Support service utilization and out-of-pocket payments for health services in a population-based sample of adults with neurological conditions.

BACKGROUND: Social support can help to deal with the consequences of neurological conditions and promote functional independence and quality of life. Our aim was to evaluate the impact of neurological conditions on the use of support and health-care services in a population-based sample of community-dwelling adults with neurological conditions. METHODS: Data were from the Survey of Living with Neurological Conditions in Canada, which was derived from a representative sample of household residents. Formal and informal support received and out-of-pocket payments were assessed by personal interviews. Logistic regression was used to explore the association between support service utilization and six common neurological conditions (Stroke, Parkinson's disease, Alzheimer's disease/dementias, traumatic brain injury, spinal cord injury and multiple sclerosis) with stroke as the reference category. RESULTS: The sample contained 2,410 respondents and equate to an estimated 459,770 when sample weights were used. A larger proportion of people within each of the neurological conditions received informal support than formal support (at least twice as much). Samples with the non-stroke conditions were more likely to receive formal assistance for personal (odds ratios 2.7 to 5.6; P < 0.05) and medical (odds ratios 2.4 to 4.4; P < 0.05) care compared to the stroke group. Also, the non-stroke conditions were more likely to receive informal assistance (odds ratios 2.7 to 17.9; P < 0.05) and less likely to make out-of-pocket payments for rehabilitation therapy (odds ratios 0.2 to 0.3; P < 0.05) than the stroke group. The Alzheimer's disease/dementia group had the highest proportion who received formal and informal support services. CONCLUSIONS: Our findings suggest that Canadians with neurological conditions receive more informal assistance than formal assistance. Furthermore, it appears that stroke survivors receive less support services, while those with Alzheimer's disease/dementia receive the most compared to other adult neurological conditions. Such data can help inform the development of support services in the community.

US Spending on Personal Health Care and Public Health, 1996-2013.

Importance: US health care spending has continued to increase, and now accounts for more than 17% of the US economy. Despite the size and growth of this spending, little is known about how spending on each condition varies by age and across time. Objective: To systematically and comprehensively estimate US spending on personal health care and public health, according to condition, age and sex group, and type of care. Design and Setting: Government budgets, insurance claims, facility surveys, household surveys, and official US records from 1996 through 2013 were collected and combined. In total, 183 sources of data were used to estimate spending for 155 conditions (including cancer, which was disaggregated into 29 conditions). For each record, spending was extracted, along with the age and sex of the patient, and the type of care. Spending was adjusted to reflect the health condition treated, rather than the primary diagnosis. Exposures: Encounter with US health care system. Main Outcomes and Measures: National spending estimates stratified by condition, age and sex group, and type of care. Results: From 1996 through 2013, $30.1 trillion of personal health care spending was disaggregated by 155 conditions, age and sex group, and type of care. Among these 155 conditions, diabetes had the highest health care spending in 2013, with an estimated $101.4 billion (uncertainty interval [UI], $96.7 billion-$106.5 billion) in spending, including 57.6% (UI, 53.8%-62.1%) spent on pharmaceuticals and 23.5% (UI, 21.7%-25.7%) spent on ambulatory care. Ischemic heart disease accounted for the second-highest amount of health care spending in 2013, with estimated spending of $88.1 billion (UI, $82.7 billion-$92.9 billion), and low back and neck pain accounted for the third-highest amount, with estimated health care spending of $87.6 billion (UI, $67.5 billion-$94.1 billion). The conditions with the highest spending levels varied by age, sex, type of care, and year. Personal health care spending increased for 143 of the 155 conditions from 1996 through 2013. Spending on low back and neck pain and on diabetes increased the most over the 18 years, by an estimated $57.2 billion (UI, $47.4 billion-$64.4 billion) and $64.4 billion (UI, $57.8 billion-$70.7 billion), respectively. From 1996 through 2013, spending on emergency care and retail pharmaceuticals increased at the fastest rates (6.4% [UI, 6.4%-6.4%] and 5.6% [UI, 5.6%-5.6%] annual growth rate, respectively), which were higher than annual rates for spending on inpatient care (2.8% [UI, 2.8%-2.8%] and nursing facility care (2.5% [UI, 2.5%-2.5%]). Conclusions and Relevance: Modeled estimates of US spending on personal health care and public health showed substantial increases from 1996 through 2013; with spending on diabetes, ischemic heart disease, and low back and neck pain accounting for the highest amounts of spending by disease category. The rate of change in annual spending varied considerably among different conditions and types of care. This information may have implications for efforts to control US health care spending.

