Cost inefficiency and hospital health outcomes

This study explores the association between cost inefficiency and health outcomes in a national sample of acute-care hospitals in the US over the period 1999-2001, with health outcomes being measured by both mortality and complications rates. The empirical analysis examines health outcomes as a function of cost inefficiency and other determinants of outcomes, using stochastic frontier analysis to obtain hospital cost inefficiency scores. The results showed no systematic pattern of association between cost inefficiency and hospital health outcomes; the basic results were unchanged regardless of whether cost inefficiency was measured with or without using instrumental variables. The analysis also indicated, however, that the association between cost inefficiency and health outcomes may vary substantially across geographical regions. The study highlights the importance of distinguishing between 'good' costs that reflect the efficient use of resources and 'bad' costs that stem from waste and other forms of inefficiency. In particular, the study's results suggest that hospital programs focused on reducing cost inefficiency are unlikely to be associated with worsened hospital-level mortality or complications rates, while, on the other hand, across-the-board reductions in cost could well have adverse consequences on health outcomes by reducing efficient as well as inefficient costs.     

Effects of selective contracting on hospital efficiency,costs and accessibility

This paper exploits a natural experiment in the state of California, to show that pro-competitive healthcare policy may have unintended long-term liabilities unless the system as a whole is carefully designed to preserve access to care for the poor. California's Medicaid Reform Act of 1982 increased competition among hospitals in urban areas, with legislation which allowed direction of patients to more efficient providers via selective contracting. This slowed the average rate of hospital cost inflation, and saved the state billions of dollars. The substantial short-term savings have been documented in empirical research, but little attention has been paid to the longer-term effects of the reforms. We find that Medicaid contracts were awarded to more efficient hospitals. The distributional effects post-reform resulted in efficiency gains for most hospitals, but costs escalated for over half of the public hospitals in the sample, as their uncompensated care burdens rose. Public hospitals continued to fail during the period, leaving over half of California's counties without a county hospital by 1990. Because public hospitals provide the vast majority of healthcare for the poor in California, there is reason for concern about erosion of their access to care as an unintended outcome of pro-competitive reforms. © 1998 John Wiley & Sons, Ltd.     

Estimating the costs of drug-related hospital separations in Australia

OBJECTIVE: To estimate the total hospital costs of drug-related separations in Australia from 1999/2000 to 2004/05, and separate costs for the following illicit drug classes: opioids, amphetamine, cannabis and cocaine. METHODS: Australian hospital separations between 1999/2000 to 2004/05 from the National Hospital Morbidity Dataset (NHMD) with a principal diagnosis of opioids, amphetamine, cannabis or cocaine were included, as were indirect estimates of additional 'drug-caused' separations using aetiological fractions. The costs were estimated using the year-specific case weights and costs for each respective Diagnostic Related Group (DRG). RESULTS: Total constant costs decreased from $50.8 million in 1999/2000 to $43.8 million in 2002/03 then increased to $46.7 million in 2004/05. The initial decrease was driven by a decline in numbers of opioid-related separations (with costs decreasing by $11.5 million) between 1999/2000 and 2001/02. Decreases were evident in separations within the opioid use, dependence and poisoning DRGs. Increases in costs were observed between 1999/00 and 2004/05 for amphetamine (an increase of $2.4 million), cannabis ($1.8 million) and cocaine ($330,000) related separations. Several uncommon but very expensive drug-related separations constituted 12.7% of the total drug-related separations. CONCLUSIONS AND IMPLICATIONS: Overall, the costs of drug-related hospital separations have decreased by $4.1 million between 1999 and 2005, which is primarily attributable to fewer opioid-related separations. Small reductions in the number of costly separations through harm reduction strategies have the potential to significantly reduce drug-related hospital costs.     

