Primary care in Canada: so much innovation, so little change

The development of Canadian primary care has been shaped by a series of policy legacies that continue to affect the possibilities for change in primary care through their cumulative effects on the health care system and the process of health policy development. The pursuit of radical systemwide change in the face of unfavorable circumstances (created in large part by those legacies) has resulted in missed opportunities for cumulative incremental change. While major changes in primary care policy seem unlikely in the near future, significant incremental change is possible, but it will require a reorientation of the policy development process.     

Elder choice and health care costs

While strategists struggle with the dilemmas of health care, they seem to overlook a practice that might simultaneously relieve the suffering of elder patients and limit the costs of their treatment. If elder patients were given a clear opportunity to choose, many might reject the costly procedures that keep them breathing in misery during the last weeks, months, and even years of their survival. Other elders who see the clouds of debility approaching might be freed of the dread of endless imprisonment in a nursing home. Empowering elders to make these choices does not require changes in law, but only changes in how we provide and finance care.     

Age-specific increases in health care costs

BACKGROUND: The escalating costs of health care raise questions about demographic, epidemiological and technological determinants and future projections. The objectives of this work are to describe the age pattern of health care costs, to analyse the age-specific cost changes and to project future health care costs in an ageing population. METHODS: Comprehensive cost-of-illness data for the whole Dutch population in 1988 and 1994 are compared by age and type of care. National data on all hospital admissions, nursing days and clinical interventions for the period 1988-1994 is used to describe trends in hospital care. Population forecasts are used to project the age distribution of future health care costs. RESULTS: The distribution of health care costs per capita depends strongly on age. The growth rate of per capita costs increases by age for acute care but decreases by age for long-term care. Both combined cause an average annual growth rate of 4.6%, nearly constant with age. CONCLUSIONS: Ageing will result in increasing health care demands and costs. Secular trends in acute and long-term care indicate major shifts in costs from younger to older people and from long-term to acute care.     

Predicting post-hospital discharge health care costs

Patients in this study represented an important group for health services research; their postdischarge costs were high, resulted from readmissions (especially for nonelective reasons), and were incurred by a minority of patients. Moreover, intensive interventions delivered by ambulatory care providers has the potential to reduce overall costs if patients at highest risk for readmission could be identified prospectively (Smith et al., 1988; Weinberger et al., 1988). We developed a model to predict post-hospital discharge costs in these patients using strategies to maximize their predictive capability. Although the model appeared to account for more variance in costs than currently available models in the derivation set, its performance in the validation set, albeit statistically significant, was disappointing. Because we considered a broad array of predictors, expanding the number of patient-oriented variables may not be fruitful. Instead, future research may need to consider more homogenous subgroups of patients in whom specific laboratory tests would have clinical significance; variance in providers' behaviors; and studies in health maintenance organizations, where control over resource utilization may make costs more predictable. Finally, empirically derived models must be tested in an independent sample. Without validating predictive models, the models' ability to predict health care costs may be overestimated.     

The Stark regulations: so much text; so little substance

Regulations outlining providers' rights and responsibilities under the first Stark self-referral law are here at last. The authors argue they weren't worth the wait.