Payment rates for personal care assistants and the use of long-term services and supports among those dually eligible for Medicare and Medicaid.

OBJECTIVE: To examine the association between payment rates for personal care assistants and use of long-term services and supports (LTSS) following hospital discharge among dual eligible Medicare and Medicaid beneficiaries. DATA SOURCES: State hospital discharge, Medicaid and Medicare claims, and assessment data on California Medicaid LTSS users from 2006 to 2008. STUDY DESIGN: Cross-sectional study. We used multinomial logistic regression to analyze county personal care assistant payment rates and postdischarge LTSS use, and estimate marginal probabilities of each outcome across the range of rates paid in California. DATA EXTRACTION METHODS: We identified dual eligible Medicare and Medicaid adult beneficiaries discharged from an acute care hospital with no hospitalizations or LTSS use in the preceding 12 months. PRINCIPAL FINDINGS: Personal care assistant payment rates were modestly associated with home and community-based services (HCBS) use versus nursing facility entry following hospital discharge (RRR 1.2, 95 percent CI: 1.0-1.4). For a rate of $6.75 per hour, the probability of HCBS use was 5.6 percent (95 percent CI: 4.2-7.1); at $11.75 per hour, 18.0 percent (95 percent CI: 12.5-23.4). Payment rate was not associated with the probability of nursing facility entry. CONCLUSIONS: Higher payment rates for personal care assistants may increase utilization of HCBS, but with limited substitution for nursing facility care.

[Current situation and challenges in companion diagnostics development].

The personalized health care, it is defined as a medical care which provide the optimal therapy for each individual in consideration of a patient's individual difference, such as a genetic background and a physiological state. A companion diagnosis to stratify a patient appropriately is essential for the spread of personalized health care, and it is important that a companion diagnostic reagent used for the companion diagnosis is properly developed and clinically applied. However, as for the development of companion diagnostics and pharmaceuticals that require it, there are still many challenges such as its business model of cooperation of diagnostics companies and pharmaceutical companies, also, the regulations related to companion diagnostics. Furthermore, even in clinical practice, there are many issues such as the way of reimbursement for companion diagnostics and also the handling of laboratory developed test (LDT) as companion diagnostics. These are issues that should continue to discuss with industry, government and academia. In this report, from the point of view of a diagnostics company, we discuss the various challenges in clinical applications from the development of companion diagnostics.

What really matters in cancer?: Putting people back into the heart of cancer policy.

Twenty-first century cancer is framed by the biomedical revolution. The cancer patient today enters a world dominated by the success and failures of biomedical science from gene to statistic. By any measure, bibliometric, financial, media profile or simply the lingua franca of everyday discourse about cancer, biomedicine occupies the majority of the cultural discourse around cancer. Yet the reality is that patients are people who are diagnosed, treated, survive and die with cancer in a world bounded by their personal and social experiences. Others they have known with the disease shape their values and concepts. The social determinants of cancer are of far greater importance in terms of prevention, treatment and care than is acknowledged in policy terms. In light of the demographic trend of a rapidly ageing population, increasing costs of healthcare and the urgent need to be able to deliver affordable cancer care set against the population's almost insatiable ability to absorb all types of healthcare, there is an urgent need to redress policy balance in terms of both understanding the social determinants of cancer and bringing new insights into evidence-based national cancer planning and delivery of services.

National health spending in 2011: overall growth remains low, but some payers and services show signs of acceleration.

In 2011 US health care spending grew 3.9 percent to reach $2.7 trillion, marking the third consecutive year of relatively slow growth. Growth in national health spending closely tracked growth in nominal gross domestic product (GDP) in 2010 and 2011, and health spending as a share of GDP remained stable from 2009 through 2011, at 17.9 percent. Even as growth in spending at the national level has remained stable, personal health care spending growth accelerated in 2011 (from 3.7 percent to 4.1 percent), in part because of faster growth in spending for prescription drugs and physician and clinical services. There were also divergent trends in spending growth in 2011 depending on the payment source: Medicaid spending growth slowed, while growth in Medicare, private health insurance, and out-of-pocket spending accelerated. Overall, there was relatively slow growth in incomes, jobs, and GDP in 2011, which raises questions about whether US health care spending will rebound over the next few years as it typically has after past economic downturns.

