Performance of private sector health care: implications for universal health coverage.

Although the private sector is an important health-care provider in many low-income and middle-income countries, its role in progress towards universal health coverage varies. Studies of the performance of the private sector have focused on three main dimensions: quality, equity of access, and efficiency. The characteristics of patients, the structures of both the public and private sectors, and the regulation of the sector influence the types of health services delivered, and outcomes. Combined with characteristics of private providers-including their size, objectives, and technical competence-the interaction of these factors affects how the sector performs in different contexts. Changing the performance of the private sector will require interventions that target the sector as a whole, rather than individual providers alone. In particular, the performance of the private sector seems to be intrinsically linked to the structure and performance of the public sector, which suggests that deriving population benefit from the private health-care sector requires a regulatory response focused on the health-care sector as a whole.

Impact of Maryland's 2011 alcohol sales tax increase on alcoholic beverage sales.

BACKGROUND: Increasing alcohol taxes has proven effective in reducing alcohol consumption, but the effects of alcohol sales taxes on sales of specific alcoholic beverages have received little research attention. Data on sales are generally less subject to reporting biases than self-reported patterns of alcohol consumption. OBJECTIVES: We aimed to assess the effects of Maryland's July 1, 2011 three percentage point increase in the alcohol sales tax (6-9%) on beverage-specific and total alcohol sales. METHODS: Using county-level data on Maryland's monthly alcohol sales in gallons for 2010-2012, by beverage type, multilevel mixed effects multiple linear regression models estimated the effects of the tax increase on alcohol sales. We controlled for seasonality, county characteristics, and national unemployment rates in the main analyses. RESULTS: In the 18 months after the tax increase, average per capita sales of spirits were 5.1% lower (p < 0.001), beer sales were 3.2% lower (p < 0.001), and wine sales were 2.5% lower (p < 0.01) relative to what would have been expected from sales trends in the 18 months prior to the tax increase. Overall, the alcohol sales tax increase was associated with a 3.8% decline in total alcohol sold relative to what would have been expected based on sales in the prior 18 months (p < 0.001). CONCLUSION: The findings suggest that increased alcohol sales taxes may be as effective as excise taxes in reducing alcohol consumption and related problems. Sales taxes also have the added advantages of rising with inflation and taxing the highest priced beverages most heavily.

Economic evaluation of neonatal care packages in a cluster-randomized controlled trial in Sylhet, Bangladesh.

OBJECTIVE: To evaluate and compare the cost-effectiveness of two strategies for neonatal care in Sylhet division, Bangladesh. METHODS: In a cluster-randomized controlled trial, two strategies for neonatal care--known as home care and community care--were compared with existing services. For each study arm, economic costs were estimated from a societal perspective, inclusive of programme costs, provider costs and household out-of-pocket payments on care-seeking. Neonatal mortality in each study arm was determined through household surveys. The incremental cost-effectiveness of each strategy--compared with that of the pre-existing levels of maternal and neonatal care--was then estimated. The levels of uncertainty in our estimates were quantified through probabilistic sensitivity analysis. FINDINGS: The incremental programme costs of implementing the home-care package were 2939 (95% confidence interval, CI: 1833-7616) United States dollars (US$) per neonatal death averted and US$ 103.49 (95% CI: 64.72-265.93) per disability-adjusted life year (DALY) averted. The corresponding total societal costs were US$ 2971 (95% CI: 1844-7628) and US$ 104.62 (95% CI: 65.15-266.60), respectively. The home-care package was cost-effective--with 95% certainty--if healthy life years were valued above US$ 214 per DALY averted. In contrast, implementation of the community-care strategy led to no reduction in neonatal mortality and did not appear to be cost-effective. CONCLUSION: The home-care package represents a highly cost-effective intervention strategy that should be considered for replication and scale-up in Bangladesh and similar settings elsewhere.

The economic impact of Mexico City's smoke-free law.

