When the technical is also normative: a critical assessment of measuring health inequalities using the concentration index-based indices.

BACKGROUND: Concentration index-based measures are one of the most popular tools for estimating socioeconomic-status-related health inequalities. In recent years, several variants of the concentration index have been developed that are designed to correct for deficiencies of the standard concentration index and which are increasingly being used. These variants, which include the Wagstaff index and the Erreygers index, have important technical and normative differences. MAIN BODY: In this study, we provide a non-technical review and critical assessment of these indices. We (i) discuss the difficulties that arise when measurement tools intended for income are applied in a health context, (ii) describe and illustrate the interrelationship between the technical and normative properties of these indices, (iii) discuss challenges that arise when determining whether index estimates are large or of policy significance, and (iv) evaluate the alignment of research practice with the properties of the indices used. Issues discussed in parts (i) and (ii) include the different conceptions of inequality that underpin the indices, the types of changes to a distribution which leave inequality unchanged and the importance of the measurement scale and range of the outcome variable. These concepts are illustrated using hypothetical examples. For parts (iii) and (iv), we reviewed 44 empirical studies published between 2015 and 2017 and find that researchers often fail to provide meaningful interpretations of the index estimates. CONCLUSION: We propose a series of questions to facilitate further sensitivity analyses and provide a better understanding of the index estimates. We also provide a guide for researchers and policy analysts to facilitate the critical assessment of studies using these indices, while helping applied researchers to choose inequality measures that have the normative properties they seek.

Economic Evaluation of Early Psychosis Interventions From A Canadian Perspective.

BACKGROUND: Compared to treatment as usual (TAU), early psychosis intervention programs (EPI) have been shown to reduce mortality, hospitalizations and days of assisted living while improving employment status. AIMS: The study aim was to conduct a cost-benefit analysis (CBA) and a cost-effectiveness analysis (CEA) to compare EPI and TAU in Canada. METHODS: A decision-analytic model was used to estimate the 5-year costs and benefits of treating patients with a first episode of psychosis with EPI or TAU. EPI benefits were derived from randomized controlled trials (RCTs) and Canadian administrative data. The cost of EPI was based on a published survey of 52 EPI centers in Canada while hospitalizations, employment and days of assisted living were valued using Canadian unit costs. The outcomes of the CBA and CEA were expressed in terms of net benefit (NB) and incremental cost per life year gained (LYG), respectively. Scenario analyses were conducted to examine the impact of key assumptions. Costs are reported in 2019 Canadian dollars. RESULTS: Base case results indicated that EPI had a NB of $85,441 (95% CI: $41,140; $126,386) compared to TAU while the incremental cost per LYG was $26,366 (95% CI: EPI dominates TAU (less costs, more life years); $102,269). In all sensitivity analyses the NB of EPI remained positive and the incremental cost per LYG was less than $50,000. CONCLUSIONS: In addition to EPI demonstrated clinical benefits, our results suggest that large-scale implementation of EPI in Canada would be desirable from an economic point of view .

Here comes the SUN: Self-assessed unmet need, worsening health outcomes, and health care inequity.

Utilization-based approaches have predominated the measurement of socioeconomic-related inequity in health care. This approach, however, can be misleading when preferences over health and health care are correlated with socioeconomic status, especially when the underlying focus is on equity of access. We examine the potential usefulness of an alternative approach to assessing inequity of access using a direct measure of possible barriers to access-self-reported unmet need (SUN)-which is documented to vary with socioeconomic status and is commonly asked in health surveys. Specifically, as part of an assessment of its external validity, we use Canadian longitudinal health data to test whether self-reported unmet need in one period is associated with a subsequent deterioration in health status in a future period, and find that it is. This suggests that SUN does reflect in part reduced access to needed health care, and therefore may have a role in assessing health system equity as a complement to utilization-based approaches.

A population-based analysis of incentive payments to primary care physicians for the care of patients with complex disease.

