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Biomedical subjects

Dana P Goldman

Publications and source records attributed to Dana P Goldman.

At least 19 recordsLinked to original sources
PubMed2006

Rising medicare costs: are we in crisis?

Kenneth Thorpe and David Howard provide an important snapshot of the long-term trends in Medicare beneficiaries' health care spending. They use clever methods to shed new light on increases in per capita spending, convincingly demonstrating that treatment patterns are a major factor. But several puzzles remain. Trends in per capita spending differ from other findings in that Thorpe and Howard find costs rising fastest for those with multiple conditions, and it is unclear what would happen if one took lifetime spending into account. Reliable predictions about long-term trends will require information on any health benefits associated with increases in diagnosis and treatment.

Aged↗
PubMed2006

Varying pharmacy benefits with clinical status: the case of cholesterol-lowering therapy.

OBJECTIVE: To determine whether a pharmacy benefit that varies copayments for cholesterol-lowering (CL) therapy according to expected therapeutic benefit would improve compliance and reduce use of other services. METHODS: Using claims data from 88 health plans, we studied 62 274 patients aged 20 years and older who initiated CL therapy between 1997 and 2001. We examined the association between copayments and compliance in the year after initiation of therapy, and the association between compliance and subsequent hospital and emergency department (ED) use for up to 4 years after initiation. RESULTS: The fraction of fully compliant patients fell by 6 to 10 percentage points when copayments increased from 10 dollars to 20 dollars, depending on patient risk (P < .05). Full compliance was associated with 357 fewer hospitalizations annually per 1000 high-risk patients (P < .01) and 168 fewer ED visits (P < .01) compared with patients not in full compliance. For patients at low risk, full compliance was associated with 42 fewer hospitalizations (P = .02) and 21 fewer ED visits (P = .22). Using these results, we simulated a policy that eliminated copayments for high- and medium-risk patients but raised them (from 10 dollars to 22 dollars) for low-risk patients. Based on a national sample of 6.3 million adults on CL therapy, this policy would avert 79,837 hospitalizations and 31,411 ED admissions annually. CONCLUSION: Although many obstacles exist, varying copayments for CL therapy by therapeutic need would reduce hospitalizations and ED use--with total savings of more than 1 billion dollars annually.

Adult↗
PubMed2005

A socioeconomic profile of older adults with HIV.

The objective of this study was to assess the socioeconomic circumstances of older patients with HIV and acquired immunodeficiency syndrome (AIDS). The investigators compared subjects from a national probability sample of 2,864 respondents from the HIV Cost and Services Utilization Study (HCSUS, 1996) with 9,810 subjects from Wave 1 (1992) of the Health and Retirement Survey (HRS). Bivariate analyses compare demographic characteristics, financial resources, and health insurance status between older and younger adults and between older adults with HIV and the general population. It was found that nearly 10% of the HIV-positive population is between the ages of 50 and 61 years. Older whites with HIV are mostly homosexual men who are more well educated, more often privately insured, and more financially stable than the HIV population as a whole. In contrast, older minorities with HIV possess few economic resources in either absolute or relative terms. The success of new drug therapies and the changing demographics of the HIV population necessitate innovative policies that promote labor force participation and continuous access to antiretroviral therapies.

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PubMed2005

The lifetime burden of chronic disease among the elderly.

The high costs of treating chronic diseases suggest that reducing their prevalence would improve Medicare's financial stability. In this paper we examine the impact of selected chronic diseases on the distribution of health spending and its variation over the course of disease. We also use a microsimulation model to estimate these conditions' impact on life expectancy and health spending from age sixty-five to death. A sixty-five-year-old with a serious chronic illness spends 1000-2000 dollars more per year on health care than a similar adult without the condition. However, cumulative Medicare payments are only modestly higher for the chronically ill because of their shorter life expectancy.

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PubMed2005

The health and cost consequences of obesity among the future elderly.

Obesity could have serious consequences for older cohorts. We used a microsimulation to estimate lifetime costs, life expectancy, disease, and disability for seventy-year-olds based on body mass. Obese seventy-year-olds will live about as long as those of normal weight but will spend more than 39,000 dollars more on health care. Moreover, they will enjoy fewer disability-free life years and experience higher rates of diabetes, hypertension, and heart disease. Medicare will spend about 34 percent more on an obese person than on someone of normal weight. Obesity might cost Medicare more than other diseases, because higher costs are not offset by reduced longevity.