OBJECTIVE: To evaluate the economic impact of Mexico City's 2008 smoke-free law--The Non-Smokers' Health Protection Law on restaurants, bars and nightclubs. MATERIAL AND METHODS: We used the Monthly Services Survey of businesses from January 2005 to April 2009--with revenues, employment and payments to employees as the principal outcomes. The results are estimated using a differences-in-differences regression model with fixed effects. The states of Jalisco, Nuevo León and México, where the law was not in effect, serve as a counterfactual comparison group. RESULTS: In restaurants, after accounting for observable factors and the fixed effects, there was a 24.8% increase in restaurants' revenue associated with the smoke-free law. This difference is not statistically significant but shows that, on average, restaurants did not suffer economically as a result of the law. Total wages increased by 28.2% and employment increased by 16.2%. In nightclubs, bars and taverns there was a decrease of 1.5% in revenues and an increase of 0.1% and 3.0%, respectively, in wages and employment. None of these effects are statistically significant in multivariate analysis. CONCLUSIONS: There is no statistically significant evidence that the Mexico City smoke-free law had a negative impact on restaurants' income, employees' wages and levels of employment. On the contrary, the results show a positive, though statistically non-significant, impact of the law on most of these outcomes. Mexico City's experience suggests that smoke-free laws in Mexico and elsewhere will not hurt economic productivity in the restaurant and bar industries.

Medical costs of secondhand-smoke exposure in North Carolina.

BACKGROUND: The health hazards of exposure to secondhand smoke (SHS) are well-defined. Less is known about the economic costs. We performed an analysis of the medical costs of SHS in North Carolina that was based on a similar study conducted in Minnesota. METHODS: We used 2006 Blue Cross and Blue Shield of North Carolina claims data and national and state surveillance data to calculate the treated prevalence of medical conditions that have been found to be related to exposure to SHS, as established by a 2006 report from the US surgeon general. We used the population attributable risk for these conditions to calculate the number of individuals whose episodes of illness could be attributed to exposure to SHS. We adjusted these treatment costs for other types of insurance provided in the state, using Medical Expenditure Panel Survey data. RESULTS: The total annual cost of treatment for conditions related to SHS exposure in North Carolina was estimated to be $293,304,430, in 2009 inflation-adjusted dollars. Sensitivity analysis showed a range of $208.2 million to $386.3 million. The majority of individuals affected were children, but the greatest costs were for cardiovascular conditions. CONCLUSION: These cost data provide additional rationale for regulating smoking in all work sites and public places.

Self-reported price of cigarettes, consumption and compensatory behaviours in a cohort of Mexican smokers before and after a cigarette tax increase.

OBJECTIVE: To assess the impact of a 2007 cigarette tax increase from 110% to 140% of the price to the retailer on cigarette price and consumption among Mexican smokers, including efforts to offset price increases. METHODS: Data were analysed from the 2006 and 2007 administrations of the International Tobacco Control (ITC) Policy Evaluation Survey in Mexico, which is a population-based cohort of adult smokers. Self-reported price of last cigarette purchase, place of last purchase, preferred brand, daily consumption and quit behaviour were assessed at baseline and follow-up. RESULTS: Self-reported cigarette prices increased by 12.7% after the tax increase, with prices for international brands increasing more than for national brands (13.5% vs 8.7%, respectively). Although the tax increases were not fully passed onto consumers particularly on national brands, no evidence was found for smokers changing behaviour to offset price increases. Consistent declines in consumption across groups defined by sociodemographic and smoking-related psychosocial variables suggest a relatively uniform impact of the tax increase across subpopulations. However, decreased consumption appeared limited to people who smoked relatively more cigarettes a day (>5 cigarettes/day). Average daily consumption among lighter smokers did not significantly decline. A total of 13% (n=98) of the sample reported being quit for a month or more at follow-up. In multivariate models, lighter smokers were more likely than heavier smokers to be quit. CONCLUSIONS: Results suggest that the 2007 tax increase was passed on to consumers, whose consumption generally declined. Since no other tobacco control policies or programmes were implemented during the period analysed, the tax increase appears likely to have decreased consumption.

Expensive cancer drugs: a comparison between the United States and the United Kingdom.

