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.

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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.

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Sam Watson’s journal round-up for 18th July 2016

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.

Mortality inequality: the good news from a county-level approach. Journal of Economic Perspectives [RePEcPublished Spring 2016

Research on mortality trends always focuses on the bad news. For example, in a well publicized article Anne Case and Angus Deaton report on finding significant increases in mortality for middle-aged white non-Hispanic men and women in the US.  (Although this article did attract some criticism for bias due to aggregation of age groups.) This essay by Janet Currie and Hannes Schwandt takes an altogether different line: it suggests that there is good news on the whole. Examining life expectancy at birth it is shown that mortality inequality between rich and poor counties declined significantly between 1990 and 2010. However, mortality rates and inequality in life expectancy have shifted a lot less for older age groups – a factor many previous ‘bad news’ type studies have focussed on. One explanation for such a trend is that there has been more smoking cessation in wealthier areas.The authors conclude then that for the youngest people, inequality is likely to remain low, while for older generations positive health behaviours such as smoking cessation are also likely to spread, improving inequality in mortality. However, one might suggest such conclusions are overly optimistic. Poverty and low socio-economic status have a complex relationship with health; reductions in mortality at lower ages may create a survivor bias so that the overall cohort has worse health on average now as those in poor health who may have died a number of years ago now survive to older ages. Nevertheless, Currie and Schwandt are right to suggest that policy makers should be made aware that improvements in mortality are possible and that evidence such as this should be used to mobilise efforts to improve the health of high risk groups.

The tax-free year in Iceland: A natural experiment to explore the impact of a short-term increase in labor supply on the risk of heart attacks. Journal of Health Economics [PubMedPublished 23rd June 2016

In 1987, owing to a change in the tax system in Iceland, no-one had to pay income tax. As a result labour supply increased substantially, which provides a neat natural experiment. In this study, the authors aim to examine whether increased labour market participation increases the risk of acute myocardial infarction (AMI). There is a growing literature of the relationship between macroeconomic conditions and health; a seminal article was Christopher Ruhm’s 2000 study that showed that economic downturns are associated with decreases in the overall mortality rate. However, the mechanisms that mediate such an effect remain elusive. Using panel data on individuals from 1982-92 linked to data on coronary events the authors show an increase in the risk of AMI in both 1987 and 1988 among men. However, some of the results seem improbably large, e.g. a 149% increase in the probability of AMI among self-employed men aged 45-64. While taken as a whole I think the evidence does suggest an increase in AMI risk in 1987, I was left with a number of questions: why no individual effect in the specification?; could the errors be serially correlated?; why wasn’t an instrumental variable approach used if the motivation is that the 1987 policy exogenously shifted labour market participation?; aside from having lower average risk, is there any reason to separately analyse men and women? These results also contradict an earlier study, also from Christopher Ruhm, that showed unemployment was associated with increases in deaths from coronary heart disease. At the very least, this study shows us that we just don’t really understand the complex interplay between economy, society, and health.

Gender roles and medical progress. Journal of Political Economy [RePEcPublished 3rd May 2016

Over the past century female labour market participation has improved as restrictive female gender roles have shifted and technological innovations have reduced the burden of many tasks traditionally assigned to women. Ha-Joon Chang posits that the invention of the washing machine was a more important invention than the internet in the way it revolutionised the labour market. This paper argues that the reduction in maternity conditions as a result of medical progress over the 20th century had a significant impact on female labour market participation. Indeed, they estimate that medical progress can account for 50% of the rise in female labour market participation between 1930 and 1960.

Photo credit: Antony Theobald (CC BY-NC-ND 2.0)