The Societal Burden of HBV-Related Disease: South Korea

To highlight the societal burden of HBV infection in South Korea, we estimated the annual societal costs of HBV-related diseases for the year 2005. For the economic costs of HBV-infection-related diseases estimate, baseline data was collected from the Health Insurance Review and Assessment Service (HIRA) database. To complement data from the HIRA database, hospital charts from sample hospitals was reviewed and patient surveys were conducted. In 2005, the societal cost of HBV infection was 1.937 trillion KRW, including 474,642 million KRW of direct costs and 1.463 trillion KRW of indirect costs. The cost breakdown by disease was CHB at 465,167 million KRW, cirrhosis at 533,449 million KRW, hepatocellular carcinoma at 863,940 million KRW, and liver transplantation at 74,635 million KRW. The estimated amount is equivalent to 0.24% of the 2005 Korean GDP. This analysis emphasizes how important the prevention and treatment of these diseases are from the perspectives of the Korean society.     

How big is the financial burden of hepatitis B to society? A cost‐of‐illness study of hepatitis B infection in Singapore

Summary.  Hepatitis B virus (HBV) infection is the most common cause of chronic viral liver disease in Singapore. Nevertheless, very little data exist on the financial burden of HBV infection to the society as a whole. The aim of this study was therefore to assess the direct and indirect cost of HBV infection in a cost-of-illness analysis. The combined data from the direct and indirect cost with the estimated prevalence for different disease stages of HBV infection would represent the annual financial burden of HBV infection to the Singaporean society as a whole. The estimated total annual cost of chronic HBV infection and its associated complications in Singapore was US$279 million (range US$34–941 million when allowing various assumptions as tested by the sensitivity analyses), with 58% or US$161 million attributable to direct cost. Based on the base-case estimation, total direct cost alone is equivalent to 12% of the national healthcare expenditure for 2003. The total cost incurred by chronic hepatitis B patients represents the biggest cost component, followed by decompensated cirrhosis (DC) patients. The ratio of direct to indirect costs based on the base-case estimation increased with disease severity, with the highest ratio obtained for the post-liver transplants (40.2:1), followed by hepatocellular carcinoma (7.4:1) and DC patients (2.7:1). The results of this study suggest that the management of HBV infection poses more than a medical challenge as it is a sizeable economic burden from both the payer and societal perspectives.     

Economic burden of asthma in Korea

Understanding the magnitude of the economic impact of an illness on society is fundamental to planning and implementing relevant policies. South Korea operates a compulsory universal health insurance system providing favorable conditions for evaluating the nationwide economic burden of illnesses. The aim of this study was to estimate the economic costs of asthma imposed on Korean society. The Korean National Health Insurance claims database was used for determining the health care services provided to asthma patients defined as having at least one inpatient or outpatient claim(s) with a primary diagnosis of asthma in 2008. Both direct and indirect costs were included. Direct costs were those associated directly with treatment, medication, and transportation. Indirect costs were assessed in terms of the loss of productivity in asthma patients and their caregivers and consisted of morbidity cost, mortality cost, and caregivers' time cost. The estimated cost for 2,273,290 asthma patients in 2008 was $831 million, with an average per capita cost of $336. Among the cost components, outpatient and medication costs represented the largest cost burden. Although the costs for children accounted for the largest proportion of the total cost, the per capita cost was highest among patients ≥50 years old. The economic burden of asthma in Korea is considerable. Considering that the burden will increase with the rising prevalence, implementation of effective national prevention approaches aimed at the appropriate target populations is imperative.     

Economic burden of acute pesticide poisoning in South Korea

Objectives To investigate the magnitude and characteristics of the economic burden resulting from acute pesticide poisoning (APP) in South Korea. Methods The total costs of APP from a societal perspective were estimated by summing the direct medical and non‐medical costs together with the indirect costs. Direct medical costs for patients assigned a disease code of pesticide poisoning were extracted from the Korean National Health Insurance Reimbursement Data. Direct non‐medical costs were estimated using the average transportation and caregiving costs from the Korea Health Panel Survey. Indirect costs, incurred by pre‐mature deaths and work loss, were obtained using 2009 Life Tables for Korea and other relevant literature. Results In 2009, a total of 11 453 patients were treated for APP and 1311 died, corresponding to an incidence of 23.1 per 100 000 population and a mortality rate of 2.6 per 100 000 population in South Korea. The total costs of APP were estimated at approximately US$ 150 million, 0.3% of the costs of total diseases. Costs due to pre‐mature mortality accounted for 90.6% of the total costs, whereas the contribution of direct medical costs was relatively small. Conclusion Costs from APP demonstrate a unique characteristic of a large proportion of the indirect costs originating from pre‐mature mortality. This finding suggests policy implications for restrictions on lethal pesticides and safe storage to reduce fatality and cost due to APP.     

