Brent Gibbons’s journal round-up for 22nd January 2018

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.

Is retirement good for men’s health? Evidence using a change in the retirement age in Israel. Journal of Health Economics [PubMed] Published January 2018

This article is a tour de force from one chapter of a recently completed dissertation from the Hebrew University of Jerusalem. The article focuses on answering the question of what are the health implications of extending working years for older adults. As many countries are faced with critical decisions on how to adjust labor policies to solve rising pension costs (or in the case of the U.S., Social Security insolvency) in the face of aging populations, one obvious potential solution is to change the retirement age. Most OECD countries appear to have retirement ages in the mid-60’s with a number of countries on track to increase that threshold. Israel is one of these countries, having changed their retirement age for men from age 65 to age 67 in 2004. The author capitalizes on this exogenous change in retirement incentives, as workers will be incentivized to keep working to receive full pension benefits, to measure the causal effect of working in these later years, compared to retiring. As the relationship between employment and health is complicated by the endogenous nature of the decision to work, there is a growing literature that has attempted to deal with this endogeneity in different ways. Shai details the conflicting findings in this literature and describes various shortcomings of methods used. He helpfully categorizes studies into those that compare health between retirees and non-retirees (does not deal with selection problem), those that use variation in retirement age across countries (retirement ages could be correlated with individual health across countries), those that exploit variation in specific sector retirement ages (problem of generalizing to population), and those that use age-specific retirement eligibility (health may deteriorate at specific age regardless of eligibility for retirement). As this empirical question has amounted conflicting evidence, the author suggests that his methodology is an improvement on prior papers. He uses a difference-in-difference model that estimates the impact on various health outcomes, before and after the law change, comparing those aged 65-66 years after 2004 with both older and younger cohorts unaffected by the law. The assumption is that any differences in measured health between the age 65-66 group and the comparison group are a result of the extended work in later years. There are several different datasets used in the study and quite a number of analyses that attempt to assuage threats to a causal interpretation of results. Overall, results are that delaying the retirement age has a negative effect on individual health. The size of the effect found is in the ballpark of 1 standard deviation; outcome measures included a severe morbidity index, a poor health index, and the number of physician visits. In addition, these impacts were stronger for individuals with lower levels of education, which the author relates to more physically demanding jobs. Counterfactuals, for example number of dentist visits, which are not expected to be related to employment, are not found to be statistically different. Furthermore, there are non-trivial estimated effects on health care expenditures that are positive for the delayed retirement group. The author suggests that all of these findings are important pieces of evidence in retirement age policy decisions. The implication is that health, at least for men, and especially for those with lower education, may be negatively impacted by delaying retirement and that, furthermore, savings as a result of such policies may be tempered by increased health care expenditures.

Evaluating community-based health improvement programs. Health Affairs [PubMed] Published January 2018

For article 2, I see that the lead author is a doctoral student in health policy at Harvard, working with colleagues at Vanderbilt. Without intention, this round-up is highlighting two very impressive studies from extremely promising young investigators. This study takes on the challenge of evaluating community-based health improvement programs, which I will call CBHIPs. CBHIPs take a population-based approach to public health for their communities and often focus on issues of prevention and health promotion. Investment in CBHIPs has increased in recent years, emphasizing collaboration between the community and public and private sectors. At the heart of CBHIPs are the ideas of empowering communities to self-assess and make needed changes from within (in collaboration with outside partners) and that CBHIPs allow for more flexibility in creating programs that target a community’s unique needs. Evaluations of CBHIPs, however, suffer from limited resources and investment, and often use “easily-collectable data and pre-post designs without comparison or control communities.” Current overall evidence on the effectiveness of CBHIPs remains limited as a result. In this study, the authors attempt to evaluate a large set of CBHIPs across the United States using inverse propensity score weighting and a difference-in-difference analysis. Health outcomes on poor or fair health, smoking status, and obesity status were used at the county level from the BRFSS (Behavioral Risk Factor Surveillance System) SMART (Selected Metropolitan/Micropolitan Area Risk Trends) data. Information on counties implementing CBHIPs was compiled through a series of systematic web searches and through interviews with leaders in population health efforts in the public and private sector. With information on the exact years of implementation of CBHIPs in each county, a pre-post design was used that identified county treatment and control groups. With additional census data, untreated counties were weighted to achieve better balance on pre-implementation covariates. Importantly, treated counties were limited to those with CBHIPs that implemented programs related to smoking and obesity. Results showed little to no evidence that CBHIPs improved population health outcomes. For example, CBHIPs focusing on tobacco prevention were associated with a 0.2 percentage point reduction in the rate of smoking, which was not statistically significant. Several important limitations of the study were noted by the authors, such as limited information on the intensity of programs and resources available. It is recognized that it is difficult to improve population-level health outcomes and that perhaps the study period of 5-years post-implementation may not have been long enough. The researchers encourage future CBHIPs to utilize more rigorous evaluation methods, while acknowledging the uphill battle CBHIPs face to do this.

