Emmett B. Keeler

Does free care improve adults' health? Results from a randomized controlled trial.

Does free medical care lead to better health than insurance plans that require the patient to shoulder part of the cost? In an effort to answer this question, we studied 3958 people between the ages of 14 and 61 who were free of disability that precluded work and had been randomly assigned to a set of insurance plans for three or five years. One plan provided free care; the others required enrollees to pay a share of their medical bills. As previously reported, patients in the latter group made approximately one-third fewer visits to a physician and were hospitalized about one-third less often. For persons with poor vision and for low-income persons with high blood pressure, free care brought an improvement (vision better by 0.2 Snellen lines, diastolic blood pressure lower by 3 mm Hg); better control of blood pressure reduced the calculated risk of early death among those at high risk. For the average participant, as well as for subgroups differing in income and initial health status, no significant effects were detected on eight other measures of health status and health habits. Confidence intervals for these eight measures were sufficiently narrow to rule out all but a minimal influence, favorable or adverse, of free care for the average participant. For some measures of health in subgroups of the population, however, the broader confidence intervals make this conclusion less certain.

COMPARISON OF HEALTH OUTCOMES AT A HEALTH MAINTENANCE ORGANISATION WITH THOSE OF FEE-FOR-SERVICE CARE

To determine whether health outcomes in a health maintenance organisation (HMO) differed from those in the fee-for-service (FFS) system, 1673 individuals ages 14 to 61 were randomly assigned to one HMO or to an FFS insurance plan in Seattle, Washington for 3 or 5 years. For non-poor individuals assigned to the HMO who were initially in good health there were no adverse effects. Health outcomes in the two systems of care differed for high and low income individuals who began the experiment with health problems. For the high income initially sick group, the HMO produced significant improvements in cholesterol levels and in general health ratings by comparison with free FFS care. The low income initially sick group assigned to the HMO reported significantly more bed-days per year due to poor health and more serious symptoms than those assigned free FFS care, and a greater risk of dying by comparison with pay FFS plans.

The Costs of Poor Health Habits

Conceptual framework data and statistical methods the external costs of smoking the external costs of heavy drinking the external costs of sedentary life-styles conclusions, limitations and implications. Appendices: literature review of the costs of smoking and drinking survival parameters from the HRA model HIE habit batteries statistical methods comparability of HIE and NHIS excise taxes and demand parameters used in the cost model a note on the alcohol tax.

Cost-effectiveness of CT screening in the National Lung Screening Trial.

BACKGROUND The National Lung Screening Trial (NLST) showed that screening with low-dose computed tomography (CT) as compared with chest radiography reduced lung-cancer mortality. We examined the cost-effectiveness of screening with low-dose CT in the NLST. METHODS We estimated mean life-years, quality-adjusted life-years (QALYs), costs per person, and incremental cost-effectiveness ratios (ICERs) for three alternative strategies: screening with low-dose CT, screening with radiography, and no screening. Estimations of life-years were based on the number of observed deaths that occurred during the trial and the projected survival of persons who were alive at the end of the trial. Quality adjustments were derived from a subgroup of participants who were selected to complete quality-of-life surveys. Costs were based on utilization rates and Medicare reimbursements. We also performed analyses of subgroups defined according to age, sex, smoking history, and risk of lung cancer and performed sensitivity analyses based on several assumptions. RESULTS As compared with no screening, screening with low-dose CT cost an additional

The Thyroid Nodule

1,631 per person (95% confidence interval [CI], 1,557 to 1,709) and provided an additional 0.0316 life-years per person (95% CI, 0.0154 to 0.0478) and 0.0201 QALYs per person (95% CI, 0.0088 to 0.0314). The corresponding ICERs were

DEDUCTIBLES AND THE DEMAND FOR MEDICAL CARE SERVICES: THE THEORY OF A CONSUMER FACING A VARIABLE PRICE SCHEDULE UNDER UNCERTAINTY

52,000 per life-year gained (95% CI, 34,000 to 106,000) and

The External Costs of a Sedentary Life-Style

81,000 per QALY gained (95% CI, 52,000 to 186,000). However, the ICERs varied widely in subgroup and sensitivity analyses. CONCLUSIONS We estimated that screening for lung cancer with low-dose CT would cost

Short- and Long-Term Residents of Nursing Homes

81,000 per QALY gained, but we also determined that modest changes in our assumptions would greatly alter this figure. The determination of whether screening outside the trial will be cost-effective will depend on how screening is implemented. (Funded by the National Cancer Institute; NLST ClinicalTrials.gov number, NCT00047385.).

Prevention of Unintentional Weight Loss in Nursing Home Residents: A Controlled Trial of Feeding Assistance

Abstract The various techniques for evaluating a thyroid nodule are described and their relative values analyzed. Fine-needle aspiration is the most sensitive and specific test among the leading te...

Effect of Epidural Analgesia for Labor on the Cesarean Delivery Rate

We consider a theoretical model of a consumer who faces a price that varies with the number of units bought, and who faces random future changes in his demand for the good. An example is cumulative deductibles in health insurance policies. The problem is treated as a dynamic program involving medical demand under an insurance policy with a deductible. In this model, the perceived price of care falls (following a nonlinear path) as the consumer approaches the deductible. The model suggests: (i) Because demand and administrative costs are likely to be insensitive to the size of the deductible above a certain range, deductibles above that range will not be optimal; they add risk with no return. (ii) Demand estimates will be biased if insurance policies in the sample contain deductibles and if the dependent variable is annual medical demand. (iii) Demand analysis by episode of illness is the appropriate framework in such circumstances. THE THEORY OF A CONSUMER facing a deductible in a health insurance policy is considered in this paper. The important differences from the usual theory of the consumer are two: the nominal price per unit changes if a specified amount of medical services are bought within a specified period, and uncertainty is present regarding future demand within the period. We shall construct a model of consumer behavior that implies the consumer acts as though he faces a shadow price lower than the nominal price in the range below the deductible. The implications of the model for the estimation of medical demand functions and for the design of optimal insurance policies are explored below. Additionally, we touch on such diverse applications for the model as unemployment benefits, the taking of sick leave, family and work-group relationships, and political logrolling. Deductibles are common in existing health insurance; in 1970, about 40 per cent of the private insurance policies had a deductible [13], as did Medicare. The