How does cost matter in health‐care discrete‐choice experiments?

Willingness‐to‐pay (WTP) estimates derived from discrete‐choice experiments (DCEs) generally assume that the marginal utility of income is constant. This assumption is consistent with theoretical expectations when costs are a small fraction of total income. We analyze the results of five DCEs that allow direct tests of this assumption. Tests indicate that marginal utility often violates theoretical expectations. We suggest that this result is an artifact of a cognitive heuristic that recodes cost levels from a numerical scale to qualitative categories. Instead of evaluating nominal costs in the context of a budget constraint, subjects may recode costs into categories such as ‘low’, ‘medium’, and ‘high’ and choose as if the differences between categories were equal. This simplifies the choice task, but undermines the validity of WTP estimates as welfare measures. Recoding may be a common heuristic in health‐care applications when insurance coverage distorts subjects' perception of the nominal costs presented in the DCE instrument. Recoding may also distort estimates of marginal rates of substitution for other attributes with numeric levels. Incorporating ‘cheap talk’ or graphic representation of attribute levels may encourage subjects to be more attentive to absolute attribute levels. Copyright © 2010 John Wiley & Sons, Ltd.     

What has influenced patient health‐care expenditures in Japan?: variables of age,death, length of stay,and medical care

This study considers variables related to health-care expenditures associated with aging and long-term hospitalization in Japan. We focused on daily per capita inpatient health-care expenditures, and examined the impact of inpatient characteristics such as sex, age, survived or deceased, length of stay, adult disease, and type of medical care received during the duration of each stay. We analyzed data from the Survey of Medical-Care Activities in Public Health Insurance by multinomial logistic regression analyses. Age of patient had little impact on per capita inpatient health-care expenditures per day. As regards length of stay, inpatient stays of 8-14 days had a little impact on health-care expenditures. This study suggested that these results might be due to the kind of medical care received. More research is needed to determine the appropriate medical services to reduce long-term hospitalization. In the last month of care for patients who died, medical examinations had a great influence on health-care expenditures. This study showed that increasing medical examinations in the end-of-life care needs further investigation.     

Exploring variations in health‐care expenditures—What is the role of practice styles?

Variations in medical resource usage, both across and within geographical regions, have been widely documented. In this paper, we explore physician practice styles as a possible determinant of these variations. In particular, we exploit patient mobility between physicians to identify practice styles among general practitioners (GPs) in Austria. We use a large administrative data set containing detailed information on a battery of different health‐care services and implement a model with additive patient and GP fixed effects that allows flexibly for systematic differences in patients' health states. We find that, although GPs explain only a small part of the overall variation in medical expenses, heterogeneities in spending patterns among GPs are substantial. Conditional on patient characteristics, we document a difference of € 751.47 per patient per year in total medical expenses (which amounts to roughly 45% of the sample mean) between high‐ and low‐spending GPs.     

Limiting health‐care access to undocumented immigrants: A wise option?

The number of undocumented migrants in high‐income countries has increased in recent decades, imposing considerable political, fiscal, and social pressures on governments. This has fostered discussions on whether and to what extent undocumented migrants should get access to public programs and public benefits. Looking at the 2012 Spanish health reform, this is the first paper to document the impacts of a restriction on access to the health‐care system for undocumented migrants on health‐care utilization, health‐care system perceptions, and self‐reported health in a high‐income country. We show that such restrictions may significantly reduce planned care for undocumented migrants and result in sharp fall in positive opinions about the health‐care services still left available to them. We also exploit the heterogeneity in implementing the policy across regions and report stronger effects in regions that enforced the national ban more fully. Furthermore, in the first 3 years since the implementation of the reform, we find suggestive evidence of a worsening in self‐assessed health. This study is relevant for policymakers in the developed world, especially in countries that have recently implemented initiatives aimed at reducing the health‐care coverage for targeted groups, such as the United Kingdom and the United States.     

Preference‐based index measurement of health‐related quality of life: when does it reflect only arbitrary settings of the researcher?

