Financial protection of households against health shocks in Greece during the economic crisis.

BACKGROUND: Harsh funding cutbacks along with measures shifting cost to patients have been implemented in the Greek health system in recent years. Our objective was to investigate the evolution of financial protection of Greek households against out-of-pocket payments (OOPP) during the economic crisis. METHODS: National representative data of 33,091 households were derived from the Household Budget Surveys for the period 2008-2015. Financial protection was assessed by applying the approaches of catastrophic (CHE) and impoverishing OOPP. The determinants of CHE and impoverishment were examined using binary logistic regressions. RESULTS: OOPP dropped by 23.5% in real values between 2008 and 2015, though their share in households' budget rose from 6.9% to 7.8%, with an increasing trend since 2012. These outcomes were driven by significant increases in medical products (20.2%) and inpatient (63%) OOPP, while outpatient expenses decreased considerably (-62%). Both incidence and overshoot of CHE were significantly exacerbated. The additional burden was distributed progressively, hence, financial risk inequalities decreased. Food poverty increased, but its incidence still remains at very low levels. Both incidence and intensity of relative poverty increased considerably in real terms. The poverty impact of OOPP is aggravating following 2012, and 1.9% of individuals were impoverished due to OOPP in 2015. Households of higher size, lower expenditure quintile, in urban areas, without disabled, elderly or young children members, and with younger or retired, better-educated breadwinners were significantly less vulnerable to CHE. Households in the lower-middle expenditure quintile, in rural regions, and with elderly members were facing higher risk, while wealthier families exhibited a considerable lower likelihood of impoverishment. CONCLUSIONS: The expansion of reliance of healthcare funding on OOPP has increased the financial risk and hardship of Greek households, which may disrupt their living conditions and create barriers to healthcare access. Cost-sharing policies should recognise the different social protection needs of households.

Referral patterns and implementation costs of the Partners in Recovery initiative in Gippsland: learnings for the National Disability Insurance Scheme.

OBJECTIVE:: The purpose of this paper is to provide some learnings for the NDIS from the referral pattern and cost of implementing the Partners in Recovery initiative of Gippsland. METHOD:: Information on referral areas made for each consumer was collated from support facilitators. Cost estimates were determined using budget estimates, administrative costs and a literature review and are reported from a government perspective. RESULTS:: Sixty-three per cent of all referrals were made to organisations that provided multiple types of services. Thirty-one per cent were to Mental Health Community Support Services. Eighteen per cent of referrals were made to clinical mental health services. The total cost of providing the service for a consumer per year (set-up and ongoing) was estimated to be AUD$15,755 and the ongoing cost per year was estimated to be AUD$13,434. The cost of doing nothing is likely to cost more in the longer term, with poor mental health outcomes such as hospital admission, unemployment benefits, prison, homelessness and psychiatric residential care. CONCLUSIONS:: Supporting recovery in persons with Severe and Persistent Mental Illness is likely to be economically more beneficial than not doing so. Recovery can be better supported when frequently utilised services are co-located. These might be some learnings for the NDIS.

Cost of Care for the Initial Management of Ovarian Cancer.

OBJECTIVE: To examine the cost of care during the first year after a diagnosis of ovarian cancer, estimate the sources of cost, and explore the out-of-pocket costs. METHODS: We performed a retrospective cohort study of women with ovarian cancer diagnosed from 2009 to 2012 who underwent both surgery and adjuvant chemotherapy using the Truven Health MarketScan database. This database is comprised of patients covered by commercial insurance sponsored by more than 100 employers in the United States. Medical expenditures, including physician reimbursement, for a 12-month period beginning on the date of surgery were estimated. All payments were examined, including out-of-pocket costs for patients. Payments were divided into expenditures for inpatient care, outpatient care (including chemotherapy), and outpatient drug costs. The 12-month treatment period was divided into three phases: surgery to 30 days (operative period), 1-6 months (adjuvant therapy), and 6-12 months after surgery. The primary outcome was the overall cost of care within the first year of diagnosis of ovarian cancer; secondary outcomes included assessment of factors associated with cost. RESULTS: A total of 26,548 women with ovarian cancer who underwent surgery were identified. After exclusion of patients with incomplete insurance enrollment or coverage, those who did not undergo chemotherapy, and those with capitated plans, our cohort consisted of 5,031 women. The median total medical expenditures per patient during the first year after the index procedure were $93,632 (interquartile range $62,319-140,140). Inpatient services accounted for $30,708 (interquartile range $20,102-51,107; 37.8%) in expenditures, outpatient services $52,700 (interquartile range $31,210-83,206; 58.3%), and outpatient drug costs $1,814 (interquartile range $603-4,402; 3.8%). The median out-of-pocket expense was $2,988 (interquartile range $1,649-5,088). This included $1,509 (interquartile range $705-2,878) for outpatient services, $589 (interquartile range $3-1,715) for inpatient services, and $351 (interquartile range $149-656) for outpatient drug costs. CONCLUSION: The average cost of care for women with ovarian cancer in the first year after surgery is approximately $100,000. Patients bear approximately 3% of these costs in the form of out-of-pocket expenses.

