Measuring catastrophic medical expenditures: Reflections on three issues

In the “basic” approach, medical expenses are catastrophic if they exceed a prespecified percentage of consumption or income; the approach tells us if expenses cause a large percentage reduction in living standards. The ability‐to‐pay (ATP) approach defines expenses as catastrophic if they exceed a prespecified percentage of consumption less expenses on nonmedical necessities or an allowance for them. The paper argues that the ATP approach does not tell us whether expenses are large enough to undermine a household's ability to purchase nonmedical necessities. The paper compares the income‐based and consumption‐based variants of the basic approach, and shows that if the individual is a borrower after a health shock, the income‐based ratio will exceed the consumption‐based ratio, and both will exceed the more theoretically correct Flores et al. ratio; whereas if the individual continues to be a saver after a health shock, the ordering is reversed and the income‐based ratio may not overestimate Flores et al.'s ratio. Last, the paper proposes a lifetime money metric utility (LMMU) approach defining medical expenses as catastrophic in terms of their lifetime consequences. Under certain assumptions, the LMMU and Flores et al. approaches are identical, and neither requires data on how households finance their medical expenses.     

Investigating the relationship between social care supply and healthcare utilization by older people in England

Since 2010, adult social care spending in England has fallen significantly in real terms whilst demand has risen. Reductions in social care supply may also have impacted demand for NHS services, particularly for those whose care is provided at the interface of the health and care systems. We analyzed a panel dataset of 150 local authorities (councils) to test potential impacts on hospital utilization by people aged 65 and over: emergency admission rates for falls and hip fractures (“front‐door” measures); and extended stays of 7 days or longer; and 21 days or longer (“back‐door” measures). Changes in social care supply were assessed in two ways: gross current expenditure (per capita 65 and over) adjusted by local labor costs and social care workforce (per capita 18 and over). We ran negative binomial models, controlling for deprivation, ethnicity, age, unpaid care, council class, and year effects. To account for potential endogeneity, we ran instrumental variable regressions and dynamic panel models. Sensitivity analysis explored potential effects of funding for integrated care (the Better Care Fund). There was no consistent evidence that councils with higher per capita spend or higher social care staffing rates had lower hospital admission rates or shorter hospital stays.     

An income-weighted international average for comparative analysis of health expenditures

Data from 17 countries across 28 years are used to estimate an international health expenditure function based on real per capita GNP. Actual and expected spending levels are compared for 24 countries. Between 1960 and 1987, it has been rare for health expenditure in any country to be more than +/- 20 per cent from the projected value. The norm is for spending to rise at 1.5 times the growth rate of GDP. Two countries appear to display significant anomalies. Spending in the United Kingdom is consistently 15-25 per cent below normal for all years, and Danish expenditure has declined from 7 to 6 per cent of GDP since 1975.     

The clinical physiology of aging

International Urology and Nephrology -     

Patients’ experience of partial tooth loss and expectations to treatment: a qualitative study in Danish and Swedish patients

Knowledge of impairments, wishes and expectations is essential to make correct decisions regarding oral rehabilitation. The purpose of this study was to investigate discomforts, wishes and expectations in patients’ with partial edentulism before entering oral rehabilitation. In Copenhagen, Denmark, and Malmö, Sweden, respectively, 20 patients with partial edentulism seeking rehabilitation were interviewed in a semistructured qualitative manner. The interviews were transcribed and analysed yielding overall domains. Six themes appeared as overall domains: (i) experienced impairments, (ii) experienced social awareness, (iii) expectation to treatment, (iv) expectation to durability/survival, (v) coping strategies dealing with the tooth loss including explanations of the tooth loss and (vi) modifications to experienced impairment. The impairments were mostly experienced as problems in social settings. Most participants expressed a simple wish to function normally; a fixed solution was preferred. Many Danish participants accepted a removable solution whereas only few Swedish participants did so. The domains ‘coping strategies’ and ‘modifications’ were not part of the chosen topics of interest, indicating a high wish of the participants to explain their tooth loss and how they coped with it. In conclusion, a large degree of social impairment was found in the patient group along with several coping strategies. The impairments were modified by a number of factors indicating that highly individualised care and treatment is needed. A state of normality was described as the primary treatment wish with a higher acceptance of removable solutions in Denmark than in Sweden. For final decision‐making, surrounding factors seemed to influence the patients’ choices.     

