Should administrative costs in health insurance be included in the risk-equalization? An analysis of five countries

Most countries that apply risk-equalization in their health insurance market(s) perform risk-equalization on medical claims but do not include other components of the insurance premium, such as administrative costs. Using fixed effects panel regressions from individual insurers in Australia, Germany, the Netherlands, Switzerland, and the US, we find evidence that health insurers with a high morbidity population on average have higher administrative costs. We argue that administrative costs should also be included in risk-equalization and we show that such equalization results in additional equalization payments nontrivial in size. Using examples from Germany and the US, we show how in practice policymakers can include administrative costs in risk-equalization. We are skeptical about applying risk-equalization to other components of the insurance premium, such as profits or costs related to solvency requirements of insurers.

     

Should sensory impairment be considered in frailty assessment? A study in the GAZEL cohort

Objectives

The assessment of sensory difficulties is sometimes included in the screening of frailty in ageing population. This study aimed to compare the prevalence of frailty and associated risk of adverse outcomes depending on whether sensory difficulties participated in the definition of frailty.

Design

Prospective cohort study–GAZEL cohort.

Setting

France.

Participants

The 13,128 subjects who completed a questionnaire in 2012.

Measurements

According to the Strawbridge questionnaire, subjects were considered frail if they reported difficulties in two domains or more among physical, nutritive, cognitive and sensory domains. The risk of adverse health outcomes was assessed by using logistic regression models (hospitalisations, onset of difficulty in performing movements of everyday life) and multivariate Cox proportional hazards models (mortality).

Results

Mean age was 66.8 +/? 3.4 years and 73.8% were males. The prevalence of frailty varied from 4.4 to 14.2% depending on whether the sensory domain was excluded or included. During follow-up, 182 deaths (1.4%), 479 hospitalisations (3.6%) and 703 cases of new disability (8.0%) were observed. Both definitions of frailty predicted the onset of difficulties to perform everyday movements, with 2 to 3-fold increase in the risk. The inclusion of the sensory domain in the definition made frailty predictive of hospitalisations (Odds Ratio 1.31 [1.01–1.70]) but the association with mortality was only observed when sensory difficulties were ignored (Hazard Ratio 2.28 [1.32–3.92]).

Conclusion

The inclusion of a sensory domain into a frailty screening instrument has a major impact in terms of prevalence and modifies the risk profile associated with frailty. In order to develop the use of frailty screening instruments in clinical practice, further researches will need to carefully evaluate the impact on risk prediction of the different domains involved.

     

Should night eating syndrome be included in the DSM?

OBJECTIVE: This article examines the status of the literature on night-eating syndrome (NES) according to five criteria that have been proposed by Blashfield, Sprock, and Fuller(1) (Compr Psychiatry 1990; 31:15-19) to determine whether NES warrants inclusion in the psychiatric nosology as a distinct eating disorder. METHOD: Relevant research papers were identified in Medline and PsychInfo using the search term "night-eating syndrome." RESULTS: None of the five criteria was met. Specifically, at the time of review, there were not yet 25 empirical papers on NES; no commonly accepted definition of or assessment approach to NES has been adopted; the utility and validity of NES need to be established, and NES needs to be differentiated more clearly from other eating disorder syndromes. CONCLUSION: This review suggests that the most pressing step toward clarifying the status of NES is to develop a uniform definition of NES. Once accomplished, research can progress to accumulating the necessary evidence to determine whether NES should be included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.     

Should Age be a Deciding Factor in Ethical Decision-Making?

The question of age as a factor in ethical decision-making takes two forms. The first form considers age as a factor at the societal, or policy, level, and the second as a factor in determining the capacity of the individual patient to make decisions regarding their own care. This article satisfies itself with a consideration of only the latter question. The issue of whether age is contributing factor in medical decision-making is frequently posited when one considers ethically charged instances of medical decision making at the end of life. Few would argue that the person who has the capacity for decision-making should be denied the ability to exercise that facility and so, it is when a person has lost their ability for making those choices that the question of age as a contributing factor in ethical decision making is raised. The question therefore becomes one of capacity more then age, with age as a useful, but inexact, gauge of that capacity. The inexactitude of age as a surrogate of capacity is a contributing factor to the problem posed in this series of articles. Therefore, to define the relative contribution of age to the capacity for ethical decision-making this article will focus not on the loss of that ability, but rather on the factors that define the realization of that faculty. To do this it will be necessary to define how that faculty is to be to be measured and what are the characteristics of an ethical decision that define it apart from other decisions. Since at the beginning of life, if age is the only variable (adjusting for other co-morbid states) then the issue of surrogacy is a temporary one and is unlike the adult where the presumption is that the person is unlikely to regain decision-making capacity as they slip further into their morbid state.     

