Addressing multimorbidity to improve healthcare and economic sustainability.

Patients with multimorbidity are responsible for more than half of all healthcare utilization, challenging the healthcare budgets of all European nations. Although the European Union is showing signs of a fragile economic recovery, achieving sustainable growth will depend on delivering a combination of fiscal responsibility, structural reforms, and improved efficiency. Addressing the challenges of multimorbidity and providing more effective, affordable, and sustainable care, has climbed the political agenda at a global, European, and national level. Current healthcare systems are poorly adapted to cope with the challenges of patients with multimorbidity. Little is known about the epidemiology and natural history of multimorbidity; the evidence base is weak; clinical guidelines are not always relevant to this population; and financing and delivery systems have not evolved to adequately measure and reward quality and performance. Pockets of innovation are, however, beginning to emerge. In Spain, for example, the ongoing economic crisis has forced regional governments to deliver substantial efficiency savings and, with this in mind, integrated care programmes have been introduced across the country for people with chronic disease and multimorbidity. Early results suggest that formalized integrated care for patients with multimorbidity improves their perceptions of care coordination, reduces hospital and emergency admissions and readmissions, and reduces average costs per capita. Such innovations require meaningful investments at a national level - something that is now supported within the framework of the European Union's Stability and Growth Pact.

Erratum to: Addressing multimorbidity to improve healthcare and economic sustainability.

[This corrects the article DOI: 10.15256/joc.2016.6.74.].

Should chronic hepatitis B be treated as early as possible?

OBJECTIVES: We studied the cost-effectiveness of tenofovir and entecavir in e antigen positive (CHBe+) and negative (CHBe-) chronic hepatitis B. METHODS: Using a multicenter survey including 544 patients we measured patient quality of life and attributable costs by clinical disease stage. Natural disease progression was studied in 278 patients in a single center. A Markov model was constructed to follow hypothetical cohorts of treated and untreated 40-year-old CHBe+ and CHBe- patients and 50-year-old patients with compensated cirrhosis. RESULTS: We did not find an improvement in quality of life when viral load was reduced under treatment. Transition rates to liver cirrhosis were found to be age-dependent. Assuming equal effectiveness, tenofovir dominates the entecavir strategy because of its lower price in Belgium. The incremental cost-effectiveness ratio (ICER) of tenofovir after 20 years is more favorable for treating Caucasian cirrhotic patients (mean ICER €29,000/quality-adjusted life-year [QALY]) compared with treating non-cirrhotic patients (mean ICER €110,000 and 131,000/QALY for CHB e+ and e-, respectively). Within the non-cirrhotic patients the ICER decreases with increasing cohort starting age from 30 to 50 years. CONCLUSIONS: Results of long-term models for tenofovir or entecavir treatment of CHB need to be interpreted with caution as long-term trials with hard end points are lacking. Especially the effect on HCC remains highly uncertain. Based on cost-effectiveness considerations such antiviral treatment should be targeted at patients with cirrhosis or at risk of rapid progression to this disease stage.

Demand, selection and patient outcomes in German acute care hospitals.

This paper examines the effects of variation in unexpected demand on patient outcomes in acute care German hospitals. Naturally, an unexpected surge in demand may negatively affect the quality of care and thus patient outcomes, such as in-hospital mortality. We estimate models explaining patient outcomes depending on demand, unobservable patient selection and seasonal factors, as well as patient-specific risk factors and unobservable hospital and department fixed-effects. The main message of this analysis is that hospitals are well prepared to deal with this unexpected volatility in demand, as by and large it does not negatively affect patient outcomes. Hospitals seem to deal with high unexpected workload by steering the patients' length of stay relating to their severity of illness. Elective patients are discharged earlier, while discharges of high-risk emergency patients are postponed.

Ownership and financial sustainability of German acute care hospitals.

This paper considers the role of ownership form for the financial sustainability of German acute care hospitals over time. We measure financial sustainability by a hospital-specific yearly probability of default (PD) trying to mirror the ability of hospitals to survive in the market in the long run. The results show that private ownership is associated with significantly lower PDs than public ownership. Moreover, path dependence in the PD is substantial but far from 100%, indicating a large number of improvements and deteriorations in financial sustainability over time. Yet, the general public hospitals have the highest path dependence. Overall, this indicates that public hospitals, which are in a poor financial standing, remain in that state or even deteriorate over time, which may be conflicting with financial sustainability.

Expansion in markets with decreasing demand-for-profits in the German hospital industry.

Over the last 20 years, acute-care hospitals in most OECD countries have built up costly overcapacities. From the perspective of economic policy, it is desirable to know how hospitals of different ownership forms respond to changes in demand and are probably best suited to deal with existing overcapacities. This article examines ownership-specific differences in the responsiveness to changes in demand for hospital services in Germany between 1996 and 2006. With respect to the speed of adaptation to increasing demand, the study finds for-profit ownership to be superior to public and nonprofit ownership. However, contrary to other ownership types, for-profits also tend to expand in markets with decreasing demand - mainly through conversions of publicly owned hospitals. Thus, in short term, the privatization of the hospital sector may slow down the reduction of excess capacities and be therefore socially wasteful.

Discrimination in waiting times by insurance type and financial soundness of German acute care hospitals.

This paper shows that patients with private health insurance (PHI) are being offered significantly shorter waiting times than patients with statutory health insurance (SHI) in German acute hospital care. This behavior may be driven by the higher expected profitability of PHI relative to SHI holders. Further, we find that hospitals offering private insurees shorter waiting times when compared with SHI holders have a significantly better financial performance than those abstaining from or with less discrimination.