Social construction of disability and substance abuse within public disability benefit systems.

Federal legislation passed in 1996 in the United States changed the eligibility criteria for public disability benefit programmes. After 1996, persons with a primary diagnosis of substance abuse no longer qualified to receive disability benefits. Using a framework of social construction, a qualitative comparative analysis examines how the national disability systems of eight countries - Australia, Canada, Germany, Japan, the Netherlands, South Africa, Sweden, the United Kingdom, and the US - address issues of substance abuse. The US is the only country among the focal countries that does not currently allow disability benefits to be awarded to those with primary conditions of substance use disorders. International experience in providing disability benefits to persons with substance use disorders can inform US policy makers as to how the current US federal disability benefit system might be expanded to be more inclusive of persons with substance abuse disorders.

The role of outcomes research in defining and measuring value in benefit decisions.

OBJECTIVE: To identify ways that health care leaders at all levels can quantify the value proposition, thus influencing health care delivery and improving patient care. SUMMARY: Payers and providers need to support, with rigorous research, the value proposition for customers. Outcomes research focusing on clinical and cost-effectiveness analysis can provide an understanding of successful, replicable interventions. Randomized controlled trials and observational studies can be used to reinforce and refine the business proposition in health care, and they can be integrated to target populations needing health care services. Evaluations using clinical and outcomes research can also predict what is likely to be successful in the future. To maximize the business value of projects, they must incorporate a prospective evaluation component that includes asking the right research questions, identifying an appropriate time period, including a targeted population, articulating a replicable intervention, and determining the correct statistical analysis. CONCLUSION: Well-designed studies to analyze specific patient populations and their patterns of care can be used to determine a generalizable model to refine successful interventions that meet the critical value proposition for employers.

Commentary on Sommer et al. 'A randomized experiment of the effects of including alternative medicine in the mandatory benefit package of health insurance.

The study by Sommer et al. recently reported in Complementary Therapies in Medicine has been heavily criticised in Switzerland since its original publication. Its major problems are an inadequate reflection of real practice, an inadequate study design relative to the central research objective, questionable value of the applied instrument and procedure for health assessment, methodological and statistical problems, and failure to consider literature relevant to the topic. For these reasons, this experimental study does not allow an answer to its central questions as to costs and effectiveness of complementary medicine made available within Switzerland's mandatory basic health insurance provisions. We propose more practice-related, non-experimental prospective study designs to realistically answer these questions.

A randomized experiment of the effects of including alternative medicine in the mandatory benefit package of health insurance funds in Switzerland.

OBJECTIVES: The present investigation focuses on the following questions: 1. Are complementary medical services paid for by a health insurer used in addition to orthodox medical services, or as substitute for them?; 2. If health insurers include complementary medical services in the basic cover, what will be the effect on costs?; 3. If complementary medical services as included in the basic cover, what will be the effect on the policyholders' subjective state of health? STUDY DESIGN: A randomized experiment was set up in which 7500 members of Switzerland's biggest health insurance fund, Helvetia, were offered free supplementary insurance for alternative medicine for 3 years. This simulated a situation in which the experimental group had access to the full range of complementary medical treatments under their health insurance policies. The remaining members in the scheme (670,000) people) formed the control group. To evaluate the effect on costs, we analysed the health insurer's cost and benefits data. In addition, a survey was carried out among random samples of subjects from the experimental group and from the control group using the 36-Item Short-Form Health Survey (SF-36) to examine the effects of including complementary medicine on subjective state of health. RESULTS: The analysis of the cost data shown that subjects used alternative in addition to orthodox medical services. It is also clear that alternative medical treatments are given in combination with orthodox medicine; less than 1% of the experimental group used exclusively alternative medical services. However, as only a very small percentage of experimental subjects (6.6%) took advantage of complementary medicine, no significant impact on overall health costs can be inferred. On the other hand, multiple regressions show that use of complementary medicine has a greater effect on treatment costs than sex, age or language region. Neither at the beginning nor the end of the experiment were any significant differences noted in the scales of the SF-36 between the experimental and the control group. Nor did multiple regressions reveal any effects on subjects' state of health due to the inclusion of complementary medicine in the basic insurance cover.