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PubMed2005

Disability and health care spending among medicare beneficiaries.

This paper forecasts the impact of changing disability rates on spending by Medicare beneficiaries. We adjust for differential changes in spending by the disabled because the composition of the disabled population and the intensity of their treatment are changing. Among community-dwelling elderly, spending growth among the least disabled grew more quickly than among the most disabled, which offsets some of the cost savings associated with declining disability rates. Using estimates of spending trends by disability category, we project that the cost savings associated with improved disability rates will not dramatically slow Medicare spending in the long run.

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PubMed2005

Consequences of health trends and medical innovation for the future elderly.

Recent innovations in biomedicine seem poised to revolutionize medical practice. At the same time, disease and disability are increasing among younger populations. This paper considers how these confluent trends will affect the elderly's health status and health care spending over the next thirty years. Because healthier people live longer, cumulative Medicare spending varies little with a beneficiary's disease and disability status upon entering Medicare. On the other hand, ten of the most promising medical technologies are forecast to increase spending greatly. It is unlikely that a "silver bullet" will emerge to both improve health and dramatically reduce medical spending.

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PubMed2005

Technological advances in cancer and future spending by the elderly.

This paper forecasts the consequences of scientific progress in cancer for total Medicare spending between 2005 and 2030. Because technological advance is uncertain, widely varying scenarios are modeled. A baseline scenario assumes that year 2000 technology stays frozen. A second scenario incorporates recent cancer treatment advances and their attendant discomfort. Optimistic scenarios analyzed include the discovery of an inexpensive cure, a vaccine that prevents cancer, and vastly improved screening techniques. Applying the Future Elderly Model, we find that no scenario holds major promise for guaranteeing the future financial health of Medicare.

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PubMed2005

Identifying potential health care innovations for the future elderly.

We used a method that combined literature review and expertjudgment to assess potential medical innovations for older adults. We evaluated innovations in four domains: cardiovascular disease, cancer, the biology of aging, and neurologic disease. The innovations can be categorized by common themes: improved disease prevention, better detection of subclinical or early clinical disease, and treatments for established disease. We report the likelihood, potential impact, and potential cost implications for thirty-four innovations, and we revisit this forecast five years later. Many of the innovations have the potential to greatly affect the costs and outcomes of health care.

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PubMed2004

Pharmacy benefits and the use of drugs by the chronically ill.

CONTEXT: Many health plans have instituted more cost sharing to discourage use of more expensive pharmaceuticals and to reduce drug spending. OBJECTIVE: To determine how changes in cost sharing affect use of the most commonly used drug classes among the privately insured and the chronically ill. DESIGN, SETTING, AND PARTICIPANTS: Retrospective US study conducted from 1997 to 2000, examining linked pharmacy claims data with health plan benefit designs from 30 employers and 52 health plans. Participants were 528,969 privately insured beneficiaries aged 18 to 64 years and enrolled from 1 to 4 years (960,791 person-years). MAIN OUTCOME MEASURE: Relative change in drug days supplied (per member, per year) when co-payments doubled in a prototypical drug benefit plan. RESULTS: Doubling co-payments was associated with reductions in use of 8 therapeutic classes. The largest decreases occurred for nonsteroidal anti-inflammatory drugs (NSAIDs) (45%) and antihistamines (44%). Reductions in overall days supplied of antihyperlipidemics (34%), antiulcerants (33%), antiasthmatics (32%), antihypertensives (26%), antidepressants (26%), and antidiabetics (25%) were also observed. Among patients diagnosed as having a chronic illness and receiving ongoing care, use was less responsive to co-payment changes. Use of antidepressants by depressed patients declined by 8%; use of antihypertensives by hypertensive patients decreased by 10%. Larger reductions were observed for arthritis patients taking NSAIDs (27%) and allergy patients taking antihistamines (31%). Patients with diabetes reduced their use of antidiabetes drugs by 23%. CONCLUSIONS: The use of medications such as antihistamines and NSAIDs, which are taken intermittently to treat symptoms, was sensitive to co-payment changes. Other medications--antihypertensive, antiasthmatic, antidepressant, antihyperlipidemic, antiulcerant, and antidiabetic agents--also demonstrated significant price responsiveness. The reduction in use of medications for individuals in ongoing care was more modest. Still, significant increases in co-payments raise concern about adverse health consequences because of the large price effects, especially among diabetic patients.

