SELECTED FOR YOU... APRIL 2009: books of the month - working papers

All the Selected for you

BOOKS

Primary Health Care : people, practice, place.

Crooks V.A. / éd. Andrexs G.J. / éd.

Burlington : Ashgate Publishing Company : 2009 : 16-280 p.

Health care is constantly undergoing change and refinement resulting from the adoption of new practices and technologies, the changing nature of societies and populations, and also shifts in the very places from which care is delivered. Primary Health Care: People, Practice, Place draws together significant contributions from established experts across a variety of disciplines to focus on such changes in primary health care, not only because it is the most basic and integral form of health service delivery, but also because it is an area to which geographers have made significant contributions and to which other scholars have engaged in 'thinking geographically' about its core concepts and issues. Including perspectives from both consumers and producers, it moves beyond geographical accounts of the context of health service provision through its explicit focus on the practice of primary health care. With arguments well-supported by empirical research, this book will appeal not only to scholars across a range of social and health sciences, but also to professionals involved in health services.

The care revolution : man at the centre of the global service revolution

Vial M.

Nouveaux débats publics : 2008 : 182 p.

After the Industrial Revolution and the Digital Revolution, will the new revolution of the post-industrial era be that of personal services? Powerful social and cultural trends are driving this new global paradigm including an ageing population, increasing urbanisation, broken families and the priority today attached to health and well-being which are all factors set to bring about an explosion in the demand for personal services in both industrialised and emerging countries: The Care Revolution is more than just a revolution in personal services, as it also embodies qualitative changes in the demand for tailored services. It is a clear indication of a new demand from consumers to be personally taken care of in solving theirproblems, whether day-to-day situations or the more dramatic. Personal services are a major economic sector, but one which is still undervalued and given insufficient regard. As Martin Vial sees it, the combination of the latest technology and tailored local access to services will make it possible to expand the range of possibilities while also generating greater economic value. At the same time, the author argues the case for a huge effort to professionalise the various participants in this industry and to ensure that their activities receive the recognition they so rightly deserve. The Care Revolution is also a social and ethical challenge as the health and treatment of the elderly form the very nucleus of this revolution. Life Management Programs are designed to support us throughout our lives to guarantee our physical and psychological health and well-being. The challenge of dependency is also a major factor: we need to devote ever more financial and human resources to caring for an expanding dependent population, in which the use of new technologies will need to be extended to all. To support this global revolution, many key economic players have made their contribution, although the prevailing economic model still remains to be defined. One thing is certain though: the various participants in the “insuristance” sector (a combination of traditional insurance and modern forms of personal assistance services) will certainly be at the very forefront of events.

WORKING PAPERS

Health expenditure

Income and health spending : evidence from oil price shocks.

Acemoglu D., Finkelstein A., Notowidigdo D.
Cambridge : NBER : 2009/02 : 74 p.

Health expenditures as a share of GDP have more than tripled over the last half century. A common conjecture is that this is primarily a consequence of rising real per capita income, which more than doubled over the same period. We investigate this hypothesis empirically by instrumenting for local area income with time-series variation in global oil prices between 1970 and 1990 interacted with cross-sectional variation in the oil reserves across different areas of the Southern United States. This strategy enables us to capture both the partial equilibrium and the local general equilibrium effects of an increase in income on health expenditures. Our central estimate is an income elasticity of 0.7, with an elasticity of 1.1 as the upper end of the 95 percent confidence interval. Point estimates from alternative specifications fall on both sides of our central estimate, but are almost always less than 1. We also present evidence suggesting that there are unlikely to be substantial national or global general equilibrium effects of rising income on health spending, for example through induced innovation. Our overall reading of the evidence is that rising income is unlikely to be a major driver of the rising health share of GDP.

Health inequalities

Measuring disparities in health status and access and use of health care in OECD countries.

De Looper M., Lafortune G.
Paris : OCDE : 2009/03 : 53 p.

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.