An economic analysis of the current universal 2-dose measles-mumps-rubella vaccination program in the United States

To evaluate the economic impact of the current 2-dose measles-mumps-rubella (MMR) vaccination program in the United States, a decision tree-based analysis was conducted with population-based vaccination coverage and disease incidence data. All costs were estimated for a hypothetical US birth cohort of 3803295 infants born in 2001. The 2-dose MMR vaccination program was cost-saving from both the direct cost and societal perspectives compared with the absence of MMR vaccination, with net savings (net present value) from the direct cost and societal perspectives of US dollars 3.5 billion and US dollars 7.6 billion, respectively. The direct and societal benefit-cost ratios for the MMR vaccination program were 14.2 and 26.0. Analysis of the incremental benefit-cost of the second dose showed that direct and societal benefit-cost ratios were 0.31 and 0.49, respectively. Varying the proportion of vaccines purchased and administered in the public versus the private sector had little effect on the results. From both perspectives under even the most conservative assumptions, the national 2-dose MMR vaccination program is highly cost-beneficial and results in substantial cost savings.     

The social cost of alcohol,tobacco and illicit drugs in France, 1997

AIM, DESIGN AND SETTING: The economic costs of alcohol, tobacco and illicit drugs to French society are estimated using a cost of illness framework. MEASUREMENTS: For the cause of disease or death (using ICD-9 categories), pooled relative risk estimates from meta-analyses were combined with prevalence data by age and gender to derive the proportion attributable to alcohol, tobacco and/or illicit drugs. The resulting estimates of attributable deaths and hospitalizations were used to calculate the associated health care, law enforcement, productivity and other costs. The results were compared with those of other studies, and sensitivity analyses were conducted by alternative ways of measuring risk attribution and costs. FINDINGS: The use of alcohol, tobacco and illicit drugs cost more than 200 billion francs (FF) in France in 1997, representing 3714 FF per capita or 2.7% of the gross domestic product (GDP). Alcohol is the drug that gives rise to the greatest cost in France, i.e. 115420.91 million FF (1.42% of GDP) or an expenditure per capita of 1966 FF in 1997. Alcohol takes more than half of the social cost of drugs to society. The greatest share of the social cost of alcohol comes from the loss of productivity (57555.66 million FF), due to premature death (53168.60 million FF), morbidity (3884.0 million FF) and imprisonment (503.06 million FF). Tobacco leads to a social cost of 89256.90 million FF, that is an expenditure per capita of 1520.56 FF or 1.1% of GDP. Productivity losses amount to 50446.70 million FF, with losses of 42765.80 million FF as a result of premature death and 7680.90 million FF linked to morbidity. Health care costs for tobacco occupy second place at 26973.70 million FF. Illicit drugs generate a social cost of 13350.28 million FF, that is an expenditure per capita of 227.43 FF or 0.16% of GDP. Productivity losses reach 6099.19 million FF, with 5246.92 million FF linked to imprisonment and 852.27 million FF to premature death. The cost of enforcing the law for illicit drugs occupies second place at 3911.46 million FF, followed by health care costs of 1524.51 million FF. CONCLUSION: Substance abuse exact a considerable toll from French society in terms of illness, injury, death and economic costs.     

Hepatitis B virus mutations related to liver disease progression of Korean patients

Hepatitis B virus(HBV)infection is a global health problem and more than 350 million people worldwide are chronic carriers of the virus.Despite the recent dramatic decline in HBV chronic patients through successful programs of hepatitis B surface antigen vaccination,South Korea is still recognized as an endemic area of HBV infection.HBV infections in South Korea exhibit several distinct features in epidemiologic and clinical aspects.In this review paper,we summarize the distinct HBV mutation patterns related to clinical severity and the molecular epidemiologic traits in Korean chronic patients based on previous reports.Generally,several lines of evidence,including our previous results,have led to the conclusion that a combination of the exclusive predominance of genotype C2,which is prone to mutations,the high prevalence of basal core promoter double mutations,and the presence of distinct immune responses against HBV proteins in the Korean population may generate the distinct HBV variants rarely or not encountered in other areas,which results in distinct clinical manifestations in Korean chronic patients.This may provide a novel insight into the relationships between clinical severity,HBV genotype distribution,and HBV naturally occurring variants.     