BACKGROUND: In 2007, the province of British Columbia implemented incentive payments to primary care physicians for the provision of comprehensive, continuous, guideline-informed care for patients with 2 or more chronic conditions. We examined the impact of this program on primary care access and continuity, rates of hospital admission and costs. METHODS: We analyzed all BC patients who qualified for the incentive based on their diagnostic profile. We tracked primary care contacts and continuity, hospital admissions (total, via the emergency department and for targeted conditions), and cost of physician services, hospital care and pharmaceuticals, for 24 months before and 24 months after the intervention. RESULTS: Of 155 754 eligible patients, 63.7% had at least 1 incentive payment billed. Incentive payments had no impact on primary care contacts (change in contacts per patient per month: 0.016, 95% confidence interval [CI] -0.047 to 0.078) or continuity of care (mean monthly change: 0.012, 95% CI -0.001 to 0.024) and were associated with increased total rates of hospital admission (change in hospital admissions per 1000 patients per month: 1.46, 95% CI 0.04 to 2.89), relative to preintervention trends. Annual costs per patient did not decline (mean change: $455.81, 95% CI -$2.44 to $914.08). INTERPRETATION: British Columbia's $240-million investment in this program improved compensation for physicians doing the important work of caring for complex patients, but did not appear to improve primary care access or continuity, or constrain resource use elsewhere in the health care system. Policymakers should consider other strategies to improve care for this patient population.

Unexplained health inequality--is it unfair?

INTRODUCTION: Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health - a difference in health - is inequitable. Empirically operationalizing definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question - whether unexplained health inequality is unfair - determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity. METHODS: We use the American sample of the 2002-03 Joint Canada/United States Survey of Health and measure health by the Health Utilities Index (HUI). We model variation in the observed HUI by demographic, socioeconomic, health behaviour, and health care variables using Ordinary Least Squares. We estimate unfair HUI by standardizing fairness, removing the fair component from the observed HUI. We consider health inequality due to factors amenable to policy intervention as unfair. We contrast estimates of inequity using two fairness-standardization methods: direct (considering unexplained inequality as ethically acceptable) and indirect (considering unexplained inequality as unfair). We use the Gini coefficient to quantify inequity. RESULTS: Our analysis shows that about 75% of the variation in the observed HUI is unexplained by the model. The direct standardization results in a smaller inequity estimate (about 60% of health inequality is inequitable) than the indirect standardization (almost all inequality is inequitable). CONCLUSIONS: The choice of the fairness-standardization method is ethical and influences the empirical health inequity results considerably. More debate and analysis is necessary regarding which treatment of the unexplained inequality has the stronger foundation in equity considerations.

A three-stage approach to measuring health inequalities and inequities.

INTRODUCTION: Measurement of health inequities is fundamental to all health equity initiatives. It is complex because it requires considerations of ethics, methods, and policy. Drawing upon the recent developments in related specialized fields, in this paper we incorporate alternative definitions of health inequity explicitly and transparently in its measurement. We propose a three-stage approach to measuring health inequities that assembles univariate health inequality, univariate health inequity, and bivariate health inequities in a systematic and comparative manner. METHODS: We illustrate the application of the three-stage approach using the Joint Canada/United States Survey of Health, measuring health by the Health Utilities Index (HUI). Univariate health inequality is the distribution of the observed HUI across individuals. Univariate health inequity is the distribution of unfair HUI--components of HUI associated with ethically unacceptable factors--across individuals. To estimate the unfair HUI, we apply two popular definitions of inequity: "equal opportunity for health" (health outcomes due to factors beyond individual control are unfair), and "policy amenability" (health outcomes due to factors amenable to policy interventions are unfair). We quantify univariate health inequality and inequity using the Gini coefficient. We assess bivariate inequities using a regression-based decomposition method. RESULTS: Our analysis reveals that, empirically, different definitions of health inequity do not yield statistically significant differences in the estimated amount of univariate inequity. This derives from the relatively small explanatory power common in regression models describing variations in health. As is typical, our model explains about 20% of the variation in the observed HUI. With regard to bivariate inequities, income and health care show strong associations with the unfair HUI. CONCLUSIONS: The measurement of health inequities is an excitingly multidisciplinary endeavour. Its development requires interdisciplinary integration of advances from relevant disciplines. The proposed three-stage approach is one such effort and stimulates cross-disciplinary dialogues, specifically, about conceptual and empirical significance of definitions of health inequities.