International differences in cost and consumption of ready-to-consume food and drink products: United Kingdom and Brazil, 2008–2009

This paper tests the hypothesis that one important factor determining household availability of ready-to-consume products is their cost relative to the rest of the diet. National food expenditure surveys in the UK (2008) and Brazil (2008–09) were used. Purchased food quantities were converted into dietary energy (calories) and classified into three groups: (1) foods that are unprocessed or minimally processed; (2) processed culinary ingredients; and (3) ready-to-consume products, either processed or ultra-processed. The contribution of these groups to diets in each country was calculated as a percentage of total energy. Relative cost of ready-to-consume products in each country was calculated by dividing their cost by the cost of the rest of the diet (foods plus culinary ingredients). Linear regression analysis was used to test the association between the UK to Brazil ratios of the caloric share of different ready-to-consume products, and of the relative cost of these products. The caloric share of ready-to-consume products in the UK (63.4%) was well over double that of Brazil (27.7%), whereas their cost relative to the rest of the diet was 43% lower. The lower the relative cost of ready-to-consume products in the UK (compared with Brazil), the higher their relative consumption (R²=0.38, p<0.01).     

Reimbursement for therapeutic apheresis devices and procedures for using the healthcare insurance system in Japan

The aim of this paper was to explain the insurance coverage status of therapeutic apheresis (excluding CHDF) in Japan, alongside the social system of medical reimbursement and concerns regarding the future sustainability of the healthcare system. Insurance schemes and premiums differed for individuals at different levels in the society (eg, municipal residents, employees, and public servants). Insurance premiums and their rates varied depending on the total household income, the number of people living together, age, and the place of residence. In addition, the medical expense subsidies for children through public expenditure were also described. Japan's generous insurance system and multiple medical expense subsidies provide financial support for patients. With Japan's history of medical expense subsidies based on the policy of supporting intractable diseases, we have established an environment where all citizens can receive therapeutic apheresis when needed if they are affected by a disease for which insurance coverage is indicated.     

Modeling the determinants of Medicaid home care payments for children with special health care needs: A structural equation model approach

BackgroundThe management of children with special needs can be very challenging and expensive.ObjectiveTo examine direct and indirect cost drivers of home care expenditures for this vulnerable and expensive population.MethodsWe retrospectively assessed secondary data on children, ages 4–20, receiving Medicaid Personal Care Services (PCS) (n = 2760). A structural equation model assessed direct and indirect effects of several child characteristics, clinical conditions and functional measures on Medicaid home care payments.ResultsThe mean age of children was 12.1 years and approximately 60% were female. Almost half of all subjects reported mild, moderate or severe ID diagnosis. The mean ADL score was 5.27 and about 60% of subjects received some type of rehabilitation services. Caseworkers authorized an average of 25.5 h of PCS support per week. The SEM revealed three groups of costs drivers: indirect, direct and direct + indirect. Cognitive problems, health impairments, and age affect expenditures, but they operate completely through other variables. Other elements accumulate effects (externalizing behaviors, PCS hours, and rehabilitation) and send them on a single path to the dependent variable. A few elements exhibit a relatively complex position in the model by having both significant direct and indirect effects on home care expenditures – medical conditions, intellectual disability, region, and ADL function.ConclusionsThe most important drivers of home care expenditures are variables that have both meaningful direct and indirect effects. The only one of these factors that may be within the sphere of policy change is the difference among costs in different regions.