of Women in Urban Community-based Substance Abuse Treatment

This study presents findings from a quasiexperimental, nonequivalent, group-design study with repeated measures that explored the effects of integrated trauma-informed services on the severity of substance abuse, mental health, posttraumatic stress disorder (PTSD) symptomatology among women with histories of trauma in urban, community-based substance abuse treatment. The study also explored if the model of integrated services was equally beneficial for women of various racial/ethnic groups. Participants in the study were 342 women receiving substance abuse treatment in intervention and comparison sites. Results indicated that at 6 and 12 month follow-ups, those in the trauma-informed intervention group, in contrast to the comparison group, had significantly better outcomes in drug abstinence rates in the past 30 days as well as in mental health and PTSD symptomatology. Results also showed that, overall, integrated services were beneficial for women across the different racial/ethnic groups in substance abuse treatment, although some differences appear to exist across racial/ethnic groups in improving addiction severity and mental health and PTSD symptomatology.

Specialization and competition in healthcare delivery networks

Hospital networks, which offer multiple services at multiple locations, are investigating strategies to fight the growing competition from specialty hospitals. Specialty hospitals focus on a selective range of profitable services, have better control over costs, and deliver higher (perceived) quality. A hospital network too can create specialized facilities; however, this may lead to the loss of sales from services that it no longer offers. Using a spatial model, we study when it is profitable for the network to specialize, and how to determine which facilities provide the greatest value through specialization. We find that a hospital network, when facing specialized competitors, can often improve its overall profitability by specializing some of its facilities; and that among its different facilities, the network’s best choice for specialization is the facility that is closest to the competitor, and thus most directly affected. Interestingly, we find that the value of specialization is contingent upon the competitive pressure that the specialized competitor exerts on the network. Specializing one facility yields the greatest benefits for the network when the competitor is located at the fringe of the market, thus presenting a reduced threat to the hospital network. On the other hand, if the specialized competitor is located at the core of the network’s customer base, we find that the attractiveness of specializing one facility is much smaller and that the hospital network might fare better with a strategy based on diversification, i.e., offering a full-menu of services at every facility.

The principle of double effect as a guide for medical decision-making

Many medical interventions have both negative and positive effects. When health care professionals cannot achieve a particular desired good result without bringing about some bad effects also they often rely on double-effect reasoning to justify their decisions. The principle of double effect is therefore an important guide for ethical decision-making in medicine. At the same time, however, it is a very controversial tool for resolving complex ethical problems that has been criticized by many authors. For these reasons, I examine in this paper whether the principle of double effect can serve as a basis for ethical decisions in medicine. The conclusion reached in this article is that even though this principle has desirable effects on clinical conduct, it is only an unreliable guide and physicians and nurses cannot feel secure in continuing to use this principle for ethical guidance.

The societal cost of alcohol consumption: an estimation of the economic and human cost including health effects in Sweden, 2002

This article estimates the societal cost of alcohol consumption in Sweden in 2002, as well as the effects on health and quality of life. The estimation includes direct costs, indirect costs and intangible costs. Relevant cost-of-illness methods are applied using the human capital method and prevalence-based estimates, as suggested in existing international guidelines, allowing cautious comparison with prior studies. The results show that the net cost (i.e. including protective effects of alcohol consumption) is 20.3 billion Swedish kronor (SEK) and the gross cost (counting only detrimental effects) is 29.4 billon (0.9 and 1.3% of GDP). Alcohol consumption is estimated to cause a net loss of 121,800 QALYs. The results are within the range found in prior studies, although at the low end. A large number of sensitivity analyses are performed, indicating a sensitivity range of 50%.

A multilevel analysis on the determinants of regional health care expenditure: a note

Health care in most countries is a rather “local good” for which the fiscal decentralization theory applies and heterogeneity is the result. In order to address the issue of multijurisdictional health care in estimating income elasticity, we constructed a unique sample using data for 110 regions in eight Organisation for Economic Co-operation and Development (OECD) countries in 1997. We estimated this sample data with a multilevel hierarchical model. In doing this, we tried to identify two sources of random variation: within- and between-country variation. The basic purpose was to find out whether the different relationships between health care spending and the explanatory variables are country specific. We concluded that to take into account the degree of fiscal decentralization within countries in estimating income elasticity of health expenditure proves to be important. Two plausible reasons lie behind this: (a) where there is decentralization to the regions, policies aimed at emulating diversity tend to increase national health care expenditure and (b) without fiscal decentralization, central monitoring of finance tends to reduce regional diversity and therefore decrease national health expenditure. The results of our estimation do seem to validate both these points.

Pesticides and farmer health in Nicaragua: a willingness-to-pay approach to evaluation

A contingent valuation approach to assess the health effects of chemical pesticides among Nicaraguan vegetable farmers is presented. Farmers’ valuation of health is measured as their willingness to pay (WTP) for low-toxicity pesticides. Results show that farmers are willing to spend an additional amount of about 28% of current pesticide expenditure for avoiding health risks. The validity of results is established in scope tests and with a two-step regression model. WTP depends on farmers’ experience with poisoning, income variables, and current exposure to pesticides. The results can help in designing rural health policies and in the formulation of programmes aiming to reduce the negative effects of pesticides.