Ethics and Economics of the COVID-19 Pandemic in the United States.

The Covid-19 experience provides a natural experiment in personal and social ethics. Difficult decisions are routinely made to optimize lives and livelihoods. This commentary provides background and insight into the ethical and economic foundations underpinning dilemmas of this historic pandemic.

Medical Marijuana Knowledge and Attitudes: A Survey of the California Pharmacists Association.

Views on the medical efficacy and acceptability of marijuana have changed over the years. California was the first state permitting individuals to use medical marijuana. Even with a long history of use and widespread agreement around the effectiveness of medical marijuana, the literature is sparse about the role health care providers, including pharmacists, play in this interaction. The purpose of this article is to shed light on knowledge and attitudes of pharmacists regarding medical marijuana. We developed a survey for pharmacists about their level of knowledge and attitudes toward medical marijuana. The survey was distributed using SurveyMonkey. It consisted of 44 questions and an opportunity to provide comments. We collaborated with the California Pharmacists Association who provided a link to the survey in October 2017 to their members. Results from 474 responses indicate a majority of providers believe that marijuana has medical efficacy. Yet most providers report that they neither have much information about medical marijuana nor do they know where to get such information. One area of particular concern is the potential for drug interactions. Pharmacists would feel more comfortable discussing medical marijuana if it was approved by the Food and Drug Administration. Moreover, they believe more research needs to occur. The variance between California and federal policy leads to dysfunction among pharmacists providing information to patients. We believe federal policy should change.

Merger & Acquisition and Capital Expenditure in Health Care.

Investment, especially through merger and acquisition (M&A), is a leading topic of concern among health care managers. In addition, the implications of this activity for organization and market concentration are of great interest to policy makers. Using a sample of 2256 firm-year observations in the health care industry during the period from 1985 to 2011, this article provides novel evidence that managers learn from financial markets in making capital expenditure (CAPEX) and M&A investment decisions. Within the industry, managers in the Drugs subsector are most likely to do so, whereas managers in the Medical Equipment and Supplies are least likely to do so. We find informative stock prices improve firm financial performance. This article highlights the importance of financial markets for real economic activity in the health care industry.

Organization and Finance of China's Health Sector: Historical Antecedents for Macroeconomic Structural Adjustment.

China has exploded onto the world economy over the past few decades and is undergoing rapid transformation toward relatively more services. The health sector is an important part of this transition. This article provides a historical account of the development of health care in China since 1949. It also focuses on health insurance and macroeconomic structural adjustment to less saving and more consumption. In particular, the question of how health insurance impacts precautionary savings is considered. Multivariate analysis using data from 1990 to 2012 is employed. The household savings rate is the dependent variable in 3 models segmented for rural and urban populations. Independent variables include out-of-pocket health expenditures, health insurance payouts, housing expenditure, education expenditure, and consumption as a share of gross domestic product (GDP). Out-of-pocket health expenditures were positively correlated with household savings rates. But health insurance remains weak, and increased payouts by health insurers have not been associated with lower levels of household savings so far. Housing was positively correlated, whereas education had a negative association with savings rates. This latter finding was unexpected. Perhaps education is perceived as investment and a substitute for savings. China's shift toward a more service-oriented economy includes growing dependence on the health sector. Better health insurance is an important part of this evolution. The organization and finance of health care is integrally linked with macroeconomic policy in an environment constrained by prevailing institutional convention. Problems of agency relationships, professional hegemony, and special interest politics feature prominently, as they do elsewhere. China also has a dual approach to medicine relying heavily on providers of traditional Chinese medicine. Both of these segments will take part in China's evolution, adding another layer of complexity to policy.

Price-transparency and cost accounting: challenges for health care organizations in the consumer-driven era.

Health care reform is directed toward improving access and quality while containing costs. An essential part of this is improvement of pricing models to more accurately reflect the costs of providing care. Transparent prices that reflect costs are necessary to signal information to consumers and producers. This information is central in a consumer-driven marketplace. The rapid increase in high deductible insurance and other forms of cost sharing incentivizes the search for price information. The organizational ability to measure costs across a cycle of care is an integral component of creating value, and will play a greater role as reimbursements transition to episode-based care, value-based purchasing, and accountable care organization models. This article discusses use of activity-based costing (ABC) to better measure the cost of health care. It describes examples of ABC in health care organizations and discusses impediments to adoption in the United States including cultural and institutional barriers.

Rising gasoline prices increase new motorcycle sales and fatalities.