The costs of community care for former long-stay psychiatric hospital residents

Support for people with long-term mental health problems is gradually being relocated from hospital to community settings. One of the questions raised by the shifting locus of care concerns the cost implications. This paper describes the cost of supporting people with long-term mental health problems who have moved to the community after many years in hospital. After summarizing the national and local policy contexts, and the methodology, the paper describes the people who have moved to the community, the services they use, and the cost of community care.     

医院部分仪器设备服务项目标准成本的研究

利用专家咨询法和专项调查，在对有关参数进行标化和量化的基础上核算了7种设备18个项目的标准成本。通过标准成本与收费标准的对比及标准成本中直接和间接成本、固定和变动成本构成的分析提出目前医疗服务价格体制改革的重点及此项研究对加强医院经营管理的指导意义。     

The impact of research on hospital costs of care: an empirical study

The goal of this study was to examine the impact of research activities on hospital costs and lengths of stay in French public hospitals. Our data consist of a random sample of 30 000 inpatient stays in 38 hospitals that were extracted from the French Hospital Cost Survey database. Hospital characteristics were added using data from a French national survey and performing a bibliometric study. This is a retrospective study of hospitalizations. We used multilevel modelling. We considered separate models to explain the cost per day and the length of hospital stay (LOS). Research output was defined based on the quartiles of the distribution of the number of impact‐weighted scientific publications produced in our sample of hospitals over a 6‐year period. Research production was associated with a higher cost of care. The cost per day was 19% higher in hospitals in the 3rd quartile and 42% higher in hospitals in the 4th quartile compared to that in hospitals that were not involved in research activities. This result was sensitive to the type of care under consideration. The effect was stronger in oncology but not significant in routine care. Scientific production did not impact the LOS. Copyright © 2010 John Wiley & Sons, Ltd.     

A dynamic model for estimating changes in health status and costs

We develop an innovative method to assess total treatment costs over a finite period of time while incorporating the dynamics of change in the health status of patients. Costs are incurred through medical care use while patients sojourn in health states. Because complete ascertainment of costs and observation of events are not always feasible, some patient utilization will be incomplete and events will also be censored. A Markov model is used to estimate the transition probabilities between health states and the impact of patient variables on transition intensities. A mixed-effects model is used for sojourn costs with transition times as random effects and patient variables as fixed effects. The models are combined to estimate net present values (NPVs) of expenditures over a finite time interval as a function of patient characteristics. The method is applied to a data set of 624 incident cases of cancer. Physical functioning after cancer diagnosis was assessed periodically through structured interviews. The outcomes of interest are normal physical function, impaired physical function, or the terminal state, dead. Charges were obtained from Medicare claim files for 2 years following cancer diagnosis. For demonstration purposes, we estimate NPVs for charges incurred over 2 years by cancer site and cancer stage. Our method, a joint regression model, provides a flexible approach to assessing the influence of patient characteristics on both cost and health outcomes while accommodating heteroscedasticity, skewness and censoring in the data.     

Cataract surgery in a community hospital outreach clinic: patients’ costs and satisfaction

A cataract day surgery service for the population of central Norfolk, UK, was provided by the main ophthalmic department in a district general hospital and in an outreach clinic in a community hospital 40 km distant. The outreach clinic aimed to extend the accessibility of this particular service in a rural area where many patients faced long journeys to the main hospital. Samples of 201 patients attending the main hospital for day cataract surgery and 198 patients attending the outreach clinic for the same procedure were identified. Patients were interviewed and given questionnaire forms to establish their general health before the operation, their arrangements to get to hospital and their satisfaction with the clinic and the care they had received. The sample of patients attending the outreach clinic was slightly older, less affluent and in slightly poorer general health than the patients attending the main hospital. The two samples were similar in terms of visual acuity after the operation, complication rates, satisfaction with the outcome of the operation and subsequent use of health services. The journey to hospital was quicker, more convenient and less costly for the outreach clinic patients than the main hospital patients. The net benefit to patients of the outreach clinic was estimated as £39,000 per annum. Satisfaction with administrative matters, facilities at the two clinics and the care received was high in both samples, but patients were significantly more satisfied with arrangements at the smaller outreach clinic. This evidence suggests that an outreach clinic in a small community hospital can provide cataract day surgery under local anaesthesia as effectively as a district centre, at a reduced social cost and with positive social benefits. Further study of heath service costs is vital, but political pressure to acknowledge patient preferences for more local services is growing.     