In health economics, health-related quality of life (HRQoL) is often assessed by means of preference-based index measurement instruments (e.g. EQ-5D, SF-6D, HUI). Each instrument of this kind consists of (1) a multi-attribute classification system for distinguishing health states and (2) a scoring function which assigns a valuation to each health state distinguished within the classification system. Scoring functions are often produced according to the so-called statistical approach which consists of two steps: (1) the valuations of some of the health states of the classification system are empirically determined and (2) the scoring function values for all health states are estimated from the empirically determined valuations using a theoretical model, i.e. an index model. This approach can run into problems because the empirically determined valuations necessarily contain arbitrary settings. This article is concerned with how these arbitrary settings together with the index model affect the final scoring function values. It is shown that for many conceivable index models the final scoring function values have no empirical meaning. Only additive models with a free additive constant are appropriate for representing the information contained in the empirically determined valuation. Only these models should be used within the statistical approach.     

Preferences and person trade‐offs: forcing consistency or inconsistency in health‐related quality of life measures?

We consider assumptions about preferences implicit in the person trade-off exercises used to derive health-related quality of life measures for the Global and US Burden of Disease Projects. Because these methods and their results have the potential of being adopted by other researchers, a critical review of this methodology and its assumptions is warranted. Exercise participants are told that quality of life valuation is approached using two different questions to reveal logical inconsistencies in each person's responses. An inconsistency is claimed to exist if a participant's two responses violate a particular mathematical relationship, and participants are forced to modify their responses to satisfy that relationship. We demonstrate that this supposed 'logical' relationship need not hold for logically consistent, rational individuals, and we prove that the relationship will in fact hold only for a particular class of social value functions exhibiting two characteristics that may not be consistent with the preferences of some participants. These results imply that the forced modification may invalidate some responses, as it may require some participants to provide final answers that are inconsistent with their true preferences. We then discuss preference characterizations in the existing person trade-off literature, from which this relationship may have been derived.     

Self‐care as care left undone? The ethics of the self‐care agenda in contemporary healthcare policy

Self‐care, or self‐management, is presented in healthcare policy as a precursor to patient empowerment and improved patient outcomes. Alternatively, critiques of the self‐care agenda suggest that it represents an over‐reliance on individual autonomy and responsibility, without adequate support, whereby ‘self‐care’ is potentially unachievable and becomes ‘care left undone’. In this sense, self‐care contributes to a blame culture where ill‐health is attributed to personal behaviours or lack thereof. Furthermore, self‐care may represent a covert form of rationing, as the fiscal means to enable effective self‐care and supplement, or replace, self‐care capacities, is not provided. This paper explores these arguments through a contemporary ethical analysis of the self‐care agenda. The terms self‐care and self‐management are used interchangeably throughout whereby self‐management is understood as a point in the wider self‐care continuum.     

Socio‐economic inequality in health service utilisation: Does accounting for seasonality in health‐seeking behaviour matter?

Seasonal variation exists in disease incidence. The variation could occur across the different regions in a country. This paper argues that using national household data that are not adjusted for seasonal and regional variations in disease incidence may not be directly suitable for assessing socio‐economic inequality in annual outpatient service utilisation, including for cross‐country comparison. In fact, annual health service utilisation may be understated or overstated depending on the period of data collection. This may lead to miss‐estimation of socio‐economic inequality in health service utilisation depending, among other things, on how health service utilisation, across geographical areas, varies by socio‐economic status. Using a nationally representative dataset from South Africa, the paper applies a seasonality index that is constructed from the District Health Information System, an administrative dataset, to annualise public outpatient health service visits. Using the concentration index, socio‐economic inequality in health service visits, after accounting for seasonal variations, was compared with that when seasonal variations are ignored. It was found that, in some cases, socio‐economic inequality in outpatient health service visits depends on the socio‐economic distribution of the seasonality index. This may justify the need to account for seasonal and geographical variations.     

The role of educational theory in continuing medical education: has it helped us?

Despite the existence of many approaches to understanding learning and change and attempts to incorporate these into continuing education research and practice, the search continues for a comprehensive understanding of how learning is engendered in professional practice and the processes by which learning and change occur. This article considers four broad questions in relation to the practice of continuing education: (1) What can be expected of theory? (2) How does theory relate to the educational practice of those in continuing education and the goals of continuing medical education ? (3) How have practice and theory mutually informed our current understandings? (4) How can theory serve the field more effectively in the future? Broad orientations to understanding learning provide a framework for examining the contributions of theory and practice. The orientations include behaviorist, cognitivist, social learning, humanist, and constructivist; for each, an example is presented. Newer understandings also are introduced. The article concludes by considering reasons as to why theory appears not to have served us better and by offering ways in which those in continuing education can ensure greater usefulness of theory while contributing to its continued development.     