Through the looking glass: estimating effects of medical homes for people with severe mental illness. Health Services Research [PubMed] Published October 2017

The third article in this round-up comes from a publication from October of last year, however, it is from the latest issue of Health Services Research so I deem it fair play. The article uses the topic of medical homes for individuals with severe mental illness to critically examine the topic of heterogeneous treatment effects. While specifically looking to answer whether there are heterogeneous treatment effects of medical homes on different portions of the population with a severe mental illness, the authors make a strong case for the need to examine heterogeneous treatment effects as a more general practice in observational studies research, as well as to be more precise in interpretations of results and statements of generalizability when presenting estimated effects. Adults with a severe mental illness were identified as good candidates for medical homes because of complex health care needs (including high physical health care needs) and because barriers to care have been found to exist for these individuals. Medicaid medical homes establish primary care physicians and their teams as the managers of the individual’s overall health care treatment. The authors are particularly concerned with the reasons individuals choose to participate in medical homes, whether because of expected improvements in quality of care, regional availability of medical homes, or symptomatology. Very clever differences in estimation methods allow the authors to estimate treatment effects associated with these different enrollment reasons. As an example, an instrumental variables analysis, using measures of regional availability as instruments, estimated local average treatment effects that were much smaller than the fixed effects estimates or the generalized estimating equation model’s effects. This implies that differences in county-level medical home availability are a smaller portion of the overall measured effects from other models. Overall results were that medical homes were positively associated with access to primary care, access to specialty mental health care, medication adherence, and measures of routine health care (e.g. screenings); there was also a slightly negative association with emergency room use. Since unmeasured stable attributes (e.g. patient preferences) do not seem to affect outcomes, results should be generalizable to the larger patient population. Finally, medical homes do not appear to be a good strategy for cost-savings but do promise to increase access to appropriate levels of health care treatment.

Credits

Chris Sampson’s journal round-up for 4th December 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.

Funding breakthrough therapies: a systematic review and recommendation. Health Policy Published 2nd December 2017

One of the (numerous) financial pressures on health care funders in the West is the introduction of innovative (and generally very expensive) new therapies. Some of these can be considered curative, which isn’t necessarily the best way for manufacturers to create a steady income. New funding arrangements have been proposed to facilitate patient access while maintaining financial sustainability. This article focuses on a specific group of innovative therapies known as ‘Advanced Therapy Medicinal Products’ (ATMPs), which includes gene therapies. The authors conducted a systematic review of papers proposing funding models and considered their appropriateness for ATMPs. There were 48 papers included in the review that proposed payment mechanisms for high-cost therapies. Three top-level groups were identified: i) financial agreements, ii) performance-based agreements, and iii) healthcoin (a tradable currency representing the value of outcomes). The different mechanisms are compared in terms of their feasibility, acceptability, burden, ‘financial attractiveness’ and their appeal to payers and manufacturers. Annuity payments are identified as relatively attractive compared to other options, but each mechanism is summarily shown to be imperfect in the ATMP context. So, instead, the authors propose an ATMP-specific fund. For UK readers, this will likely smell a bit too much like the disastrous Cancer Drugs Fund. It isn’t clear why such a programme would be superior to annuity payments or more inventive mechanisms, or even whether it would be theoretically sound. Thus, the proposal is not convincing.