CONTEXT: This article compares the United Kingdom's and the United States' experiences with expensive cancer drugs to illustrate the challenges posed by new, extremely costly, medical technologies. METHODS: This article describes British and American coverage, access, and cost-sharing policies with regard to expensive cancer drugs and then compares the costs of eleven such drugs to British patients, American Medicare beneficiaries, and American patients purchasing the drugs in the retail market. Three questions posed by these comparisons are then examined: First, which system is fairer? In which system are cancer patients better off? Assuming that no system can sustainably provide to everyone at least some expensive cancer drugs for some clinical indications, what challenges does each system face in making these difficult determinations? FINDINGS: In both the British and American health care systems, not all patients who might benefit from or desire access to expensive cancer drugs have access to them. The popular characterization of the United States, where all cancer drugs are available for all to access as and when needed, and that of the British NHS, where top-down population rationing poses insurmountable obstacles to British patients' access, are far from the reality in both countries. CONCLUSIONS: Key elements of the British system are fairer than the American system, and the British system is better structured to deal with difficult decisions about expensive end-of-life cancer drugs. Both systems face common ethical, financial, organizational, and priority-setting challenges in making these decisions.

The economic impact of exposure to secondhand smoke in Minnesota.

OBJECTIVES: Using the risk categories established by the 2006 US surgeon general's report, we estimated medical treatment costs related to exposure to secondhand tobacco smoke (SHS) in the state of Minnesota. METHODS: We estimated the prevalence and costs of treated medical conditions related to SHS exposure in 2003 with data from Blue Cross and Blue Shield (Minnesota's largest insurer), the Current Population Survey, and population attributable risk estimates for these conditions reported in the scientific literature. We adjusted treatment costs to the state level by health insurance category by using the Medical Expenditure Panel Survey. RESULTS: The total annual cost of treatment in Minnesota for conditions for which the 2006 surgeon general's report found sufficient evidence to conclude a causal link with exposure to SHS was $228.7 million in 2008 dollars-equivalent to $44.58 per Minnesota resident. Sensitivity analyses showed a range from $152.1 million to $330.0 million. CONCLUSIONS: The results present a strong rationale for regulating smoking in public places and were used to support the passage of Minnesota's Freedom to Breathe Act of 2007.

Rationale, design, and methodology for the healthy mothers-healthy children study: a randomized controlled trial.

BACKGROUND: Hispanic women and children who become overweight or obese are at risk for developing prediabetes, type 2 diabetes, and cardiovascular disease later in life. Interdisciplinary interventions which target Hispanic women and their 3-5-year old children to improve nutrition and physical activity behaviors, manage adiposity and weight in mothers, and prevent excessive adiposity and weight gain trajectory in their children offer promise to break the intergenerational cycle. METHODS: Using a randomized two-group, repeated measures experimental design, the goal of the proposed study is to investigate the efficacy of a 12-week nutrition and physical activity program including education, coping skills training, and home-based intervention in Hispanic women and their 3-5-year old children. The program includes 6 months of continued monthly contact to help overweight and obese Hispanic mothers and their children improve adiposity, weight (trajectory for children), health behaviors (nutrition and physical activity), and self-efficacy We will partner with two federally qualified health departments in Durham and Chatham counties, North Carolina to enroll participants. We will partner with community centers to deliver the intervention. A total of 294 Hispanic women with a BMI ≥ 25 kg/m2 and 294 Hispanic 3-5-year old children with a ≥ 25th BMI percentile will be enrolled over 4 years and randomized to the experimental or equal attention control group. Data will be collected at Time 1 (0 months [baseline]) to Time 2 (9 months [completion of the intervention]) and Time 1 to Time 3 (15 months [after 6 months with no contact from the study staff]). Data collected will include adiposity and weight in mothers and children (primary outcomes). Secondary outcomes will include health behaviors and self-efficacy in the mothers and in the children. We will also evaluate the cost of delivering the program for public health departments. We will use general linear mixed models to test the hypotheses. DISCUSSION: Decreasing overweight and obesity in Hispanic women and slowing adiposity and weight gain trajectory in young Hispanic children is urgently needed to decrease morbidity, mortality, and future health care costs. TRIAL REGISTRATION: NCT03866902. (March 7, 2019).

The costs of non-insurance in Maryland.

