Testicular cancer follow-up costs in Germany from 2000 to 2015.

PURPOSE: Advances in testicular cancer screening and therapy increased 10-year survival to 97% despite a rising incidence; eventually expanding the population of survivors requiring follow-up. We analyzed 10-year follow-up costs after testicular cancer treatment in Germany during 2000, 2008, and 2015. METHODS: Testicular cancer follow-up guidelines were extracted from the European Association of Urology. Per patient costs were estimated with a micro-costing approach considering direct and indirect medical expenses derived from expert interviews, literature research, and official scales of tariffs. Three perspectives covering costs for patients, providers, and insurers were included to estimate societal costs. Cost progression was compared across cancer histology, stage, stakeholders, resource use, and follow-up years. RESULTS: Mean 10-year follow-up costs per patient for stage I seminomatous germ-cell tumors (SGCT) on surveillance declined from EUR 11,995 in 2000 to EUR 4,430 in 2015 (p < 0.001). Advanced SGCT spending shrank from EUR 13,866 to EUR 9,724 (p < 0.001). In contrast, expenditure for stage II SGCT increased from EUR 7,159 to EUR 9,724 (p < 0.001). While insurers covered 32% of costs in 2000, only 13% of costs were reimbursed in 2015 (p < 0.001). 70% of SGCT follow-up resources were consumed by medical imaging (x-ray, CT, ultrasound, FDG-PET). Spending was unevenly distributed across follow-up years (years 1-2: 50%, years 3-5: 39%, years 5-10: 11%). CONCLUSIONS: The increasing prevalence of testicular cancer survivors caused German statutory insurers to cut per patient cost by up to 80% by budgeting services and decreasing reimbursement rates. The economic burden was gradually redistributed to patients and providers.

The Economic Rationality of Religious-Based Medical Abstinence in the Early Twentieth Century: The Case of Philadelphia's Faith Tabernacle Congregation.

At the turn of the twentieth century, Faith Tabernacle Congregation's commitment to medical abstinence was an economically rational practice. To the working poor of Philadelphia, who constituted the earliest members, Faith Tabernacle's therapy was financially attainable, psychologically supportive, and physically rejuvenating. Orthodox medicine was deficient in these three areas based on the patient narratives (i.e., testimonies) published in the church's monthly periodical Sword of the Spirit and testimony book Words of Healing. First, some early members spent all their money on orthodox medical care without relief causing significant financial hardship, while others found medical care prohibitive. Second, many early members experienced a great loss of hope because orthodox physicians ended treatment due to chronic or critical illness, both of which were interpreted as psychologically harmful. Third, early members of the church perceived getting physically worse by physicians because of low quality care, which was compounded by low access to orthodox medicine. Faith Tabernacle alternatively provided care that - in the patient narratives of the earliest members - helped them improve and get back to work faster.

Direct Costs of Opioid Abuse in an Insured Population in the United States.

