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

All the Selected for you


Our daily meds

Petersen M.

New York : Picador. 2009. 432 p.

"Our Daily Meds" shows how corporate salesmanship has triumphed over science inside the biggest pharmaceutical companies and, in turn, how this promotion-driven industry has taken over the practice of medicine.









The Culture of Our Discontent: Beyond the Medical Model of Mental Illness

Small M.F.

Washington : Joseph Henry Press. 2006. 195 p.

By many estimations, the Western medical model of mental health is dangerously incomplete. If we step outside of the traditional disease model there are many new and different ways to understand, treat, and even accept mental illness. Culture--how we collectively live, interact, and view the world frames our mental outlook.







Health Economics

Zweifel P., Breyer F., Kiemann M.

Dordrecht : Heidelberg. 2009. 529 p.

The most thorough book available on the economics of health and health care delivery, Health Economics develops the theory necessary to examine these issues analytically and presents empirical evidence on each issue, summarizing results for easy comprehension. Issues discussed include the "cost explosion" in health care, the role of physicians and the power of medical associations, and the control of technological change in medicine. Because the level of sophistication is rapidly expanding in health economics, this book also provides key analytic tools required to understand research that is currently in progress.




The globalization of managerial innovation in Health Care

Cambridge : Cambridge University Press. 2008. 379 p.

In 1983, the first patient classification system to be used on a national basis, the Diagnosis Relate Groups (DRGs), was adopted as part of the Prospective Payment System in the United States. This system caught the attention of health policy makers in other countries, and a number of them began to implement similar approaches. What motivated them to adopt these systems? What similarities and differences were there among their experiences in implementing these systems? What can we learn about introducing change into national health systems by comparing their experiences? The Globalization of Managerial Innovation in Health Care answers these and other questions by examining patient classification systems in fifteen different countries throughout the world. The result is a remarkable collection of case studies of how change can be introduced effectively into national health systems as well as a careful synthesis of what can be learned from them.


Health Insurance

The effect of private health insurance on medical care utilization and self-assessed health in Germany

Hullegie P., Klein T.J

York : HEDG 2009/07. 27 p.

In Germany, employees are generally obliged to participate in the public health insurance system, where coverage is universal, co-payments and deductables are moderate, and premia are based on income. However, they may buy private insurance instead if their income exceeds the compulsory insurance threshold. Here, premia are based on age and health, individuals may choose to what extent they are covered, and deductables and co-payments are common. In this paper we estimate the effect of private insurance coverage on the number of doctor visits and self-assessed health. Variation in income around the compulsory insurance threshold provides a natural experiment that we exploit to control for selection into private insurance. We document that income is measured with error and suggest an approach to take this into account. We find negative effects of private insurance coverage on the number of doctor visits and positive effects on health.

Health Economics

What explains variation in the costs of treating patients in english obstetrics specialities ?

Laudicella M., Olsen K.M., Street A.

York : University of York 2009/07. 19 p.

We assess patients admitted to English obstetrics departments to identify what proportion of variation in their costs is explained by patient characteristics and what proportion is due to departmental characteristics. Hospital Episode Statistics records for every patient admitted to obstetrics departments are matched to Reference Cost data by HRG reported by all English hospitals for the year 2005/6. Our sample consists of 951,277 patients in 136 departments. We estimate fixed effects models analysing patient-level costs, explore departmental characteristics that drive variation in costs at department-level and explore the sensitivity of results to the use of the full sample and sub-samples of obstetrics patients. Patient costs depend on various diagnostic characteristics over and above the HRG classification, particularly whether the patient suffered infection. After controlling for patient characteristics a substantial amount of unexplained variation in costs remains at departmental level. Higher costs are evident in departments that are not supported by a neonatology specialty and where factor prices are higher. There is evidence of lower costs in departments with high volumes of activity. We identify departments where further scrutiny of their high costs is required.


The geography of hospital admission in a National Health Service with patient choice: Evidence from Italy

Fabbri D., Robone S.

York : HEDG. 2009/07. 32 p.

