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PubMed2007

Vaccination versus "wait and treat": how to subsidize them?

In this paper we discuss the application of different co-payment rates to alternative medical strategies. Two such strategies are considered: a "vaccination strategy", in which patients apply preventive measures before knowing if they have the disease, and a "wait and treat" strategy, in which patients are treated later only if they contract the disease. We show the second approach should be more generously subsidized by the regulator. This is, at least at first sight, a surprising result.

Cost Sharing↗

PubMed2001

Assessment of groundwater quality impacts due to use of coal combustion byproducts to control subsidence from underground mines.

Coal combustion byproducts are to be placed in an underground coal mine to control subsidence. The materials were characterized to determine potential groundwater impacts. No problems were found with respect to heavy or toxic metals. Coal combustion byproduct leachates are high in dissolved solids and sulfates. Chloride and boron from fly ash may also leach in initially high concentrations. Because the demonstration site is located beneath deep tight brine-bearing aquifers, no problems are anticipated at the demonstration site.

Air Pollutants↗

PubMed1999

The menu-setting problem and subsidized prices: drug formulary illustration.

The menu-setting problem (MSP) determines the goods and services an institution offers and the prices charged. It appears widely in health care, from choosing the services an insurance arrangement offers, to selecting the health plans an employer proffers. The challenge arises because purchases are subsidized, and consumers (or their physician agents) may make cost-ineffective choices. The intuitively comprehensible MSP model--readily solved by computer using actual data--helps structure thinking and support decision making about such problems. The analysis uses drug formularies--lists of approved drugs in a plan or institution--to illustrate the framework.

Budgets↗

PubMed2004

Patellar subsidence in heavy patients undergoing bilateral knee arthroplasty.

A retrospective review of 40 patients undergoing simultaneous bilateral total knee replacement was undertaken to investigate the link between patient body weight and patellar subsidence. Of the 40 patients, three (five knees) had collapse or fracture of the patellar bone and four (five knees) had developed radiolucent lines around the patellar implant. None of these patients were symptomatic and their Knee Society and Oxford functional scores were satisfactory. All of the seven patients had body weights significantly greater than the average for the series.

Arthroplasty, Replacement, Knee↗

PubMed2003

Automated image analysis technique for measurement of femoral component subsidence in total hip joint replacement.

A new technique for the measurement of subsidence of the femoral components is proposed. The method relies on the implantation of two ball markers around the femoral stem. A single radiographic image of the hip is analysed using image-processing techniques to minimize subjectivity related to manual identification of landmarks. Dimensions of the stem are used to correct for magnification and out-of-plane rotations resulting from radiographic positioning. This technique has been applied to a specific design of implant (Exeter). A study of the effect of radiographic positioning has been conducted using a cadaveric bone phantom. Results for the variation in the measurement of axial migration compared to the neutral position (in millimetres) were: 0.942 (10 degrees extension); 0.347 (20 degrees flexion); -0.435 (40 degrees internal rotation); 0.187 (30 degrees external rotation) for distances measured between the bone marker and the implant. Results for distances measured between the implant and the cement centralizer were: 0.107 (10 degrees extension); -0.277 (20 degrees flexion); 0.085 (40 degrees internal rotation); 0.280 (30 degrees external rotation). The variations from within a more realistic range of positions demonstrate that axial migration measurements of ca. 0.5 mm between the bone and implant, and less than 0.3 mm between the implant and the bone cement, may be expected.

Cadaver↗

PubMed2000

A longitudinal study of young Finnish adults' use of subsidized, private sector dental care, 1986-1997.