The association between health risk status and health care costs among the membership of an Australian health plan

Health promotion in Australia has developed into an accepted strategy for solving public health problems and promoting the health of its citizens. However, there are few evidence-based research studies in Australia that measure health risk status or track health changes over time with defined cost outcome measures. Those individuals with more high-risk lifestyle behaviors have been associated with higher costs compared with those with low-risk behaviors. Although intuitively it was believed that the health promotion programs had a positive impact on health behaviors and consequently on health care costs, the relationship between health risk status and health care costs had yet to be tested in the Australian population. Consequently, a verification study was initiated by the Australian Health Management Group (AHMG) to confirm that those relationships between health risks and medical costs that had been published would also hold in the Australian population using Australian private health care costs as the outcome measure. Eight health risks were defined using a Health Risk Appraisal (HRA) to determine the health risk status of participants. Consistent with previous studies, low-risk participants were associated with the lowest health care costs (377 Australian dollars) compared with medium- (484 Australian dollars) or high-risk (661 Australian dollars) participants and non-participants (438 Australian dollars). If the health care costs of those at low risk were considered as the baseline costs, excess health care costs associated with excess health risks in this population were calculated at 13.5% of total expenditures. Health risk reduction and low-risk maintenance can provide important strategies for improving/maintaining the health and well-being of the membership and for potential savings in health care costs.     

The sources of hospital cost variability

Hospital heterogeneity is a major issue in defining a reimbursement system. If hospitals are heterogeneous, it is difficult to distinguish which part of the differences in costs is due to cost containment efforts and which part cannot be reduced, because it is due to other unobserved sources of hospital heterogeneity. In this paper, we apply an econometric approach to analyse hospital cost variability. We use a nested three-dimensional database (stays-hospitals-years) in order to explore the sources of variation in hospital costs, taking into account unobservable components of hospital cost heterogeneity. The three-dimensional structure of our data makes it possible to identify transitory and permanent components of hospital cost heterogeneity. Econometric estimates are performed on a sample of 7314 stays for acute myocardial infarction (AMI) observed in 36 French public hospitals over the period 1994-1997. Transitory unobservable hospital heterogeneity is far from negligible: its estimated standard error is about 50% of the standard error we estimate for cost variability due to permanent unobservable heterogeneity between hospitals.     

The relationship between education and health behavior: some empirical evidence

Although researchers agree that more educated people typically engage in healthier behaviors, they have not uncovered the reason why. This paper considers several explanations, including future opportunity costs. Future opportunity costs represent any utility-improving future outcome that is affected by currently engaging in health-related behavior. This paper also examines whether there are degree effects in the health behaviors of binge drinking and smoking. Results suggest that future opportunity costs may affect smoking, although other interpretations cannot be ruled out. The results also find degree effects with regard to binge drinking.     

Hospital costs estimation and prediction as a function of patient and admission characteristics

The present work analyzed the association between hospital costs and patient admission characteristics in a general public hospital in the city of Rio de Janeiro, Brazil. The unit costs method was used to estimate inpatient day costs associated to specific hospital clinics. With this aim, three "cost centers" were defined in order to group direct and indirect expenses pertaining to the clinics. After the costs were estimated, a standard linear regression model was developed for correlating cost units and their putative predictors (the patients gender and age, the admission type (urgency/elective), ICU admission (yes/no), blood transfusion (yes/no), the admission outcome (death/no death), the complexity of the medical procedures performed, and a risk-adjustment index). Data were collected for 3100 patients, January 2001-January 2003. Average inpatient costs across clinics ranged from (US$) 1135 [Orthopedics] to 3101 [Cardiology]. Costs increased according to increases in the risk-adjustment index in all clinics, and the index was statistically significant in all clinics except Urology, General surgery, and Clinical medicine. The occupation rate was inversely correlated to costs, and age had no association with costs. The (adjusted) per cent of explained variance varied between 36.3% [Clinical medicine] and 55.1% [Thoracic surgery clinic]. The estimates are an important step towards the standardization of hospital costs calculation, especially for countries that lack formal hospital accounting systems.     

