Geographic Variation in Household and Catastrophic Health Spending in India: Assessing the Relative Importance of Villages,Districts, and States, 2011‐2012

Policy Points:

• Per‐capita household health spending was higher in economically developed states and was associated with ability to pay, but catastrophic health spending (CHS) was equally high in both poorer and more developed states in India.
• Based on multilevel modeling, we found that the largest geographic variation in health spending and CHS was at the state and village levels, reflecting wide inequality in the accessibility to and cost of health care at these levels.
• Contextual factors at macro and micro political units are important to reduce health spending and CHS in India.

Context

In India, health care is a local good, and households are the major source of financing it. Earlier studies have examined diverse determinants of health care spending, but no attempt has been made to understand the geographical variation in household and catastrophic health spending. We used multilevel modeling to assess the relative importance of villages, districts, and states to health spending in India.

Methods

We used data on the health expenditures of 101,576 households collected in the consumption expenditure schedule (68th round) carried out by the National Sample Survey in 2011‐2012. We examined 4 dependent variables: per‐capita health spending (PHS), per‐capita institutional health spending (PIHS), per‐capita noninstitutional health spending (PNHS), and catastrophic health spending (CHS). CHS was defined as household health spending exceeding 40% of its capacity to pay. We used multilevel linear regression and logistic models to decompose the variation in each outcome by state, region, district, village, and household levels.

Findings

The average PHS was 1,331 Indian rupees (INR), which varied by state‐level economic development. About one‐fourth of Indian households incurred CHS, which was equally high in both the economically developed and poorer states. After controlling for household level factors, 77.1% of the total variation in PHS was attributable to households, 10.1% to states, 9.5% to villages, 2.6% to districts, and 0.7% to regions. The pattern in variance partitioning was similar for PNHS. The largest interstate variation was found for CHS (15.9%), while the opposite was true for PIHS (3.2%).

Conclusions

We observed substantial variations in household health spending at the state and village levels compared with India's districts and regions. The large variation in CHS attributable to states indicates interstate inequality in the accessibility to and cost of health care. Our findings suggest that contextual factors at the macro and micro political units are important to reduce India's household health spending and CHS.     

Insurer Market Structure and Variation in Commercial Health Care Spending

ObjectiveTo examine the relationship between insurance market structure and health care prices, utilization, and spending.MethodsRegression models are used to estimate the association between insurance market concentration and health care spending, utilization, and price, adjusting for differences in patient characteristics and other market-level traits.ResultsInsurance market concentration is inversely related to prices and spending, but positively related to utilization. Our results imply that, after adjusting for input price differences, a market with two equal size insurers is associated with 3.9 percent lower medical care spending per capita (p = .002) and 5.0 percent lower prices for health care services relative to one with three equal size insurers (p < .001).ConclusionGreater fragmentation in the insurance market might lead to higher prices and higher spending for care, suggesting some of the gains from insurer competition may be absorbed by higher prices for health care. Greater attention to prices and utilization in the provider market may need to accompany procompetitive insurance market strategies.     

Differences in Food-at-Home Spending for SNAP and Non-SNAP Households Given Geographic Price Variation

BackgroundAs the largest nutrition safety net program in the United States, the Supplemental Nutrition Assistance Program (SNAP) enhances food security by providing low-income households with benefits for food-at-home (FAH) spending. A large literature finds a positive effect of SNAP on FAH spending, but it is unclear whether this relationship varies with area-level prices. SNAP benefits do not explicitly account for price variation across the contiguous United States.ObjectiveOur objectives were to examine the SNAP/non-SNAP difference in FAH spending for households with varying levels of cash income and propensity for SNAP participation and to determine whether this difference varied with area-level prices.Design/participantsCross-sectional data on 2,524 SNAP and non-SNAP households with cash income at or below 185% of the Federal Poverty Level were obtained from the National Household Food Acquisition and Purchase Survey.Main outcome measuresThe outcome was FAH spending relative to the maximum SNAP benefit corresponding to household size.Statistical analyses performedHouseholds were grouped into quintiles based on estimated propensity of SNAP participation. Regression models included interactions between a SNAP participation indicator, a continuous price index for all goods and services, and propensity score quintile indicators.ResultsAccording to some models, the SNAP/non-SNAP spending difference was positive, on average. Among households that tended to have lower cash income and higher propensity of SNAP participation, FAH spending relative to the maximum benefit was 29 to 30 percentage points higher for SNAP households compared to low-income non-SNAP households (P≤0.05). The spending difference was similar across areas with different price levels.ConclusionsSNAP households spent more on FAH compared to low-income non-SNAP households. This association did not vary with area-level prices. Beyond food spending outcomes, future research could extend this work to understand SNAP’s role in promoting food security and other outcomes, given geographic price variation.     