BACKGROUND: We examined whether sales of new motorcycles was a mechanism to explain the relationship between motorcycle fatalities and gasoline prices. METHODS: The data came from the Motorcycle Industry Council, Energy Information Administration and Fatality Analysis Reporting System for 1984-2009. Autoregressive integrated moving average (ARIMA) regressions estimated the effect of inflation-adjusted gasoline price on motorcycle sales and logistic regressions estimated odds ratios (ORs) between new and old motorcycle fatalities when gasoline prices increase. RESULTS: New motorcycle sales were positively correlated with gasoline prices (r = 0.78) and new motorcycle fatalities (r = 0.92). ARIMA analysis estimated that a US$1 increase in gasoline prices would result in 295,000 new motorcycle sales and, consequently, 233 new motorcycle fatalities. Compared to crashes on older motorcycle models, those on new motorcycles were more likely to be young riders, occur in the afternoon, in clear weather, with a large engine displacement, and without alcohol involvement. Riders on new motorcycles were more likely to be in fatal crashes relative to older motorcycles (OR 1.14, 95 % confidence interval (CI) 1.02-1.28) when gasoline prices increase. CONCLUSIONS: Our findings suggest that, in response to increasing gasoline prices, people tend to purchase new motorcycles, and this is accompanied with significantly increased crash risk. There are several policy mechanisms that can be used to lower the risk of motorcycle crash injuries through the mechanism of gas prices and motorcycle sales such as raising awareness of motorcycling risks, enhancing licensing and testing requirements, limiting motorcycle power-to-weight ratios for inexperienced riders, and developing mandatory training programs for new riders.

Triple aim program: assessing its effectiveness as a hospital management tool.

According to a recent national survey of Hospital chief executive officers, financial challenges are their top concern, especially government reimbursement. Moreover, the patient faces greater deductibles forcing hospitals to prioritize price transparency. The Triple Aim program is a tool available to hospital management to help address these challenges. This study indicates that the Triple Aim is valuable to healthcare providers and patients by reducing medical errors, improving healthcare quality, and reducing costs on a per capita basis. Managerial implications are discussed for hospitals and health systems considering this approach to addressing financial challenges.

Redefining the role of the pharmacist: medication therapy management.

PURPOSE: The purpose of this paper is to explore better use of pharmacists in rural communities as a partial solution to scarcity of physicians and other health care providers. It discusses expected reduction in public subsidies for rural health care and the changing market for pharmacists. The paper emphasizes the use of pharmacists as a backdrop for description of medication therapy management (MTM). A pilot study of MTM is also reported. METHODS: This article explores rural health access, the market for pharmacists and MTM using the literature, and economic concepts to provide historical context for this new form of health care delivery. A small case study from a university-based clinic provided primary data to demonstrate viability. FINDINGS: MTM can augment rural health by providing care for patients who receive increasing numbers of complex medications. It helps better integrate pharmacists into primary care and holds promise as a cost-effective, if not cost-saving alternative. CONCLUSION: More constrained fiscal conditions are a virtual certainty going forward. The rural health community needs cost-effective health care alternatives that can prosper with lower levels of public financial support. MTM is one such option.

Pulmonary impairment after tuberculosis and its contribution to TB burden.

BACKGROUND: The health impacts of pulmonary impairment after tuberculosis (TB) treatment have not been included in assessments of TB burden. Therefore, previous global and national TB burden estimates do not reflect the full consequences of surviving TB. We assessed the burden of TB including pulmonary impairment after tuberculosis in Tarrant County, Texas using Disability-adjusted Life Years (DALYs). METHODS: TB burden was calculated for all culture-confirmed TB patients treated at Tarrant County Public Health between January 2005 and December 2006 using identical methods and life tables as the Global Burden of Disease Study. Years of life-lost were calculated as the difference between life expectancy using standardized life tables and age-at-death from TB. Years lived-with-disability were calculated from age and gender-specific TB disease incidence using published disability weights. Non-fatal health impacts of TB were divided into years lived-with-disability-acute and years lived-with-disability-chronic. Years lived-with-disability-acute was defined as TB burden resulting from illness prior to completion of treatment including the burden from treatment-related side effects. Years lived-with-disability-chronic was defined as TB burden from disability resulting from pulmonary impairment after tuberculosis. RESULTS: There were 224 TB cases in the time period, of these 177 were culture confirmed. These 177 subjects lost a total of 1189 DALYs. Of these 1189 DALYs 23% were from years of life-lost, 2% were from years lived-with-disability-acute and 75% were from years lived-with-disability-chronic. CONCLUSIONS: Our findings demonstrate that the disease burden from TB is greater than previously estimated. Pulmonary impairment after tuberculosis was responsible for the majority of the burden. These data demonstrate that successful TB control efforts may reduce the health burden more than previously recognized.