Every year 35% of the 10 million hospital admissions in Italy occurs outside the patients' Local Health Authority of residence. In this paper we look for explanation for this phenomenon and estimate gravity equations for "trade" in hospital care using a Poisson pseudo maximum likelihood method. Our results suggest that the gravity model is a good framework for explaining patient mobility in most of the examined diagnostic groups. We find that the ability to restrain the imports of hospital services increases with the size of the pool of enrollees. Moreover, the ability to export hospital services, as proxied by the ratio of export-to-internal demand, is U-shaped. Therefore our evidence suggests that there are scale effects played by the size of the pool of enrollees.

Health inequalities

Geographical patterns of unmet health care needs in Italy

Cavalieri M.

Munich : Munich Personal RepEc Archive. 2009/06. 26 p.

In recent years, health care reforms and restrained budgets have risen concerns about accessibility to health services, even in countries with universal coverage health systems. Previous studies have explored the issue by using objective event-oriented measures such as those related to utilization of health care. Analyzing access through subjective process-oriented indicators allows to better disentangle the process of seeking care, to investigate self-perceived barriers to health services and to account for differences in individual health care preferences. In this paper, data from the 2006 Italian component of the European Survey on Income and Living Conditions (EU-SILC) are used to explore reasons and predictors of self-reported unmet needs for specialist and/or dental care among adult Italians aged 18 and over. Results reveal different patterns across socio-economic groups and geographical macro-areas. Evidence of income-related inequalities and violations of the horizontal equity principle are also found both at a national and regional level. Policies to address unmet health care needs should adopt a multidimensional approach and be tailored so as to consider such heterogeneities.

The impact of accessibility on the use of specialist health care in Norway

Iversen T., Kopperud G.S

Oslo : HERO. 2002. 35 p.

What factors contribute to the utilization of specialist health care in Norway, and to what extent is the policy goal of allocating health care according to peoples medical need fulfilled? With this scope the authors analyse the impact of a person's health relative to the impact of access to specialist care. It is distinguished between services provided by public hospitals and services provided by private specialists financed by the National Insurance Scheme. The data allow to consider individual patient characteristics since Survey of Living Conditions data are merged with data on capacity and access to general practice and specialist care. The estimation of logit models and negative binomial models show significant differences between the factors that influence contacts with private specialists and contacts with hospitals. While a person's self-assessed health plays a major role in the utilization of hospitals, there is no significant effect of this variable on the utilization of private specialists. The supply-side variables measured by GP density and the accessibility indices for specialist care have significant effects on the utilization of private specialists, but not on hospital visits and inpatient stays. A preliminary conclusion is that the utilization of hospital services is rationed according to patients' health status, and not influenced by patients' access. Hence, the utilization of hospital services seems to be in accordance with officially stated health policy. On the other hand, private specialists seem to function as an alternative to general practice. Moreover, the significant effect of chronic conditions on the utilization of private specialists suggests that regular check-ups of chronic patients are an important part of the services provided by private specialists. The challenge to policy makers is to consider measures that bring the utilization of publicly funded private specialists in accordance with national health policy.


Dynamic Cost-offsets of Prescription Drug Expenditures: Panel Data Analysis Using a Copula-based Hurdle Model

Deb P., Trivedi P.K., Zimmer D.M.

Cambridge : NBER. 2009/07. Pages : 40 p.

This paper presents a new multivariate copula-based modeling approach for analyzing cost-offsets between drug and nondrug expenditures. Estimates are based on panel data from the Medical Expenditure Panel Survey (MEPS) with quarterly measures of medical expenditures. The approach allows for nonlinear dynamic dependence between drug and nondrug expenditures as well as asymmetric contemporaneous dependence. The specification uses the standard hurdle model with two significant extensions. First, it is adapted to the bivariate case. Second, because the cost-offset hypothesis is inherently dynamic, the bivariate hurdle framework is extended to accommodate dynamic relationships between drug and nondrug spending. The econometric analysis is implemented for six different groups defined by specific health conditions. There is evidence of modest cost-offsets of expenditures on prescribed drugs.

