The direct health care costs of obesity in the United States.

OBJECTIVES: Recent estimates suggest that obesity accounts for 5.7% of US total direct health care costs, but these estimates have not accounted for the increased death rate among obese people. This article examines whether the estimated direct health care costs attributable to obesity are offset by the increased mortality rate among obese individuals. METHODS: Data on death rates, relative risks of death with obesity, and health care costs at different ages were used to estimate direct health care costs of obesity from 20 to 85 years of age with and without accounting for increased death rates associated with obesity. Sensitivity analyses used different values of relative risk of death, given obesity, and allowed the relative costs due to obesity per unit of time to vary with age. RESULTS: Direct health care costs from 20 to 85 years of age were estimated to be approximately 25% lower when differential mortality was taken into account. Sensitivity analyses suggested that direct health care costs of obesity are unlikely to exceed 4.32% or to be lower than 0.89%. CONCLUSIONS: Increased mortality among obese people should be accounted for in order not to overestimate health care costs.     

The impact of obstetrical liability on access to perinatal care in the rural United States.

Liability issues have caused large numbers of obstetrical providers, particularly family and general practitioners, to discontinue offering perinatal care in rural areas. Losses of even small numbers of rural obstetrical providers can severely limit access to care for large geographic areas. A lack of access to local obstetrical care can result in less than adequate prenatal care and in potential delays in the diagnosis and care of acute perinatal complications. Women who live in these underserved rural communities suffer increased adverse birth outcomes, leading to significantly higher medical costs. Proposed solutions to the problem include risk management programs associated with reduced liability premiums; increased Medicaid reimbursement for obstetrical care; health department subsidies to offset insurance premiums for rural obstetrical care; and programs in predoctoral and residency training designed to identify, assess and address the health care needs of rural areas. Although some measure of success has resulted from these efforts, more systematic and comprehensive policy changes are needed to meet the challenge of this crisis.     

The organization and financing of kidney dialysis and transplant care in the United States of America

In the United States, end-stage renal disease (ESRD) patients are primarily insured by the publicly funded Medicare program. Compared to other countries in the International Study of Health Care Organization and Financing (ISHCOF), the United States has the highest health care expenditures for the general population and among ESRD patients. However, because the Medicare program is more influential in the market for ESRD-related services than for other medical services, ESRD price controls have been relatively stringent. Nonetheless, ESRD costs have grown substantially through increases in prevalence and use of ancillary services. Treatment costs are also controlled by the relatively high rate of transplantation. Proposed reforms include bundling more services into a prospective payment system, developing case-mix adjustments, and financially rewarding providers for quality.      

The Cochrane pregnancy and childbirth database. Implications for perinatal care policy and practice in the United States

The Cochrane Pregnancy and Childbirth Database (CCPC) is the most sophisticated realization of the meta-analytic potential within the health fields. At the core of this ongoing collaborative international project are about 600 systematic reviews of the effectiveness of specific forms of perinatal care, which have been created from a registry of clinical trials. The scale and quality of information available through CCPC are unprecedented. An examination of implications of CCPC suggests that many far-reaching changes in perinatal policy and practice are indicated. CCPC has become a model for similar work that is being organized in many other clinical areas under the umbrella of the pan-clinical Cochrane Collaboration, and the experience and implications of CCPC will be of interest to many working in other areas. The implications of these ambitious meta-analytic projects are profound; the degree to which they will be realized is less certain.     

Health care administration in the United States and Canada: micromanagement, macro costs.

A decade ago, U.S. health administration costs greatly exceeded Canada's. Have the computerization of billing and the adoption of a more business-like approach to care cut administrative costs? For the United States and Canada, the authors calculated the 1999 administrative costs of health insurers, employers' health benefit programs, hospitals, practitioners' offices, nursing homes, and home care agencies; they analyzed published data, surveys of physicians, employment data, and detailed cost reports filed by hospitals, nursing homes, and home care agencies; they used census surveys to explore time trends in administrative employment in health care settings. Health administration costs totaled at least dollar 294.3 billion, dollar 1,059 per capita, in the United States vs. dollar 9.4 billion, dollar 307 per capita, in Canada. After exclusions, health administration accounted for 31.0 percent of U.S. health expenditures vs. 16.7 percent of Canadian. Canada's national health insurance program had an overhead of 1.3 percent, but overhead among Canada's private insurers was higher than in the U.S.: 13.2 vs. 11.7 percent. Providers' administrative costs were far lower in Canada. Between 1969 and 1999 administrative workers' share of the U.S. health labor force grew from 18.2 to 27.3 percent; in Canada it grew from 16.0 percent in 1971 to 19.1 percent in 1996. Reducing U.S. administrative costs to Canadian levels would save at least dollar 209 billion annually, enough to fund universal coverage.     

