Bianca K. Frogner

Health Spending In OECD Countries: Obtaining Value Per Dollar

In 2005 the United States spent

Health Savings Accounts and Health Care Spending

6,401 per capita on health care-more than double the per capita spending in the median Organization for Economic Cooperation and Development (OECD) country. Between 1970 and 2005, the United States had the largest increase (8.3 percent) in the percentage of gross domestic product (GDP) devoted to health care among all OECD countries. Despite having the third-highest level of spending from public sources, public insurance covered only 26.2 percent of the U.S. population in 2005. The United States was equally likely to be in the top and bottom halves for sixteen quality measures compiled by the OECD.

Welfare Reform in the Mid-2000s: How African American and Hispanic Families in Three Cities Are Faring

OBJECTIVE The impact of consumer-driven health plans (CDHPs) has primarily been studied in a small number of large, self-insured employers, but this work may not generalize to the wide array of firms that make up the overall economy. The goal of our research is to examine effects of health savings accounts (HSAs) on total, medical, and pharmacy spending for a large number of small and midsized firms. DATA SOURCES Health plan administrative data from a national insurer were used to measure spending for 76,310 enrollees over 3 years in 709 employers. All employers began offering a HSA-eligible plan either on a full-replacement basis or alongside traditional plans in 2006 and 2007 after previously offering only traditional plans in 2005. STUDY DESIGN We employ difference-in-differences generalized linear regression models to examine the impact of switching to HSAs. DATA EXTRACTION METHODS; Claims data were aggregated to enrollee-years. PRINCIPAL FINDINGS For total spending, HSA enrollees spent roughly 5-7 percent less than non-HSA enrollees. For pharmacy spending, HSA enrollees spent 6-9 percent less than traditional plan enrollees. More of the spending decrease was observed in the first year of enrollment. CONCLUSIONS Our findings are consistent with the notion that CDHP benefit designs affect decisions that are at the discretion of the consumer, such as whether to fill or refill a prescription, but have less effect on care decisions that are more at the discretion of the provider.

Incorporating new research into Medicare risk adjustment.

This article reports on a sample of 538 African American and Hispanic women who were receiving Temporary Assistance for Needy Families (TANF) in 1999, 416 of whom left the program by 2005. The Hispanic women consisted of a Mexican-origin group and a second group that was primarily Puerto Rican and Dominican. Combining the experiences of the employed and the non-employed welfare leavers, the authors find at best a modest decline in the average poverty rate among African American welfare leavers between 1999 and 2005. Hispanic leavers showed larger average declines in poverty. Among just the welfare leavers who were employed in 2005, the averages for women in all racial-ethnic groups showed increases in household income and declines in poverty. Among those who were not employed, African Americans had experienced a decline in household income and were further below the poverty line than in 1999, whereas Hispanic women had experienced modest declines or slight increases in their household incomes.

Community Health Centers Employ Diverse Staffing Patterns, Which Can Provide Productivity Lessons For Medical Practices

Background:The Medicare Advantage payment system underpays health plans that enroll beneficiaries with multiple and complex chronic conditions. Objectives:This article addresses 3 major problems in the current payment system: (1) underreporting of chronic disease prevalence in fee-for-service (FFS) Medicare claims data, (2) overpayment of healthier and underpayment of sicker beneficiaries in the current payment system, and (3) underpayment for new beneficiaries in Medicare Advantage plans that require the beneficiaries to have at least one chronic disease to enroll. Research Design:We incorporate 2 years of data and a count of chronic diseases in the current Medicare payment model. We develop a separate payment adjustment for new enrollees. Subjects:A nationally representative sample of FFS beneficiaries in the 2004–2006 Medicare 5% claims data. Measures:We use predictive ratios to evaluate whether our enhanced model improves the predictive accuracy over the current model overall and for subsets of beneficiaries. Results:The underreporting of chronic disease prevalence in Medicare FFS by 20% leads to systematic bias in the disease coefficients and demographic adjusters. The enhanced model reduces the level of payment for healthy beneficiaries and increases the payment for beneficiaries with multiple and complex chronic conditions. It improves payment for plans that enroll new enrollees with specific chronic conditions. Conclusions:Our enhanced model reduces financial incentives for health plans to engage in risk selection against beneficiaries with multiple chronic conditions.