Adult↗
PubMed2004

Effective HIV treatment and the employment of HIV(+) adults.

OBJECTIVE: To examine whether highly active antiretroviral therapy (HAART) helps HIV-infected patients return to work, remain employed, and maintain hours of work. DATA SOURCE: Longitudinal data from a national probability sample of HIV+ patients older than 18 years old who made at least one visit in the contiguous United States in early 1996. STUDY DESIGN: We consider the effect of HAART on three employment outcomes: (1) returning to work within six months of treatment, conditional on not working pretreatment; (2) remaining employed within six months of treatment, conditional on working pretreatment; (3) hours of work conditional on working at the second follow-up survey. We use a bivariate probit model to jointly model employment and treatment with HAART for the first two outcomes and the two-stage least squares method for hours of work. State policies regarding prescription drug coverage are used as instrumental variables for HAART to account for a key source of potential bias-the more severely ill tend to have the most difficulty working, but are also the most likely to be on HAART. PRINCIPAL FINDINGS: Our results indicate that HAART increases the probability of remaining employed by HIV patients and hours of work for those working within six months of treatment. In the case of remaining employed, the employment effect (an increase from 58 percent to 94 percent in the probability of remaining employed) is statistically significant and the related incremental income is sizable compared to the incremental costs of HAART. Sensitivity analyses demonstrate that the results are robust to different specifications for insurance coverage. CONCLUSIONS: Patients who are working are more likely to remain employed because of treatment with HAART. HAART prescribed to patients in less advanced stages of the infection may lead to the greatest gain in employment.

Adult↗
PubMed2004

Disability forecasts and future Medicare costs.

The traditional focus of disability research has been on the elderly, with good reason. Chronic disability is much more prevalent among the elderly, and it has a more direct impact on the demand for medical care. It is also important to understand trends in disability among the young, however, particularly if these trends diverge from those among the elderly. These trends could have serious implications for future health care spending because more disability at younger ages almost certainly translates into more disability among tomorrow's elderly, and disability is a key predictor of health care spending. Using data from the Medicare Current Beneficiary Survey (MCBS) and the National Health Interview Study (NHIS), we forecast that per-capita Medicare costs will decline for the next fifteen to twenty years, in accordance with recent projections of declining disability among the elderly. By 2020, however, the trend reverses. Per-capita costs begin to rise due to growth in disability among the younger elderly. Total costs may well remain relatively flat until 2010 and then begin to rise because per-capita costs will cease to decline rapidly enough to offset the influx of new elderly people. Overall, cost forecasts for the elderly that incorporate information about disability among today's younger generations yield more pessimistic scenarios than those based solely on elderly data sets, and this information should be incorporated into official Medicare forecasts.

Adult↗
PubMed2004

Employee responses to health insurance premium increases.

OBJECTIVE: To determine the sensitivity of employees' health insurance decisions--including the decision to not choose health maintenance organization or fee-for-service coverage--during periods of rapidly escalating healthcare costs. STUDY DESIGN: A retrospective cohort study of employee plan choices at a single large firm with a "cafeteria-style" benefits plan wherein employees paid all the additional cost of purchasing more generous insurance. METHODS: We modeled the probability that an employee would drop coverage or switch plans in response to employee premium increases using data from a single large US company with employees across 47 states during the 3-year period of 1989 through 1991, a time of large premium increases within and across plans. RESULTS: Premium increases induced substantial plan switching. Single employees were more likely to respond to premium increases by dropping coverage, whereas families tended to switch to another plan. Premium increases of 10% induced 7% of single employees to drop or severely cut back on coverage; 13% to switch to another plan; and 80% to remain in their existing plan. Similar figures for those with family coverage were 11%, 12%, and 77%, respectively. Simulation results that control for known covariates show similar increases. When faced with a dramatic increase in premiums--on the order of 20%--nearly one fifth of the single employees dropped coverage compared with 10% of those with family coverage. CONCLUSIONS: Employee coverage decisions are sensitive to rapidly increasing premiums, and single employees may be likely to drop coverage. This finding suggests that sustained premium increases could induce substantial increases in the number of uninsured individuals.

Adult↗
PubMed2003

Incremental treatment costs in national cancer institute-sponsored clinical trials.