Placental abruption and perinatal mortality in the United States

Placental abruption is an uncommon obstetric complication associated with high perinatal mortality rates. The authors explored the associations of abruption with fetal growth restriction, preterm delivery, and perinatal survival. The study was based on 7,508,655 singleton births delivered in 1995 and 1996 in the United States. Abruption was recorded in 6.5 per 1,000 births. Perinatal mortality was 119 per 1,000 births with abruption compared with 8.2 per 1,000 among all other births. The high mortality with abruption was due, in part, to its strong association with preterm delivery; 55% of the excess perinatal deaths with abruption were due to early delivery. Furthermore, babies in the lowest centile of weight (<1% adjusted for gestational age) were almost nine times as likely to be born with abruption than those in the heaviest (> or =90%) birth weight centiles. This relative risk progressively declined with higher birth weight centiles. After controlling for fetal growth restriction and early delivery, the high risk of perinatal death associated with abruption persisted. Even babies born at 40 weeks of gestation and birth weight of 3,500-3,999 g (where mortality was lowest) had a 25-fold higher mortality with abruption. The link between fetal growth restriction and abruption suggests that the origins of abruption lie at least in midpregnancy and perhaps even earlier.     

Managed care, deficit financing, and aggregate health care expenditure in the United States: A cointegration analysis

We applied a battery of cointegration tests comprising those of Johansen and Juselius [19], Phillips and Hansen [35], and Engle and Granger [6], to model aggregate health care expenditure using 1960–96 US data. The existence of a stable long-run economic relationship or cointegration is confirmed, in the United States, between aggregate health care expenditure and real GDP, population age distribution, managed care enrollment, number of practicing physicians, and government deficits. The evidence of cointegration among these variables, chosen on the theoretical basis of prior studies, implies that while they are individually non-stationary in levels, together they are highly correlated and move, in the long run to form an economic equilibrium relationship of US aggregate health care expenditure. More specifically, and for the first time in this line of inquiry, (i) managed care enrollment is found to be negatively associated with the level of health care spending, (ii) supply disinduced demand effects of physicians tend to moderate health expenditure, and (iii) government deficit financing is positively related to health care spending. The observed sign and magnitude of the income coefficient are consistent with health care being a luxury good. This revised version was published online in July 2006 with corrections to the Cover Date.     

Hospital swing-bed care in the United States.

As a result of federal legislation implemented in 1982, hospital beds that are used to provide both long-term care and acute care are now proliferating rapidly throughout the country. Termed swing beds, such beds are currently restricted to rural areas. However, due largely to the impacts of Medicare DRG reimbursement, pressure is mounting to expand the swing-bed approach to urban settings. Swing beds appear to fill a significant gap between the relatively intense medical needs of post-acute care patients (now discharged earlier) and the capacity of our current nursing home delivery system to meet such needs. The evolution of swing beds is marked by an unusual blend of experimentation, scientific investigation, and public policy response to community and personal health care needs. This article summarizes that evolution, highlighting research findings and key policy developments. It concludes with the current status of the national swing-bed program and issues pertinent to future directions.     

Malpractice litigation and medical costs in the United States

This paper examines the relationship of medical malpractice litigation and medical costs in the United States. We relate medical malpractice settlements to medical costs for 190 metro and non‐metro areas in the United States over a 5‐year period and find that litigation is positively and significantly related to medical costs. Using a panel data set and a fixed‐effects specification, the estimates indicate that malpractice litigation accounts for roughly 2–10% of medical expenditures, with the impact exceeding the dollar amount of settlements. Copyright © 2009 John Wiley & Sons, Ltd.     

The future of health care in the United States

The U.S. government is involved in health care in various ways that include (1) providing services to veterans, (2) paying for care received by Medicare and Medicaid beneficiaries, (3) assuring quality through regulatory activity, (4) financing the discovery of medical breakthroughs, and (5) training members of the health workforce and assuring that the nation has an adequate supply of them. With the aging of the population, the role of the government in these endeavors will increase. This essay considers ways in which the health care of tomorrow will be affected by the intermingling of factors such as demography, epidemiology, economics, technology, globalization, and individual health behavior.