OBJECTIVE: To (a) describe the demographics of opioid abusers; (b) compare the prevalence rates of selected comorbidities and the medical and drug utilization patterns of opioid abusers with patients from a control group, for the period from 1998 to 2002; and (c) calculate the mean annual per-patient total health care costs (e.g., inpatient, outpatient, emergency room, drug, other) from the perspective of a private payer. METHODS: An administrative database of medical and pharmacy claims from 1998 to 2002 of 16 self-insured employer health plans with approximately 2 million lives was used to identify "opioid abusers"-patients with claims associated with ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) codes for opioid abuse (304.0, 304.7, 305.5, and 965.0 [excluding 965.01]). A control group of nonabusers was selected using a matched sample (by age, gender, employment status, and census region) in a 3:1 ratio. Per-patient annual health care costs (mean total medical and drug costs) were measured in 2003 U.S. dollars. Multivariate regression techniques were also used to control for comorbidities and to compare costs with a benchmark of depressed patients. RESULTS: 740 patients were identified as opioid abusers, a prevalence of 8 in 10,000 persons aged 12 to 64 years continuously enrolled in health care plans for whom 12 months of data were available for calculating costs. Opioid abusers, compared with nonabusers, had significantly higher prevalence rates for a number of specific comorbidities, including nonopioid poisoning, hepatitis (A, B, or C), psychiatric illnesses, and pancreatitis, which were approximately 78, 36, 9, and 21 (P<0.01) times higher, respectively, compared with nonabusers. Opioid abusers also had higher levels of medical and prescription drug utilization. Almost 60% of opioid abusers had prescription drug claims for opioids compared with approximately 20% for nonabusers. Prevalence rates for hospital inpatient visits for opioid abusers were more than 12 times higher compared with nonabusers (P<0.01). Mean annual direct health care costs for opioid abusers were more than 8 times higher than for nonabusers ($15,884 versus $1,830, respectively, P < 0.01). Hospital inpatient and physician-outpatient costs accounted for 46% ($7,239) and 31% ($5,000) of opioid abusers' health care costs, compared with 17% ($310) and 50% ($906), respectively, for nonabusers. Mean drug costs for opioid abusers were more than 5 times higher than costs for nonabusers ($2,034 vs. $386, respectively, P<0.01), driven by higher drug utilization (including opioids) for opioid abusers. Even when controlling for comorbidities using a multivariate regression model of a matched control of depressed patients, the average health care costs of opioid abusers were 1.8 times higher than the average health care costs of depressed patients. CONCLUSION: The high costs of opioid abuse were driven primarily by high prevalence rates of costly comorbidites and high utilization rates of medical services and prescription drugs. DISCLOSURES: Funding for this research was provided by an unrestricted grant from Janssen Medical Affairs, L.L.C. and was obtained by authors Susan Vallow and Jeff Schein, who are employed by Janssen Medical Affairs, L.L.C. Nathaniel Katz is a consultant to Janssen and numerous other pharmaceutical companies that manufacture branded opioid products and nonopioid analgesics; authors Alan G. White, Howard G. Birnbaum, Milena N. Mareva, and Maham Daher disclose no potential bias or conflict of interest relating to this article. White served as principal author of the study. Study concept and design were contributed primarily by White, Vallow, Schein, and Katz. Analysis and interpretation of data were contributed by all authors. Drafting of the manuscript was primarily the work of White, and its critical revision was the work of White and Vallow. Statistical expertise was contributed by White, Birnbaum, and Daher, and administrative, technical, and/or material support was provided by Analysis Group, Inc., Boston, MA.

Tracking Japan's development assistance for health, 2012-2016.

BACKGROUND: Development assistance for health (DAH) is one of the most important means for Japan to promote diplomacy with developing countries and contribute to the international community. This study, for the first time, estimated the gross disbursement of Japan's DAH from 2012 to 2016 and clarified its flows, including source, aid type, channel, target region, and target health focus area. METHODS: Data on Japan Tracker, the first data platform of Japan's DAH, were used. The DAH definition was based on the Organisation for Economic Co-operation and Development's (OECD) sector classification. Regarding core funding to non-health-specific multilateral agencies, we estimated DAH and its flows based on the OECD methodology for calculating imputed multilateral official development assistance (ODA). RESULTS: Japan's DAH was estimated at 1472.94 (2012), 823.15 (2013), 832.06 (2014), 701.98 (2015), and 894.57 million USD (2016) in constant prices of 2016. Multilateral agencies received the largest DAH share of 44.96-57.01% in these periods, followed by bilateral grants (34.59-53.08%) and bilateral loans (1.96-15.04%). Ministry of Foreign Affairs (MOFA) was the largest contributors to the DAH (76.26-82.68%), followed by Ministry of Finance (MOF) (10.86-16.25%). Japan's DAH was most heavily distributed in the African region with 41.64-53.48% share. The channel through which the most DAH went was Global Fund to Fight AIDS, Tuberculosis, and Malaria (20.04-34.89%). Between 2012 and 2016, approximately 70% was allocated to primary health care and the rest to health system strengthening. CONCLUSIONS: With many major high-level health related meetings ahead, coming years will play a powerful opportunity to reevaluate DAH and shape the future of DAH for Japan. We hope that the results of this study will enhance the social debate for and contribute to the implementation of Japan's DAH with a more efficient and effective strategy.

Changing costs of type 1 diabetes care among US children and adolescents.

BACKGROUND: Modern therapy for type 1 diabetes (T1D) increasingly utilizes technology such as insulin pumps and continuous glucose monitors (CGMs). Prior analyses suggest that T1D costs are driven by preventable hospitalizations, but recent escalations in insulin prices and use of technology may have changed the cost landscape. METHODS: We conducted a retrospective analysis of T1D medical costs from 2012 to 2016 using the OptumLabs Data Warehouse, a comprehensive database of deidentified administrative claims for commercial insurance enrollees. Our study population included 9445 individuals aged ≤18 years with T1D and ≥13 months of continuous enrollment. Costs were categorized into ambulatory care, hospital care, insulin, diabetes technology, and diabetes supplies. Mean costs for each category in each year were adjusted for inflation, as well as patient-level covariates including age, sex, race, census region, and mental health comorbidity. RESULTS: Mean annual cost of T1D care increased from $11 178 in 2012 to $17 060 in 2016, driven primarily by growth in the cost of insulin ($3285 to $6255) and cost of diabetes technology ($1747 to $4581). CONCLUSIONS: Our findings suggest that the cost of T1D care is now driven by mounting insulin prices and growing utilization and cost of diabetes technology. Given the positive effects of pumps and CGMs on T1D health outcomes, it is possible that short-term costs are offset by future savings. Long-term cost-effectiveness analyses should be undertaken to inform providers, payers, and policy-makers about how to support optimal T1D care in an era of increasing reliance on therapeutic technology.