Who bears the cost of 'informal mhealth'? Health-workers' mobile phone practices and associated political-moral economies of care in Ghana and Malawi.

Africa's recent communications 'revolution' has generated optimism that using mobile phones for health (mhealth) can help bridge healthcare gaps, particularly for rural, hard-to-reach populations. However, while scale-up of mhealth pilots remains limited, health-workers across the continent possess mobile phones. This article draws on interviews from Ghana and Malawi to ask whether/how health-workers are using their phones informally and with what consequences. Health-workers were found to use personal mobile phones for a wide range of purposes: obtaining help in emergencies; communicating with patients/colleagues; facilitating community-based care, patient monitoring and medication adherence; obtaining clinical advice/information and managing logistics. However, the costs were being borne by the health-workers themselves, particularly by those at the lower echelons, in rural communities, often on minimal stipends/salaries, who are required to 'care' even at substantial personal cost. Although there is significant potential for 'informal mhealth' to improve (rural) healthcare, there is a risk that the associated moral and political economies of care will reinforce existing socioeconomic and geographic inequalities.

Contrary to cost-shift theory, lower Medicare hospital payment rates for inpatient care lead to lower private payment rates.

Many policy makers believe that when Medicare constrains its payment rates for hospital inpatient care, private insurers end up paying higher rates as a result. I tested this "cost-shifting" theory using a unique new data set that combines MarketScan private claims data with Medicare hospital cost reports. Contrary to the theory, I found that hospital markets with relatively slow growth in Medicare inpatient hospital payment rates also had relatively slow growth in private hospital payment rates during 1995-2009. Using regression analyses, I found that a 10 percent reduction in Medicare payment rates led to an estimated reduction in private payment rates of 3 percent or 8 percent, depending on the statistical model used. These payment rate spillovers may reflect an effort by hospitals to rein in their operating costs in the face of lower Medicare payment rates. Alternatively, hospitals facing cuts in Medicare payment rates may also cut the payment rates they seek from private payers to attract more privately insured patients. My findings indicate that repealing cuts in Medicare payment rates would not slow the growth in spending on hospital care by private insurers and would in fact be likely to accelerate the growth in private insurers' costs and premiums.

Hospitals respond to Medicare payment shortfalls by both shifting costs and cutting them, based on market concentration.

The coverage expansions planned under the Affordable Care Act are to be financed in part by slowing Medicare payment updates to hospitals, thereby reigniting the debate over whether low prices paid by public payers cause hospitals to increase prices to private insurers--a practice known as cost shifting. Recently, the Medicare Payment Advisory Commission (MedPAC) proposed an alternative explanation of hospital pricing and profitability that could be used to support policies that pressure hospitals to reduce overall costs rather than to only raise prices. This study evaluated the cost-shift and MedPAC perspectives using 2008 data on hospital margins for 30,514 Medicare and privately insured patients undergoing any of seven major procedures in markets where robust hospital competition exists and in markets where hospital care is concentrated in the hands of a few providers. The study presents empirical evidence that, faced with shortfalls between Medicare payments and projected costs, hospitals in concentrated markets focus on raising prices to private insurers, while hospitals in competitive markets focus on cutting costs. Policy makers need to examine whether efforts to promote clinical coordination through provider integration may interfere with efforts to restrain overall health care cost growth by restraining Medicare payment rates.

How much do hospitals cost shift? A review of the evidence.