The societal cost of tuberculosis: Tarrant County, Texas, 2002.

PURPOSE: Cost analyses of tuberculosis (TB) in the United States have not included elements that may be prevented if TB were prevented, such as losses associated with TB-related disability, personal and other costs to society. Unmeasured TB costs lead to underestimates of the benefit of prevention and create conditions that could result in a resurgence of TB. We gathered data from Tarrant County, Texas, for 2002, to estimate the societal cost due to TB. METHODS: We estimated societal costs due to the presence or suspicion of TB using known variable and fixed costs incurred to all parties. These include costs for infrastructure; diagnostics and surveillance; inpatient and outpatient treatment of active, suspected, and latent TB infection (LTBI); epidemiologic activities; personal costs borne by patients and by others for lost time, disability, and death; and the cost of secondary transmission. A discount rate of 3% was used. RESULTS: During 2002, 108 TB cases were confirmed in Tarrant County, costing an estimated $40,574,953. The average societal cost per TB illness was $ 376,255. Secondary transmission created 47% and pulmonary impairment after TB created 35.4% of the total societal cost per illness. CONCLUSIONS: Prior estimates have concluded that treatment costs constitute most (86%) TB-related expenditures. From a societal perspective treatment and other direct costs account for little (3.3%) of the full burden. These data predict that preventing infection through earlier TB diagnosis and treatment of LTBI and expanding treatment of LTBI may be the most feasible strategies to reduce the cost of TB.

Gasoline prices and their relationship to rising motorcycle fatalities, 1990-2007.

Motor vehicle accidents are the leading cause of death among young adults. Although automobile fatalities have declined in recent years, motorcycle fatalities are rapidly increasing. The purpose of our research was to quantify the relationship between changing fuel prices and motorcycle fatalities. Our findings suggest that people increasingly rely on motorcycles to reduce their fuel costs in response to rising gasoline prices. We estimate that use of motorcycles and scooters instead of 4-wheeled vehicles results in over 1500 additional motorcycle fatalities annually for each dollar increase in gas prices. Motorcycle safety should receive more attention as a leading public health issue.

Personal and societal health quality lost to tuberculosis.

BACKGROUND: In developed countries, tuberculosis is considered a disease with little loss of Quality-Adjusted Life Years (QALYs). Tuberculosis treatment is predominantly ambulatory and death from tuberculosis is rare. Research has shown that there are chronic pulmonary sequelae in a majority of patients who have completed treatment for pulmonary tuberculosis (PTB). This and other health effects of tuberculosis have not been considered in QALY calculations. Consequently both the burden of tuberculosis on the individual and the value of tuberculosis prevention to society are underestimated. We estimated QALYs lost to pulmonary TB patients from all known sources, and estimated health loss to prevalent TB disease. METHODOLOGY/PRINCIPAL FINDINGS: We calculated values for health during illness and treatment, pulmonary impairment after tuberculosis (PIAT), death rates, years-of-life-lost to death, and normal population health. We then compared the lifetime expected QALYs for a cohort of tuberculosis patients with that expected for comparison populations with latent tuberculosis infection and without tuberculosis infection. Persons with culture-confirmed tuberculosis accrued fewer lifetime QALYs than those without tuberculosis. Acute tuberculosis morbidity cost 0.046 QALYs (4% of total) per individual. Chronic morbidity accounted for an average of 0.96 QALYs (78% of total). Mortality accounted for 0.22 QALYs lost (18% of total). The net benefit to society of averting one case of PTB was about 1.4 QALYs. CONCLUSIONS/SIGNIFICANCE: Tuberculosis, a preventable disease, results in QALYs lost owing to illness, impairment, and death. The majority of QALYs lost from tuberculosis resulted from impairment after microbiologic cure. Successful TB prevention efforts yield more health quality than previously thought and should be given high priority by health policy makers. (Refer to Abstracto S1 for Spanish language abstract).

Osteopathic medicine in transition: postmortem of the Osteopathic Medical Center of Texas.

The stand-alone osteopathic hospital was a necessity to the osteopathic medical profession in an era when it was isolated from allopathic medicine. As osteopathic medicine has become increasingly integrated with allopathic medicine, however, an independent osteopathic hospital is no longer a necessity. Moreover, a stand-alone institution seems to be economically out of place in today's market. The Osteopathic Medical Center of Texas in Fort Worth is an example of a stand-alone hospital that was unable to capitalize on the benefits realized by integrated hospital systems. The author believes that this failure contributed to the institution's demise. The market power of a hospital system can be used for more favorable contracting with vendors and providers, as well as facilitating negotiations with payers. System affiliation provides economic efficiency, security, and protection in the highly uncertain, complex, and competitive healthcare market.