Twenty-year health and economic impact of reducing cigarette use: Minnesota 1998-2017.

BACKGROUND: Adult smoking prevalence in Minnesota fell from 21.8% in 1997 to 15.2% in 2016. This reduction improved heart and lung health, prevented cancers, extended life and reduced healthcare costs, but quantifying these benefits is difficult. METHODS: 1.3 million individuals were simulated in a tobacco policy model to estimate the gains to Minnesotans from 1998 to 2017 in health, medical spending reductions and productivity gains due to reduced cigarette smoking. A constant prevalence scenario was created to simulate the tobacco harms that would have occurred had smoking prevalence stayed at 1997 levels. Those harms were compared with tobacco harms from a scenario of actual smoking prevalence in Minnesota from 1998 to 2017. RESULTS: The simulation model predicts that reducing cigarette smoking from 1998 to 2017 has prevented 4560 cancers, 31 691 hospitalisations for cardiovascular disease and diabetes, 12 881 respiratory disease hospitalisations and 4118 smoking-attributable deaths. Minnesotans spent an estimated $2.7 billion less in medical care and gained $2.4 billion in paid and unpaid productivity, inflation adjusted to 2017 US$. In sensitivity analysis, medical care savings ranged from $1.7 to $3.6 billion. CONCLUSIONS: Minnesota's investment in comprehensive tobacco control measures has driven down smoking rates, saved billions in medical care and productivity costs and prevented tobacco related diseases of its residents. The simulation method employed in this study can be adapted to other geographies and time periods to bring to light the invisible gains of tobacco control.

Biosimilars: Exploring the History, Science, and Progress.

BACKGROUND: Biosimilars provide opportunities for improving healthcare access and outcomes and reducing overall healthcare costs for patients with cancer. OBJECTIVES: The purpose of this article is to explore the history of biosimilars, regulatory pathways, and barriers to biosimilar approval. This article also aims to describe the patient and clinician barriers to biosimilars use and the progress that has been achieved since the first biosimilar approval in Europe in 2006 and in the United States in 2015. METHODS: A literature search was conducted to retrieve articles that are highly relevant to the history of biosimilars development and regulatory pathways in the United States, Europe, Asia, and Canada. Patient and clinician perspectives on safety issues and concerns regarding immunogenicity and bioequivalence that limit use of biosimilars are also included. FINDINGS: Patient and provider concerns regarding immunologic patient safety issues, such as immunogenicity, lack of comparability, and low biosimilarity, still exist. The clinical safety, efficacy, and tolerability of biosimilars are among the top concerns in patients, prescribers, and clinicians.

Bearing the right to healthcare, autonomy and hope.

In this article, I discuss the significance of understanding within the context of the campaign for affordable and accessible HIV/AIDS treatments in South Africa, the transformational effects of the interplay between political rationality and affect for HIV-positive subjectivities. The article focuses on the policy tactics, in 2001, of the lobbying for a policy to prevent mother-to-child-transmission of HIV. A close reading of the lobby groups' rationalization of healthcare as a fundamental human right reveals a strategic attempt to recast a sense of helplessness into self-responsibilization, which concurrently involved nourishing hope in the preferred future for women with HIV to be afforded the right to individual choice associated with self-determination. Therefore, the struggle for a policy to prevent mother-to-child-transmission of HIV - an exemplary initiative to reconstitute HIV-positive subjectivity - maneuvered within both rationalizing and emotive spaces. Ongoing engagement of the broader campaign's contribution to redefining being HIV-positive thus also necessitates accounting for the effects of the convergence of political rationality and emotion in its tactically emancipatory project.

O Tratamento dos doentes insanos de Vila Viçosa no hospital de Rilhafoles (segunda metade do século XIX) / The treatment of the insane patients at the hospital in Vila Viçosa rilhafoles (second half of the nineteenth century)

Neste trabalho analisamos os trâmites processuais respeitantes ao envio de doentes insanos de Vila Viçosa para o hospital de Rilhafoles, na segunda metade do século XIX, e as relações estabelecidas com o hospital desta vila alentejana relativamente ao pagamento do tratamento. A braços com uma grave crise financeira, o hospital de Vila Viçosa recusava sistematicamente a responsabilidade de enviar os alienados para Rilhafoles, numa tentativa de passar esse ónus para a administração do concelho, mostrando-se muito renitente no pagamento das faturas que lhe chegavam do hospital de São José. O conflito entre as duas instituições chegou ao monarca e sem outra alternativa que a do pagamento, o hospital da vila alentejana procedeu ao envio de parcelas de dinheiro, ainda que de forma muito atrasada. Para a realização deste trabalho servimo-nos dos livros de atas da Misericórdia e do fundo do Governo Civil de Évora, custodiadas pelo Arquivo Distrital da mesma cidade. Estas fontes resultam essencialmente da correspondência estabelecida entre a Misericórdia de Vila Viçosa, o administrador do concelho e o governador civil de Évora (AU)

In this work we examined the procedural requirements related to the sending of insane patients of Vila Viçosa to the hospital of Rilhafoles, in the second half of the 19th century, and the relationships established with the hospital of this Alentejo town relating to the payment of treatment. Faced with a severe financial crisis, the hospital of Vila Viçosa systematically refused the responsibility to send the insane patients to the Rilhafoles hospital in an attempt to pass this burden on the administration of the county, being very reluctant to pay the bills that came to him from the hospital of São José. The conflict between the two institutions came to the monarch with no other alternative than the payment, the hospital of village of the Alentejo region proceeded to sending parcels of money, albeit way too late. For the realization of this work we use the books of the Misericórdia and the documents of the Civil Governor found of the city of Évora under the custody of the Distrital Archive of the same city. This documents results, basically, from the correspondence between the Misericórdia of Vila Viçosa, the council administrator and the civil governor of Évora (AU)

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Cost trend analysis of initial cancer treatment in Taiwan.

BACKGROUND: Despite the high cost of initial cancer care, that is, care in the first year after diagnosis, limited information is available for specific categories of cancer-related costs, especially costs for specific services. This study purposed to identify causes of change in cancer treatment costs over time and to perform trend analyses of the percentage of cancer patients who had received a specific treatment type and the mean cost of care for patients who had received that treatment. METHODOLOGY/PRINCIPAL FINDINGS: The analysis of trends in initial treatment costs focused on cancer-related surgery, chemotherapy, radiation therapy, and treatments other than active treatments. For each cancer-specific trend, slopes were calculated for regression models with 95% confidence intervals. Analyses of patients diagnosed in 2007 showed that the National Health Insurance (NHI) system paid, on average, $10,780 for initial care of a gastric cancer patient and $10,681 for initial care of a lung cancer patient, which were inflation-adjusted increases of $6,234 and $5,522, respectively, over the 1996 care costs. During the same interval, the mean NHI payment for initial care for the five specific cancers increased significantly (p<0.05). Hospitalization costs comprised the largest portion of payments for all cancers. During 1996-2007, the use of chemotherapy and radiation therapy significantly increased in all cancer types (p<0.05). In 2007, NHI payments for initial care for these five cancers exceeded $12 billion, and gastric and lung cancers accounted for the largest share. CONCLUSIONS/SIGNIFICANCE: In addition to the growing number of NHI beneficiaries with cancer, treatment costs and the percentage of patients who undergo treatment are growing. Therefore, the NHI must accurately predict the economic burden of new chemotherapy agents and radiation therapies and may need to develop programs for stratifying patients according to their potential benefit from these expensive treatments.

Legal requirements for optimal haemophilia treatment in Germany.

The clinical benefits of early prophylaxis in the treatment of haemophilia have been unquestioned since publication of the results of the first randomized study. The question of whether or not prophylaxis is cost-effective remains to be proven. For European physicians treating haemophilia patients, and for German clinicians in particular, the law largely supports the use of prophylaxis in haemophilia, but many doctors are unaware of this. The aim of this review was therefore to describe the German legal framework and outline how it can be used to support appropriate clinical decision-making in the treatment of haemophilia and justify the use of prophylaxis to health insurers and third-party payers. The German Disability Equalisation Law and German Social Law Books V and IX outline legal requirements to prevent or ameliorate disability, and support the argument that all haemophilia patients, including adults, have the right to receive appropriate, adequate, and cost-effective treatment. "Appropriate" treatment means that it must be in accordance with state-of-the-art medical knowledge taking into account medical progress. "Adequate" treatment must be conducive to the goals of haemophilia management, which are to prevent bleeds, treat bleeding episodes, maintain and/or restore joint function, and integrate patients into a normal social life. This can only be achieved when long-term treatment is adequately dosed and regularly administered for as long as it is required. Thankfully, with the availability of virus-safe factor concentrates, the introduction of home treatment programmes, and the law on our side, we are in a very strong position to achieve these goals.

The projection of burden of disease in Islamic Republic of Iran to 2025.

OBJECTIVE: Iran as a developing country is in the transition phase, which might have a big impact on the Burden of Disease and Injury (BOD). This study aims to estimate Burden of Disease and Injury (BOD) in Iran up to 2025 due to four broad cause groups using Disability-Adjusted Life Year (DALY). METHODS: The impacts of demographic and epidemiological changes on BOD (DemBOD and EpiBOD) were assessed separately. We estimated DemBOD in nine scenarios, using different projections for life expectancy and total fertility rate. EpiBOD was modeled in two scenarios as a proportion of DemBOD, based on the extracted parameters from an international study. FINDINGS: The BOD is projected to increase from 14.3 million in 2003 to 19.4 million in 2025 (95% uncertainty interval: 16.8, 21.9), which shows an overall increase of 35.3%. Non-communicable diseases (12.7 million DALY, 66.0%), injuries (4.6 million DALY, 24.0%), and communicable diseases, except HIV/AIDS (1.8 million DALY, 9%) will be the leading causes of losing healthy life. Under the most likely scenario, the maximum increase in disease burden due to DemBOD is projected to be observed in HIV/AIDS and Non-communicable diseases (63.9 and 62.4%, respectively) and due to EpiBOD in HIV/AIDS (319.5%). CONCLUSION: It seems that in the following decades, BOD will have a sharp increase in Iran, mainly due to DemBOD. It seems that communicable diseases (except HIV/AIDS) will have less contribution, and especially non-communicable diseases will play a more significant role.

Open versus endovascular stent graft repair for abdominal aortic aneurysms: an historical view.

Development of endovascular abdominal aortic aneurysms repair (EVAR), now in its 4th decade, has involved at least 16 different devices, not counting major modifications of some, only 4 of which have emerged from clinical trials and gained US Food and Drug Administration approval. The main impetus behind EVAR has been its potential for significantly reducing procedural mortality and morbidity, but it was also expected to speed recovery and reduce costs through decreased use of hospital resources. At the outset, EVAR was touted as a better alternative to OPEN in high-risk patients with large abdominal aortic aneurysms, and to "watchful waiting" (periodic ultrasound surveillance) for those with small abdominal aortic aneurysms. This new technology has evoked a mixed response with enthusiasts and detractors debating its pros and cons. Bias and conflict of interest exist on both sides. This review will attempt to present a balanced review of the development and current status of this controversial competition between EVAR and OPEN, comparing them in terms of the following key considerations: mortality and morbidity, complications, failure modes and durability, and costs.

Pharmaceutical high profits: the value of R&D, or oligopolistic rents?

Pharmaceutical firms attribute high prices and high profits to costs associated with researching and developing the next generation of life-saving drugs. Using data from annual reports, this article tests the validity of this claim. We find that while pharmaceutical firms do invest in R&D, they also enjoy strong rents; between 1988 and 2009, pharmaceuticals enjoyed profits of 3 to 37 times the all-industry average, depending on the years, while investing proportionately less in R&D than other high-R&D firms. Costs of pharmaceutical drugs have successfully flown below the radar in much of the current health care debate, with producers managing to obstruct alternative sourcing as well as payment cuts. While health care is examined for savings in other areas, sustained high pharmaceutical profits suggest that as a new health care policy develops in the U.S., the pharmaceutical industry should not be excluded from examination for significant savings in health care costs.

Does ownership matter for the provision of professionalized services? Hip operations at publicly and privately owned clinics in Denmark.

In terms of clinical procedures (to take the example used in this article, hip operations), both public and private organizations provide highly professionalized services. For this service type, our knowledge about ownership differences is sparse. To begin to fill this gap, we investigate how the ownership of hip clinics affects professional behaviour, treatment quality and patient satisfaction. The comparison of private and public hip clinics is based on data from the Danish Hip Arthroplasty Register and the Danish Central Patient Register combined with 20 semi-structured interviews. We find that private clinics employ stronger individual financial incentives and try harder to increase the income/costs ratio than do public clinics. Private clinics optimize non-clinical factors such as waiting time much more than public clinics and have fewer complication-prone patients than public clinics. However, the clinical procedures are very similar in the two types of clinics. Private clinics do not achieve better clinical results, but patient satisfaction is nevertheless higher with private clinics. The implication is that ownership matters for highly professionalized services, but professionalism neutralizes some ­ but not all ­ ownership differences.