Study protocol: to investigate effects of highly specialized rehabilitation for patients with multiple sclerosis. A randomized controlled trial of a personalized, multidisciplinary intervention.

BACKGROUND: Multiple sclerosis (MS) is a complex, chronic and progressive disease and rehabilitation services can provide important support to patients. Few MS rehabilitation programs have been shown to provide health improvements to patients in a cost-effective manner. The objective of this study is to assess the effects in terms of changes measured by a variety of standardized quality of life, mastery, coping, compliance and individual goal-related endpoints. This combination provides the basis for analyzing the complexity of MS and outcomes of a personalized rehabilitation. METHODS/DESIGN: Patients with MS referred to hospital rehabilitation services will be randomized to either early admission (within two months) or usual admission (after an average waiting time of eight months). They will complete a battery of standardized health outcome instruments prior to randomization, and again six and twelve months after randomization, and a battery of goal-related outcome measures at admission and discharge, and again one, six and twelve months after randomization. DISCUSSION: The results of the study are expected to contribute to further development of MS rehabilitation services and to discussions about the design and content of such services. The results will also provide additional information to health authorities responsible for providing and financing rehabilitation services. TRIAL REGISTRATION: Current Controlled Trials (ISRCTN05245917).

Tax subsidization of personal assistance services.

BACKGROUND: Personal assistance services (PAS) is the term used to describe the range of assistance, services, and supports many people with disabilities and older Americans need to remain in their homes and communities. The Americans with Disabilities Act requires that people with disabilities receive essential services in the communities of their choice rather than in institutional settings. PAS availability often determines whether persons with disabilities become institutionalized or remain in their communities. PAS, however, are not inexpensive or broadly available. Strategies are needed to improve their availability to people with disabilities and the elderly. We sought to analyze 8 provisions of the Internal Revenue Code for their utility to make PAS more affordable and available. METHODS: The authors conducted a legal analysis of 8 statutory provisions, as interpreted by regulations, court decisions, and other authoritative sources. RESULTS: Each of the tax provisions analyzed covers some PAS expenses incurred by an individual or family. Favorable tax treatment is impacted by the nature and amount of expenses and by the location and conditions of services. The current limitations and complexities of legal interpretations and the fact that many individuals with disabilities are uninformed about these tax provisions present challenges and opportunities. CONCLUSIONS: As the need for PAS grows, reform of tax policy is an important complement to health care and long-term services and supports for people with disabilities. To increase utilization of current beneficial tax provisions that subsidize the cost of PAS, individuals with disabilities and tax preparers must become better informed about using these provisions.

The relationship between formal and informal care among adult Medicaid Personal Care Services recipients.

OBJECTIVES: To test hypotheses concerning the relationship between formal and informal care and to estimate the impact of hours of formal care authorized for Medicaid Personal Care Services (PCS) on the utilization of informal care. DATA SOURCES/STUDY SETTING: Data included home care use and adult Medicaid beneficiary characteristics from assessments of PCS need in four Medicaid administrative areas in Texas. STUDY DESIGN: Cross-sectional design using ordinary least-squares (OLS) and instrumental variable (IV) methods. DATA COLLECTION/EXTRACTION METHODS: The study database consisted of assessment data on 471 adults receiving Medicaid PCS from 2004 to 2006. PRINCIPAL FINDINGS: Both OLS and IV estimates of the impact of formal care on informal care indicated no statistically significant relationship. The impact of formal care authorized on informal care utilization was less important than the influence of beneficiary need and caregiver availability. Living with a potential informal caregiver dramatically increased the hours of informal care utilized by Medicaid PCS beneficiaries. CONCLUSIONS: More formal home care hours were not associated with fewer informal home care hours. These results imply that policies that decrease the availability of formal home care for Medicaid PCS beneficiaries will not be offset by an increase in the provision of informal care and may result in unmet care needs.

Healthy vocations: field nursing and the religious overtones of public health.