The economic burden of rheumatic heart disease in South Korea

Understanding the impact of rheumatic heart disease (RHD) has become increasingly important among aging populations around the world, and Korea is no exception. This study was conducted to estimate total annual patient costs associated with RHD in Korea for 2008 using nationally representative data. The subjects were South Korean citizens with RHD (ICD-10 codes I01-I09). The primary information for this study was obtained from claims data compiled by the National Health Insurance Corporation of Korea. Direct medical care costs were estimated using expenses paid by insurers and patients for non-covered care and pharmaceutical costs. Direct non-medical costs were estimated using data on transportation costs for hospital visits and costs for caregivers. Indirect costs included the costs of productivity loss and premature death in RHD patients. The economic burden of RHD in 2008 was estimated at $67.25 million US dollars. The indirect costs amounted to 39.04 % (US $26.26 million) of the total RHD costs. When stratified by age, the costs incurred by the group of patients older than 60 years were US $31.63 million. The prevalence of the disease in the same age group was 791.07 cases per 100,000 people. This study confirms that the prevalence of RHD was highest in patients older than 60 years in 2008. Furthermore, the patterns of disease in South Korea were similar to patterns observed in other high-income countries. These findings indicate that secondary prevention strategies for the early detection of RHD are needed in South Korea.     

Economic evaluation of pneumococcal conjugate vaccination in Finland

The aim of this study was to evaluate cost-effectiveness of pneumococcal conjugate vaccine (PCV7) in children <5 y of age. A Markov simulation model was used to compare the cost-effectiveness of 4 doses (assumed 50.5 euros per dose) of PCV7 with no intervention. Only direct effects of the vaccine were taken into account. In Finland, vaccination of a birth cohort of 57,500 healthy infants would potentially prevent annually 60 cases of invasive PD, 1,400 cases of pneumococcal pneumonia, 15,000 episodes of acute otitis media, 3,000 otological surgery procedures and 0.9 deaths in children aged <5 y. Investing 12.0 million euros to vaccinate a birth cohort would save annually 6.3 million euros in medical, and 2.0 million euros in productivity and other, costs. Therefore, investing 1 euros in a vaccination programme would return 0.53 euros in medical costs and 0.70 euros in societal costs. In the base case, vaccination would cost society 139,986 euros per life y gained. To achieve cost savings from a health care provider (societal) perspective, without considering herd effects or replacement phenomenon, the price of PCV7 should be 50% (70%) of the price used in the base case.     

Assessment of the economic burden of COPD in the U.S.: a review and synthesis of the literature

The costs of chronic obstructive pulmonary disease (COPD) pose a major economic burden to the United States. Studies evaluating COPD costs have generated widely variable estimates; we summarized and critically compared recent estimates of the annual national and per-patient costs of COPD in the U.S. Thirteen articles reporting comprehensive estimates of the direct costs of COPD (costs related to the provision of medical goods and services) were identified from searches of relevant primary literature published since 1995. Few papers reported indirect costs of COPD (lost work and productivity). The National Heart, Lung, and Blood Institute (NHLBI) provides the single current estimate of the total (direct plus indirect) annual cost of COPD to the U.S., $38.8 billion in 2005 dollars. More than half of this cost ($21.8 billion) was direct, aligning with the $20-26 billion range reported by two other recent analyses of large national datasets. For per-patient direct costs (in $US 2005), studies using recent data yield attributable cost estimates (costs deemed to be related to COPD) in the range of $2,700-$5,900 annually, and excess cost estimates (total costs incurred by COPD patients minus total costs incurred by non-COPD patients) in the range of $6,100-$6,600 annually. Studies of both national and per-patient costs that use data approximately 8-10 years old or older have produced estimates that tend to deviate from these ranges. Cost-of-illness studies using recent data underscore the substantial current cost burden of COPD in the U.S.     