Health and Economic Gains: What Is at Stake in South Africa's Health Reform?

Community health centers are at the forefront of ambulatory care practices in their use of nonphysician clinicians and team-based primary care. We examined medical staffing patterns, the contributions of different types of staff to productivity, and the factors associated with staffing at community health centers across the United States. We identified four different staffing patterns: typical, high advanced-practice staff, high nursing staff, and high other medical staff. Overall, productivity per staff person was similar across the four staffing patterns. We found that physicians make the greatest contributions to productivity, but advanced-practice staff, nurses, and other medical staff also contribute. Patterns of community health center staffing are driven by numerous factors, including the concentration of clinicians in communities, nurse practitioner scope-of-practice laws, and patient characteristics such as insurance status. Our findings suggest that other group medical practices could incorporate more nonphysician staff without sacrificing productivity and thus profitability. However, the new staffing patterns that evolve may be affected by characteristics of the practice location or the types of patients served.

The Missing Technology: An International Comparison of Human Capital Investment in Healthcare

Background: Health reform is on the agenda of the recently elected South African president. A National Health Insurance Scheme (NHI), a single-payer and universal health insurance plan, is the foremost option under consideration. This study examines the health and economic gains that South Africa may have at stake in health reform. Method: This descriptive study estimates the avoidable mortality rate in South Africa, or deaths that occur prematurely and could have been prevented with proper treatment for select conditions. The study also estimates the disability-adjusted life years (DALYs) associated with these premature deaths. The study compares the avoidable mortality rate in South Africa with the rates in countries falling into three overlapping groups: (1) countries with similar national health spending as South Africa, (2) countries with similar national health spending and universal health insurance coverage, and (3) countries with similar national health spending, universal health insurance coverage, and single-payer systems. Data: The source of data for avoidable mortality estimates is the World Health Organization (WHO) mortality database reporting the number of registered deaths in 2005. The source of data for the associated DALYs is the Mortality and Burden of Disease Estimate for WHO Member States in 2004. Results: South Africa could potentially gain up to 184,085 lives and reduce the burden of disease by 14.2 million DALYs by avoiding premature deaths under a single-payer system like the NHI. Meeting United Nations Millennium Development Goals could save an additional 32,190 lives. In addition to health reform, a healthy, productive, and skilled workforce is necessary to reach these goals, but the countrys skilled-labor unemployment rate is high and its investment in health-professional training is low. Conclusion: Reform could impact health and economic growth via a healthier, productive workforce and demand for quality healthcare.

Comparative drug policies--heresy: learning from other countries.

This article explores human capital investment to understand cross-sectional variation and differences in growth of health spending among the US, Australia and Canada. Using a human capital model developed by Mincer, the article examines how rate of return to schooling and years of schooling impact wage rate levels in healthcare. The model is extended to approximate the probable trajectory of healthcare wage rate growth and thus the impact on health spending. The results suggest that a higher rate of return to schooling and a more educated healthcare workforce in the US may contribute to higher healthcare wage rates and thus contribute to higher health spending levels than in Canada and Australia. The results also suggest that average healthcare wage rates are growing at the rate of potential GDP; healthcare wage rates are not driving the growth of health spending.

Health care spending and use of information technology in OECD countries.

THE safety, price, and utilization of prescription drugs is already a major clinical and policy issue in the United States and all indications are that the level of attention will intensify over the next several years. Although it may be considered heresy in some clinical and policy circles to even suggest that the United States can learn from other countries, pharmaceutical policy is one area in which cross-national learning may be possible. The previous issue of The Journal of Ambulatory Care Management offered several ideas from Europe that US policymakers should consider. Beginning with the previous issue and reviewing other articles detailing the experiences in Canada, Australia, Korea, and Taiwan, clinical and policy communities in the United States can examine pharmaceutical policies that have been implemented in other countries (Anderson, 1989; Birkett et al., 2001; Cheng, 2003; Kanavos &