Should adjustment for covariates be used in prevalence estimations?

Background

Adjustment for covariates (also called auxiliary variables in survey sampling literature) is commonly applied in health surveys to reduce the variances of the prevalence estimators. In theory, adjusted prevalence estimators are more accurate when variance components are known. In practice, variance components needed to achieve the adjustment are unknown and their sample estimators are used instead. The uncertainty introduced by estimating variance components may overshadow the reduction in the variance of the prevalence estimators due to adjustment. We present empirical guidelines indicating when adjusted prevalence estimators should be considered, using gender adjusted and unadjusted smoking prevalence as an illustration.

Methods

We compare the accuracy of adjusted and unadjusted prevalence estimators via simulation. We simulate simple random samples from hypothetical populations with the proportion of males ranging from 30% to 70%, the smoking prevalence ranging from 15% to 35%, and the ratio of male to female smoking prevalence ranging from 1 to 4. The ranges of gender proportions and smoking prevalences reflect the conditions in 1999–2003 Behavioral Risk Factors Surveillance System (BRFSS) data for Massachusetts. From each population, 10,000 samples are selected and the ratios of the variance of the adjusted prevalence estimators to the variance of the unadjusted (crude) ones are computed and plotted against the proportion of males by population prevalence, as well as by population and sample sizes. The prevalence ratio thresholds, above which adjusted prevalence estimators have smaller variances, are determined graphically.

Results

In many practical settings, gender adjustment results in less accuracy. Whether or not there is better accuracy with adjustment depends on sample sizes, gender proportions and ratios between male and female prevalences. In populations with equal number of males and females and smoking prevalence of 20%, the adjusted prevalence estimators are more accurate when the ratios of male to female prevalences are above 2.4, 1.8, 1.6, 1.4 and 1.3 for sample sizes of 25, 50, 100, 150 and 200, respectively.

Conclusion

Adjustment for covariates will not result in more accurate prevalence estimator when ratio of male to female prevalences is close to one, sample size is small and risk factor prevalence is low. For example, when reporting smoking prevalence based on simple random sampling, gender adjustment is recommended only when sample size is greater than 200.     

Should the capability approach be applied in Health Economics?

This editorial questions the implications of the capability approach for health economics. Two specific issues are considered: the evaluative space of capablities (as opposed to health or utility) and the decision-making principle of maximisation. The paper argues that the capability approach can provide a richer evaluative space enabling improved evaluation of many interventions. It also argues that more thought is needed about the decision-making principles both within the capability approach and within health economics more generally. Specifically, researchers should analyse equity-oriented principles such as equalisation and a 'decent minimum' of capability, rather than presuming that the goal must be the maximisation of capability.     

Should we be tracking AIDS virus transmission in India?

In India HIV infection was 1st found among prostitutes in Madras city in February, 1986. The government and the Indian Council of Medical Research set up 40 surveillance centers equipped with enzyme-linked immunosorbent assay readers and HIV antibody test kits. In 1987, a rural middle-aged breadwinner received a blood transfusion for ulcers and contracted AIDS. The donor was traced and found to be infected with HIV, as were also his wife and child. He had had sexual intercourse with prostitutes in 1984. In 1988, a 3rd man was found to have AIDS; he had had homosexual contacts with many partners. The country's rapid mobilization against AIDS has been criticized on grounds that India has more pressing problems. However, the public health efforts against AIDS have not been diverted from any other program, and if a similar campaign had been mounted against hepatitis B virus infection, many lives would have been saved. 1% to 3% of patients in venereal disease clinics in Vellore have been found to be HIV-positive, and the rate of HIV infection in blood banks is 1.6/1000 donors, which indicates that there are probably 500,000 people already infected with AIDS in India. The Indian government's response to the impending AIDS epidemic should serve as a model in the fight against other communicable diseases.