Social science & medicine. Medical economics最新文献

Over the past 35 years medical care resources in the United States have become increasingly concentrated in medical centers and university hospitals of large urban areas. This trend has left inhabitants of rural areas increasingly relatively deprived of access to health care resources. More importantly, this relative deprivation of access to medical resources has been a key factor explaining ruralite's deprivation in the utilization of those resources.

Although policy makers have been aware of the evolving structural pattern of the industry for some time, to date they appear unwilling and/or unable to fundamentally alter its continued growth and development. This review describes various forces influencing this developmental pattern at both the individual and the system (macro) level. It further discusses how government health policy, the characteristics of the health delivery system and the characteristics of the U.S. people transactionally relate to affect access to and utilization of health care resources.

This study compares medical care use under two prepaid plans offered to the same group of employees and their families. One is a Kaiser plan under which all care is provided on a prepaid basis by a closed panel group practice, and hospital care is provided in hospitals owned by the Kaiser system. Thus physicians are at risk for the entire costs of the covered services of their enrollees. Under the other plan. Clinic plan for short, physician services and outpatient ancillary services are provided by a large, predominantly fee-for-service group practice while hospital care is covered by a Blue Cross policy incorporated into the plan. Thus physicians under this plan are not at risk for the hospital costs of their enrollees and, since prepaid patients are such a small percentage of their total patient populations and they usually do not know if a patient is prepaid or fee-for-service, they are unlikely to treat their prepaid patients differently from their fee-for-service patients.

Our findings show that with minor exceptions, the pattern of medical care use under the two forms of group practice is strikingly similar. (1) The rate of ambulatory care is much the same, averaging 2.97 physician visits per year for Kaiser members and 3.05 for Clinic members. (2) There is no significant difference in the rates of patient-initiated visits and physician-initiated visits, either in terms of visits per plan member or per episode of illness. (3) Most important, hospital use under the two plans is practically identical. The age-sex adjusted number of hospital days per 1000 personyears is 249.8 for Kaiser members and 250.7 for Clinic members. These rates are low not only compared to the national rates and rates under alternative insurance plans but also compared to some other prepaid group practice plans. The few differences which do exist are minor. Clinic members are somewhat heavier users of preventive services and of some outpatient ancillary services, notably laboratory tests used in preventive care and to a lesser degree. X-rays. But the overall picture which emerges is one of great similarity between the patterns of use under the two plans.

We hypothesized that the conservative use of hospital as well as of ancillary and of physician-initiated services under fee-for-service group practice is due largely to the control over the supply of physicians exercised by the group, which is unlikely to add physicians unless all its members are fully occupied.

This paper is concerned with the evaluation of recent policy attempts to achieve a more equitable allocation of resources to the regions of England for the provision of health services. Alternative objective functions, derived from the policy statements of governments for the health service, are examined. These objective functions represent the view of the policy-maker and are based on the aggregation of health service effects on individuals. The appropriate treatment of equity-efficiency conflicts is examined in order to identify the policy response to variations in the cost of providing treatment in different geographical areas. The implications are then used to generate the optimal allocation to each region based on the individuals in the regional populations.

The theoretical framework developed is used to judge the appropriateness of recent British policy to achieve equity in the National Health Service. This section focuses on the 1976 policy proposals which attempt to introduce epidemiological and demographic data as the sole bases for regional provision, replacing earlier schemes which contained large, historical influences on funding.

This paper outlines the problems involved in determining how people perceive risks to human life, safety or health. Central to the paper is the argument that one cannot arbitrarily assume that some convenient, probability measure actually has any relevance to the bases upon which people decide that one activity is riskier than another. The empirical results presented indicate that respondents made a series of distinctions between hazards, assessing the risks of each type upon different bases, suggesting that people do not appear to evaluate risks to health and safety in the abstract. Indeed the principal problem of eliciting individuals' preferences in the context of risk is that people are unlikely to know what their preferences are before they confront a choice. In consequence it is proposed that any elicitation method must be so designed that respondents are first enabled to discover their preferences before stating them.

Economic analysis of health care necessarily includes pharmaceutical therapy as one production factor of health. Recent research shows that within the available production factors for health the highest productivity increases have come from technological advances in drug therapy. Future productivity increases will be influenced by the way in which pharmaceutical markets are organised. Empirical findings show that short-term cost containment measures act against an adequate intertemporal allocation and increasingly more nations disagree with the international allocation of research costs.