OBJECTIVES: Finns born after 1956 are now entitled to subsidized private sector dental care, or such persons could be enrolled in the Public Dental Service. Until 1986, eligibility was more restrictive. The purpose of this study was to investigate the use and costs of private dental care and effects of regularity of care on costs and treatment received among young Finnish adults during 1986-1997. METHODS: All 1986, 1990 and 1994 recipients of reimbursement for dental care from the Social Insurance Institution were included in the study. Five separate age cohorts were compared. Using their civil registration numbers, individuals were tracked from their first contact with a private dentist in one of the years 1986, 1990 or 1994 until the year 1997. RESULTS: While the total number of young adults who had received reimbursement for private dental care increased from about 53000 (1986) to 200000 (1994) due to extended eligibility, the number of users in the youngest group decreased from 53000 to 23000. Attending infrequently (1-2 times during the study period) was most common among the youngest adults and frequent attendance (annually) was most common among older adults. The annual mean cost was slightly lower among the frequent attenders in almost every cohort. Variation in the mean number of annual visits was directly correlated with costs. Frequent attenders most often received diagnostic and preventive measures while restorations and surgery were most common for the infrequent attenders. CONCLUSIONS: A substantial decline in the demand for private services among the 19-25-year-olds and stable demand among 26-34-year-olds was detected, indicating falling treatment needs or a preference for the Public Dental Service. All groups had a stable mean number of visits per year and almost constant costs. The mean number of dental visits per year remained steady in all cohorts indicating rigid treatment patterns.

Adult↗

PubMed1998

Compliance with restrictions on the subsidized use of proton pump inhibitors in Australia.

AIMS: To determine among a cohort of patients newly dispensed a prescription for a proton pump inhibitor (PPI) the extent of prior use of other less expensive agents such as antacids and H2-receptor antagonists as evidence of a 'stepped care' approach to peptic ulcer and oesophageal disease. METHODS: A retrospective drug utilization study was conducted within the Pharmaceutical Benefits Scheme (PBS) claims database in Australia. A cohort of social security recipients, who received approval for PPI supply in the month of October 1996, had no prior PPI approval in the previous 18 months and went on to have the drug dispensed, was assembled. This group of 'new PPI starters' was then examined for supply of less expensive prescription medicines to treat peptic ulcer and oesophageal disease in the 12 months prior to obtaining their PPI approval. RESULTS: In a cohort of 4554 defined new PPI users, 1205 (26.5%) showed no use of H2-receptor antagonists, antacids, cisapride, cytoprotectants or antiregurgitants in the 12 month period prior to commencing the PPI. The major reason for use given by prescribers for PBS supply was 'severe refractory ulcerating oesophagitis'. CONCLUSIONS: Subsidized supply is currently restricted on cost-effectiveness grounds to refractory peptic ulcer disease or severe oesophageal disease. Despite this, utilization and epidemiological data suggest that there is widespread leakage of use outside these indications particularly to less severe forms of oesophageal disease. This patient tracking study has shown within the PBS database that around a quarter of the patients are treated directly with a PPI without being prescribed less expensive agents at least in the preceding 12 months.

Anti-Ulcer Agents↗

PubMedDate not supplied

Predictors of long-term persistence on statins in a subsidized clinical population.

OBJECTIVES: The use of statins in primary prevention of cardiovascular disease is currently under debate. This study characterizes and identifies predictors of the persistence of use of statins in a clinical cohort of subsidized new users of similar age to the WOSCOPS trial subjects. METHODS: Medical, pharmaceutical, and demographic records for the period January 1, 1987 through December 31, 1994 were extracted from the databases of Québec's provincial health plan for a 10% random sample of social assistance recipients. Patients remained eligible for inclusion if they had received a first dispensation of a statin between January 1, 1987 and July 31, 1994. Persistence was defined as the number of days on treatment with a statin while continuing to renew dispensations within a defined time limit. RESULTS: New users of statins included 983 social assistance recipients who were observed for a total of 2,439,153 person-days. Median persistence on statin treatment was 173 (95% CI = 155, 204) days. Only 13% of patients persisted for 5 years of treatment. A higher index of chronic morbidity, pre-existing cardiovascular disease, and previous use of nicotinic acid were predictive of longer persistence on statin medication. Those patients whose first statin dispensation was for lovastatin discontinued treatment earlier than those whose first dispensation was for pravastatin or simvastatin. CONCLUSIONS: New users showed low persistence on statins in a cohort of socially assisted persons aged 45-64, in spite of the minimal financial cost of the drug for such beneficiaries of Québec's provincial health plan.