OBJECTIVES: This study calculates expenditures and costs related to a lack of health insurance coverage in the State of Maryland. RESEARCH METHODS: The study is based on detailed primary and secondary data collection on the following sources of payment and care related to non-insurance: (1) uncompensated hospital care; (2) other public subsidies; (3) ambulatory services; (4) philanthropic spending; and (5) uninsured individuals' costs. RESULTS: Expenditures by and for the uninsured in Maryland total $1.47 billion dollars. On a per-capita basis, this is equivalent to $2,371 per full-year uninsured person in the state. Twenty-seven percent of this total, or $633 per uninsured person, is paid directly by the uninsured themselves in out-of-pocket medical expenditures. The state and local governments spent $497 per uninsured person (21% of the total), and the federal government spent an additional $401 (17%). Private payers (including insurance, physicians, and philanthropy) accounted for $460 (19%). CONCLUSIONS: The sources and flows of spending on the uninsured are complex, and these expenditure levels should not be interpreted as savings that would directly result from an expansion of insurance coverage. Our results are consistent with earlier studies completed at the national level, and add considerable detail.

Determinants of child morbidity in Latin America: a pooled analysis of interactions between parental education and economic status.

Diarrhea and respiratory infections account for more than two-fifths of all deaths among children under five. Parental education and economic status are well-known risk factors for child morbidity, but little is known about whether education and economic status operate synergistically or independently to influence children's health. Confirming the presence and direction of such interactions is important to better target education and development policies. Our objective is to test for interactions between parental education and economic status in predicting the risk of diarrhea and respiratory illness among children under five, before and after adjusting for key proximate risk factors. We pool 12 Demographic and Health Surveys (DHS) and nine Living Standards Measurement Surveys (LSMS) from Latin America, creating two large databases. Quintiles of economic status are constructed from principal components asset indices. We use logistic regression to analyze episodes of diarrhea and respiratory illness, and interactions between economic quintile and maternal and paternal education are evaluated via likelihood ratio tests. We find that mother's education and quintile interact synergistically in the DHS data, while results are inconclusive in the LSMS data. The effect of increasing maternal education appears to be more protective for children in wealthy families than for children in poor families. Conversely, improvements in economic status reduce health risks more for children whose mothers are better educated. Father's education is protective and operates independently of economic status. Our findings imply that poverty alleviation efforts occurring in concert with programs to educate women and girls will be more effective for improving children's health than either approach alone.

Health spending in the United States and the rest of the industrialized world.

U.S. citizens spent $5,267 per capita for health care in 2002--53 percent more than any other country. Two possible reasons for the differential are supply constraints that create waiting lists in other countries and the level of malpractice litigation and defensive medicine in the United States. Services that typically have queues in other countries account for only 3 percent of U.S. health spending. The cost of defending U.S. malpractice claims is estimated at $6.5 billion in 2001, only 0.46 percent of total health spending. The two most important reasons for higher U.S. spending appear to be higher incomes and higher medical care prices.

The costs of interpersonal violence--an international review.

This article reviews evidence of the economic impact of interpersonal violence internationally. In the United States, estimates of the costs of interpersonal violence reach 3.3% of GDP. The public sector-and thus society in general-bears the majority of these costs. Interpersonal violence is defined to include violence between family members and intimate partners, and violence between acquaintances and strangers that is not intended to further the aims of any formally defined group or cause. Although these types of violence disproportionately affect poorer countries, there is a scarcity of studies of their economic impact in these countries. International comparisons are complicated by the calculation of economic losses based on foregone wages and income, thus undervaluing economic losses in poorer countries.

Weight-for-age malnutrition in Indonesian children, 1992-1999.

BACKGROUND: This article measures changes over time in Indonesia in the prevalence of moderate and severe child malnutrition, and examines the factors associated with these changes. A child with a weight-for-age Z-score below -2.0 is classified as underweight and either moderately or severely malnourished. METHODS: A pooled cross-sectional dataset of 163 986 children <5 years of age from the 1992, 1995, 1998, and 1999 Indonesia Socioeconomic Household Surveys was analysed using multivariate logistic regression, and by running separate pooled regressions to calculate the effect of the each of the principal independent variables separately for each year. Robust regression techniques corrected for non-constant variance resulting from multilevel modelling. RESULTS: The overall percentage of children <5 years that are underweight decreased from 37.7% in 1992 to 28.5% in 1999. Nearly all of the gains occurred in children over one year of age. Child nutritional status improved for all major social groups in Indonesia. There was no measurable general effect of the 1997-1999 East Asian economic crisis on levels of underweight children. CONCLUSIONS: Disparities among social and economic groups have narrowed over time in Indonesia; the relatively high risk of male children compared with females has also decreased. Maternal education and economic status-as measured by quintile of adjusted per-capita household expenditures-have continued to be very strong predictors of children's nutritional outcomes.