CONTEXT: Concern about additional costs for direct patient care impedes efforts to enroll patients in clinical trials. But generalizable evidence substantiating these concerns is lacking. OBJECTIVE: To assess the additional cost of treating cancer patients in the National Cancer Institute (NCI)-sponsored clinical trials in the United States across a range of trial phases, treatment modalities, and patient care settings. DESIGN: Retrospective cost study using a multistage, stratified, random sample of patients enrolled in 1 of 35 active phase 3 trials or phase 1 or any phase 2 trials between October 1, 1998, and December 31, 1999. Unadjusted and adjusted costs were compared and related to trial phase, institution type, and vital status. SETTING AND PARTICIPANTS: A representative sample of 932 cancer patients enrolled in nonpediatric, NCI-sponsored clinical trials and 696 nonparticipants with a similar stage of disease not enrolled in a research protocol from 83 cancer clinical research institutions across the United States. MAIN OUTCOME MEASURES: Direct treatment costs as measured using a combination of medical records, telephone survey, and Medicare claims data. Administrative and other research costs were excluded. RESULTS: The incremental costs of direct care in trials were modest. Over approximately a 2.5-year period, adjusted costs were 6.5% higher for trial participants than nonparticipants (35,418 dollars vs 33,248 dollars; P =.11). Cost differences for phase 3 studies were 3.5% (P =.22), lower than for phase 1 or 2 trials (12.8%; P =.20). Trial participants who died had higher costs than nonparticipants who died (17.9%; 39,420 dollars vs 33,432 dollars, respectively; P =.15). CONCLUSIONS: Treatment costs for nonpediatric clinical trial participants are on average 6.5% higher than what they would be if patients did not enroll. This implies total incremental treatment costs for NCI-sponsored trials of 16 million dollars in 1999. Incremental costs were higher for patients who died and who were in early phase studies although these findings deserve further scrutiny. Overall, the additional treatment costs of an open reimbursement policy for government-sponsored cancer clinical trials appear minimal.

Adult↗
PubMed2003

Participation of patients 65 years of age or older in cancer clinical trials.

PURPOSE: Although 61% of new cases of cancer occur among the elderly, recent studies indicate that the elderly comprise only 25% of participants in cancer clinical trials. Further investigation into the reasons for low elderly participation is warranted. Our objective was to evaluate the participation of the elderly in clinical trials sponsored by the National Cancer Institute (NCI) and assess the impact of protocol exclusion criteria on elderly participation. PATIENTS AND METHODS: We conducted a retrospective analysis using NCI data, analyzing patient and trial characteristics for 59,300 patients enrolled onto 495 NCI-sponsored, cooperative group trials, active from 1997 through 2000. Our main outcome measure was the proportion of elderly patients enrolled onto cancer clinical trials compared with the proportion of incident cancer patients who are elderly. RESULTS: Overall, 32% of participants in phase II and III clinical trials were elderly, compared with 61% of patients with incident cancers in the United States who are elderly. The degree of underrepresentation was more pronounced in trials for early-stage cancers than in trials for late-stage cancers (P <.001). Furthermore, protocol exclusion criteria on the basis of organ-system abnormalities and functional status limitations were associated with lower elderly participation. We estimate that if protocol exclusions were relaxed, elderly participation in cancer trials would be 60%. CONCLUSION: The elderly are underrepresented in cancer clinical trials relative to their disease burden. Older patients are more likely to have medical histories that make them ineligible for clinical trials because of protocol exclusions. Insurance coverage for clinical trials is one step toward improvement of elderly access to clinical trials. Without a change in study design or requirements, this step may not be sufficient.

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PubMed2003

Forecasting the nursing home population.

OBJECTIVE: To forecast growth in the US nursing home population, as a function of trends in disability and marriage. METHODS: Nursing home residence is modeled as a function of disability status, marital status, and other demographic covariates. Our predictions for nursing home residence are built upon joint forecasts of marriage and disability. We use data from the 1992 to 1996 Medicare Current Beneficiary Surveys, which are individual-level data sets designed to be representative of the US population older than the age of 65. RESULTS: Today's young cohorts will have higher rates and levels of institutionalization than their older counterparts. This will reverse several decades of decline in rates of disability and institutionalization. The nursing home population is likely to be 10-25% higher than would be suggested by a simple extrapolation of past declines in disability. CONCLUSIONS: In recent years, the rate of institutionalization among the elderly has been falling. It is predicted that this trend will reverse itself within the next decade, and that we will see substantial increases in the incidence of institutionalization among the elderly. This result is generated by our prediction of rising disability among the younger cohorts that are beginning to approach old age.

Activities of Daily Living↗