CONTEXT: Hospital cost shifting--charging private payers more in response to shortfalls in public payments--has long been part of the debate over health care policy. Despite the abundance of theoretical and empirical literature on the subject, it has not been critically reviewed and interpreted since Morrisey did so nearly fifteen years ago. Much has changed since then, in both empirical technique and the health care landscape. This article examines the theoretical and empirical literature on cost shifting since 1996, synthesizes the predominant findings, suggests their implications for the future of health care costs, and puts them in the current policy context. METHODS: The relevant literature was identified by database search. Papers describing policies were considered first, since policy shapes the health care market in which cost shifting may or may not occur. Theoretical works were examined second, as theory provides hypotheses and structure for empirical work. The empirical literature was analyzed last in the context of the policy environment and in light of theoretical implications for appropriate econometric specification. FINDINGS: Most of the analyses and commentary based on descriptive, industry-wide hospital payment-to-cost margins by payer provide a false impression that cost shifting is a large and pervasive phenomenon. More careful theoretical and empirical examinations suggest that cost shifting can and has occurred, but usually at a relatively low rate. Margin changes also are strongly influenced by the evolution of hospital and health plan market structures and changes in underlying costs. CONCLUSIONS: Policymakers should view with a degree of skepticism most hospital and insurance industry claims of inevitable, large-scale cost shifting. Although some cost shifting may result from changes in public payment policy, it is just one of many possible effects. Moreover, changes in the balance of market power between hospitals and health care plans also significantly affect private prices. Since they may increase hospitals' market power, provisions of the new health reform law that may encourage greater provider integration and consolidation should be implemented with caution.

The use of source apportionment for air quality management and health assessments.

Receptor modeling is the application of data analysis methods to elicit information on the sources of air pollutants. Typically, it employs methods of solving the mixture resolution problem using chemical composition data for airborne particulate matter (PM) samples. In such cases, the outcome is the identification of the pollution source types and estimates of the contribution of each source type to the observed concentrations. Receptor modeling also involves efforts to identify the locations of the sources through the use of local meteorology or ensembles of air parcel back trajectories. Compositional data were collected in a number of monitoring programs. The U.S. Environmental Protection Agency deployed a network of urban airborne PM samplers to provide PM(2.5) composition data for urban centers across the United States. In addition, advanced monitoring methods were deployed at "supersites." These data show the differences in composition in different part of the country and were also used to identify and apportion the particle sources. These results were used to (1)develop effective and efficient air quality management plans and (2) refine emission inventories for input into deterministic models to predict changes in air quality as the result of the implementation of various management plans. The apportionments also serve as exposure estimates for health effects models to identify those components of the PM that are most closely related to observed adverse health effects. Although current regulations target total airborne mass concentrations, such health effects results might result in targeting those sources that are most likely linked to adverse health effects and thus produce the maximum health benefit.

Cost drivers and resource allocation in military health care systems.

This study illustrates the feasibility of incorporating technical efficiency considerations in the funding of military hospitals and identifies the primary drivers for hospital costs. Secondary data collected for 24 U.S.-based Army hospitals and medical centers for the years 2001 to 2003 are the basis for this analysis. Technical efficiency was measured by using data envelopment analysis; subsequently, efficiency estimates were included in logarithmic-linear cost models that specified cost as a function of volume, complexity, efficiency, time, and facility type. These logarithmic-linear models were compared against stochastic frontier analysis models. A parsimonious, three-variable, logarithmic-linear model composed of volume, complexity, and efficiency variables exhibited a strong linear relationship with observed costs (R(2) = 0.98). This model also proved reliable in forecasting (R(2) = 0.96). Based on our analysis, as much as $120 million might be reallocated to improve the United States-based Army hospital performance evaluated in this study.

[Case allocation of extensive operations on head and neck within the German DRG system 2004-2007: what is the net result of the continued developments in case allocation?]. / Analyse der Abbildungsqualität grosser operativer Eingriffe an Kopf und Hals in den G-DRG-Systemen 2004-2007: Was hat die Weiterentwicklung der Fallpauschalen gebracht?

BACKGROUND: When the German DRG system was implemented there was some doubt about whether patients with extensive head and neck surgery would be properly accounted for. Significant efforts have therefore been invested in analysis and case allocation of those in this group. The object of this study was to investigate whether the changes within the German DRG system have led to improved case allocation. METHODS: Cost data received from 25 ENT departments on 518 prospective documented cases of extensive head and neck surgery were compared with data from the German institute dealing with remuneration in hospitals (InEK). Statistical measures used by InEK were used to analyse the quality of the overall system and the homogeneity of the individual case groups. RESULTS: The reduction of variance of inlier costs improved by about 107.3% from the 2004 version to the 2007 version of the German DRG system. The average coefficient of cost homogeneity rose by about 9.7% in the same period. Case mix index and DRG revenues were redistributed from less extensive to the more complex operations. Hospitals with large numbers of extensive operations and university hospitals will gain most benefit from this development. CONCLUSION: Appropriate case allocation of extensive operations on the head and neck has been improved by the continued development of the German DRG system culminating in the 2007 version. Further adjustments will be needed in the future.

