Costs for Colon Cancer Treatment Comparing Benefit Types and Care Sources in the US Military Health System.

INTRODUCTION: Cancer is one of the leading causes of morbidity and mortality in the USA, contributing largely to US healthcare spending. Provision of services (direct or purchased) and insurance benefit type may impact cost for cancer care. As a common cause of cancer in both men and women, we aim to compare colon cancer treatment costs between insurance benefit types and care sources in the US Military Health System (MHS) to better understand whether and to what extent these system factors impact cancer care costs. MATERIALS AND METHODS: Department of Defense Central Cancer Registry records and MHS Data Repository administrative claims were used to identify MHS beneficiaries aged 18-64 who were diagnosed with primary colon adenocarcinoma and received treatment between 2003 and 2008. The data linkage was approved by the Institutional Review Boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health. Costs to the MHS for each claim related to cancer treatment were extracted from the linked data and adjusted to 2008 USD. We used quantile regression models to compare median cancer treatment costs between benefit types and care sources (direct, purchased, or both), adjusted for demographic, tumor, and treatment characteristics. RESULTS: The median per capita (n = 801) costs for colon cancer care were $60,321 (interquartile range $24,625, $159,729) over a median follow-up of 1.7 years. The model-estimated treatment costs were similar between benefit types. Patients using direct care had significantly lower estimated median costs [$34,145 (standard error $4,326)] than patients using purchased care [$106,395 ($10,559)] or both care sources [$82,439 ($13,330)], controlled for patient demographic, tumor, and treatment characteristics. Differences in cost by care source were noted for patients with later stage tumors and by treatment type. Relative costs were 2-3 times higher for purchased care compared to direct care for patients with late-stage tumors and for patients receiving chemotherapy or radiation treatment. CONCLUSIONS: In the MHS, median cost for colon cancer treatment was lower in direct care compared to purchased care or patients using a combination of direct and purchased care. The variation in cancer treatment costs between care sources may be due to differences in treatment incentives or capabilities. Additional studies on cost differences between direct and purchased services are needed to understand how provision of care affects cancer treatment costs and to identify possible targets for cost reduction.

Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain.

OBJECTIVE: The aim of this study was to measure the effects of a managed chiropractic benefit on the rates of specific diagnostic and therapeutic procedures for the treatment of back pain and neck pain. DESIGN: This study is a retrospective analysis of claims data from a managed-care health plan over a 4-year period. The use rates of advanced imaging, surgery, inpatient care, and plain-film radiographs were compared between employer groups with and without a chiropractic benefit. RESULTS: For patients with low back pain, the use rates of all 4 studied procedures were lower in the group with chiropractic coverage. On a per-episode basis, the rates in the group with coverage were reduced by the following: surgery (-32.1%); computed tomography (CT)/magnetic resonance imaging (MRI) (-37.2%); plain-film radiography (-23.1%); and inpatient care (-40.1%). On a per-patient basis, the rates were reduced by the following: surgery (-13.7%); CT/MRI (-20.3%); plain-film radiography (-2.2%); and inpatient care (-24.8%). For patients with neck pain, the use rates were reduced per episode in the group with chiropractic coverage as follows: surgery (-49.4%); CT/MRI (-45.6%); plain-film radiography (-36.0%); and inpatient care (-49.5%). Per patient, the rates were surgery (-31.1%); CT/MRI (-25.7%); plain-film radiography (-12.5%); and inpatient care (31.1%). All group differences were statistically significant. CONCLUSION: For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.

Criteria and procedures for determining benefit packages in health care. A comparative perspective.

The legitimacy of procedures and criteria for determining benefit packages depends crucially on the representation of stakeholders in decision-making bodies, the transparency of procedures and the consistency of benefit decisions. Moreover, the assessment of the costs of healthcare services and its application as a decision criterion can be an important policy instrument in order to increase the overall efficiency of healthcare systems. Our analysis of procedures and criteria for determining benefit packages in England, Germany and Switzerland established potential for developing more legitimate procedures and criteria for benefits decisions. In Germany, representation of stakeholders and transparency of procedures can be improved. Consistency of decision-making is hindered by the veto positions of selected stakeholders. Moreover, benefit decisions are made for different healthcare sectors separately. In Switzerland, transparency of procedures is virtually non-existent at the moment. Thus, it is impossible to assess the consistency of decision-making. Only in England the costs of healthcare services influence the decision to include or exclude them.

Is German long-term care insurance a model for the United States?

German long-term care insurance, implemented in 1995, significantly extends the coverage of care-related risks. Given the similarities of German and U.S. institutional features, the German social insurance approach has been put forward as a possible model for long-term care in the United States. Using a political economy framework, the authors conducted a policy analysis that compares the main shortfalls of long-term care (LTC) provision in the United States and Germany, examines the responses provided by LTC insurance in Germany, and relates them to broader trends and proposals for change in welfare policy in both countries. German LTC insurance includes a high degree of consumer direction and compensation and protection for informal caregivers; it supports the extension of community-based services. Its shortfalls include the continued split between health and LTC insurance. In both countries, decentralization and institutional and financial fragmentation are some of the characteristics responsible for the failure to promote egalitarian social policy and substantially expand social protection to family- and care-related risks. The German LTC program is a good model for the United States. With a social insurance approach to LTC, costs are spread across the largest possible risk pool. Major goals that can be reached with such a program include establishment of universal entitlements to LTC benefits, consumer choice, and equitability and uniformity.