How would case managers’ practice change in a consumer‐directed care environment in Australia?

The aim of this study was to explore case managers’ perceived changes in their practice in the future when consumer‐directed care (CDC) is widely implemented in Australia's community aged care system. Purposeful sampling was used and semi‐structured individual and group interviews were conducted between September 2012 and March 2013. Participants were drawn from a list of all case managers who administered publicly funded community aged care packages in Victoria, Australia. Empowerment theory was used to guide the analysis and interpretation of the data. The thematic analysis revealed that case managers had mixed views about CDC. They also perceived changes in case managers’ practice in the future when CDC is widely implemented. These might specifically include: first, case managers would not directly manage clients’ budgets. While some case managers were concerned about losing power for this change, others believed that they would still have important financial roles to perform, such as setting rules, providing financial support and monitoring clients’ use of budgets. Second, case managers would focus on performing roles in providing information, and empowering, facilitating and educating clients. These would help to strengthen clients’ capacities and assist them to self‐manage their care. Third, case managers would work in partnership with clients through frequent or skilful communication, mutual goal setting and goal facilitation. Fourth, case managers would manage more clients. In addition, they would provide less support to each individual client and perform less care co‐ordination role. The findings suggest case managers paying attention to power balance regarding budget management in a CDC environment. Furthermore, they might frequently or skilfully communicate with, empower, facilitate and educate clients; work together with them to set up goals; and facilitate them to achieve goals. New research using empowerment theory to examine the actual practice of case managers in a well‐established CDC system is warranted.     

Practice variation in the Dutch long‐term care and the role of supply‐sensitive care: Is access to the Dutch long‐term care equitable?

Universal access and generous coverage are important goals of the Dutch long‐term care (LTC) system. It is a legal requirement that everyone eligible for LTC should be able to receive it. Institutional care (IC) made up for 90% of Dutch LTC spending. To investigate whether access to IC is as equitable as the Dutch government aspires, we explored practice variation in entitlements to IC across Dutch regions. We used a unique dataset that included all individual applications for Dutch LTC in January 2010–December 2013 (N = 3,373,358). This dataset enabled an accurate identification of the need for care. We examined the local variation in the probability of being granted long‐term IC and in the intensity of the care granted given that individuals have applied for LTC. We also investigated whether the variation observed was related to differences in the local availability of care facilities. Although our analyses indicated the presence of some practice variation, its magnitude was very small by national and international standards (up to 3%). Only a minor part of the practice variation could be accounted for by local supply differences in care facilities. Overall, we conclude that, unlike many other developed countries, the Dutch system ensured equitable access to long‐term IC.     

How do hospital‐specialty characteristics influence health system responsiveness? An empirical evaluation of in‐patient care in the Italian region of Emilia‐Romagna

Studies of health system responsiveness mostly focus on the demand side by investigating the association between sociodemographic characteristics of patients and their reported level of responsiveness. However, little is known about the influence of supply‐side factors. This paper addresses that research gap by analysing the role of hospital‐specialty characteristics in explaining variations in patients' evaluation of responsiveness from a sample of about 38,700 in‐patients treated in public hospitals within the Italian Region of Emilia‐Romagna. The analysis is carried out by adopting a 2‐step procedure. First, we use patients' self‐reported data to derive 5 measures of responsiveness at the hospital‐specialty level. By estimating a generalised ordered probit model, we are able to correct for variations in individual reporting behaviour due to the health status of patients and their experience of being in pain. Second, we run cross‐sectional regressions to investigate the association between patients' responsiveness and potential supply‐side drivers, including waiting times, staff workload, the level of spending on non‐clinical facilities, the level of spending on staff education and training, and the proportion of staff expenditure between nursing and administrative staff. Results suggest that responsiveness is to some extent influenced by the supply‐side drivers considered.