Cost-benefit analysis of a nationwide infant immunization programme against hepatitis A in an area of intermediate endemicity

BACKGROUND/AIMS: The availability of safe and effective Hepatitis A vaccines prompts an evaluation of a nationwide infant vaccination campaign to supplement strategies aimed at high-risk groups such as travellers and military personnel. METHODS: A spreadsheet model was used to estimate costs and benefits of a nationwide infant immunization programme against Hepatitis A for the period from 1997-2014 in Israel. RESULTS: Immunizing all one year olds in Israel from 1997-2014 would for a cost of $32.0 million to the health services and $42.1 million to society (including $10.1 million lost work and transport costs), reduce the number of cases of Hepatitis A during the next 45 years from 181,000 to 47,000. This would save $57.5 million in health service resources alone, $32.0 million in averted work absences and transport costs in addition to a further $17.0 million in averted premature mortality costs. The health service, resource and societal benefit:cost ratios are 1.80:1, 2.13:1 and 2.54:1, respectively. CONCLUSIONS: The recent adoption of a nationwide infant HAV immunisation policy in Israel is both medically and economically justifiable.     

Health care costs of diarrheal disease and estimates of the cost-effectiveness of rotavirus vaccination in Vietnam

BACKGROUND: Rotavirus disease causes a significant health and economic burden worldwide. Several rotavirus vaccines may soon be available for use. A country's decision to introduce these vaccines will depend on its rotavirus disease burden, on the cost of the vaccine, and on the results of an economic assessment of the cost and effectiveness of a rotavirus vaccination program. METHODS: Data on medical and nonmedical direct costs and indirect costs were established in Khanh Hoa Province, Vietnam, and extrapolated to national estimates on the basis of the birth cohort in 2004. The main outcome measures were economic burden and cost-effectiveness ratio (United States dollars per disability-adjusted life-year averted and dollars per life saved) of vaccination. RESULTS: The disease burden is equivalent to an economic burden of an estimated 3.1 million US dollars in medical direct costs, 685,000 US dollars in nonmedical direct costs, and 1.5 million US dollars in indirect costs. From a societal perspective, treatment of rotavirus disease costs an estimated 5.3 million US dollars per year. From the health care system perspective, universal vaccination of infants at a cost of < or = 7.26 US dollars/vaccine dose would be a cost-effective public health intervention, according to the World Bank cost-effectiveness standard for low-income countries (140 US dollars/disability-adjusted life-year). CONCLUSIONS: Vaccination can effectively reduce the disease burden and health care costs of rotavirus-specific diarrhea in Vietnam.     

Epidemiology,burden, and policy of chronic obstructive pulmonary disease in South Korea: a narrative review

Chronic obstructive pulmonary disease (COPD) is a global health problem and a significant cause of mortality and morbidity worldwide. COPD also occupies a significant and considerable economic burden on individuals and society in South Korea. We investigated the epidemiology and burden of COPD in South Korea and reviewed the policy regarding COPD. In South Korea, a national COPD prevalence survey has been conducted for two decades. The prevalence of COPD has increased with increasing age, particularly among males, and those also with a higher smoking history and with lower income. The total societal cost of COPD increased by 1.85 times between 2004 and 2013. As the use of inhaled medications has increased, the total medical cost per person has increased. The trends of increasing numbers of patients diagnosed with COPD and the total societal costs are expected to continue. There is one universal-health-coverage system in South Korea. The costs and reimbursement criteria of COPD drugs are established and controlled by the Health Insurance Review and Assessment Service (HIRA). The HIRA has also implemented quality assessment, including evaluating the appropriateness of a COPD diagnosis and treating all COPD patients to reduce the severity of illness and improve the adequacy of medical-care benefits.     