The mechanism of pricing of pharmaceuticals is available as a means to allocate financial resources. However, cost-orientated pricing is not wholly practical for research-based companies where a high proportion of costs cannot be allocated to individual products. However, it is argued that heterogeneous competition between research-based companies during the patent life-time and homogeneous competition of non-research-based companies after patent expiration protect the patient from exploitation. Empirical data indicate that the coexistence of both types of competition has worked quite satisfactorily in the past.

The combination of the tendency of cost-containment measures to concentrate on drug prices and the present phase of the industry may have an effect which, in the long run, works to the detriment of society. The contribution of health economists should lead to a policy in which short-term and politically opportune cost cuttings do not dominate but one which results in long-run technical and economic production of health.

The productivity of hospital labor is affected not only by the quantity of labor employed in hospitals but also by the quality of labor employed. In this paper changes in the quantity and quality of the U.S. hospital labor force from 1950 to 1976 are measured and the resulting indices compared with similar characteristics for the U.S. labor force. Quality of hospital workers is measured by changes in education and experience. When these indices are multiplied by a quantity index of man hours worked by hospital workers, a measure of total hospital labor input corrected for changes in quality results.

Assuming that the wage rate is proportional to the marginal product of hospital labor, hospital labor of different socio-demographic characteristics is combined by weighting each cell by the average hourly wage rate earned by hospital workers within the cell. The weights are derived from the 1960 1% Public Use Sample of census data where the overall sample was sorted to include only current, income-earning, hospital employees. From this subsample, estimates of yearly income and yearly hours were derived so that an age-sex-education cross-classification of average hourly earnings for hospital employees in 1960 could be produced.

There is no reason to believe that hospital workers with general skills are paid other than their marginal product, but workers with health specific skills not easily transferable to other industries might be paid at other than their marginal product. To examine this possibility the economy-wide weights developed by Fuchs from the 1960 1% Census data were substituted for the hospital wage rate weights.

Denison has developed a labor input index for the civilian labor force that includes the period from 1950 to 1976. This index, excluding Denison's measure of the effects of changing efficiency due to changes in hours, was used as a comparison for changes in the hospital labor input index.

The results of these analyses are presented and discussed and it is shown that changes in the quality of the hospital labor force are not a significant factor in explaining the substantial increase in the hospital labor input index. The growth of education in the overall economy is substantially above the growth of education among hospital workers. Substituting economy-wide wage rates for hospital wage rates as weights has no substantial effect on the importance of quality changes among hospital workers.

An approach to measuring health with respect to a set of 12 dimensions representing perceived health, physiological and social functioning is suggested. Each dimension is divided into four or five discrete levels. Health states are defined as mutually exclusive combinations of the levels on the dimensions. This classification of health states is disease-independent, quite sensitive and valid in the sense that it reflects the concept of health underlying Finnish health policy, but is likely to be of equal relevance in other societies.

In an experiment to elicit empirical values for health states, a non-random sample of the general public, consisting of hospital patients and ‘healthy’ non-health professionals was used. Based on self-administered questionnaires, two scaling techniques, a magnitude method and a category method, were applied. For each subject the type of questionnaire was determined randomly.

When judged in the light of the understandability of the questions involved and difficulty in answering them, there was no significant difference in the feasibility between the methods. As to the values the methods produced closely comparable and relatively reliable results. The first experiences gained from the approach suggest that it is a viable one and worth testing and developing further.

After a description of the production structure of the hospital sector in the Netherlands the outputs and the inputs are defined: outputs as weighted admissions, weighted patient days and inter- mediate production and inputs as the number of beds, the number of specialists, the facility-index (a scale index of the composition of the infrastructure of the hospital), drugs (in monetary terms) and the number of staff (subdivided into nurses, paramedical staff and so on).

We have estimated three types of models: Cobb-Douglas, CES and the more general translog specification and the characteristics of these are compared. Using data for 110 general acute hospitals, the Cobb-Douglas and translog specifications are estimated by ordinary least squares method; the CES-specification by several methods (OLS and non-linear methods).

We conclude that the more general translog specification fits the data better than the Cobb-Douglas or the CES specification.

The results are interpreted in terms of the output elasticities, the elasticities of substitution and the scale effects. Thereafter, following Feldstein, we construct indices of productivity, of cost and of input efficiency.

This paper purports to compare quantitatively health care delivery in three countries: the United States, the United Kingdom, and Australia. Since each of the societies relies on a different means of financing—the United States representing a decentralized and mixed model; the United Kingdom centralized and publicly financed, and Australia a system somewhere in-between the two—the impact of fiscal structure on health care is examined in particular. In the context of this study, the “goodness” of health care is measured on the basis of cost and availability of care.