Aggregation and the measurement of health care costs

OBJECTIVE: This study evaluated the extent to which the causes of variation in health care costs differ by the level at which observations are made. METHODS: More than 40 U.S. and international studies providing empirical estimates of the sources of variation in health care costs were reviewed and arrayed by size of observational units. A simplified graphical analysis demonstrating how estimated correlation coefficients change with the level and type of aggregation is presented. RESULTS: As the unit of observation becomes larger, association between health care costs and health status/morbidity becomes weaker and smaller in magnitude, while correlation with income (per capita GDP) becomes stronger and larger. Individual expenditure variation within a particular health care system is largely due to differences in health status, but across systems, morbidity has almost no effect on costs. For nations, differences in per capita income explain over 90 percent of the variation in both time series and cross section. CONCLUSIONS: Units of observation used for analysis of health care costs must be matched to the units at which decision making occurs. The observed pattern of empirical results is consistent with a multilevel allocative model incorporating aggregate capacity constraints. To the extent that macro constraints determine total budgets at the national level, policy interventions at the micro level (substitution of generic pharmaceuticals, use of CEA for allocation of treatments, controls on construction and technology, etc.) can act to improve efficiency, equity and average health status, but will not usually reduce aggregate average per capita costs of medical care.     

The relationship between health expenditures and the age structure of the population in OECD countries

The purpose of this study was to analyse national health expenditures of OECD countries relative to their age structures. Using econometric techniques designed to analyse cross-sectional time series data, the ageing of the population was found to affect health spending in several countries while having no effect in others. In addition, the effect of income on health spending was lower than that generally reported in the literature. These findings suggest that unobserved country-specific factors play a major role in determining the amount of resources allocated to health services in a country. Such factors also determine if the ageing of the population is associated with increased health spending.     

Competition in the NHS internal market: an overview of its effects on hospital prices and costs

The 1989 reforms of the UK National Health Service (NHS) introduced competition in the supply of hospital services. This paper synthesizes both the theory underlying the introduction of competition into the NHS, and the limited existing evidence on whether competition affects the prices posted by sellers of medical services, and the costs of producing these services. The results indicate high levels of price variability, widespread disregard for average cost pricing rules and some indication that competition had some effect on prices. It appears that lower prices may be offered to smaller purchasers, such as General Practice Fund Holders (GPFH). This effect of competition on price was mirrored, with a delay, in hospital costs. © 1998 John Wiley & Sons, Ltd.     

医院和医疗保险的经济学分析

随着卫生体制改革的深入，应对老龄化危机，降低不断提高的医疗服务费用，提高医疗服务质量，提高医疗服务可及性问题和公平性，是我们面对的切实问题。医院是提供医疗卫生服务的场所，也是提供医疗卫生服务的主体单位，了解医院的经济学特性和组织特点，有利于我们对市场经济环境下的医院行为有所了解，为卫生体制改革和医疗保险改革提供理论依据。     

中国长期照护的政策选择

随着我国人口老龄化进程的推进,国务院于2017年出台了“十三五”国家老龄事业发展和养老体系建设规划,强调多部门协同合作发展老龄化事业。然而,我国现有卫生体系在应对老龄化问题时面临较大压力。2015年世界卫生组织发布了《关于老龄化与健康的全球报告》,为各国应对人口老龄化提供了政策框架和实践经验。本文旨在对《报告》进行解读,以期为我国卫生体系应对人口老龄化提供参考。