Physician response to pay-for-performance: evidence from a natural experiment.

This study exploits a natural experiment in the province of Ontario, Canada, to identify the impact of pay-for-performance (P4P) incentives on the provision of targeted primary care services and whether physicians' responses differ by age, size of patient population, and baseline compliance level. We use administrative data that cover the full population of Ontario and nearly all the services provided by primary care physicians. We employ a difference-in-differences approach that controls for selection on observables and selection on unobservables that may cause estimation bias. We implement a set of robustness checks to control for confounding from other contemporaneous interventions of the primary care reform in Ontario. The results indicate that responses were modest and that physicians responded to the financial incentives for some services but not others. The results provide a cautionary message regarding the effectiveness of employing P4P to increase the quality of health care.

Fair reckoning: a qualitative investigation of responses to an economic health resource allocation survey.

OBJECTIVE: To investigate how participants in an economic resource allocation survey construct notions of fairness. DESIGN: Qualitative interview study guided by interpretive grounded theory methods. SETTING AND PARTICIPANTS: Qualitative interviews were conducted with volunteer university- (n=39) and community-based (n =7) economic survey participants. INTERVENTION OR MAIN VARIABLES STUDIED: We explored how participants constructed meanings to guide or explain fair survey choices, focusing on rationales, imagery and additional desired information not provided in the survey scenarios. MAIN OUTCOME MEASURES: Data were transcribed and coded into qualitative categories. Analysis iterated with data collection iterated through three waves of interviews. RESULTS: Participants compared the survey dilemmas to domains outside the health system. Most compared them with other micro-level, inter-personal sharing tasks. Participants raised several fairness-relevant factors beyond need or capacity to benefit. These included age, weight, poverty, access to other options and personal responsibility for illness; illness duration, curability or seriousness; life expectancy; possibilities for sharing; awareness of other's needs; and ability to explain allocations to those affected. They also articulated a fairness principle little considered by equity theories: that everybody must get something and nobody should get nothing. DISCUSSION AND CONCLUSIONS: Lay criteria for judging fairness are myriad. Simple scenarios may be used to investigate lay commitments to abstract principles. Although principles are the focus of analysis and inference, participants may solve simplified dilemmas by imputing extraneous features to the problem or applying unanticipated principles. These possibilities should be taken into account in the design of resource allocation surveys eliciting the views of the public.

Trajectories of the socioeconomic gradient of mental health: Results from the CLSA COVID-19 Questionnaire Study.

As the coronavirus disease (COVID-19) pandemic prolongs, documenting trajectories of the socioeconomic gradient of mental health is important. We describe changes in the prevalence and absolute and relative income-related inequalities of mental health between April and December 2020 in Canada. We used data from the Canadian Longitudinal Study on Aging (CLSA) COVID-19 Questionnaire Study and the pre-pandemic CLSA Follow-up 1. We estimated the prevalence proportion, the concentration index (relative inequality), and the generalized concentration index (absolute inequality) for anxiety and self-reported feeling generally unwell at multiple points in April-December 2020, overall, by sex and age group, by region, and among those who reported poor or fair overall health and mental health pre-pandemic. Overall, the prevalence of anxiety remained unchanged (22.45 to 22.10%, p = 0.231), but self-reported feeling generally unwell decreased (9.83 to 5.94%, p = 0.004). Relative and absolute income-related inequalities were unchanged for both anxiety and self-reported feeling generally unwell, with exceptions of an increased concentration of self-reported feeling generally unwell among the poor, measured by the concentration index, overall (-0.054 to -0.115, p = 0.004) and in Ontario (-0.035 to -0.123, p = 0.047) and British Columbia (-0.055 to -0.141, p = 0.044). The COVID-19 pandemic appeared to neither exacerbate nor ameliorate existing income-related inequalities in mental health among older adults in Canada between April and December 2020. Continued monitoring of inequalities is necessary.