Did Project Liberty displace community-based medicaid services in New York?

OBJECTIVE: This study analyzed how the introduction of Project Liberty services after the September 11, 2001, terrorist attacks affected agencies' provision of community-based Medicaid mental health services in the New York metropolitan area. METHODS: Provision of Medicaid mental health services was tracked between January 2000 and June 2003 for provider agencies participating in Project Liberty (N=164) and for a comparison group of mental health provider agencies that did not participate in this program (N=94). RESULTS: Overall, participation in Project Liberty did not significantly affect the volume of Medicaid services provided. However, for agencies with one site, a statistically significant difference was seen; compared with agencies in the comparison group, agencies that participated in Project Liberty claimed a mean+/-SE decrease of $4.66+/-3.57 less in Medicaid services per month per Project Liberty visit. CONCLUSIONS: Project Liberty permitted rapid expansion of the total volume of services provided by community-based organizations without interfering with the provision of traditional services, although a modest effect was seen for smaller agencies. Although the results do not imply that "supply side" planning for disaster needs would not improve system response, they do imply that implementation of flexible "demand side" financing can call forth a large volume of new services rapidly and without interfering with other community services.

Direct patient treatment costs in the Allergology Service of a University Hospital.

Health resources are limited and consequently real cost generators must be identified to optimize resources. In the present article, we describe the structure of the Allergy Unit of the University Hospital Virgen de la Arrixaca in Murcia (Spain), the health area in which allergic patients are attended, and the final healthcare products generated. Based on the 2004-2005 budget, variable costing was used to calculate the costs of the healthcare products generated (first visits, subsequent visits, and diverse laboratory tests) by two of the three homogeneous functional groups (HFG), i.e., HFG of the ambulatory service and HFG of complementary tests. The following conclusions can be drawn: 1) the current system of variable costing provides information, which should be useful to health professionals; 2) the real cost generators in the microcosm of daily clinical practice should be identified to allow resource reallocation; 3) the costing system used enables modifications to be made that allow decision making on optimal use of the budget; 4) clinical management and complementary tests should go hand in hand with a view to optimizing resources.

The cost of hospital care in Canada: a comparison of two alternatives.

This article compares resource intensity weight costs with case costs for selected patient groups at St. Paul's Hospital, British Columbia. Analysis found that average case costs for surgical patients were 23.9% higher than their resource intensity weight costs, whereas case costs for non-surgical patients were 14.8% lower. Average case costs for patients receiving surgical implants were 32.8% higher than resource intensity weight costs. For patients receiving internal defibrillators average case costs were three times higher.

The costs of care in general practice: patients compared by the council tax valuation band of their home address.

BACKGROUND: It is difficult to measure and compare workload in UK general practice. A GP/health economist team recently proposed a means of calculating the unit cost of a GP consulting. It is therefore now possible to extrapolate to the costs of other clinical tasks in a practice and then to compare the workloads of caring for different patients and compare between practices. OBJECTIVES: The study aims were: (i) to estimate the relative costs of daily clinical activities within a practice (implying workload); and (ii) to compare the costs of caring for different types of patients categorized by gender, by age, and by socio-economic status as marked by the Council Tax Valuation Band (CTVB) of home address. METHODS: The study design was a cross-sectional cost comparison of all clinical activity aggregated, by patient, over one year in an English semi-rural general practice. The subjects were 3339 practice patients, randomly selected. The main outcome measures were costs per clinical domain and overall costs per patient per year; both then compared by gender, age group and by CTVB. RESULTS: CTVB is as significant a predictor of patient care cost (workload) as is patient gender and age (both already known). CONCLUSIONS: It is now possible to estimate the cost of care of different patients in such a way that NHS planning and especially resource allocation to practices could be improved.

Inpatient-outpatient cost shifting in Washington hospitals.

This paper empirically investigates the phenomenon known as "cost shifting" across inpatient and outpatient hospital services. That is, we examine whether, when faced with lower government reimbursement for outpatient services, providers raise inpatient prices for non-government patients (and analogously for lower inpatient government reimbursement). Using a panel of hospitals from Washington State, we find that private, nonprofit hospitals do cost shift across types of services. We also find that a firm's cost shifting behavior differs based on the type government insurance program (i.e., Medicare versus Medicaid). Government owned hospitals do not cost shift with respect to any type of government insurance plan.