nep-hea New Economics Papers
on Health Economics
Issue of 2009‒03‒22
twelve papers chosen by
Yong Yin
SUNY at Buffalo, USA

  1. Variation in the costs of healthcare for chronic disease in Australia: The case of asthma, CHERE Working Paper 2008/7 By Patsy Kenny; Jane Hall; Madeleine King
  2. Issues in evaluating the costs and cost-effectiveness of Cognitive Behavioural Therapy for overweight/obese adolescents, CHERE Working Paper 2009/1 By Marion Haas; Richard Norman; Jeff Walkley; Leah Brennan
  3. Health and Income: a Robust Comparison of Canada and the US By Jean-Yves Duclos; Damien Échevin
  4. Horizontal Inequity in Access to Healthcare Services and Educational Level in Spain By Roberto Montero Granados; José Jesús Martín Martín; Juan de Dios Jiménez Aguilera
  5. Ageing, Health and Life Satisfaction of the Oldest Old: An Analysis for Germany By Gwozdz, Wencke; Sousa-Poza, Alfonso
  6. The Macro-Micro Nexus in Scaling-Up Aid: The Case of HIV and AIDS Control in Kenya, Malawi and Zambia By Degol Hailu; Sonal Singh
  7. More equal but heavier: A longitudinal analysis of income-related obesity inequalities in an adult Swedish cohort By Ljungvall , Åsa; Gerdtham , Ulf-G
  8. Measuring Disparities in Health Status and in Access and Use of Health Care in OECD Countries By Michael de Looper; Gaetan Lafortune
  9. The preferred doctor scheme: A political reading of a French experiment of Gate-keeping By Michel Naiditch; Paul Dourgnon
  10. Do immigrants work in riskier jobs? By Pia M. Orrenius; Madeline Zavodny
  11. Waiting Time Targets in Healthcare Markets: How Long Are We Waiting? By Huw Dixon; Luigi Siciliani
  12. The Effects of the War in Iraq on Nutrition and Health: An Analysis Using Anthropometric Outcomes of Children By Guerrero Serdan, Gabriela

  1. By: Patsy Kenny (CHERE, University of Technology, Sydney); Jane Hall (CHERE, University of Technology, Sydney); Madeleine King
    Abstract: Objectives Individuals with chronic conditions represent a high healthcare cost group and understanding the cost variation among individuals is important for developing appropriate policy. This study aimed to investigate the sources of variation in the cost of healthcare for a cohort of people with asthma. It examines the costs to the health system and patient out-of-pocket costs. Methods A longitudinal observational study of asthma-related healthcare costs in a cohort of people with asthma (n=252). Participants were followed for three years using six-monthly postal surveys and individual administrative data. The factors associated with health system and patient out-of-pocket costs were investigated using generalised linear mixed models. Results There was substantial variability around the average costs of healthcare for asthma which were associated with asthma-related health measures and socio-demographic variables. The health system costs were less for those living in regional areas relative to Sydney residents and both the health system and patient out-of-pocket costs were highest in the oldest age group and lowest for children. The health system and patient out-of-pocket costs were highest for the high income group while the middle income group had the lowest total cost. Conclusions Our findings suggest that variations should be explored in developing strategies for chronic disease management and that Australia has achieved reasonable equity in access. However, out-of-pocket costs may be a deterrent for the middle income group, which should be a general concern for policies targeting the most disadvantaged group to the exclusion of concern with universal access.