The burden of selected digestive diseases in the United States

BACKGROUND & AIMS: Gastrointestinal (GI) and liver diseases inflict a heavy economic burden. Although the burden is considerable, current and accessible information on the prevalence, morbidity, and cost is sparse. This study was undertaken to estimate the economic burden of GI and liver disease in the United States for use by policy makers, health care providers, and the public. METHODS: Data were extracted from a number of publicly available and proprietary national databases to determine the prevalence, direct costs, and indirect costs for 17 selected GI and liver diseases. Indirect cost calculations were purposefully very conservative. These costs were compared with National Institutes of Health (NIH) research expenditures for selected GI and liver diseases. RESULTS: The most prevalent diseases were non-food-borne gastroenteritis (135 million cases/year), food-borne illness (76 million), gastroesophageal reflux disease (GERD; 19 million), and irritable bowel syndrome (IBS; 15 million). The disease with the highest annual direct costs in the United States was GERD ($9.3 billion), followed by gallbladder disease ($5.8 billion), colorectal cancer ($4.8 billion), and peptic ulcer disease ($3.1 billion). The estimated direct costs for these 17 diseases in 1998 dollars were $36.0 billion, with estimated indirect costs of $22.8 billion. The estimated direct costs for all digestive diseases were $85.5 billion. Total NIH research expenditures were $676 million in 2000. CONCLUSIONS: GI and liver diseases exact heavy economic and social costs in the United States. Understanding the prevalence and costs of these diseases is important to help set priorities to reduce the burden of illness.     

Costs of COPD in Sweden according to disease severity

OBJECTIVES: COPD is a common and disabling disease that entails high costs for society. The objectives of this study were to measure the societal costs of COPD in Sweden, and to examine the relationship between severity of illness and costs. METHODS: The costs of COPD were examined using a well-defined and representative cohort of subjects with mild, moderate, and severe COPD. Regular telephone interviews regarding resource utilization were made to a cohort of 212 subjects with COPD derived from studies of the general population in Northern Sweden. RESULTS: The annual per capita cost for COPD in Swedish crowns (SEK) was estimated at SEK 13,418 (1,284 US dollars (USD); 1,448 euros (EUR). The direct and indirect costs were SEK 5,592 (42%) and SEK 7,828 (58%), respectively. A highly significant relationship was found between severity of disease and costs. Costs for severe disease were 3 times as high as costs for moderate disease and > 10 times as high as for mild disease. Large individual variations in the level of costs were found. CONCLUSION: Assuming that the prevalence and treatment patterns are representative of Sweden as a whole, the total costs of COPD to society in 1999 were estimated at SEK 9.1 billion (USD 871 million; EUR 982 million). Subjects with mild disease (83%) accounted for 29%, while subjects with moderate disease (13%) accounted for 41% of the total costs. The subjects with severe disease (4%) accounted for the remainder (30%). Prevention, early diagnosis, and postponement of disease progression should have large monetary and policy implications.     

The Burden of Dengue and the Financial Cost to Colombia, 2010–2012

Data on the burden of dengue and its economic costs can help guide health policy decisions. However, little reliable information is available for Colombia. We therefore calculated the burden of the disease, expressed in disability-adjusted life years (DALYs), for two scenarios: endemic years (average number of cases in non-epidemic years 2011 and 2012) and an epidemic year (2010, when the highest number of dengue cases was reported in the study period). We also estimated the total economic cost of the disease (U.S. dollars at the average exchange rate for 2012), including indirect costs to households derived from expenses such as preventing entry of mosquitos into the home and costs to government arising from direct, indirect, and prevention and monitoring activities, as well as the direct medical and non-medical costs. In the epidemic year 2010, 1,198.73 DALYs were lost per million inhabitants versus 83.88 in endemic years. The total financial cost of the disease in Colombia from a societal perspective was US$167.8 million for 2010, US$129.9 million for 2011, and US$131.7 million for 2012. The cost of mosquito prevention borne by households was a major cost driver (accounting for 46% of the overall cost in 2010, 62% in 2011, and 64% in 2012).     

Current and future medical costs of asthma and chronic obstructive pulmonary disease in The Netherlands