Options for future OECD work in measuring health inequalities are provided through suggesting a small set of indicators for development and inclusion in the OECD Health Data database. Some indicators appear to be more advanced for international data collection, since comparable data are already being collected in a routine fashion in most OECD countries. These include the indicators of inequalities in selfrated health, self-rated disability, the extent of public health care coverage and private health insurance coverage, and self-reported unmet medical and dental care needs.

Increased availability and comparability of data will improve the validity of cross-national comparisons of socioeconomic inequalities in health status and health care access and use. Harmonisation of definitions and collection instruments, and the greater use of data linkages in order to allow disaggregation by socioeconomic status, will determine whether health inequalities can be routinely monitored across OECD countries.

Drugs

Towards an Efficient Mechanism for Prescription Drug Procurement.

Fong K., Schwartz M.
Cambridge : NBER : 2009/02 : 35 p.

This paper applies ideas from mechanism design to model procurement of prescription drugs. We present a mechanism for government-funded market-driven drug procurement that achieves very close to full static efficiency - all members have access to all but at most a single drug - without distorting incentives for innovation.

The obesity epidemic : analysis of past and projected future trends in selected OECD countries.

Sassi F., Devaux M., Cecchini M., Rusticelli E.
Paris : OCDE : 2009/03 : 79 p.

This paper provides an overview of past and projected future trends in adult overweight and obesity in OECD countries. Using individual-level data from repeated cross-sectional national surveys, some of the main determinants and pathways underlying the current obesity epidemic are explored, and possible policy levers for tackling the negative health effect of these trends are identified. First, projected future trends show a tendency towards a progressive stabilisation or slight shrinkage of pre-obesity rates, with a projected continued increase in obesity rates. Second, results suggest that diverging forces are at play, which have been pushing overweight and obesity rates into opposite directions. On one hand, the powerful influences of obesogenic environments (aspects of physical, social and economic environments that favour obesity) have been consolidating over the course of the past 20-30 years. On the other hand, the long term influences of changing education and socio-economic conditions have made successive generations increasingly aware of the health risks associated with lifestyle choices, and sometimes more able to handle environmental pressures. Third, the distribution of overweight and obesity in OECD countries consistently shows pronounced disparities by education and socio-economic condition in women (with more educated and higher socio-economic status women displaying substantially lower rates), while mixed patterns are observed in men. Fourth, the findings highlight the spread of overweight and obesity within households, suggesting that health-related behaviours, particularly those concerning diet and physical activity, are likely to play a larger role than genetic factors in determining the convergence of BMI levels within households.

Long term care

Long-term care: regional disparities in Belgium.

Gungor K.
Bruxelles ; Université libre : 2009

This paper analyzes the problem of population ageing in terms of non-medical care needs of persons who are dependent or have lost their autonomy, in order to provide the various public and private administrations active in these fields with some food for thought. The anticipated increase in dependency poses significant challenges in terms of needs evolution and financing. Using administrative data on the Belgian population to build indicators on the prevalence of dependency at home in the three regions in 2001, it finds that the likelihood of a sustained increase in the Flemish prevalence rates ultimately amplifies the magnitude of the financing problems that the Flemish dependency insurance scheme has experienced since its first years of operation. Results also show that the smaller increases or the decreases (according to the scenario selected) expected in Wallonia and Brussels are likely to mitigate concern about the sustainability of any long-term care insurance in Wallonia and therefore to facilitate its eventual introduction.

Coping with Chronic Disease? Chronic Disease and Disability in Elderly American Population 1982-1999.

Aranovich G., Bhattacharya J., Garber A.M., Macurdy T.E.
Cambridge : NBER : 2009/03 : 33 p.

