Reading list

The Impacts of State Health Reform Initiatives on Adults in New York and Massachusetts, by Sharon K. Long, Karen Stockley

Objective. To analyze the effects of health reform efforts in two large states—New York and Massachusetts.

Data Sources/Study Setting. National Health Interview Survey (NHIS) data from 1999 to 2008.

Study Design. We take advantage of the “natural experiments” that occurred in New York and Massachusetts to compare health insurance coverage and health care access and use for adults before and after the implementation of the health policy changes. To control for underlying trends not related to the reform initiatives, we subtract changes in the outcomes over the same time period for comparison groups of adults who were not affected by the policy changes using a differences-in-differences framework. The analyses are conducted using multiple comparison groups and different time periods as a check on the robustness of the findings.

Data Collection/Extraction Methods. Nonelderly adults ages 19–64 in the NHIS.

Principal Findings. We find evidence of the success of the initiatives in New York and Massachusetts at expanding insurance coverage, with the greatest gains reported by the initiative that was broadest in scope—the Massachusetts push toward universal coverage. There is no evidence of improvements in access to care in New York, reflecting the small gains in coverage under that state’s reform effort and the narrow focus of the initiative. In contrast, there were significant gains in access to care in Massachusetts, where the impact on insurance coverage was greater and a more comprehensive set of reforms were implemented to improve access to a full array of health care services. The estimated gains in coverage and access to care reported here for Massachusetts were achieved in the early period under health reform, before the state’s reform initiative was fully implemented.

Conclusions. Comprehensive reform initiatives are more successful at addressing gaps in coverage and access to care than are narrower efforts, highlighting the potential gains under national health reform. Tracking the implications of national health reform will be challenging, as sample sizes and content in existing national surveys are not currently sufficient for in-depth evaluations of the impacts of reform within many states.

Impact of High-Deductible Health Plans on Health Care Utilization and Costs, by Teresa M. Waters, Cyril F. Chang, William T. Cecil, Panagiotis Kasteridis, David Mirvis

Background. High-deductible health plans (HDHPs) are of high interest to employers, policy makers, and insurers because of potential benefits and risks of this fundamentally new coverage model.

Objective. To investigate the impact of HDHPs on health care utilization and costs in a heterogeneous group of enrollees from a variety of individual and employer-based health plans.

Data. Claims and member data from a major insurer and zip code-level census data.

Study Design. Retrospective difference-in-differences analyses were used to examine the impact of HDHP plans. This analytical approach compared changes in utilization and expenditures over time (2007 versus 2005) across the two comparison groups (HDHP switchers versus matched PPO controls).

Results. In two-part models, HDHP enrollment was associated with reduced emergency room use, increases in prescription medication use, and no change in overall outpatient expenditures. The impact of HDHPs on utilization differed by subgroup. Chronically ill enrollees and those who clearly had a choice of plans were more likely to increase utilization in specific categories after switching to an HDHP plan.

Conclusions. Whether HDHPs are associated with lower costs is far from settled. Various subgroups of enrollees may choose HDHPs for different reasons and react differently to plan incentives.

Costs and quality of hospitals in different health care systems: a multi-level approach with propensity score matching, by Jonas Schreyögg, Tom Stargardt, Oliver Tiemann

Cross-country comparisons of costs and quality between hospitals are often made at the macro level. The goal of this study was to explore methods to compare micro-level data from hospitals in different health care systems. To do so, we developed a multi-level framework in combination with a propensity score matching technique using similarly structured data for patients receiving treatment for acute myocardial infarction in German and US Veterans Health Administration hospitals. Our case study shows important differences in results between multi-level regressions based on matched and unmatched samples. We conclude that propensity score matching techniques are an appropriate way to deal with the usual baseline imbalances across the samples from different countries. Multi-level models are recommendable to consider the clustered structure of the data when patient-level data from different hospitals and health care systems are compared. The results provide an important justification for exploring new ways in performing health system comparisons.

Discounting future health benefits: the poverty of consistency arguments, by Erik Nord

In economic evaluation of health care, main stream practice is to discount benefits at the same rate as costs. But main papers in which this practice is advocated have missed a distinction between two quite different evaluation problems: (1) How much does the time of program occurrence matter for value and (2) how much do delays in health benefits from programs implemented at a given time matter? The papers have furthermore focused on logical and arithmetic arguments rather than on real value considerations. These ‘consistency arguments’ are at best trivial, at worst logically flawed. At the end of the day, there is a sensible argument for equal discounting of costs and benefits rooted in microeconomic theory of rational, utility maximising consumers’ saving behaviour. But even this argument is problematic, first because the model is not clearly supported by empirical observations of individuals’ time preferences for health, second because it relates only to evaluation in terms of overall individual utility. It does not provide grounds for claiming that decision makers with a wider societal perspective, which may include concerns for fair distribution, need to discount health benefits and costs equally. This applies even if health benefits are measured in monetary terms.

Discounting and decision making in the economic evaluation of health-care technologies, by Karl Claxton, Mike Paulden, Hugh Gravelle, Werner Brouwer, Anthony J. Culyer

Discounting costs and health benefits in cost-effectiveness analysis has been the subject of recent debate – some authors suggesting a common rate for both and others suggesting a lower rate for health. We show how these views turn on key judgments of fact and value: on whether the social objective is to maximise discounted health outcomes or the present consumption value of health; on whether the budget for health care is fixed; on the expected growth in the cost-effectiveness threshold; and on the expected growth in the consumption value of health. We demonstrate that if the budget for health care is fixed and decisions are based on incremental cost effectiveness ratios (ICERs), discounting costs and health gains at the same rate is correct only if the threshold remains constant. Expecting growth in the consumption value of health does not itself justify differential rates but implies a lower rate for both. However, whether one believes that the objective should be the maximisation of the present value of health or the present consumption value of health, adopting the social time preference rate for consumption as the discount rate for costs and health gains is valid only under strong and implausible assumptions about values and facts.

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