Journal Article↗

PubMed2002

Subsidized IVF: the development of 'egg sharing' in the United Kingdom.

Egg sharing is an arrangement in which a woman is offered free or reduced-cost assisted conception treatment in return for 'donating' oocytes for the treatment of another woman, the cost of her treatment being subsidized by the recipient of her oocytes. Egg sharing has been developed for a variety of reasons: to ameliorate donor oocyte shortages, to avoid potential health risks to non-patient donors and, given the limited availability of publicly funded assisted conception treatment in the UK, to make treatment more readily available to individuals on lower incomes, thus expediting treatment by reducing waiting lists. This paper outlines the development and current status of egg sharing in the UK through analysis of responses to a consultation on payment to gamete donors initiated by the Human Fertilisation and Embryology Authority (HFEA) and the HFEA's Guidance for Egg Sharing Arrangements.

Ethics, Medical↗

PubMed1985

The ability of aggregate data to predict self-sufficiency levels in subsidized rural primary care practices.

American rural health policy has as its long-term goal the reallocation of health facilities and manpower to permit equitable access to primary care for all citizens. Rural health centers subsidized by governmental and philanthropic programs frequently have been placed in places of high need for their services. Yet both government and philanthropic policymakers expect these primary care practices to become economically self-sufficient within a few years of practice. The problem is how to assign rural practices to communities with a planning process that will enhance the likelihood that these conflicting goals of serving need and financial self-sufficiency will be achieved. This study uses actual 1980 self-sufficiency data from 167 randomly selected rural primary care clinics as the dependent variable. Independent variables for the corresponding communities five or more years earlier were taken from a database often used by policymakers to make site evaluations. These data tend to be selected from aggregate county level measures. Regression analysis were used to determine how well these data could predict actual self-sufficiency in later years. The result of the analysis is that these aggregate level data have little capacity to predict the ability of rural primary care practices to achieve self-sufficiency. Much better predictions can be made on the basis of local, practice-specific variables. Therefore, planning for economically viable rural practices calls for a much different forecasting approach.

Catchment Area, Health↗

PubMed1989

A subsidized perinatal care program in a rural Colorado county.

A large number of medically indigent women in rural areas currently receive little or no prenatal care, raising major concerns regarding perinatal health. In Colorado, subsidized prenatal and labor/delivery programs have been instituted to address this problem. This article describes the implementation of two programs in one rural county. In these rural programs, private physicians, health department personnel, and social work staff at the local hospital collaborate to provide financial assistance, comprehensive health education, and quality medical care for eligible pregnant women. The identified benefits and barriers unique to the provision of quality perinatal care in rural settings are discussed.

Colorado↗

PubMed2005

Accessing government subsidized specialist oral and maxillofacial surgery services in Western Australia.

BACKGROUND: In Western Australia the vast majority of government subsidized dental specialist services is provided through the University of Western Australia (UWA). With predicted expanding demand for services and the high cost of providing specialist services it is important that access to specialist care is targeted at need. In this study the waiting lists for oral surgery services at UWA was analyzed to test the hypothesis that demand for oral surgical care is distributed evenly across the eligible population of Western Australia. METHODS: Data were obtained from de-identified waiting lists for oral surgery at UWA. This data included all patients on the oral surgery waiting list from November 2001 to December 2003. RESULTS: Results indicated significantly less entries on the waiting list for people in remote and very remote postcode regions, and people living in postcode regions associated with a fixed government clinic were significantly more likely to be on the waiting list for oral surgery. CONCLUSIONS: The data presented identify that demand for specialist services is not driven through the expected factors of disease burden as indicated by socio-economic status, but by access to general dental services.

Analysis of Variance↗

PubMed2002

Who should receive subsidized psychotherapy?: Analysis of decision makers' think-aloud protocols.