Systematic review of literature on the cost-effectiveness of nutrition services.

Employers and health plan directors would like to know whether it is cost-effective to include outpatient nutrition services as a covered benefit. The purpose of this systematic review was to examine the strength of evidence on the cost-effectiveness of outpatient nutrition services from an economic perspective. All randomized controlled trials published between January 1966 and September 2001 that reported on costs and effectiveness of outpatient nutrition services for any indicated condition were identified and reviewed. Paired reviewers abstracted data from and assessed the quality of each eligible randomized controlled trial; 13 studies met the eligibility criteria. Relatively consistent evidence exists to support the cost-effectiveness of nutrition services in the reduction of serum cholesterol levels (eg, 20 dollars to 1,268 dollars per mmol/L decrease in serum low-density lipoprotein level), weight loss (2.40 dollars to 10 dollars per pound lost), and blood glucose (5 dollars per mmol/L decrease), and for target populations with diabetes mellitus and hypercholesterolemia. However, the randomized controlled trials had important limitations and used different cost perspectives. Limited evidence of economic benefit exists to support coverage of outpatient nutrition services for selected indications. More randomized controlled trials of nutrition services should be conducted, taking into consideration all potential candidates for nutrition therapy and all potential costs to patients, providers, and payers.

Pricing health services for purchasers--a review of methods and experiences.

This article reviews methodologies and international experience related to costing and pricing health services for health care purchasers. The main factors affecting price-setting methods are: (1) provider payment systems; (2) information available on actual costs, service volumes and outcomes; and (3) characteristics of providers and purchasers. These factors are strongly interrelated. Provider payment systems determine the unit of services to be priced. In order to minimize incentives for under- or over-utilization, the prices that purchasers pay for health care services should be related to the actual unit costs of services, but accurately calculating real unit costs is intensive in terms of resources and information. Pertinent provider characteristics influencing price-setting include provider autonomy, provider negotiating power, and the degree of competition. The article presents a series of examples that run through each of these three sets of factors. The examples are from Denmark, the UK, and Thailand (for capitation); Australia, Hungary, and the United States (for case-based payment); and Germany, Korea, and Taiwan (for fee-for-service payment mechanisms). From these experiences, the article concludes with appropriate lessons for low- and middle-income countries, where the principal constraint on the development of provider payments systems is the limited availability of information on costs, volumes, and patient characteristics.

Measuring financial protection in health in the United States.

One rationale for health insurance coverage is to provide financial protection against catastrophic health expenditures. This article defines a lack of financial protection as household spending on health care when: (1) out-of-pocket (OOP) health expenditures exceed 10% of family income; (2) out-of-pocket expenditures exceed an absolute level of 2000 US dollars per family member on an annual basis; and (3) combined out-of-pocket and prepaid health expenditures exceed 40% of family income. The article explores how the likelihood of households in the United States surpassing these thresholds varies by income level, extent of insurance coverage, and the number of chronic conditions. The results show clearly that there is a lack of financial protection for health services for a wide segment of the US population-particularly so for poor families and those with multiple chronic conditions. The results are placed in an international context. Similar studies in other countries would allow for more in-depth comparisons of financial protection than are currently possible.

The global burden of unsafe medical care: analytic modelling of observational studies.