Patients W.A.I.T. Indicator : Phase 8 report

IMS Health

Bruxelles : EFPIA. 2007/11. 62 p.

In 2004, EFPIA commissioned IMS Health to produce a bi-annual study of delays between marketing authorization and effective patient access to new medicines in different EU Member States. The resulting "Patients' W.A.I.T. Indicator Report" (Waiting to Access Innovative Therapies) reveals substantial differences in patient access to new medicines across the European Union. The latest edition - the Patients' W.A.I.T. Indicator Phase 8 Report published in November 2007 - shows that, for 18 of the 20 European countries covered in the report, 20 to 94% of the medicines that received a marketing authorisation between 1 January 2003 and 31 December 2006 were still not available to patients on 30 June 2007.

Primary health care

Choosing a GP - Experiences from the implementation of a list patient system in Norway

Luras H.

Oslo : HERO. 2004. 35 p.

When the list patient system was introduced in Norway in 2001, the population was requested to choose a general practitioner (GP). Prior to the reform they were asked to rank their three most preferred GPs in an entry form. Information from the entry form was input for the algorithm that allocated GPs and inhabitants. The first aim of this paper is to explore what factors the Norwegian population considered to be important when they filled in the entry form and selected their preferred GP. We question whether they considered the GP's medical skill, practical matters or continuity of care, or if they felt that the opportunity set restricted their possibilities to make a choice. The second aim of the study is to identify factors of importance to the outcome of the allocation process. Important questions are whether the whole population participates in the list patient system, what factors characterize those who refuse to participate, and what factors that determine whether individuals' are allocated to their first-choice doctor. The third aim of the study is to identify factors of importance as to whether people express satisfaction with their GP after the reform. We question whether predisposing factors, prior illness or individuals' preferences matter, whether characteristics of the personal GP are of importance and finally, whether the outcome of the allocation process and the organization of the local health care market influence individuals' satisfaction with their GP.

Copayments for doctor visits in Germany and the probability of visiting a physician - Evidence from a natural experiment

Farbmacher H.

Munich : university of Munich. 2009. 16p.

The German health care reform of 2004 imposes a charge of 10 Euro for the first visit to a doctor in each quarter of the year. At first glance, there is no inhibiting effect of this fee on utilization in the German Socio-Economic Panel. However, this study reveals that the true effect is diluted by a special characteristic of the fee. Exploiting random variation in the interview date, this study finds a substantial effect of the new fee on the probability of visiting a physician. In addition, the identification strategy makes it possible to disentangle this effect from the influence of the contemporaneous increase of copayments for prescription drugs.

Health care systems

OECD Reviews of Health Systems : Turquie

Paris : OCDE. 2009/02. 141 p.

This comprehensive review of Turkey's health care system shows that health status has improved rapidly in Turkey in recent decades, partly as a result of higher health spending. It describes the introduction of an ambitious Health Transformation Programme in 2003 which brought universal health insurance to Turkey in 2008 and has begun the process of public hospital reforms and the rolling out of family-practitioner services throughout the country. Challenges remain, however, including completing the Health Transformation Programme and ensuring that the new health system provides value for money and stays affordable. This report analyses these challenges and sets out policy suggestions aimed at addressing them.

A Value-Added Based Measure of Health System Output and Estimating the Efficiency of OECD Health Systems

Discussion Paper; 2009. 38 p.

Life expectancy at birth is the most commonly used measure for health system output. However, there are a number of reasons why it may be a poor proxy. First, life expectancy assumes a stationary population and thus does not take into account the current demographic structure of a country; and second, the output of a health system should be measured in terms of the value-added to the population's health status rather than health status itself. The paper develops a new measure of health system output, the Incremental Life Years to address these problems. The new measure is applied to study health system output, efficiency and total factor productivity in OECD countries for the years 2000 and 2004. The new measure provides different results compared to those based on the traditional life expectancy measure, and the differences are further accentuated when changes in efficiency and productivity are estimated.