What are the costs of suspected but not reported tuberculosis?

PURPOSE: Little is known regarding patients suspected, but not proven, to have tuberculosis before meeting reporting requirements. These patients generate unmeasured tuberculosis costs to the health care system. Elimination efforts are undervalued without fully quantifying the burden of tuberculosis. This may lead to decreased support and resurgence of this disease. This report provides a preliminary quantification of these costs. METHODS: We used acid-fast bacillus (AFB) cultures completed as a proxy to estimate the number of patients with suspected tuberculosis who are never reported. We collected data on the number of AFB tests conducted in Tarrant County, TX, for calendar year 2002. We excluded all tests positive for Mycobacterium tuberculosis or secondary to growth of mycobacteria not M tuberculosis. We considered all AFBs conducted on an individual within 90 days to be single diagnostic episodes. We measured the number of diagnostic episodes, number of AFBs, number of AFBs meeting inclusion criteria, estimated cost incurred by testing, and individuals affected. RESULTS: The Tarrant County hospitals sampled completed 6935 AFB cultures on an inpatient volume of 142,356 patients. One hundred ninety-three cultures confirmed tuberculosis or other mycobacteria, and 6742 AFBs were collected on persons suspected, but not proved, to have tuberculosis at an estimated $114.06 per culture. The total cost of eliminating tuberculosis as a cause of illness was $768,993. Laboratory costs for each patient with suspected, but not confirmed, tuberculosis averaged $364.11. One hundred forty-eight AFB cultures costing $16,830 were needed to confirm one case of tuberculosis. CONCLUSIONS: The suspicion of tuberculosis incurs significant burdens and cost in the US health care system. More fully valuing tuberculosis elimination is important for tuberculosis management and will help maintain support for tuberculosis elimination.

Gastric bypass surgery in the United States, 1998-2002.

We assessed the prevalence of gastric bypass surgeries in the United States on the basis of data from the 1998 to 2002 National Hospital Discharge Survey. Between 1998 and 2002, rates (per 100,000 adults) increased significantly (P<.001): from 7.0 to 38.6. This observed increase in the rate of gastric bypass surgery for the treatment of obesity may be attributed in part to improvements in surgical technique, improved patient outcomes, and increased popularity of this procedure.

Using cost and health impacts to prioritize the targeted testing of tuberculosis in the United States.

PURPOSE: Evaluation improves efficiency and effectiveness. Current U.S. tuberculosis (TB) control policies emphasize the treatment of latent TB infection (LTBI). However, this policy, if not targeted, may be inefficient. We determined the efficiency of a state-law mandated TB screening program and a non state-law mandated one in terms of cost, morbidity, treatment, and disease averted. METHODS: We evaluated two publicly funded metropolitan TB prevention and control programs through retrospective analyses and modeling. Main outcomes measured were TB incidence and prevalence, TB cases averted, and cost. RESULTS: A non state-law mandated TB program for homeless persons in Tarrant County screened 4.5 persons to identify one with LTBI and 82 persons to identify one with TB. A state-law mandated TB program for jail inmates screened 109 persons to identify one with LTBI and 3274 persons to identify one with TB. The number of patients with LTBI treated to prevent one TB case was 12.1 and 15.3 for the homeless and jail inmate TB programs, respectively. Treatment of LTBI by the homeless and jail inmate TB screening programs will avert 11.9 and 7.9 TB cases at a cost of 14,350 US dollars and 34,761 US dollars per TB case, respectively. CONCLUSIONS: Mandated TB screening programs should be risk-based, not population-based. Non mandated targeted testing for TB in congregate settings for the homeless was more efficient than state-law mandated targeted testing for TB among jailed inmates.

Cost-effective osteopathic manipulative medicine: a literature review of cost-effectiveness analyses for osteopathic manipulative treatment.

Despite the value that osteopathic manipulative medicine (OMM) may offer to healthcare consumers in a managed care, evidence-based healthcare system, very little research has been published on the cost-effectiveness of osteopathic manipulative treatment compared with other treatment modalities. The authors searched MEDLINE and OSTMED for English-language articles published between January 1966 and June 2002 using the key terms cost-effectiveness, osteopathic medicine, workers' compensation, hospital length of stay, healthcare providers, and manipulative medicine. The authors then extended their search by reviewing the reference lists provided in the articles initially identified as relevant by these databases. The purpose, methods, findings, and conclusions of each study were evaluated for how the cost-effectiveness of OMM was analyzed. The authors conclude that the osteopathic medical profession needs to conduct and publish research that is consistent with current practices in the conventional medical literature.