Public and private health-care financing with alternate public rationing rules.

We develop a model to analyze parallel public and private health-care financing under two alternative public sector rationing rules: needs-based rationing and random rationing. Individuals vary in income and severity of illness. There is a limited supply of health-care resources used to treat individuals, causing some individuals to go untreated. Insurers (both public and private) must bid to obtain the necessary health-care resources to treat their beneficiaries. Given individuals' willingnesses-to-pay for private insurance are increasing in income, the introduction of private insurance diverts treatment from relatively poor to relatively rich individuals. Further, the impact of introducing parallel private insurance depends on the rationing mechanism in the public sector. We show that the private health insurance market is smaller when the public sector rations according to need than when allocation is random.

Physician resource planning in Canada: the need for a stronger behavioural foundation.

An effective solution to the problem of access to physician services in Canada must extend beyond an over-exclusive focus on the number of providers to consider the behaviour of physicians in greater depth. The amount of labour and associated services supplied by physicians depends importantly on their attitudes regarding work, on practice and non-practice income opportunities, and on the policy environment in which they practise. Hence, the amount of labour supplied by a given stock of physicians can change over time. Only by considering the full range of factors that affect the labour supply of physicians can we effectively plan for physician resources.

Cautionary tails of grip strength in health inequality studies: An analysis from the Canadian longitudinal study on aging.

Self-rated health is widely used in studies of the socioeconomic gradient of health in community-based populations. Its subjectivity may lead to under- or over-estimation of a true underlying socioeconomic gradient and has increased interest in searching for alternative, objective measures of health. Grip strength has emerged as one such alternative for community-based older populations, yet no study has directly assessed the relationship between these two measures and compared their associations with socioeconomic status and health behaviours. Using 26,754 participants aged 45-85 years in the baseline data of the Canadian Longitudinal Study on Aging Comprehensive Cohort, we estimated adjusted-grip strength through indirect standardization using age, sex, height, weight, and their square terms and used ANOVA to assess the variance of adjusted-grip strength within and between each self-rated health category. We ran four separate logistic regression models, examining unhealthy tails (those reporting poor health vs. not and those at the bottom 8th percentile of adjusted-grip strength vs. above) and healthy tails (those reporting excellent health vs. not and those at the top 20th percentile of adjusted-grip strength vs. below). Stronger adjusted-grip strength correlated with better self-rated health, but only 2% of the total variance of adjusted-grip strength was explained by variance between the self-rated health categories. While self-rated health largely showed the expected socioeconomic gradients and positive relationships with health enhancing behaviours, adjusted-grip strength showed no clear, consistent associations with either socioeconomic or health behaviour variables. The results give caution about using grip strength as an objective alternative to self-rated health in studies of social inequalities in health. Empirical approaches demand careful considerations as to which dimensions of health and corresponding measures of health are most relevant to the context being studied.

Inequality aversion in income, health, and income-related health.

Based on a survey of a sample of the general public, we estimate inequality aversion across income, health, and bivariate income-health. Inequality aversion is domain specific: mean inequality aversion is greater for income than for health, but the underlying distributions of aversion attitudes differ, with a highly bi-modal distribution of inequality-aversion values for health in which nearly half the participants display very low aversion and nearly half display very high aversion. Aversion to income-related health inequality is greater than that to income or health alone. Consistent with previous literature, we find only weak associations between aversion attitudes and individual characteristics. The magnitude of the estimates implies potentially large gains in welfare from reducing inequality in these domains.

Does moral reasoning influence public values for health care priority setting?: A population-based randomized stated preference survey.