Jurisdiction Size and Local Public Health Spending

Objective. To examine if a minimum efficient scale (MES) holds with respect to the population serviced by a local health department (LHD) given the congestability, externality, and scale/scope economy effects potentially associated with public health services. Data Sources/Study Setting. A nationally representative sample of LHDs in 2005. Study Design. Multiple regression analysis is used to isolate the relation between population and spending while controlling for other factors known to influence local public health costs. Data Collection. Data were obtained from the 2005 National Profile of Local Public Health Agencies, a project supported through a cooperative agreement between the National Association of County and City Health Officials and the Centers for Disease Control and Prevention. Principal Findings. The MES of a local public health department is approximately 100,000 people. After that size, additional population has little impact on public health spending per capita. Conclusions. Seventy‐seven percent of LHDs in the sample fall below the 100,000 MES. Higher levels of government may want to provide financial inducements so that smaller LHDs consolidate or enter into agreements with larger public health organizations to provide services.     

Variation in Inpatient Hospital Prices and Outpatient Service Quantities Drive Geographic Differences in Private Spending in Texas

ObjectiveTo measure the contribution of market-level prices, utilization, and health risk to medical spending variation among the Blue Cross Blue Shield of Texas (BCBSTX) privately insured population and the Texas Medicare population.ConclusionsThe conventional wisdom that Medicare does a better job of controlling prices and private plans do a better job of controlling volume is an oversimplification. BCBSTX does a good job of controlling outpatient and professional prices, but not at controlling inpatient prices. Strategies to manage the variation in spending may need to differ substantially depending on the service and payer.     

The Relationship between Commercial Health Care Prices and Medicare Spending and Utilization

ObjectiveTo explore the relationship between commercial health care prices and Medicare spending/utilization across U.S. regions.ConclusionsCommercial health care prices are negatively associated with Medicare spending across regions. Providers may respond to low commercial prices by shifting service volume into Medicare. Further investigation is needed to establish causality.     

Patterns and Correlates of Public Health Informatics Capacity Among Local Health Departments: An Empirical Typology

Objective: Little is known about the nationwide patterns in the use of public health informatics systems by local health departments (LHDs) and whether LHDs tend to possess informatics capacity across a broad range of information functionalities or for a narrower range. This study examined patterns and correlates of the presence of public health informatics functionalities within LHDs through the creation of a typology of LHD informatics capacities.Methods: Data were available for 459 LHDs from the 2013 National Association of County and City Health Officials Profile survey. An empirical typology was created through cluster analysis of six public health informatics functionalities: immunization registry, electronic disease registry, electronic lab reporting, electronic health records, health information exchange, and electronic syndromic surveillance system. Three-categories of usage emerged (Low, Mid, High). LHD financial, workforce, organization, governance, and leadership characteristics, and types of services provided were explored across categories.Results: Low-informatics capacity LHDs had lower levels of use of each informatics functionality than high-informatics capacity LHDs. Mid-informatics capacity LHDs had usage levels equivalent to high-capacity LHDs for the three most common functionalities and equivalent to low-capacity LHDs for the three least common functionalities. Informatics capacity was positively associated with service provision, especially for population-focused services.Conclusion: Informatics capacity is clustered within LHDs. Increasing LHD informatics capacity may require LHDs with low levels of informatics capacity to expand capacity across a range of functionalities, taking into account their narrower service portfolio. LHDs with mid-level informatics capacity may need specialized support in enhancing capacity for less common technologies.     

The Impact of Health Insurance on Health Outcomes and Spending of the Elderly: Evidence from China's New Cooperative Medical Scheme

This paper investigates the effects of China's New Cooperative Medical Scheme (NCMS) on health outcomes and healthcare expenditure of the elderly in rural China, using panel data from the 2005 and 2008 waves of the Chinese Longitudinal Healthy Longevity Survey. We employ a strategy that combines propensity score matching with a difference‐in‐differences approach to address selection bias. Results show that the NCMS has significantly improved the elderly enrollees' activities of daily living and cognitive function but has not led to better self‐assessed general health status. We find no significant effect of NCMS on mortality for the previously uninsured elderly in NCMS counties, although there is moderate evidence that it is associated with reduced mortality for the elderly enrollees. We also find that the elderly participants are more likely to get adequate medical services when sick, which provides a good explanation for the beneficial health effects of NCMS. However, there is no evidence that the NCMS has reduced their out‐of‐pocket spending. Furthermore, we also find that low‐income seniors benefit more from NCMS participation in terms of health outcomes and perceived access to health care, suggesting that the NCMS helps reduce health inequalities among the rural elderly. Copyright © 2014 John Wiley & Sons, Ltd.     

流动人口生殖健康公共服务的内涵及政策分析

对我国流动人口生殖健康公共服务的内涵及我国流动人口生殖健康公共服务的相关政策法规进行了分析,并且从人力资源、经费投入及相关政策法规3个方面,分析了当前我国流动人口生殖健康公共服务存在的问题,并提出了促进我国流动人口生殖健康公共服务供给的建议。     

The Faculty of Public Health in Sofia: activities and experiences in setting New Public Health as a national priority

The article outlines the development and recent national and international activities of the Faculty of Public Health, Medical University - Sofia (FPH, MU - Sofia). It has a leading position in public health education and research in Bulgaria and plays a key role in the introduction of the New Public Health approach to Bulgarian health system and policy. A general aim of the FPH is to build up a well-trained capacity of public health specialists and thus strengthen human recourses in the public health sphere in the country. A major objective of the FPH is to create a new generation of healthcare managers ready for the challenges of the dynamic European market of health services. During its 5-year history, the FPH has been an extremely active player on the regional and international public health stage as well as on a national level. The main priority of the FPH for the future is to guarantee public health education in harmony within the south eastern Europe (SEE) region as well as with European standards. It also strives to provide methodological support to health politicians and decision makers in Bulgaria in order to establish a socially orientated, equitable, effective and high-quality healthcare system.     