The aim of this study was to estimate the healthcare costs of asthma and chronic obstructive pulmonary disease (COPD), in the Netherlands, in 1993. Also studied was the future development of these costs, as a result of ageing and possible changes in smoking behavior. A prevalence-based cost-of-illness approach was used to estimate direct medical costs. Age- and gender-specific data were obtained from representative national registries and large, representative surveys. To model future costs, cost estimates were linked to an epidemiological model based on a dynamic multi-state lifetable. It describes 1 yr changes, from one state to another, that result from ageing, birth, migration, incidence, recovery from asthma and death due to asthma, COPD or other causes, and starting or quitting smoking. Three different scenarios were modelled: 1) a reference scenario which primarily predicts the impact of ageing. 2) an 'attainable' smoking reduction scenario and 3) an 'extreme' smoking reduction scenario. Direct medical costs were estimated to be $US 346 million in 1993. With increasing age, the relative importance of asthma in total asthma and COPD costs decreased from 91% to less than 4%. Annual costs per patient were estimated to be $US 499 for asthma and $US 876 for COPD. The breakdown of costs differed considerably between asthma and COPD. The reference scenario predicted the costs to increase by 60% to reach $US 555 million by 2010, COPD prevention as modelled in the second and the third scenario reduced the projected cost increase from 60%, to 57% and 48%, respectively. Together, the direct costs of asthma and COPD represent 1.3% of the Dutch health care budget. The breakdown of the costs shows different patterns for asthma and COPD. The costs of these diseases are expected to increase by 60% in the near future. In the short run the impact of smoking reduction on reducing this increase is relatively small, but it will be greater in the long run.     

Cost-description of a pilot parenteral vaccination campaign against rabies in dogs in N'Djaména, Chad

In the discussion about policies and strategies for rabies prevention in developing countries, intervention costs arise as a major issue. In a pilot mass vaccination campaign against rabies in N'Djaména, Chad, 3000 dogs were vaccinated. We assessed vaccination coverage and cost, showing the cost per dog vaccinated for the public sector and for society. An extrapolation to city level calculated the approximate cost of vaccinating all 23 600 dogs in N'Djaména. In the pilot mass campaign with 3000 dogs the average cost per dog was 1.69 euro. to the public and the full societal cost was 2.45 euro. If all 23 600 dogs in N'Djaména were vaccinated, the average cost would fall to 1.16 euro to the public and 1.93 euro to society. Private sector costs account for 31% of the cost to vaccinate 3000 dogs, and 40% of the cost to vaccinate 23 600 dogs. Mass dog vaccination could be a comparatively cheap and ethical way to both control the disease in animals and prevent human cases and exposure, especially in developing countries. The cost-effectiveness of dog vaccination compared with treating victims of dog bites for prevention of human rabies should be further assessed and documented.     

Current status and clinical course of hepatitis C virus in Korea

The mortality due to chronic liver disease, including liver cirrhosis and hepatocellular carcinoma (HCC), ranks as one of the highest in Korea. The prevalence rates of hepatitis C virus (HCV) and hepatitis B virus (HBV) infections in the general Korean population are approximately 1 and 5%, respectively. Blood transfusion was the strongest risk factor for the transmission of HCV infection. Therefore, the evaluation of risk factors for HCV infection including blood transfusion, intravenous drug user, hemophilia, and hemodialysis, is important. The most prevalent HCV genotype is 1b followed by 2a. The annual incidence of HCC among HCV-related liver cirrhosis has been estimated at 5%, and approximately 12% of HCC is attributable to HCV and 68% to HBV in Korea. HCV infection is more closely associated with HCC in elderly patients than HBV-related HCC. Even though the prevalence of anti-HCV in Korea has been reduced and the risk of HCV transmission through blood transfusion has markedly decreased, public-health programs to prevent de novo infections should be developed. This review describes the HCV prevalence and risk factors among the general population, and the distribution of HCV genotypes as well as the clinical course of HCV in Korea.     

The burden of overweight and obesity-related ill health in the UK

This paper reviews previous cost studies of overweight and obesity in the UK. It proposes a method for estimating the economic and health costs of overweight and obesity in the UK which could also be used in other countries. Costs of obesity studies were identified via a systematic search of electronic databases. Information from the WHO Burden of Disease Project was used to calculate the mortality and morbidity cost of overweight and obesity. Population attributable fractions for diseases attributable to overweight and obesity were applied to National Health Service (NHS) cost data to estimate direct financial costs. We estimate the direct cost of overweight and obesity to the NHS at pound 3.2 billion. Other estimates of the cost of obesity range between pound 480 million in 1998 and pound 1.1 billion in 2004 [Correction added after online publication 11 June 2007: 'of the cost of obesity' added after 'Other estimates']. There is wide variation in methods and estimates for the cost of overweight and obesity to the health systems of developed countries. The method presented here could be used to calculate the costs of overweight and obesity in other countries. Public health initiatives are required to address the increasing prevalence of overweight and obesity and reduce associated healthcare costs.