Supply-side effects from public insurance expansions: evidence from physician labor markets. Health Economics [PubMed] Published 1st December 2017

Crazy though American health care may be, its inconsistency in coverage can make for good research fodder. The Child Health Insurance Program (CHIP) was set up in 1997 and then, when the initial money ran out 10 years later, the program was (eventually) expanded. In this study, the authors use the changes in CHIP to examine the impact of expanded public coverage on provider behaviour, namely; subspecialty training (which could become more attractive with a well-insured customer base), practice setting and prevailing wage offers. The data for the study relate to the physician labour market for New York state for 2002-2013, as collected in the Graduate Medical Education survey. A simple difference-in-differences analysis is conducted with reference to the 2009 CHIP expansion, controlling for physician demographics. Paediatricians are the treatment group and the control group is adult physician generalists (mostly internal medicine). 2009 seems to be associated with a step-change in the proportion of paediatricians choosing to subspecialise – an increased probability of about 8 percentage points. There is also an upward shift in the proportion of paediatricians entering private practice, with some (weak) evidence that there is an increased preference for rural areas. These changes don’t seem to be driven by relative wage increases, with no major change in trends. So it seems that the expanded coverage did have important supply-side effects. But the waters are muddy here. In particular, we have the Great Recession and Obamacare as possible alternative explanations. Though it’s difficult to come up with good reasons for why these might better explain the observed changes.

Reflections on the NICE decision to reject patient production losses. International Journal of Technology Assessment in Health Care [PubMedPublished 20th November 2017

When people conduct economic evaluations ‘from a societal perspective’, this often just means a health service perspective with productivity losses added. NICE explicitly exclude the inclusion of these production losses in health technology appraisals. This paper reviews the issues at play, focussing on the normative question of why they should (or should not) be included. Findings from a literature review are summarised with reference to the ethical, theoretical and policy questions. Unethical discrimination potentially occurs if people are denied health care on the basis of non-health-related characteristics, such as the ability to work. All else equal, should health care for men be prioritised over health care for women because men have higher wages? Are the unemployed less of a priority because they’re unemployed? The only basis on which to defend the efficiency of an approach that includes productivity losses seems to be a neoclassical welfarist one, which is hardly tenable in the context of health care. If we adopt the extra-welfarist understanding of opportunity cost as foregone health then there is really no place for production losses. The authors also argue that including production losses may be at odds with policy objectives, at least in the context of the NHS in the UK. Health systems based on privately-funded care or social insurance may have different priorities. The article concludes that taking account of production losses is at odds with the goal of health maximisation and therefore the purpose of the NHS in the UK. Personally, I think priority setting in health care should take a narrow health perspective. So I agree with the authors that production losses shouldn’t be included. I’m not sure this article will convince those who disagree, but it’s good to have a reference to vindicate NICE’s position.

Credits

Paul Mitchell’s journal round-up for 26th December 2016

Every Monday (even if it’s Boxing Day here in the UK) 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.

Out-migration and attrition of physicians and dentists before and after EU accession (2003 and 2011): the case of Hungary. European Journal of Health Economics [PubMedPublished 2nd December 2016