OBJECTIVE: Preferences of members of the public are recognized as important inputs into health care priority-setting, though knowledge of such preferences is scant. We sought to generate evidence of public preferences related to healthcare resource allocation among adults and children. METHODS: We conducted an experimental stated preference survey in a national sample of Canadian adults. Preferences were elicited across a range of scenarios and scored on a visual analogue scale. Intervention group participants were randomized to a moral reasoning exercise prior to each choice task. The main outcomes were the differences in mean preference scores by group, scenario, and demographics. RESULTS: Our results demonstrate a consistent preference by participants to allocate scarce health system resources to children. Exposure to the moral reasoning exercise weakened but did not eliminate this preference. Younger respondent age and parenthood were associated with greater preference for children. The top principles guiding participants' allocative decisions were treat equally, relieve suffering, and rescue those at risk of dying. CONCLUSIONS: Our study affirms the relevance of age in public preferences for the allocation of scarce health care resources, demonstrating a significant preference by participants to allocate healthcare resources to children. However, this preference diminishes when challenged by exposure to a range of moral principles, revealing a strong public endorsement of equality of access. Definitions of value in healthcare based on clinical benefit and cost-effectiveness may exclude moral considerations that the public values, such as equality and humanitarianism, highlighting opportunities to enrich healthcare priority-setting through public engagement.

Inequity in publicly funded physician care: what is the role of private prescription drug insurance?

This study examines the impact that private financing of prescription drugs in Canada has on equity in the utilization of publicly financed physician services. The complementary nature of prescription drugs and physician service use alongside the reliance on private finance for drugs may induce an income gradient in the use of physicians. We use established econometric methods based on concentration curves to measure equity in physician utilization and its contributors in the province of Ontario. We find that individuals with prescription drug insurance make more physician visits than do those without insurance, and the effect on utilization is stronger for the likelihood of a visit than the conditional number of visits, and stronger for individuals with at least one chronic condition than those with no conditions. Results of the equity analyses reveal that the most important contributors to the pro-rich inequity in physician utilization are income and private prescription drug insurance, while public insurance, which covers older people and those on social assistance, has a pro-poor effect. These findings highlight that inequity in access to and use of publicly funded services may arise from the interaction with privately financed health services that are complements to the use of public services.

Physician labour supply in Canada: a cohort analysis.

This paper employs a cohort analysis to examine the relative importance of different factors in explaining changes in the number of hours spent in direct patient care by Canadian general/family practitioners (GPs) over the period 1982-2003. Cohorts are defined by year of graduation from medical school. The results for male GPs indicate that there is little age effect on hours of direct patient care, especially among physicians aged 35-55, there is no strong cohort effect on hours of direct patient care, but there is a secular decline in hours of direct patient care over the period. The results for female GPs indicate that female physicians on average work fewer hours than male physicians, there is a clear age effect on hours of direct patient care, there is no strong cohort effect, and there has been little secular change in average hours of direct patient care. The changing behaviour of male GPs accounted for a greater proportion of the overall decline in hours of direct patient care from the 1980s through the mid-1990 s than did the growing proportion of female GPs in the physician stock.

Selecting effective incentive structures in health care: A decision framework to support health care purchasers in finding the right incentives to drive performance.

BACKGROUND: The Ontario health care system is devolving planning and funding authority to community based organizations and moving from steering through rules and regulations to steering on performance. As part of this transformation, the Ontario Ministry of Health and Long-Term Care (MOHLTC) are interested in using incentives as a strategy to ensure alignment - that is, health service providers' goals are in accord with the goals of the health system. The objective of the study was to develop a decision framework to assist policymakers in choosing and designing effective incentive systems. METHODS: The first part of the study was an extensive review of the literature to identify incentives models that are used in the various health care systems and their effectiveness. The second part was the development of policy principles to ensure that the used incentive models are congruent with the values of the Ontario health care system. The principles were developed by reviewing the Ontario policy documents and through discussions with policymakers. The validation of the principles and the suggested incentive models for use in Ontario took place at two meetings. The first meeting was with experts from the research and policy community, the second with senior policymakers from the MOHLTC. Based on the outcome of those two meetings, the researchers built a decision framework for incentives. The framework was send to the participants of both meetings and four additional experts for validation. RESULTS: We identified several models that have proven, with a varying degree of evidence, to be effective in changing or enabling a health provider's performance. Overall, the literature suggests that there is no single best approach to create incentives yet and the ability of financial and non-financial incentives to achieve results depends on a number of contextual elements. After assessing the initial set of incentive models on their congruence with the four policy principles we defined nine incentive models to be appropriate for use in Ontario and potentially other health care systems that want to introduce incentives to improve performance. Subsequently, the models were incorporated in the resulting decision framework. CONCLUSION: The design of an incentive must reflect the values and goals of the health care system, be well matched to the performance objectives and reflect a range of contextual factors that can influence the effectiveness of even well-designed incentives. As a consequence, a single policy recommendation around incentives is inappropriate. The decision framework provides health care policymakers and purchasers with a tool to support the selection of an incentive model that is the most appropriate to improve the targeted performance.