    Keywords: asthma, out-of-pocket costs, Australia
    JEL: I10
    Date: 2008–12
  2. By: Marion Haas (CHERE, University of Technology, Sydney); Richard Norman (CHERE, University of Technology, Sydney); Jeff Walkley; Leah Brennan
    Abstract: Economic evaluation is the systematic assessment of the costs and consequences of alternative courses of action. In health and healthcare, the results can be used to inform clinicians and policy makers about the relative cost-effectiveness of options under consideration [1]. Many economic evaluations are undertaken alongside randomised controlled trials (RCTs); the advantages of this approach are that i) prospective, accurate data can be collected on costs and effects and ii) appropriate outcome measures for use in economic evaluation can be chosen. The outcome of an economic evaluation is usually described as a ratio of the costs and effects ? often called the incremental cost-effectiveness ratio (ICER). The ICER is determined by calculating the differences in the costs and effects of both intervention and control groups and dividing the former by the latter. In designing an economic evaluation, the important questions to resolve are: which costs should be included and which outcome measures are most appropriate for estimating the cost-effectiveness ratio? In 2005, the Australian Technology Network of Universities funded the Centre for Metabolic Fitness (CMF) through a competitive, peer-reviewed process. The aims of the centre are to develop and evaluate diet and exercise interventions to counteract metabolic syndrome and assess their acceptability by target community groups. Metabolic syndrome is a cluster of metabolically determined risk factors associated with obesity (e.g. hypertension, impaired blood glucose etc). A number of collaborative projects have been developed within the centre, one of which is the CHOOSE HEALTH project. As part of this project, the effectiveness of cognitive behavioural therapy (CBT) as an intervention for overweight or obese adolescents has been trialled at the University of RMIT by Leah Brennan and the University of South Australia by Margarita Tsiros, as part of their post-graduate studies1. Subsequently, it has been decided to add an economic component to this work. Trials of the effectiveness and cost-effectiveness of different means of delivering cognitive behaviourally based weight management programs are planned2. This paper reports the results of investigations into the two questions which need to be addressed prior to undertaking a formal economic evaluation of the CHOOSE HEALTH program: i) what costs should be included and ii) which measures of outcome are suitable for estimating an ICER in this context. The paper is organised in four sections. Following the introduction (section 1) and brief descriptions of the background to and context in which the program was planned (section 2), details of the RMIT trial design and results are provided in section 3. In the final section (section 4), a cost model is presented and the implications of the outcomes used in the initial trials of the effectiveness are discussed in relation to designing a prospective economic evaluation of the CHOOSE HEALTH program.
    Keywords: costs, economic evaluation, cognitive behavioural therapy (CBT), adolescent obesity, Australia
    JEL: I10
    Date: 2009–01
  3. By: Jean-Yves Duclos; Damien Échevin
    Abstract: This paper uses sequential stochastic dominance procedures to compare the joint distribution of health and income across space and time. It is the first application of which we are aware of methods to compare multidimensional distributions of income and health using procedures that are robust to aggregation techniques. The paper's approach is more general than comparisons of health gradients and does not require the estimation of health equivalent incomes. We illustrate the approach by contrasting Canada and the US using comparable data. Canada dominates the US over the lower bi-dimensional welfare distribution of health and income, though not generally in terms of the uni-dimensional distribution of health or income. The paper also finds that welfare for both Canadians and Americans has not unambiguously improved during the last decade over the joint distribution of income and health, in spite of the fact that the uni-dimensional distributions of income have clearly improved during that period.
    Keywords: Health inequality, self-reported health status, income distribution, stochastic dominance, social welfare
    JEL: I10 I32 I38 D63 D30 H51
    Date: 2009
  4. By: Roberto Montero Granados (Universidad de Granada. Deparment of Applied Economics); José Jesús Martín Martín (Universidad de Granada. Deparment of Applied Economics); Juan de Dios Jiménez Aguilera (Universidad de Granada. Deparment of Applied Economics)
    Abstract: The aim of this study is to measure horizontal equity in the use of healthcare services in Spain, proposing two methodological innovations. First by defending it as equality of access for equal need, irrespective of educational level, unlike the prevailing methodological approach to horizontal equity which relates it to income. Second, by estimating it by means of the slope index of the inequality of characteristics, analagous to the inequity index proposed by Kakwani, Wagstaff and van Doorslaer (1997; HIWV) but presenting some methodological advantages, the greater robustness of the data available on educational level than of those on income, and the possibility of isolating the net effect of the educational level on the use of healthcare by controlling for other variables. The methodology is designed in three parts: (1) estimation of the relationship between the educational level and the use of healthcare services by means of a model of the likelihood of demand for healthcare services, commonly used in the literature; (2) estimation of the relationship between educational level and health by approximating a production function of individuals' health according to their personal characteristics and other factors conditioning health; and (3) estimation of the slope index of inequality as a measure of horizontal inequity, using educational level instead of income as the criterion for ranking individuals. The data base used was a sample of 55,598 observations from the Survey of disabilities, handicaps and state of health of 1999, carried out in Spain. No significant statistical association was found between educational level and use of healthcare services. On the other hand, the relationship between educational level and health, with the three proxy variables used (perception of health, days of limitation and number of chronic illnesses) shows a positive correlation, i.e. an increase in educational level is associated with a greater probability of enjoying better health. Horizontal inequity, measured by the proposed slope index of inequality, gives a range of statistically significant values between 13.91% and 9.40%, depending on cases, i.e. the significant inverse relationship between state of health and educational level is not reflected proportionally in healthcare use, implying that, with greater need, the access of individuals with a lower educational level to public healthcare services is the same as for the rest. These results suggest that the educational level may be a variable to consider when characterizing the healthcare needs of a population in a defined geographical area, at least from the normative characterization of horizontal equity proposed
    Keywords: Education and health; Healthcare needs; Horizontal Inequity; Logistic regression ; Ordinal regression; Regional funding
    JEL: C21 H42 H77 I12 I20
    Date: 2008–11–16
  5. By: Gwozdz, Wencke (University of Hohenheim); Sousa-Poza, Alfonso (University of Hohenheim)
    Abstract: This analysis uses data from the German Socio-Economic Panel (GSOEP) and the Survey on Health, Ageing and Retirement in Europe (SHARE) to assess the effect of ageing and health on the life satisfaction of the oldest old (defined as 75 and older). We observe a U-shaped relationship between age and levels of life satisfaction for individuals aged between 16 and approximately 65. Thereafter, life satisfaction declines rapidly and the lowest absolute levels of life satisfaction are recorded for the oldest old. This decline is primarily attributable to low levels of perceived health. Once cohort effects are also controlled for, life satisfaction remains relatively constant across the lifespan.
