Age, costs of acute and long-term care and proximity to death: evidence for 1987-88 and 1994-95 in British Columbia.

BACKGROUND: the consequences of ageing populations for health care costs have become a concern for governments and health care funders in most countries. However, there is increasing evidence that costs are more closely related to proximity to death than to age. This means that projections using age-specific costs will exaggerate the impact of ageing. Previous studies of the relationship of age, proximity to death and costs have been restricted to acute medical care. OBJECTIVE: to assess the effects of age and proximity to death on costs of both acute medical care and nursing and social care, and to assess if this relationship was stable in a time of rapid change in health care expenditure. DESIGN AND METHODS: we compared all decedents in the chosen age categories for the years 1987-88 and 1994-95 with all survivors in the same age groups. We measured use of health and social care for each individual using the British Columbia linked data, and costs of care assessed by multiplying the number of services by the unit cost of each service. SETTING: the Province of British Columbia. SUBJECTS: all decedents in 1987-88 and 1994-95 in British Columbia in the chosen age groups, and all survivors in the same age groups. RESULTS: costs of acute care rise with age, but the proximity to death is a more important factor in determining costs. The additional costs of dying fall with age. In contrast, costs of nursing and social care rise with age, but additional costs for those who are dying increase with age. Similar patterns were found for the two cohorts. CONCLUSIONS: age is less important than proximity to death as a predictor of costs. However, the pattern of social and nursing care costs is different from that for acute medical care. In planning services it is important to take into account the relatively larger impact of ageing on social and nursing care than on acute care.

Emergency department use as a component of total ambulatory care: a population perspective.

OBJECTIVES: (a) To describe the overall proportion of ambulatory care provided in emergency departments for a complete urban population, (b) to describe the variation across small geographic areas in the overall proportion of ambulatory care provided in emergency departments and (c) to identify attributes of small-area populations that are related to the provision of high proportions of total ambulatory care in emergency departments. DESIGN: Cross-sectional ecologic study combining 4 sources of secondary data on health service utilization and socioeconomic status. SETTING: Winnipeg. PARTICIPANTS: A total of 657,871 residents of metropolitan Winnipeg in the period April 1991 to March 1992, grouped into 112 neighbourhoods. MAIN OUTCOME MEASURE: A proportion calculated, for each neighbourhood population, from the estimated count of emergency department visits divided by the population's use of total ambulatory care for a sample of 55 days in the study period. RESULTS: The overall proportion of ambulatory care provided in emergency departments was 4.9% (range 2.6% to 10.8%), representing 35.5 emergency department visits per 100 person-years. Neighbourhoods with a higher proportion of total ambulatory care provided in emergency departments were characterized by lower mean household income, a higher proportion of emergency department visits for mental illness and a higher proportion of residents with treaty Indian status. Measures of need for medical care for were not consistently associated with the proportion of ambulatory care received in emergency departments. CONCLUSIONS: In a health care system with an adequate supply of primary care physicians and universal insurance, this study has documented significant variation across small geographic areas in the proportion of total ambulatory care received in emergency departments. In the absence of strong evidence that this variation was associated with underlying need, the results suggest that attention be paid to the accessibility of conventional primary care.

Canadians' use of U.S. medical services.

To explore the extent of cross-border care seeking among Canadians, we analyzed the growth and distribution of Ontario Health Insurance Plan expenditures for medical care services provided in the United States to Ontario residents from 1987 to 1995. Although total out-of-province spending is low relative to in-province spending, there is evidence of cross-border care seeking for cardiovascular and orthopedic procedures, mental health services, and cancer treatments. However, combined with a preliminary investigation of cross-border patient care seeking using nonpublic funding sources, these analyses do not support the perception of widespread cross-border medical care seeking by Ontario residents.

Re-minding our Ps and Qs: medical cost controls in Canada.

During the past few years the landscape of Canadian physician reimbursement policy has undergone dramatic change. Rapidly eroding fiscal environments for provincial (and federal) governments have forced provinces to "get serious" about controlling a significant, previously uncontrolled, budget line: physician expenditures. All provinces now impose medical expenditure caps, with eight of these being hard caps under which any overruns are the responsibility of the profession. In addition, policies in five provinces now include individual income caps. One of the effects of this new environment has been a rush to adopt supply-control policies. This paper explores a number of other side effects, such as heightened interest in alternative methods of payment, as well as the emergence of, and difficulties for, joint province/medical association management committees.

Trends and determinants of prescription drug expenditures in the elderly: data from the British Columbia Pharmacare Program.

This paper uses claims data from the prescription drug program for the elderly in British Columbia to describe temporal trends in prescription drug use and the determinants of those trends. Drug expenditures under the program increased by 317% from $21.6 million in 1981-82 to $90 million in 1988-89. Of the $68.4 million-dollar increase in overall expenditures, 34% was due to new drugs, 24% to increased age-specific utilization rates of old drugs, 21% to increased prices of old drugs, and 14% to the increased size of the elderly population. The analysis indicates that 61.5% of new drug expenditures can be attributed to four specific drugs and that the relative importance of price and utilization rates in determining changes in expenditures on old drugs varies by drug category. The paper provides a framework for understanding and predicting expenditures for drug benefit plans.

On being old and sick: the burden of health care for the elderly in Canada and the United States.

The debate over health care reform in the United States has drawn Canada under the microscope. Canada's health care system is frequently offered as a model for American national health insurance. Curiously absent from this policy discussion is any talk about the relative out-of-pocket costs of alternative models. In this paper, we provide data on these costs for American and Canadian elderly for medical, hospital, and ambulatory pharmaceutical use. Despite the fact that the elderly in America are generally viewed as facing fewer problems with access and out-of-pocket costs than younger Americans, their direct costs far exceed those of their Canadian counterparts. We also present data suggesting that, despite these greater costs, rates of growth in use of these services by American elderly have followed roughly the same pattern as those found in Canada. If Uncle Sam retired north of the border, being old and sick would also mean being wealthier and happier.