《突发公共卫生事件的应对及管理》在公共卫生硕士教育的实践

目的 了解《突发公共卫生事件的应对及管理》课程在公共卫生硕士教育中的实践情况和课程满意度的影响因素。方法 编制调查问卷,对四川大学选修过该课程的公共卫生硕士进行网络调查,分析该课程的实践情况,并构建结构方程模型,定量分析影响课程满意度的因素。结果 (1)96.6%的调查对象认为该课程有助于扩大知识量,93.7%的调查对象认为助于职业,95.0%的调查对象认为该课程提升了应对突发公共卫生事件的能力,98.3%的调查对象愿意更加深入的学习该课程;(2)课程满意度影响因素主要为感知质量和学生期望(P<0.01)。结论 (1)有必要在公共卫生硕士培养中开设《突发公共卫生事件的应对及管理》课程;(2)增加该课程的感知质量和学生期望有助于增加课程满意度。     

公共卫生大数据应用

本文从公共卫生的数据需求出发,分析了公共卫生大数据特征,提出了公共卫生大数据应用架构。并通过对传染病预警预报大数据应用和基于互联网大数据舆情监测预警应用的案例分析,阐述了大数据对公共卫生的应用愿景与应用模式,并以政府主导和社会参与为技术路径,提出了应用策略与关键技术。     

新疆卫生监督机构卫生监督人员现况调查

目的了解新疆卫生监督机构卫生监督人员现状。方法对新疆各级卫生监督机构人员编制、数量、学历和年龄构成进行调查分析。结果全疆卫生监督机构编制性质不统一。卫生监督人员配置不足。人员学历集中于大专、中专及以下学历，年龄较年轻化，南、北、东疆三大区域卫生监督员学历、年龄构成存在差异。结论建议出台统一政策，制定科学、合理的编制方案，明确卫生监督机构性质、人员编制。严把人员聘用关，提高卫生监督员学历层次。     

论公共卫生与可持续发展

通过阐述公共卫生与可持续发展的关系及对公共卫生现状及政府投入,传染病防制,食品卫生,工业卫生与职业病和放射卫生等问题的揭示,提出了可持续发展应解决好的几个问题;（1）切实转变政府职能;（2）认真做好预防为主;（3）建立政事分开,高效,统一的公共卫生监督管理新体制;（4）开展重大疾病和慢性非传染性疾病的综合防治;（5）进一步加强卫生法制建设。这对于提高国民健康素质和促进社会经济的稳定,协调与持续发展具有重要意义。     

A short history of the Multidisciplinary Public Health Forum

The Multidisciplinary Public Health Forum (MPHF) was a 'network of networks' that was formed through grass roots public conferences held during the mid 1990s. It championed the development of a trained, developed and accredited multidisciplinary public health workforce in the UK. This paper draws on documentary evidence and from a series of semi-formal interviews held with individuals who were involved in the development and work of the Forum, to explore why the Forum was influential, the key milestones of the journey and the lessons that we might learn for the continued development of the public health function.     

Efforts to Locate Low-Income Women for a Study on Mammography Rescreening: Implications for Public Health Practice

Public health practice often requires locating individuals in the community. This article presents information on the methods and amount of time and effort required to locate over 2300 low-income and minority women in Maryland, New York, Ohio, and Texas for a mammography rescreening study. In 1999, we identified 2528 low-income women who had a mammogram in 1997 funded by the National Breast and Cervical Cancer Early Detection Program. Starting 30 months after that mammogram, we made numerous attempts to locate each woman while recording the number of calls, letters, and tracing attempts used and the date she was found. More than 93% of the women were located. On average, it took 73.8 days (range 1–492 days) and 7.2 calls and letters (range 1–48) to reach each woman. Locating women in racial and ethnic minority groups required more time and effort. About 10% of all located women were found only after our subject tracing protocol was implemented. The percentage of located women increased markedly with more months of effort and additional calls and letters. Because women who were more difficult to locate were less likely to have been rescreened, the mammography rescreening percentages at the end of the study were slightly lower than they would have been had we terminated location efforts after 1–3 months. Locating low-income women in the community is difficult, particularly when obtaining a high response rate from all groups is important. Terminating data collection prematurely may decrease minority group representation and introduce bias.Janet Kay Bobo is an Epidemiologist, at Battelle Centers for Public Health Research and Evaluation, Seattle, Washington. Jean A. Shapiro is an Epidemiologist at the Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Jennifer Brustrom is a Scientist at Battelle Centers for Public Health Research and Evaluation, Atlanta, GA.Disclaimer: The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this article are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory.