Impact of the free healthcare initiative on wealth-related inequity in the utilization of maternal & child health services in Sierra Leone.

BACKGROUND: As a result of financial barriers to the utilization of Maternal and Child Health (MCH) services, the Government of Sierra Leone launched the Free Health Care Initiative (FHCI) in 2010. This study aimed to examine the impact of the FHCI on wealth related inequity in the utilization of three MCH services. METHODS: We analysed data from 2008 to 2013 Sierra Leone Demographic Health Surveys (SLDHS) using 2008 SLDHS as a baseline. Seven thousand three hundred seventy-four and 16,658 women of reproductive age were interviewed in the 2008 and 2013 SLDHS respectively. We employed a binomial logistic regression to evaluate wealth related inequity in the utilization of institutional delivery. Concentration curves and indices were used to measure the inequity in the utilization of antenatal care (ANC) visits and postnatal care (PNC) reviews. Test of significance was performed for the difference in odds and concentration indexes obtained for the 2008 and 2013 SLDHS. RESULTS: There was an overall improvement in the utilization of MCH services following the FHCI with a 30% increase in institutional delivery rate, 24% increment in more than four focused ANC visits and 33% increment in complete PNC reviews. Wealth related inequity in institutional delivery has increased but to the advantage of the rich, highly educated, and urban residents. Results of the inequity statistics demonstrate that PNC reviews were more equally distributed in 2008 than ANC visits, and, in 2013, the poorest respondents ranked by wealth index utilized more PNC reviews than their richest counterparts. For ANC visits, the change in concentration index was from 0.008331[95% CI (0.008188, 0.008474)] in 2008 to - 0.002263 [95% CI (- 0.002322, - 0.002204)] in 2013. The change in concentration index for PNC reviews was from - 0.001732 [95% CI (- 0.001746, - 0.001718)] in 2008 to - 0.001771 [95% CI (- 0.001779, - 0.001763)] in 2013. All changes were significant (p value < 0.001). CONCLUSION: The FHCI appears to be improving access to and utilization of MCH services, narrowing the inequity in ANC visits and PNC reviews, but is insufficient in addressing wealth- related inequity that exists for institutional deliveries. If Sierra Leone is to realize a significant reduction in maternal and child mortality rates, it needs to strengthen the effective implementation of FHCI considering incorporating a sector wide approach (SWAp) or a "Health in all Policy" framework to reach the less educated, rural residents and ensuring culturally sensitive quality services.

[FORCE-FEEDING OR LIFE-SAVING? - DEALING WITH HUNGER STRIKES IN ISRAEL].

INTRODUCTION: Although the management of quality of care by the health funds has contributed to its improvement, medical teams criticize the way it is performed. Many call for renewed values-driven thinking and to leave the concern for quality in the hands of the medical teams, relying on "self control and enforcement", based on values, compassion, concern for others, patient service, discipline and personal responsibility. This article aims to present an economic perspective on the measurement of quality of care. It places the development of "measuring the quality of care and its management" within the development of the organization of care, health insurance and payment arrangements for medical teams. The conclusion is that there is no "first best" method to improve the quality of care. Each method - including the quantitative-functional measurement-based method used in many systems and the value-driven, self enforced method proposed by many - has advantages and disadvantages. The choice of a method should be based on these two sides, discussed jointly by medical teams, the health funds, hospitals and the Health Ministry.

[IDENTIFYING PREDICTORS OF MENTAL HEALTH SERVICES CONSUMPTION IN ISRAEL].

INTRODUCTION: The budget for health services in Israel was recently increased to cover mental health. It was suggested to divide funds for psychiatric hospitalization between the HMOs based on their share of insured members. For ambulatory care, it was suggested to add risk adjustment based on age only to the capitation formula used for allocating health care funds. This simplistic measure encourages risk selection and discrimination of costly individuals. AIMS: To identify predictors of mental health services consumption in Israel, in order to implement them in the capitation formula. METHODS: Data were gathered on 27,446 individuals hospitalized in psychiatric wards in Israel in 2012-2013, and 6115 outpatients treated during this period in one mental health clinic. The association between demographic and clinical variables with services consumption was studied. RESULTS: The average annual expenses per person on mental health were NIS 50,000 for hospitalization, NIS 1,700 for ambulatory care and NIS 7,000 for all services. Adult age and schizophrenia spectrum diagnoses predicted increased expenditure on all services. Being a male, single, Jewish and living in the economic periphery predicted increased expenditure mainly on hospitalization. Regression analysis using these variables explained up to 30% of variance. CONCLUSIONS: It is possible to predict, at least partially, mental health consumption in Israel based on clinical and demographic variables. DISCUSSION: Limitations of the study call or re-analysis using full databases, which are available only to the state authorities. Predictors of mental health consumption in Israel can be used for the risk adjustment of allocating funds for services.

Adherence to Self-Care Behaviors among Patients with Type 2 Diabetes-The Role of Risk Preferences.

OBJECTIVES: To examine whether the degree of risk aversion is associated with adherence to disease self-management among adults with type 2 diabetes. METHODS: This was a cross-sectional study of patients with type 2 diabetes (n = 408) aged 21 to 70 years who presented for routine visits in the diabetes clinic at a university medical center in Beer-Sheva, Israel. The authors used validated questionnaires to estimate adherence, risk preferences, motivation, self-efficacy, impulsivity, perceptions about the disease and the interpersonal process of care, and demographic and socioeconomic characteristics, in addition to retrieving data from computerized patient medical records of clinical indicators of disease severity. Multivariable linear and ordered-logit models examined predictors of adherence to each self-care behavior. RESULTS: Multivariable analyses revealed that, compared with others, risk-seeking patients reported lower general adherence (ß = -0.32; P ≤ 0.05), and specifically, lower adherence to healthful eating plan (ß = -0.48; P ≤ 0.1), consumption of low-fat food (ß = -0.47; P ≤ 0.1), exercise (ß = -0.73; P ≤ 0.05), blood glucose monitoring (ß = -0.69; P ≤ 0.05), and foot care (ß = -0.36; P ≤ 0.1). Risk-seeking patients did not report lower consumption of fruits and vegetables (ß = -0.19; P > 0.1). Because 96% of the study population reported optimal adherence to medication, determinants of this behavior could not be analyzed. CONCLUSIONS: Risk preference is associated with adherence to self-care behaviors. Identifying risk seekers may enable practitioners to target these patients with tailored strategies to improve adherence, thus more efficiently allocating scarce health care resources.

Preconditions for efficiency and affordability in competitive healthcare markets: Are they fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland? Ten years later.

From the mid-1990s several countries have introduced elements of the model of regulated competition in healthcare. In 2012 we assessed the extent to which in five countries ten important preconditions for achieving efficiency and affordability in competitive healthcare markets were fulfilled. In this paper we assess to what extent the fulfilment of these preconditions has changed ten years later. In 2022, as in 2012, in none of the five countries all preconditions are completely fulfilled. In the period 2012-2022 on balance there have been some improvements in the fulfillment of the preconditions, although to a different extent in the five countries. The only preconditions that were improved in most countries were 'consumer information and transparency' and 'cross-subsidies without incentives for risk selection'. On balance the Netherlands and Switzerland made most progress in the number of better fulfilled preconditions. For Belgium these preconditions no longer seem relevant because the idea of regulated competition has been completely abandoned. In Germany, Israel and Switzerland, the preconditions 'effective competition policy' and 'contestability of the markets' are not sufficiently fulfilled in 2022, just as in 2012. In Germany and Switzerland this also holds for the precondition 'freedom to contract and integrate'. Overall, the progress towards realizing the preconditions has been limited.

Cost-effectiveness of baseline low-dose computed tomography screening for lung cancer: the Israeli experience.

OBJECTIVE: Reduced mortality with low-dose computed tomography (LDCT) lung cancer screening was demonstrated in a large randomized controlled study of high-risk individuals. Cost-effectiveness must be assessed before routine LDCT screening is considered. We aimed to evaluate the cost-effectiveness of LDCT lung cancer screening in Israel. METHODS: A decision analytic framework was used to evaluate the decision to screen or not screen from the health system perspective. The screening arm included 842 moderate-to-heavy smokers aged 45 years or older, screened at Hadassah-Hebrew University Medical Center from 1998 to 2004. In the usual-care arm, stage distribution and stage-specific life expectancy were obtained from the Israel National Cancer Registry data for 1994 to 2006. Lifetime stage-specific costs were estimated from medical records of patients diagnosed and treated at Hadassah Medical Center in the period 2003 to 2004. The analysis considered possible biases-lead time, overdiagnosis, and self-selection. Cost per quality-adjusted-life-year (QALY) gained by screening was estimated. RESULTS: Base-case incremental cost per QALY gained was $1464 (2011 prices). Extensive sensitivity analysis affirmed the low cost per QALY gained. The cost per QALY gained is lower than $10,000 with probability 0.937 and is lower than $20,000 with probability 0.978. CONCLUSIONS: Our analysis suggests that baseline LDCT lung cancer screening in Israel presents a good value for the money and should be considered for inclusion in the National List of Health Services financed publicly.

Economic assessment of screening for pre-eclampsia.

BACKGROUND: Pre-eclampsia is a major contributor to maternal and neonatal morbidity and mortality. Our objectives in this study are to economically assess, from the payer perspective, routine screening for pre-eclampsia using placental markers -placental protein 13 and placental growth factor - and uterine artery Doppler compared with standard care. METHODS: A decision model was developed, which progresses through three sequential endpoints, and compares screening with no screening: (1) Pre-eclampsia yes/no: calculation of the incremental cost of pre-eclampsia-case averted; (2) Hospital discharge: calculation of the mean accumulated costs until discharge after delivery; and (3) Offspring death: calculation of the incremental cost per quality of life-adjusted life-year gained by screening. Data used includes: (1) Obstetrical data of 14 500 births; (2) cost data from the Israeli Ministry of Health and the literature; and (3) screening performance and outcome from the literature. RESULTS: (1) The incremental cost of pre-eclampsia-case averted is $66,949 and $24,723 when the prevalence is 1.7 and 5% respectively. (2) With test cost of $112, the total cost until discharge with/without screening is equal. With pre-eclampsia prevalence of 3%, screening is cheaper. (3) The cost per quality of life-adjusted life-year with screening is $18,919 and < $10,000 with pre-eclampsia prevalence of 1.7 and 3%, respectively. CONCLUSIONS: Screening for pre-eclampsia is cost-effective under various scenarios.

Economic costs of cigarette smoking among adolescents in Nigeria.

Background: Cigarette smoking is an established cause of preventable death and often initiated during adolescence. We estimated the short- and long-term costs of cigarette smoking among currently smoking adolescents in Nigeria. Methods: A cross-sectional survey among adolescents in Oyo state, Nigeria and a review of mortality records of patients managed for lung cancer in a tertiary facility in Ibadan, Nigeria were conducted. Short-term costs estimated were: (a) average weekly costs of purchasing cigarettes by currently smoking adolescents, and (b) costs of managing at least an episode of chronic cough occurring within 12 months of the survey. Long-term costs were limited to: (a) life-time expenditure on purchasing cigarettes, and (b) direct medical and non-medical (transportation) costs of managing lung cancer. Long-term costs were first projected to the approximate year when the adolescents (mean age:16.0 ± 1.8 years) might be diagnosed with lung cancer based on the average age at presentation with symptoms of lung cancer obtained from the records (59.8 years), and then discounted to 2020 prices. This was estimated as 44 years from the base year (2020). Costs were reported in 2020 prices in Nigerian Naira (NGN) and US dollar (USD) equivalent using the Central Bank of Nigeria, June 2020 exchange rate of USD 1: NGN 360.50. Results: Approximately 3.8% of the adolescents were current cigarette smokers. Average weekly expenditure on cigarettes was NGN 306.82 ± 5.74 (USD 0.85 ± 0.02). About 26% had experienced at least an episode of chronic cough which cost them an average of NGN 1226.81 ± 6.18 (USD 3.40 ± 0.02) to manage. Total future costs of cigarette smoking in 2020 prices for the 43 adolescents who were current smokers in the event that they develop lung cancer were approximately NGN 175.7 million (USD 487.3 thousand), NGN 871.8 million (USD 2.4 million) and NGN 4.6 trillion (USD 12.7 million) at assumed annual inflation rates of 10%, 15%, and 20% respectively and discount rate of 4.25%. Conclusion: The estimated economic costs of smoking were very high. Efforts to prevent smoking initiation among adolescents in our study area should be intensified. Interventions to subsidize the medical cost of health-related consequences of cigarette smoking are also required, especially as treatment costs are currently largely borne out-of-pocket. Supplementary Information: The online version contains supplementary material available at 10.1007/s10389-021-01644-5.

Real World Cost-Effectiveness Analysis of Population Screening for BRCA Variants among Ashkenazi Jews Compared with Family History-Based Strategies.

Identifying carriers of pathogenic BRCA1/BRCA2 variants reduces cancer morbidity and mortality through surveillance and prevention. We analyzed the cost-effectiveness of BRCA1/BRCA2 population screening (PS) in Ashkenazi Jews (AJ), for whom carrier rate is 2.5%, compared with two existing strategies: cascade testing (CT) in carrier's relatives (≥25% carrier probability) and international family history (IFH)-based guidelines (>10% probability). We used a decision analytic-model to estimate quality-adjusted life-years (QALY) gained, and incremental cost-effectiveness ratio for PS vs. alternative strategies. Analysis was conducted from payer-perspective, based on actual costs. Per 1000 women, the model predicted 21.6 QALYs gained, a lifetime decrease of three breast cancer (BC) and four ovarian cancer (OC) cases for PS vs. CT, and 6.3 QALYs gained, a lifetime decrease of 1 BC and 1 OC cases comparing PS vs. IFH. PS was less costly compared with CT (−3097 USD/QALY), and more costly than IFH (+42,261 USD/QALY), yet still cost-effective, from a public health policy perspective. Our results are robust to sensitivity analysis; PS was the most effective strategy in all analyses. PS is highly cost-effective, and the most effective screening strategy for breast and ovarian cancer prevention. BRCA testing should be available to all AJ women, irrespective of family history.

Change and stability: use of complementary and alternative medicine in Israel: 1993, 2000 and 2007.

BACKGROUND: Complementary and alternative health care has gained increasing popularity in Western societies in recent years. The objective of the article is to explore cross-sectional variations and temporal changes in the patterns of complementary and alternative medicine (CAM) consultations in Israel in 1993, 2000 and 2007. METHODS: Interviews were conducted with 2003 respondents in 1993, 2505 in 2000, and 752 in 2007, using identical questions. The samples represented the Israeli Jewish urban population aged 45-75 in the respective years. RESULTS: The rate of use of CAM during the previous year increased from 6% in 1993, to 10% in 2000 and reached 12% in 2007. Women and highly educated persons have been significantly and consistently more likely to use CAM. Among the users, homeopathy, acupuncture and reflexology are the main types of CAM used. Lower back pain became the leading problem for which care was sought. A significant proportion of the users continue to use conventional medicine concurrently, and an increasing share was referred to CAM by their physician. Past good experience has become a major reason for CAM use. CONCLUSIONS: Between 1993 and 2007, CAM use in the Israeli urban Jewish population aged 45-75 years increased significantly. As in other countries CAM grew from an infant industry and entered the mainstream of health care. The evidence reported here highlights the urgent need for the design of health and social policies aiming to achieve more effective integration between CAM and conventional medicine.

[What determines the market shares of the health funds in Israeli localities?].

BACKGROUND: Four health funds operate nationally in Israel, but their local market shares vary dramatically across localities. OBJECTIVES: To identify the main localities' characteristics which affect the size of the market shares of the various health funds. METHODS: A total of 60 Localities with more than 20,000 inhabitants were chosen. The following Localities' characteristics were retrieved for the year 2004: the market shares of the four health funds, average income, standardized mortality ratio (SMR), periphery index, the age structure, the distance from the nearest general hospital, the share of Arab population, and size. Four market share equations were estimated using SURE (seemingly unrelated regressions estimation), allowing for inter-equation correlations. RESULTS: The results show that the market shares of the different health funds are affected by different factors. Clalit Health Services' (CHS) share increases with the distance from Tel Aviv and SMR, and decreases with the level of mean income and the distance from the nearest CHS hospital. Leumit's market share increases only with the distance from a CHS's hospital. The market share of Maccabi Healthcare Services is higher in central localities, Jewish localities, small cities and further away from a non-CHS hospital. Meuhedet's market share is higher in big cities, rich and healthy localities, and in Localities which are further away from CHS's hospitals. CONCLUSIONS: These findings indicate that the presence of the health funds in different Localities varies according to the Localities' characteristics. There appears to be a market segmentation and "specialization" of certain health funds in specific populations, and of the other health funds in the rest of the population.

Social solidarity in healthcare: The Israeli case.

While solidarity is at the basis of all social health insurance systems, little has been done to define and analyze it empirically. Equity in the delivery of medical care and progressivity of its finance are socially important, but miss the main principle of social health insurance systems - mutual help. The present study views social solidarity not as a value but as cross-subsidies among individuals, which are necessary to achieve a separation between finance and delivery of care in order to make healthcare affordable universally. A solidarity index, derived from the Kakwani Progressivity Index, is suggested and applied to the Israeli national health insurance system in 2010. The observed solidarity index for 2010 Israel is 0.242. Adjusting for possible barriers in use does not change the index. About 85% of the solidarity index originates from income solidarity. If the entire health budget was financed by the general revenue, the solidarity index would rise to 0.259. The level of solidarity in Israel is close to the one found in Canada, Finland and France. More comparative results over time and over systems will enable further insights and uses. The sustainability of solidarity requires, however, some altruism among the rich with respect to the health state of the poor.

Cost-effectiveness analysis of screening for first-degree relatives of patients with bicuspid aortic valve.

AIMS: Bicuspid aortic valve (BAV) is the commonest congenital heart valve malformation, and is associated with life-threatening complications. Given the high heritability index of BAV, many experts recommend echocardiography screening for first-degree relatives (FDRs) of an index case. Here, we aim to evaluate the cost-effectiveness of such cascade screening for BAV. METHODS AND RESULTS: Using a decision-analytic model, we performed a cost-effectiveness analysis of echocardiographic screening for FDRs of a BAV index case. Data on BAV probabilities and complications among FDRs were derived from our institution's BAV familial cohort and from the literature on population-based BAV cohorts with long-term follow-up. Health gain was measured as quality-adjusted life years (QALYs). Cost inputs were based on list prices and literature data. One-way and probabilistic sensitivity analyses were performed to account for uncertainty in the model's variables. Screening of FDRs was found to be the dominant strategy, being more effective and less costly than no screening, with savings of €644 and gains of 0.3 QALY. Results were sensitive throughout the range of the main model's variables, including the full range of reported BAV rates among FDRs across the literature. A gradual decrease of the incremental effect was found with the increase in screening age. CONCLUSION: This economic evaluation model found that echocardiographic screening of FDRs of a BAV index case is not only clinically important but also cost-effective and cost-saving. Sensitivity analysis supported the model's robustness, suggesting its generalization.

Economic costs of terminal care for selected non-communicable diseases from a healthcare perspective: a review of mortality records from a tertiary hospital in Nigeria.

INTRODUCTION: WHO revealed that morbidity and mortality from non-communicable diseases (NCDs) are on the increase and NCDs accounted for approximately 29% of all deaths in Nigeria in 2016. This study was conducted to estimate the economic cost of selected NCDs-lung cancer, liver cancer and liver cirrhosis. These diseases are known to be associated with key modifiable health risk behaviours (smoking and alcohol use), which are prevalent in Nigeria and often commence during the adolescent years. METHODS: Data were obtained between 2016 and 2017, from mortality records of patients managed for the selected diseases in the University College Hospital, a major referral centre in Nigeria. Information on costs of treatment, clinic visits, admission and transportation was obtained. Average costs of terminal in-patient care and transportation costs (in 2020 prices) were computed per patient. Costs were converted to the US dollar equivalent using the current official rate of US$1: ₦360.50. RESULTS: Twenty-two (out of 90 cases recorded) could be retrieved and all the patients had been diagnosed in the terminal stages of the disease. The average direct costs were ₦510 152.62 (US$1415.13) for an average of 49.2 days of terminal care for lung cancer; ₦308 950.27 (US$857.00) and ₦238 121.83 (US$660.53) for an average of 16.6 and 21.7 days of terminal care for patients managed for liver cancer and liver cirrhosis, respectively. CONCLUSION: The economic costs of each of the diseases were very high. Findings emphasise the need for aggressive efforts to promote primary prevention, improve early diagnosis and provide affordable treatment in view of the fact that the monthly minimum wage is less than US$85.00 and treatment costs are borne out-of-pocket by the generality of the population in Nigeria.

Health care costs during the last 12 months of life in Israel: estimation and implications for risk-adjustment.

Accumulating research shows that decedents' costs are high, they increase towards death, and they comprise a large proportion of total lifetime costs. The objectives of this paper are (i) to examine the Israeli pattern of medical care cost during the 12 months prior to death by gender, age, and chronic conditions, and (ii) to examine the implications of the results for the Israeli risk adjustment scheme. For the first objective, we used 12 month follow-up data on a cohort of decedents. For the second objective, we supplemented the data with a cross-section of enrollees (survivors and decedents in 2004). With regard to the first objective, we found that the broad Israeli patterns of cost match previous studies from other countries. With respect to the second objective, we argue that since the cost during the last 12 months of life is very high and is concentrated among relatively few persons, in order to prevent any adverse incentives caused by the combination of age-based risk adjustment and segmentation of end-of-life health care, death should be introduced into the existing retrospective risk-sharing arrangement.

Costs of appropriate and inappropriate use of antibiotics in the emergency department.

BACKGROUND: Appropriate antibiotic use is of both clinical and economic significance to any health system and should be given adequate attention. Prior to this study, no in-depth information was available on antibiotic use patterns in the emergency department of Hadassah Medical Center. OBJECTIVES: To describe the use and misuse of antibiotics and their associated costs in the emergency department of Hadassah Medical Center. METHODS: We analyzed the charts of 657 discharged patients and 45 admitted patients who received antibiotics in Hadassah's emergency department during a 6 week period (29 April - 11 June 2007). A prescription was considered appropriate or inappropriate if the choice of antibiotic, dose and duration by the prescribing physician after diagnosis was considered suitable or wrong by the infectious diseases consultant evaluating the prescriptions according to Kunin's criteria. RESULTS: The overall prescribing rate of antibiotics was 14.5% (702/4830) of which 42% were broad-spectrum antibiotics. The evaluated antibiotic prescriptions numbered 1105 (96 prescriptions containing 2 antibiotics, 2 prescriptions containing 3 antibiotics), and 54% of them were considered appropriate. The total inappropriate cost was 3583 NIS (1109 USD PPP) out of the total antibiotic costs of 27,300 NIS (8452 USD PPP). The annual total antibiotic cost was 237,510 NIS (73,532 USD PPP) and the annual total inappropriate cost was 31,172 NIS (9648 USD PPP). The mean costs of inappropriate prescriptions were highest for respiratory (112 NIS, 35 USD PPP) and urinary tract infection (93 NIS, 29 USD PPP). There were more cases when the optimal cost was lower than the actual cost (N = 171) than when optimal cost was higher than the actual cost (N = 9). In the first case, the total inappropriate costs were 3805 NIS (1178 USD PPP), and in the second case, -222 NIS (68.7 USD PPP). CONCLUSIONS: The use of antibiotics in emergency departments should be monitored, especially in severely ill patients who require broad-spectrum antibiotics and for antibiotics otherwise restricted in the hospital wards. Our findings indicate that 12% of the total antibiotic costs could have been avoided if all prescriptions were optimal.

Toward risk adjustment in mental health in Israel: calculation of risk adjustment rates from large outpatient and inpatient databases.

BACKGROUND: In 2015, mental health services were added to the Israeli National Health Insurance package of services. As such, these services are financed by the budget which is allocated to the Health Plans according to a risk adjustment scheme. An inter-ministerial team suggested a formula by which the mental health budget should be allocated among the Health Plans. Our objective in this study was to develop alternative rates based on individual data, and to evaluate the ones suggested. METHODS: The derivation of the new formula is based on our previous study of all psychiatric inpatients in Israel in the years 2012-2013 (n = 27,446), as well as outpatients in one psychiatric clinic in the same period (n = 6115). Based on Ministry of Health and clinic data we identified predictors of mental health services consumption. Age, gender, marital status and diagnosis were used as risk adjusters to calculate the capitation rates for outpatient care and inpatient care, respectively. All prices of services were obtained from the Ministry of Health tariffs. These rates were modified to include non-users using restricted models. RESULTS: The mental health capitation scales are typically "humped" with regard to age. The rates for ambulatory care varied from a minimum 0.19 of the average consumption for males above the age of 85 to a maximum of 1.93 times the average for females between the ages of 45-54. For inpatient services the highest rate was 409.25 times the average for single, male patients with schizophrenia spectrum diagnoses, aged 45-54. The overall mental health scale ranges from 2.347 times the average for men aged 45-54, to 0.191 for women aged 85+. The modified scale for the entire post-reform package of benefits (including both mental health care and physical health care) is increasing with age to 4.094 times the average in men aged over 85. The scale is flatter than the pre-reform scale. CONCLUSIONS: The risk adjustment rates calculated for outpatient care are substantially different from the ones suggested by the inter-ministerial team. The inpatient rates are new, and indicate that for patients with schizophrenia, a separate risk-sharing arrangement might be desirable. Adopting the rates developed in this analysis would decrease the budget shares of Clalit and Leumit with their relatively older populations, and increase Maccabi and Meuhedet's shares. Future research should develop a risk-adjustment scheme which covers directly both mental and physical care provided by the Israeli Health Plans, using their data.

Economic evaluation of the decisions of the Israeli Public Committee for updating the National List of Health Services in 2006/2007.

OBJECTIVE: The Public Committee (PC), which decides on the inclusion and ranking of new technologies in the Israeli List of Health Services facing a given budget, does not explicitly consider the results of economic evaluations of the technologies discussed. The present article includes an ex post economic examination of the PC's 2006/2007 decisions. METHODS: The cost per quality-adjusted life-year (QALY) (CPQ) values of the technologies approved and rejected were retrieved from national health technologies assessments and the professional literature. RESULTS: CPQ values were found for 40 technologies out of the 52 that were approved by the PC, and for 26 out of 42 randomly sampled among those rejected. The technologies approved for inclusion produce QALYs in a cheaper way, in general, than those rejected. A CPQ of about 50,000 new Israeli shekels (NIS) (15,500 USDPPP [purchasing power parity adjusted U.S. dollars]) is identified as the best discriminating value between approved and rejected technologies. The agreement between the PC's ranking of the approved technologies and the ranking by CPQ is low, and the only significant determinant of the Committee's ranking is the number of patients expected to benefit from the technology. CONCLUSIONS: Although not considering CPQ data explicitly, the PC tends, in fact, to approve technologies with relatively low CPQ. In ranking the approved technologies, however, the PC tries to maximize the number of persons expected to benefit from the additional budget even at the expense of possibly giving up cheaper QALYs. The size of the budget should be determined in accordance with an Israeli value of QALY and Israeli values of the CPQ of the technologies submitted for inclusion.

Inequality in treatment use among elderly patients with acute myocardial infarction: USA, Belgium and Quebec.

BACKGROUND: Previous research has provided evidence that socioeconomic status has an impact on invasive treatments use after acute myocardial infarction. In this paper, we compare the socioeconomic inequality in the use of high-technology diagnosis and treatment after acute myocardial infarction between the US, Quebec and Belgium paying special attention to financial incentives and regulations as explanatory factors. METHODS: We examined hospital-discharge abstracts for all patients older than 65 who were admitted to hospitals during the 1993-1998 period in the US, Quebec and Belgium with a primary diagnosis of acute myocardial infarction. Patients' income data were imputed from the median incomes of their residential area. For each country, we compared the risk-adjusted probability of undergoing each procedure between socioeconomic categories measured by the patient's area median income. RESULTS: Our findings indicate that income-related inequality exists in the use of high-technology treatment and diagnosis techniques that is not justified by differences in patients' health characteristics. Those inequalities are largely explained, in the US and Quebec, by inequalities in distances to hospitals with on-site cardiac facilities. However, in both Belgium and the US, inequalities persist among patients admitted to hospitals with on-site cardiac facilities, rejecting the hospital location effect as the single explanation for inequalities. Meanwhile, inequality levels diverge across countries (higher in the US and in Belgium, extremely low in Quebec). CONCLUSION: The findings support the hypothesis that income-related inequality in treatment for AMI exists and is likely to be affected by a country's system of health care.

The economic burden of health disparities related to socioeconomic status in Israel.

BACKGROUND: Low socioeconomic status (SES) is often associated with excess morbidity and premature mortality. Such health disparities claim a steep economic cost: Possibly-preventable poor health outcomes harm societal welfare, impair the domestic product, and increase health care expenditures. We estimate the economic costs of health inequalities associated with socioeconomic status in Israel. METHODS: The monetary cost of health inequalities is estimated relative to a counterfactual with a more equal outcome, in which the submedian SES group achieves the average health outcome of the above-median group. We use three SES measures: the socioeceonmic ranking of localities, individuals' income, and individuals' education level. We examine costs related to the often-worse health outcomes in submedian SES groups, mainly: The welfare and product loss from excess mortality, the product loss from excess morbidity among workers and working-age adults, the costs of excess medical care provided, and the excess government expenditure on disability benefits. We use data from the Central Bureau of Statistics' (CBS) surveys and socio-health profile of localities, from the National Insurance Institute, from the Ministry of Health, and from the Israel Tax Authority. All costs are adjusted to 2014 terms. RESULTS: The annual welfare loss due to higher mortality in socioeconomically submedian localities is estimated at about 1.1-3.1 billion USD. Excess absenteeism and joblessness occasioned by illness among low-income and poorly educated workers are associated with 1.4 billion USD in lost product every year. Low SES is associated with overuse of inpatient care and underuse of community care, with a net annual cost of about 80 million USD a year. The government bears additional cost of 450 million USD a year, mainly due to extra outlays for disability benefits. We estimate the total cost of the estimated health disparities at a sum equal to 0.7-1.6% of Israel's GDP. CONCLUSIONS: Our estimates underline the substantial economic impact of SES-related health disparities in Israel. The descriptive evidence presented in this paper highlights possible benefits to the economy from policies that will improve health outcomes of low SES groups.