OBJECTIVE: To contextualise the degree of harm that comes from unsafe medical care compared with individual health conditions using the global burden of disease (GBD), a metric to determine how much suffering is caused by individual diseases. DESIGN: Analytic modelling of observational studies investigating unsafe medical care in countries' inpatient care settings, stratified by national income, to identify incidence of seven adverse events for GBD modelling. Observational studies were generated through a comprehensive search of over 16 000 articles written in English after 1976, of which over 4000 were appropriate for full text review. RESULTS: The incidence, clinical outcomes, demographics and costs for each of the seven adverse events were collected from each publication when available. We used disability-adjusted life years (DALYs) lost as a standardised metric to measure morbidity and mortality due to specific adverse events. We estimate that there are 421 million hospitalisations in the world annually, and approximately 42.7 million adverse events. These adverse events result in 23 million DALYs lost per year. Approximately two-thirds of all adverse events, and the DALYs lost from them, occurred in low-income and middle-income countries. CONCLUSIONS: This study provides early evidence that adverse events due to medical care represent a major source of morbidity and mortality globally. Though suffering related to the lack of access to care in many countries remains, these findings suggest the importance of critically evaluating the quality and safety of the care provided once a person accesses health services. While further refinements of the estimates are needed, these data should be a call to global health policymakers to make patient safety an international priority.

A cost-effectiveness analysis of India's 2008 prohibition of smoking in public places in Gujarat.

Tobacco smoking and exposure to secondhand tobacco smoke are associated with disability and premature mortality in low and middle-income countries. The aim of this study was to assess the cost-effectiveness of implementing India's Prohibition of Smoking in Public Places Rules in the state of Gujarat, compared to implementation of a complete smoking ban. Using standard cost-effectiveness analysis methods, the cost of implementing the alternatives was evaluated against the years of life saved and cases of acute myocardial infarction averted by reductions in smoking prevalence and secondhand smoke exposure. After one year, it is estimated that a complete smoking ban in Gujarat would avert 17,000 additional heart attacks and gain 438,000 life years (LY). A complete ban is highly cost-effective when key variables including legislation effectiveness were varied in the sensitivity analyses. Without including medical treatment costs averted, the cost-effectiveness ratio ranges from $2 to $112 per LY gained and $37 to $386 per acute myocardial infarction averted. Implementing a complete smoking ban would be a cost saving alternative to the current partial legislation in terms of reducing tobacco-attributable disease in Gujarat.

Cost-effectiveness analysis of a low-fat diet in the prevention of breast and ovarian cancer.

BACKGROUND: Results of the Women's Health Initiative Randomized Controlled Dietary Modification Trial (WHI-DM) suggest that a low-fat diet may be associated with beneficial health outcomes for specific groups of women. OBJECTIVE: The objective is to assess how cost-effective the WHI-DM would be if implemented as a public health intervention and under the sponsorship of private health insurers and Medicare. Breast and ovarian cancers are the health outcomes of interest. PARTICIPANTS: Two groups of WHI-DM participants form the target population for this analysis: participants consuming >36.8% of energy from fat at baseline, and participants at high risk for breast cancer with 32% or more of energy from fat at baseline. METHODS: This study uses Markov cohort modeling, following societal and health care payer perspectives, with Monte Carlo simulations and one-way sensitivity analyses. WHI-DM records, nationally representative prices, and published estimates of medical care costs were the sources of cost information. Simulations were performed for hypothetical cohorts of women aged 50, 55, 60, 65, or 70 years at the beginning of the intervention. Effectiveness was estimated by quality-adjusted life years (QALYs) and the main outcome measure was the incremental cost-effectiveness ratio (ICER). RESULTS: Following the societal perspective, the ICERs for the 50-year old cohort are $13,773/QALY (95% confidence interval $7,482 to $20,916) for women consuming >36.8% of energy from fat at baseline and $10,544/QALY ($2,096 to $23,673) for women at high risk for breast cancer. The comparable ICER from a private health care payer perspective is $66,059/QALY ($30,155 to $121,087) and from a Medicare perspective, it is $15,051/QALY ($6,565 to $25,105). CONCLUSIONS: The WHI-DM is a cost-effective strategy for the prevention of breast and ovarian cancers in the target population, from both societal and Medicare perspectives. Private health care payers have a relative short timeframe to realize a return on investment, since after age 65 years the financial benefits associated with the prevention program would accrue to Medicare. For this reason, the intervention is not cost-effective from a private health care payer perspective.