Medical staff migration is an important cross-national policy issue given the international shortage of supply of doctors to meet healthcare demand. This study uses a large administrative survey collected in Hungary from 2004-2011 and focuses on the trends of medical doctors (GPs, specialists, dentists) since Hungary joined the EU in 2004 and the introduction of full freedom of movement between Hungary with Austria and Germany in 2011. The author conducted a time-to-event analysis with monthly collection of data on a person’s occupation used as a guide for outward-migration. A competing-risks model was used to also consider medical doctors exiting the profession, becoming inactive or dying. From the 18,266 medical doctors found in this sample over the nine year period, 12% migrated, 17% exited the profession and 14% became inactive. A five-fold increase in migration was seen when the restrictions on freedom of movement between Hungary and Austria/Germany were lifted, a worrying sign of brain drain from Hungary. For those who stayed but exited the profession, relative income is argued to have been a contributory factor, with incomes increasing by on average 40% in their new line of work (although this does not account for the “thank you money” received by doctors in Hungary for healthcare access). Generous maternity leave was argued to play a key role in absence from employment. A recognised limitation in this study is the inability to conduct robust analysis on the migration patterns of new medical graduates who are likely to be more prone to migration than their established colleagues (estimated to be 40% of all medical graduates in Hungary between 2007-2010 who migrated, before restrictions on freedom of movement between Austria and Germany were lifted). Nonetheless, the study still manages to shine a light on the external (competing against countries with larger economies) but also the internal (“attrition and feminisation of workforce”) challenges to national doctor staffing policy.

Does the proportion of pay linked to performance affect the job satisfaction of general practitioners? Social Science & Medicine [PubMedPublished 24th November 2016

The impact of pay for performance (P4P) on healthcare practice has been subject to much debate surrounding the pros and cons of incentives for medical staff to achieve specific goals. This study focuses on the impact that the introduction of the Quality and Outcomes Framework (QOF) for GPs in the UK in 2004 had on their subsequent job satisfaction. Job satisfaction for GPs is argued to be an important topic area due to it having an important role in retaining GPs and the quality of care they provide to their patients. Using linked data from the the GP Worklife Survey and the QOF, that rewards GPs performance based on clinical, organisation, additional services and patient experience indicators, across three time points (2004, 2005 and 2008), the authors model the relationship between P4P exposure (i.e. the proportion of income related to performance) and job satisfaction. Using a continuous difference-in-difference model with a random effects regression, the authors find that P4P exposure has no significant effect on job satisfaction after 1 and 4 years following the introduction of the QOF P4P system. The introduction of the QOF did lead to a large increase in GP life satisfaction; this is likely to be due to the large increase in average income for GPs following the introduction of QOF. The authors argue that their findings suggest GP job satisfaction is unlikely to be affected by changes in P4P exposure, so long as the final income the GP receives remains constant. Given the generous increases on GP final income from the initial QOF, it remains to be seen how generalisable these results would be to P4P systems that did not lead to such large increases in staff income.

Country-level cost-effectiveness thresholds: initial estimates and the need for further research. Value in Health [PubMed] Published 14th December 2016

National thresholds used to determine if a health intervention is cost-effective have been under scrutiny in the UK in recent years. It has been argued on the grounds of healthcare opportunity costs that the NICE £20,000-30,000 per QALY gained threshold is too high, with an estimate of £13,000 per QALY gain proposed instead. Until now, less attention has been paid to international cost-effectiveness thresholds recommended by the WHO, who have argued for a threshold between one and three times the GDP of a country. This study provides preliminary estimates of cost-effectiveness thresholds across a number of countries with varying levels of national income. Using estimates from the recent £13,000 per QALY gain threshold study in England, a ratio between the supply-side threshold with the consumption value of health was estimated and used as a basis to calculate other national thresholds. The authors use a range of income elasticity estimates for the value placed on a statistical life to take account of uncertainty around these values. The results suggest that even the lower end of the WHO recommended threshold range of 1x national GDP is likely to be an overestimate in most countries. It would appear something closer to 50% of GDP may be a better estimate, albeit with a great amount of uncertainty and variation between high and low income countries. The importance of these estimates according to the authors is that the application of the current WHO thresholds could lead to policies that reduce instead of increase population health. However, the threshold estimates from this study rely on a number of assumptions based on UK data that may not provide an accurate estimate when setting cost-effectiveness thresholds at an international level.

Credits