It is well known that disability rates among the American elderly have declined over the past decades. The cause of this decline is less well established. In this paper, we test one important possible explanation--that the decline in disability occurred because of chronic disease prevention efforts among the elderly. For this purpose we analyze data from the National Long Term Care Survey and from the National Health and Interview Survey. Our findings suggest that primary prevention, as reflected in decreased disease prevalence, was not responsible for advances made in elderly functioning between 1980 and 2000. We found a broad decline in less severe forms of disability that is unlikely to have resulted from improved disease management. Instead, these measured improvements in functioning may reflect environmental, technological, and/or socioeconomic changes. Improvements in the more severe forms of disability were modest and were restricted to those suffering from particular illnesses, which make improved and/or more aggressive management a plausible explanation and one that might increase costs should the trend persist.

Primary health care

The effect of physician supply on health status as measured in the NPHS.

Piérard E.
Waterloo : University of Waterloo : 2009 : 39 p.

We use data from the Canadian National Population Health Survey and the Canadian Institute for Health Information to estimate the relation- ship between per capita supply of physicians, both general practitioners and specialists, on health status. Measures of quality of life, self-assessed health status and the Health Utility Index are explored. The sample consists of all individuals who were age 18 or over at the beginning of the survey in 1994, and the sub-sample includes only individuals who were not diagnosed with a chronic condition for the first four years. Most previous studies of the effect of physician supply on health status used data only on individuals who had specific health problems, and many of them used outcomes related to the length of life of the patient. Random effects ordered probits are used to model self assessed health status and quantile regressions are used for the Health Utility Index. A higher supply of specialists is correlated with worse health outcomes, while a higher supply of general practitioners is correlated with better health outcomes as measured by both measures of health status.

Do Experience Make Better Doctors?

Contreras J.M., Kim B., Tristao I.M.
Seoul : Korea University : 2009/03 : 39 p.

In this paper, we examine the “learning-by-doing” hypothesis in medicine using a longitudinal census of laser in situ keratomileusis (LASIK) eye surgeries collected directly from patient charts. LASIK surgery has precise measures of presurgical condition and postsurgical outcomes. Unlike other types of surgery, the impact of unobservable underlying patient conditions on outcomes is minimal. Individual learning-by doing is identified through observations of surgical outcomes over time based on the cumulative number of surgeries each surgeon has performed. Collective learning is identified separately through changes in a group adjustment rule determined jointly by all the surgeons through a structured internal review process. Our unique data set overcomes some of the measurement problems in patient outcomes encountered in other studies, and improves the possibility of identifying the impact of learning-by-doing separate from other effects. Our results do not support the hypothesis that the surgeon's individual learning improves outcomes, but we find strong evidence that experience accumulated by surgeons as a group in a clinic significantly improves outcomes.

Do doctors induce demand ?

Kim B.
Seoul : Korea University : 2009/02 : 31 p.

There is a huge variation in medical utilization across geographic areas in the U.S. In addition, supply of medical care is positively correlated with demand. One commonly suspected possibility is physicians induce demand using their superior medical knowledge. This paper tests the supply induced demand in medicine using the exogenous negative income shock to Obstetrics/Gynecologists due to the declining number of births in their practice area. The number of births declined more than 8 % from 1989 to 1999 and physicians may decide to choose the cesarean section instead of normal delivery, as the cesarean section is reimbursed at a higher pay rate. Physicians might also provide more prenatal care than medically necessary in order to make up their own income under the fee for service reimbursement mechanism. Some evidence of induced demand in OB/GYNs practice pattern has been found. It has been found that the cesarean section would increase by 0.5 percentage points with a unit decline of birthrate per a population of 100, but prenatal care visits did not change.

Health care systems

Regulatory Competition between European Health Systems as an Engine of Change?

Eckardt M.
Ausburg : ISRICH : 2008 : 32 p.

The health care systems of EU member states suffer from a variety of problems, making health policy reforms a permanent item on the political agenda. Since intrajurisdictional political com-petition shows a lot of wellknown problems, with agency problems due to imperfect and asymmetric information being prominent leading to policy blockades. This paper asks whether regulatory competition between the EU member states might work as an engine of reform for national health care systems. For yardstick competition, locational competition and regulatory rule competition we analyze the potential impact on improving resource allocation, controlling rentseeking activities and generating innovations. We find that so far none of these three types of regulatory competition is intense. However, within an appropriate framework, regulatory competition could exhibit an overall positive effect on national health policy reforms.