Improving incentives in the Medicare Program : report to the Congress

Washington : MEDPAC. 2009/06. 277 p.

Recent studies show that the U.S. health care system is not buying enough recommended care and is buying too much unnecessary care, much of it at very high prices, resulting in a system that costs significantly more per capita than in any other country. These facts strongly indicate that our health care system is not delivering value for its stakeholders. As a major payer, the Medicare program shares in these problems. For decades, researchers have documented the wide variation across the United States in Medicare spending and rates of service use. For example, they find that rates of use for certain kinds of care, referred to as supply-sensitive services (i.e., likely driven by a geographic area's supply of specialists and technology), differ greatly from one region to another. The higher rates of use are often not associated with better outcomes or quality and instead suggest inefficiencies. One recent analysis shows that, at the state level, no relationship exists between health care spending per capita and mortality amenable to medical care, that an inverse relationship exists between spending and rankings on quality of care, and that spending is highly correlated with both preventable hospitalizations and hospitalizations for ambulatory-care-sensitive conditions. These findings point to inefficient spending patterns that result in poor value for our health care dollars. At the same time, they point to opportunities for improvement. In this report, the Commission discusses a number of issues and challenges for Medicare payment and delivery system reform. The issues range broadly but focus on how incentives in the current Medicare payment systems could be changed to reward value not volume.

Health and Ageing

Should pensions systems recognize hazardous and arduous work ?

Zaidi A., Whitehouse E.

Paris : OCDE. 2009. 47 p.

Les régimes de retraite spéciaux pour les professions dangereuses ou pénibles existent de longue date. Depuis quelques temps, ils suscitent de multiples débats dans de nombreux pays de l'OCDE. Ces régimes ont pour origine l'idée selon laquelle les personnes qui exercent un métier dangereux ou pénible, l'exploitation minière souterraine par exemple, méritent un traitement particulier. Cette idée se justifie par le fait que ces métiers augmentent la mortalité et diminuent l'espérance de vie, réduisant ainsi la période pendant laquelle les personnes qui les exercent peuvent profiter de leurs prestations de retraite. C'est pourquoi elles ont le droit de partir à la retraite avant l'échéance fixée par le régime de retraite général national. Le présent rapport analyse l'incidence, la structure et la justification de ces régimes de retraite spéciaux dans les pays de l'OCDE. Il énumère les professions couvertes par ces régimes, et décrit les différentes sortes de privilèges existants. Il présente également une évaluation quantitative du patrimoine retraite supplémentaire auquel ont droit les travailleurs relevant des régimes spéciaux. Les conclusions formulées en fin de document s'accompagnent d'une description des réformes récemment mises en place dans certains pays de l'OCDE. Le rapport examine à la fois les problèmes pratiques et conceptuels que présentent ces régimes spéciaux, et fournit ainsi une synthèse générale des principales considérations concernant ces questions. Plusieurs conclusions d'ordre général peuvent être dégagées de l'exposé qu'il contient. Ces régimes spéciaux ne se justifient que pour des groupes étroitement définis qui restent confrontés au risque de mortalité prématurée en raison de la dangerosité ou de la pénibilité de leurs conditions de travail. Il n'en demeure pas moins que les arguments à l'appui du maintien ou de l'instauration de régimes de retraite spéciaux pour les personnes exerçant des métiers dangereux ou pénibles sont faibles. Leur maintien tient davantage à la résistance institutionnelle à leur réforme qu'à leur utilité en tant que régime public de retraite complémentaire. Par ailleurs, quand les risques pour la santé des personnes exerçant ses métiers sont avérés, des politiques sociales classiques bien ciblées, telles que les prestations chômage (avec obligation de recherche d'emploi), les pensions d'invalidité ou les prestations de maladie professionnelle permettent de traiter plus efficacement chaque cas sur une base individuelle. Si la retraite anticipée doit être maintenue pour certains métiers ou professions, elle devrait être financée par les cotisations patronales et salariales.