Three groups of judges representing clinical, political, and laypersons' perspectives were given the task of prioritizing patients for subsidized psychotherapy within the Swedish health care system. The authors documented the judges' decision-making processes in think-aloud protocols and analyzed them qualitatively, focusing on the conflict between the urgency of a case and its suitability for treatment. In an earlier statistical analysis of the same material, clinicians had seemed to pay more attention to suitability criteria, whereas health care officials and laypersons prioritized based on urgency. The qualitative findings confirmed the centrality of this conflict and contributed to a deeper understanding of decision makers' ways of coping with it. Their conceptions of suitability and urgency were also elucidated by analysis of the think-aloud protocols.

Acute Disease↗

PubMed1988

The shadow price of pluralism: the use of tax expenditures to subsidize hospital care in the United States.

During the 1980s, and particularly during the past year, controversy has arisen over the propriety of the not-for-profit hospital's tax-exempt status. In addressing the issue, policy analysts and activists have focused attention on the comparative efficiency and effectiveness of not-for-profit and for-profit hospitals' provision of social benefit, variously conceived and quantified. We review the results of current research carried out within that focus and suggest that the findings are inconclusive and the focus misplaced. A more profitable avenue of inquiry would be to explore the extent to which the dominance of tax-subsidized not-for-profit hospitals is a societally preferred means of achieving the provision of a level of access to quality care that otherwise would require a large direct government subsidy.

Economics, Hospital↗

PubMed1998

The mixed-population issue in state-subsidized elderly housing: management problems posed by nonelderly and elderly tenants.

The management experiences of all Local Housing Authorities (LHAs) in Connecticut were investigated concerning younger disabled tenants in state-subsidized elderly housing. While as a group younger disabled tenants were more likely to violate the terms of their lease, including disrupting other tenants' enjoyment of their homes, management problems with younger disabled tenants were not reported by all LHAs. In general, serious, recurrent problems involving younger disabled tenants were concentrated among a relatively small group of LHAs. Emphasizing the diversity that characterizes the experiences of LHAs, the discussion emphasizes the need for caution in drawing conclusions about the issue of a mixed population. It also focuses on examples of how some LHAs have addressed the integration of younger disabled tenants in senior housing and proposes recommendations for viewing the issue in the broader context of public policy.

Adult↗

PubMed2005

The safety net of the safety net: how federally qualified health centers "subsidize" Medicaid managed care.

In this article, I examine the impact of neoliberalism and welfare reform on the delivery of Medicaid, specifically how the advent of Medicaid managed care (MMC) has been wrought with contradictions, placing increased burdens on primary safety-net organizations and impacting the many communities they serve. I argue that federally qualified health centers (FQHCs) operate as a primary safety net among safety-net providers, supporting and subsidizing New Mexico's MMC program financially and administratively. By presenting ethnographic data, I will demonstrate how FQHCs pay many of the hidden financial and institutional costs of the shift to managed care. Such findings uncover paradoxes inherent to neoliberal ideologies and privatization, raising questions about the efficacy of a managed care system for Medicaid as well as the future of the health care safety net and access to health care for the diverse populations it serves.

Financing, Government↗

PubMed1983

An evaluation of subsidized rural primary care programs: I. A typology of practice organizations.

The design of a comprehensive evaluation of subsidized rural primary care programs on a large national scale is described, Its major purpose is to derive data whose analysis will answer major policy questions about the factors influencing the outcome of the major types of such programs in different communities. This first paper also delineates a typology which was developed of five principal organizational forms of these programs. This classification appears to provide suitable operational definitions of forms of rural practice as a basis for evaluating the differential impact of alternative types of primary care programs.

Data Collection↗

PubMed1983

An evaluation of subsidized rural primary care programs: II. The environmental contexts.

The placement of subsidized primary care programs in rural communities has been an important aspect of national health policy over the last decade. Using survey and secondary data from programs in over 700 counties in the United States, it was found that while about one-fourth of all counties with some rural populations have been affected by these programs, certain environmental factors are associated with more or less likelihood of placement. High levels of need and low levels of health care resources are positively associated with the presence of a program. States with health policy climates supportive of reimbursement and broader staffing of primary care programs also contained programs in a higher proportion of their rural counties. The effects of decreased federal funding, increased state responsibility, and the precarious market conditions for primary care programs are discussed with emphasis on the mechanisms for developing favorable climates for these programs.

Community Health Services↗