    Keywords: oldest old, health, life satisfaction
    JEL: I18 I19 J28
    Date: 2009–03
  6. By: Degol Hailu (UNDP SURF); Sonal Singh (International Policy Centre for Inclusive Growth)
    Abstract: About 33 million people currently live with HIV. The disease has reduced life expectancy by about 20 years. Nearly 12 million children are orphaned. It is now well established that the epidemic demands an immediate increase in resources. The main questions that arise are where the resources will come from, and whether they can be fully spent and absorbed. One major source of financing for HIV and AIDS control is external aid. A recent report by the International Monetary Fund (IMF) computed the macroeconomic implications of scaling-up aid as promised by the G-8 at Gleneagles. The assessments for Benin, Niger and Togo indicate that scaling-up aid will put moderate to sizable pressure on inflation and exchange rates (IMF, 2008).
    Keywords: The Macro-Micro Nexus in Scaling-Up Aid: The Case of HIV and AIDS Control in Kenya, Malawi and Zambia
    Date: 2009–01
  7. By: Ljungvall , Åsa (Department of Economics, Lund University); Gerdtham , Ulf-G (Department of Economics, Lund University)
    Abstract: Using longitudinal data over a 17 year period for a Swedish cohort aged 20-68 in 1980/81, this study analyses income-related inequalities in obesity. By use of the concentration index and decomposition techniques we answer the following questions: 1) Does obesity inequality favour or disfavour the poor? 2) What factors explain this inequality at different points in time? 3) How can the pattern of inequality over time be explained? We find that among females, inequalities in obesity favour the rich, but the estimated inequality declines over time. Income and marital status are the main driving forces behind obesity inequality, and income explains the majority of the declined obesity inequality over time. The results indicate that the main reason for the reduced obesity inequality is increased obesity prevalence, because in absolute terms obesity has increased uniformly across income groups. Thus we conclude that the reduced inequality is not due to any health policy success. Since the income elasticity of obesity is the individual most important contributor to the observed inequality, policies directed towards this factor might be the most effective. Similar trends are found for males, although less pronounced. This should be taken into account when evaluating obesity reducing policies.
    Keywords: obesity; income; inequality; ageing; women; concentration index; decomposition; Oaxaca; panel data
    JEL: I12 I18
    Date: 2009–03–09
  8. By: Michael de Looper; Gaetan Lafortune
    Abstract: Most OECD countries have endorsed as major policy objectives the reduction of inequalities in health status and the principle of adequate or equal access to health care based on need. These policy objectives require an evidence-based approach to measure progress. This paper assesses the availability and comparability of selected indicators of inequality in health status and in health care access and use across OECD countries, focussing on disparities among socioeconomic groups. These indicators are illustrated using national or cross-national data sources to stratify populations by income, education or occupation level. In each case, people in lower socioeconomic groups tend to have a higher rate of disease, disability and death, use less preventive and specialist health services than expected on the basis of their need, and for certain goods and services may be required to pay a proportionately higher share of their income to do so.<BR>Les politiques de santé dans la plupart des pays de l’OCDE ont comme objectifs majeurs la réduction des inégalités en matière de santé et le respect du principe d’un accès adéquat ou égal aux soins basé sur les besoins. Des données robustes et fiables sont nécessaires pour mesurer l’atteinte de ces objectifs politiques. Ce document de travail évalue la disponibilité et la comparabilité de certains indicateurs de l’inégalité de l’état de santé et de l’accès et de l’utilisation des soins dans les pays de l’OCDE, en se concentrant sur les disparités selon les groupes socio-économiques. Ces indicateurs sont illustrés à partir de sources de données nationales ou internationales qui permettent de distinguer les populations par niveau de revenu, d’éducation et d’emploi. Dans tous les cas, les personnes appartenant à des groupes socio-économiques désavantagés ont tendance à avoir des taux de morbidité, d’incapacité et de mortalité plus élevés, à utiliser moins de services préventifs et de soins spécialisés que ce à quoi on pourrait s’attendre sur la base de leurs besoins, et à payer une plus large part de leur revenu pour se procurer certains biens et services de santé.