This article argues that the Office of Indian Affairs (OIA) field nursing program of the 1930s, which continued much of the same assimilation-style health care practices begun generations earlier by missionaries and field matrons, perpetuated the nineteenth-century link between religion and health care. Following in the footsteps of their female predecessors, field nurses targeted native women for health education, emphasizing personal hygiene and individual responsibility at the expense of socioeconomic causes of illness. Native women nonetheless appear to have maintained agency and power in negotiating health and health care. Peaking during the era of OIA Commissioner John Collier's Indian New Deal, the history of field nursing problematizes this period, particularly with regard to women's experiences. The article is significant for its exploration of field nursing as a contested site of cultural negotiation, revealing issues of power and difference in the lives of American women.

The effect of COPD health forecasting on hospitalisation and health care utilisation in patients with mild-to-moderate COPD.

Exacerbations are a major cause of morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD) as well as having a large impact on health care utilisation (HCU). They are more frequent during periods of cold weather with a corresponding increase in hospital admissions. It has been hypothesised that COPD exacerbations and admissions can be reduced by predicting periods of cold weather coupled with patients' alerts and education. Healthy Outlook(®) service provided by the Meteorological Office, UK, was used in patients with mild-to-moderate COPD who consented to participate from three primary care practices. Outcome measures included data relating to hospital admissions for acute exacerbations as well as HCU for these patients during the intervention period (1 Nov 2008-31 Mar 2009) and compared for the same patients and same period 12 months earlier (1 Nov 2007-31 Mar 2008). A cost analysis comparing treatment cost per patient for the two periods was also conducted. A total of 157 (34% of target COPD population) patients took part in the project, with five weather alerts generated (first alert reached 150 patients; second reached 146; third reached 138 patients; fourth reached 137 patients; and the fifth reached 125 patients) during the intervention period. There was a non-statistically-significant increase in hospital admissions per patient (0.07-0.076; p = 0.83). The number of general practice visits per patient dropped from 4.9 to 3.8 (p = 0.001), with drop in average number of visits to patients by out-of-hours services from 0.52-0.14 (p = 0.013). The average number of home consultations provided by general practice increased from 0.05 to 0.92 (p = 0.001). Cost per patient increased by an average of £142 (95% CI -£128 to £412). This anticipatory care model was not associated with reduction in admissions from COPD exacerbations. Further research is required to fully understand its role in the management of patients with COPD.

Improving the power of diagnostics in the era of targeted therapy and personalized healthcare.

The field of diagnostics has unprecedented opportunities to contribute to the practice of medicine in the era of targeted therapy and personalized healthcare. Rather than simply providing information regarding the presence and classification of disease, innovative molecular diagnostic tests will directly inform patient-management decisions, such as which targeted therapies to prescribe or whether a patient should be treated more aggressively. However, in order for diagnostics to deliver this high level of medical value, several challenges ranging from technical, pre-analytical, developmental, regulatory, reimbursement and quality perspectives need to be overcome. This review focuses on recent developments in each of these areas that are expected to improve the power and impact of diagnostics.

Tailor-made finance versus tailor-made care. Can the state strengthen consumer choice in healthcare by reforming the financial structure of long-term care?

BACKGROUND: Policy instruments based on the working of markets have been introduced to empower consumers of healthcare. However, it is still not easy to become a critical consumer of healthcare. OBJECTIVES: The aim of this study is to analyse the possibilities of the state to strengthen the position of patients with the aid of a new financial regime, such as personal health budgets. METHODS: Data were collected through in-depth interviews with executives, managers, professionals and client representatives of six long-term care institutions. RESULTS: With the introduction of individual budgets the responsibility for budgetary control has shifted from the organisational level to the individual level in the caregiver-client relationship. Having more luxurious care on offer necessitates a stronger demarcation of regular care because organisations cannot simultaneously offer extra care as part of the standard care package. New financial instruments have an impact on the culture of receiving and giving care. Distributive justice takes on new meaning with the introduction of financial market mechanisms in healthcare; the distributing principle of 'need' is transformed into the principle of 'economic demand'. CONCLUSION: Financial instruments not only act as a countervailing power against providers insufficiently client-oriented, but are also used by providers to reinforce their own positions vis-à-vis demanding clients. Tailor-made finance is not the same as tailor-made care.