Health care reform in the United States.

Carey D., Herring B., Lenain P.
Paris : OCDE : 20089/02 : 42 p.

In spite of improvements, on various measures of health outcomes the United States appears to rank relatively poorly among OECD countries. Health expenditures, in contrast, are significantly higher than in any other OECD country. While there are factors beyond the health-care system itself that contribute to this gap in performance, there is also likely to be scope to improve the health of Americans while reducing, or at least not increasing spending. This paper focuses on two factors that contribute to this discrepancy between health outcomes and health expenditures in the United States: inequitable access to medical services and subsidized private insurance policies; and inefficiencies in public health insurance. It then suggests two sets of reforms likely to improve the US health-care system. The first is a package of reforms to achieve close to universal health insurance coverage. The second set of reforms relates to payment methods and coverage decisions within the Medicare programme to realign incentives and increase the extent of economic evaluation of different medical procedures.

Price regulation of pluralistic markets subject to provider collusion.

Longo R., Miraldo M., Street A.
York : University of York : 2008/12 : 19 p.

We analyse incentives for collusive behaviour when heterogeneous providers are faced with regulated prices under two forms of yardstick competition, namely discriminatory and uniform schemes. Providers are heterogeneous in the degree to which their interests correspond to those of the regulator, with close correspondence labelled altruism. Deviation of interests may arise as a result of de-nationalisation or when private providers enter predominantly public markets. We assess how provider strategies and incentives to collude relate to provider characteristics and across different market structures. We differentiate between “pure” markets with either only self-interested providers or with only altruistic providers and “pluralistic” markets with a mix of provider type. We find that the incentive for collusion under a discriminatory scheme increases in the degree to which markets are self-interested whereas under a uniform scheme the likelihood increases in the degree of provider homogeneity. Providers' choice of cost also depends on the yardstick scheme and market structure. In general, costs are higher under the uniform scheme, reflecting its weaker incentives. In a pluralistic market under the discriminatory scheme each provider's choice of cost is decreasing in the degree of the other provider's altruism, so a self-interested provider will operate at a lower cost than an altruistic provider. Under the uniform scheme providers always choose to operate at the same cost. The prospect of defection serves to moderate the chosen level of operating cost.

Ageing

Policies for Healthy Ageing: An Overview.

Oxley H.
Paris : OCDE : 2009/02 : 30 p.

This paper reviews policies in the area of healthy ageing. With the ageing of OECD countries' population over coming decades, maintaining health in old age will become increasingly important. Successful policies in this area can increase the potential labour force and the supply of non-market services to others. They can also delay the need for longer-term care for the elderly. A first section briefly defines what is meant by healthy ageing and discusses similar concepts – such as “active ageing”. The paper then groups policies into four different types and within each, it describes the range of individual types of programmes that can be brought to bear to enhance improved health of the elderly. A key policy issue in this area concerns whether such programmes have a positive effect on health outcomes and whether they are costeffective. Looking at specific programmes, the material covered by this review also suggests that important improvements to the health and welfare of older cohorts seem possible from some combination of: delaying retirement, increased community activities, improved lifestyles, health-care systems that are better adapted to the needs of the elderly, particularly where they are combined with more emphasis on cost-effective prevention. However, this study also finds that, while there is considerable evidence that certain policy instruments can help improve the health status of the elderly, it remains unclear as to which are the most (cost) effective. Thus, more research is needed in this area if policy choices are to be (more) evidence-based. But whatever the choice of specific programmes, progress towards healthy ageing would probably be enhanced by placing individual programmes within broader policy frameworks that bring together the full range of measures so as to make them mutually reinforcing.

Ageing, Health and Life Satisfaction of the Oldest Old: An Analysis for Germany.

Gwozdz W., Sousa-Poza A.
Bonn : The Institute for the Study of Labor : 2009/03 : 39 p.

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.