    JEL: I10 I18 J10
    Date: 2009–03–09
  9. By: Michel Naiditch (IRDES institut for research and information in health economics); Paul Dourgnon (IRDES institut for research and information in health economics)
    Abstract: Study objective: Since January 2005 France is exploring a new scheme termed "preferred doctor" (médecin traitant) which can be considered as an innovative version of Gate Keeping in order to reduce the excess of postulated excess in health consumption, more especially access to specialist care. This paper describes the political process which lead to it's implementation, tries to relate some of the scheme specific features with it's results after one year implementation and tries to catch a glimpse for the next steps of the reform. Material and methods: In order to measure the scheme impact on the "patient treatment pathway" and on physician income, we used a sample of 7198 individual from the 2006 "French health, Health Care and Insurance Survey "(ESPS),"including health, socioeconomic and insurance status and through a set of questions relating to patient's understanding of the scheme and different data bases of the national sickness fund as well as different studies done by regulatory agencies. Results and discussion: First results after one year implementation show that most patients chose a preferred doctor, who in a vast majority happened to be their family doctor. A vast majority of patients also considered the scheme as mandatory. Impact on access to specialist care, as measured through self assessed unmet need for specialist care, appears not negligible, especially for the less well off and those not covered by a complementary insurance. In term of financial impact, the new constraints on access to ambulatory care seem to have been offset by rises in the fee schedules for the specialities which lost direct access We discuss why these short term weak outcomes are linked with a wicked system of the health system governance and to the political and professional context in which the scheme unfolded strongly and determined its structure and implementation pathway. On a more long range perspective, we analyse how the new scheme may nevertheless lead up to reinforced managed care reforms.
    Keywords: Managed Care, Gate keeping, health care services utilization, unmet needs.
    JEL: I18
    Date: 2009–03
  10. By: Pia M. Orrenius; Madeline Zavodny
    Abstract: Recent media and government reports suggest that immigrants are more likely to hold jobs with worse working conditions than U.S.-born workers, perhaps because immigrants work in jobs that "natives don?t want." Despite this widespread view, earlier studies have not found immigrants to be in riskier jobs than natives. This study combines individual-level data from the 2003?2005 American Community Survey with Bureau of Labor Statistics data on work-related injuries and fatalities to take a fresh look at whether foreign-born workers are employed in more dangerous jobs. The results indicate that immigrants are in fact more likely to work in risky jobs than U.S.-born workers, partly due to differences in average characteristics, such as immigrants' lower English language ability and educational attainment.
    Keywords: Immigrants ; Human capital ; Labor economics
    Date: 2009
  11. By: Huw Dixon; Luigi Siciliani
    Abstract: Waiting-time targets are frequently used by policy makers in the healthcare sector to monitor providers' performance. Such targets are based on the distribution of the patients on the list. We compare and link such distribution with the distribution of waiting time of the patients treated, as opposed to on the list, which is arguably a better measure of welfare or total disutility from waiting (although it can only be calculated retrospectively). We show that the latter can be estimated from the former, and viceversa. We also show that, depending the hazard function, one distribution may be more or less favourable than the other. However, empirically we .nd that the proportion of patients waiting on the list more than x months is a downward estimate of the proportion of patients treated waiting more than x months, therefore biasing downwards the total disutility from waiting.
    Keywords: Waiting times; duration; targets.
    JEL: I11 I18
    Date: 2009–03
  12. By: Guerrero Serdan, Gabriela
    Abstract: The war in Iraq initiated in March 2003 triggered a wave of violence and turmoil in the country, exposing households to insecurity and to instability in daily life. The level of violence has varied across provinces, the south and centre areas being the most affected. Using the different intensities of the conflict across areas and the age at exposure to the war among cohorts, I analyze a possible causal effect of the war on nutritional outcomes of children. I use two empirical strategies, leading to very similar results. Estimates indicate that children born in areas affected by high levels of violence are 0.8 cm shorter than children born in low violence provinces. These results are robust to several specifications. Furthermore, the paper also addresses the channels through which the conflict has affected health and nutrition. The results have not only short-term policy implications, but also, given the empirical evidence of the impact of early child malnutrition on later education, labour and productivity outcomes, the results are of great importance for the future.
    Keywords: health; nutrition; shocks; war; children; Iraq
    JEL: I12 O15 I00 J0
    Date: 2009–02

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