Chris Sampson’s journal round-up for 14th August 2017

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Does paying service providers by results improve recovery outcomes for drug misusers in treatment in England? Addiction [PubMedPublished 10th August 2017

‘Getting what you pay for’ is a fundamentally attractive funding model, which is why we see lots of pay for performance (P4P) initiatives cropping up in the NHS. But P4P plans can go awry. This study considers an experimental setting in which 8 areas participated in P4P pilots for drug misuse treatment, from 2012-2014. Payments were aligned with 3 national priorities: i) abstinence, ii) reduced offending and iii) improved health and well-being. The participating areas allocated differing proportions of payments to the P4P model, between 10% and 100%. Data were drawn from the National Drug Treatment Monitoring System, which includes information on drug use, assessment and interventions received. Other national sources were used to identify criminal activity and mortality rates. Drug misusers attending treatment services during the 2 years before and after the introduction of the P4P scheme were included in the study. Using a difference-in-differences analysis, the researchers compared outcomes in the 8 participating areas with those in 143 non-participating areas. Separate multilevel regression models were used for a set of outcomes, each controlling for a variety of individual-level characteristics. The authors analysed ‘treatment journeys’, of which there were around 20,000 for those in participating areas and 280,000 for those in non-participating areas; roughly half before the introduction and half after. The results don’t look good for P4P. Use of opiates, crack cocaine and injecting increased. Treatment initiation increased in non-participating areas but decreased in participating areas. Moreover, longer waiting times were observed in participating areas as well as more unplanned discharges. P4P was associated with people being less likely to successfully complete treatment within 12 months. In P4P’s favour, there was evidence that abstinence increased. I’d’ve liked to have seen some attempt at matching between the areas, given that there was an element of self-selection into the scheme. Or at least, better control for the characteristics of the areas before P4P was introduced. This paper isn’t quite the final nail in the coffin. I don’t see P4P disappearing anytime soon. There’s a lot to be learnt from the paper’s discussion, which outlines some of the likely reasons and mechanisms underlying the findings. Commissioners should take note.

The short- and long-run effects of smoking cessation on alcohol consumption. International Journal of Health Economics and Management [PubMedPublished 7th August 2017

Anecdotally, it seems as if smoking and drinking are complementary behaviours. Generally, the evidence suggests that this is true. Smoking cessation programmes may, therefore, have value in their ability to reduce alcohol consumption (and vice versa). But only if the relationship is causal. This study seeks to add to that causal evidence. Using data from 5887 individuals in the Lung Health Study, the author runs a two-stage least squares estimation, with randomisation to smoking cessation treatment as an instrumental variable for smoking status. In the short term, there is some evidence that smokers tend to drink more (especially men). But findings in the longer term, up to 5 years, are more persuasive. It’s unfortunate that the (largely incoherent) rational addiction theory makes an appearance and that the findings are presented as supportive of it. A stopped clock is right twice a day. In line with rational addiction theory, the long-term relationship is measured in terms of a ‘smoking stock’, which is an aggregate measure of smoking behaviour over the 5 year period. Smoking and drinking are found to be complementary in the long term. Crucially, the extent of their complementarity is associated with particular factors. For example, people who smoke more cigarettes or who abstain for longer exhibit larger reductions in alcohol consumption when they stop smoking. People who smoke relatively few cigarettes per day do not drink more alcohol. Those smoking 6-10 per day consume around 1 extra drink per week compared with non-smokers. Quitting for 5 years can reduce alcohol consumption by more than 50%. In the long run, the effect is more pronounced for women and for people who are married. This highlights important opportunities for targeted public policy, which could achieve a win-win in terms of reducing both cigarette and alcohol consumption.

Time for a change in how new antibiotics are reimbursed: development of an insurance framework for funding new antibiotics based on a policy of risk mitigation. Health Policy Published 5th August 2017

Antibiotics have become a key component of health care, but antimicrobial resistance threatens their usefulness and we don’t see new antibiotics in the pipeline to help overcome this. It’s a fundamentally difficult problem; we want new antibiotics but we want to use them as sparingly as possible. Antibiotic development is relatively unattractive (financially) to pharmaceutical companies. Provision of research funding and regulatory changes haven’t solved the problem to date. This paper considers why this might be the case, and explores 2 alternative approaches: a premium price model and an insurance-type model. Essentially, the authors conduct a spreadsheet analysis to compare the alternative models with a base case of no incentives. The expected net present value of the base case was negative (to the tune of about $1.5 billion), demonstrating why much-needed new antibiotics aren’t being developed. Current incentives – including public-private funding partnerships and market exclusivity – are also shown to fail to reach a positive net present value. The premium price model, whereby there is an enhanced price per unit, is not particularly attractive. The daily cost of the resulting antibiotics would likely be too high, and manufacturers’ pursuit of profit would be at odds with conservative prescribing. Furthermore, it exposes areas experiencing outbreaks to serious financial risk. The insurance model, which involved an annual fee paid by each healthcare system (to manufacturers), is more promising. Pharmaceutical companies would be insured against low prices and variable use and health systems would be insured against a lack of antibiotics and the risk of an infection outbreak. The key feature here is that manufacturers’ revenues are de-linked from sales volume. This is important when we consider the need for conservative prescribing. The authors estimate that the necessary fee (for the global market) would be around $262 million per year, or $114 million if combined with current funding and regulatory incentives. Of course, these findings are based on major assumptions about infection rates, research costs and plenty besides. A number of sensitivity analyses are conducted that highlight uncertainty about what the insurance fee might need to be in the future. I think this uncertainty is somewhat understated – there are far more sensitivity and scenario analyses that would be warranted if such a policy were being seriously considered. Nevertheless, pooling risk in an insurance model looks like a promising strategy that’s worthy of further investigation and piloting.

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