Insurance coverage and the treatment of mental illness: effect on medication and provider use.

BACKGROUND: Canada's public health insurance system fully covers medically necessary hospital and physician services, but does not cover community-based non-physician mental health provider services or prescription drugs. Almost 2/3 of Canadians have private supplemental insurance for extended health benefits, typically through their employer, so its distribution is skewed to higher-income, employed Canadians, and typically features substantial cost-sharing and coverage limits. A recent national survey suggests only one-third of Canadians with selected mental disorders talked to a health professional during the previous 12 months and only a minority (19.3%) receive drug treatment. Financial barriers to care constitute a potentially important contributor to this under-use of mental health treatments. AIMS OF THE STUDY: The objective is to understand how private supplemental insurance status affects the utilization of prescription medication and four types of community-based providers for mental health problems in Canada. METHODS: The data derive from a special mental health supplement to the nationally representative Canadian Community Health Survey. Utilization of five types of prescribed medications (sleep, anxiety, mood stabilizers, anti-depressants and anti-psychotics) is measured dichotomously as use/no-use in the previous 12 months. Utilization of community-based provider services (family physician, psychiatrist, psychologist and social worker) is measured as (i) use/no-use and (ii) conditional on use, number of contacts in the previous 12 months. We employ multivariate regression methods appropriate to the binary and count nature of the dependent variable to measure the impact of supplemental private insurance status on utilization, controlling for health, demographic and socio-economic characteristics. We test for endogeneity of insurance status using instrumental variable techniques. RESULTS: Having private supplemental insurance significantly increases the odds of using medications for mental illness, with particularly large increases for anti-psychotic and mood-stabilizer medications. Private supplemental insurance coverage does not increase use of provider services. We find little evidence of endogeneity of private insurance. DISCUSSION: Lack of supplemental insurance for prescription medication is a potentially important financial barrier to mental health treatment in Canada. The estimated effect is likely understated because the utilization measure does not capture quantity of medication use. It is not surprising that no significant relationship between private insurance status and utilization of provider services is found for publicly-covered family physician and psychiatry services, where the link between supplemental insurance and use is indirect, through the need to visit a physician to obtain a prescription. The result is surprising for psychologists and social workers, and may reflect limits to private coverage which are not fully captured here. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Insurance coverage has an important relative impact on the likelihood of drug use for mental illness. IMPLICATIONS FOR HEALTH POLICIES: A program that offers insurance coverage for anti-psychotic and mood-stabilizing medication could reduce the high personal and societal burden associated with serious mental illness, without a large overall budgetary impact. IMPLICATIONS FOR FUTURE RESEARCH: Future research should incorporate insurance measures which capture details of coverage among all survey respondents. Linking survey to utilization data will help to overcome issues of recall bias.

Parallel payers and preferred access: how Canada's Workers' Compensation Boards expedite care for injured and ill workers.

Canada's workers' compensation boards (WCBs) finance healthcare for injured and ill workers in parallel with provincial health insurance plans. Parallel systems of healthcare finance can create preferred access for some. WCBs have in recent years pursued a number of strategies to expedite or improve the quality of care for injured or ill workers, including in-house provision in WCB-owned facilities; contracting with private, for-profit clinics; contracting with publicly funded hospitals and clinics for use of facilities "off-hours"; and supporting specialized clinics within publicly funded hospitals. Many of these strategies incorporate incentive payments to physicians and facilities for treating WCB cases more quickly than patients covered by provincial plans. In this paper we document the development of these strategies and discuss their implications for physicians, patients, government and the provincial public insurance plans.