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Objectives To quantify end-of-life ( EOL) medical costs for adult Medicaid beneficiaries diagnosed with cancer. Data Sources We linked Medicaid administrative data with 2000-2003 cancer registry data to identify 3,512 adult Medicaid beneficiaries who died after a cancer diagnosis and matched them to a cohort of beneficiaries without cancer who died during the same period. Study Design We used multivariable regression analysis to estimate incremental per-person EOL cost after controlling for beneficiaries' age, race/ethnicity, sex, cancer site, and state of residence. Principal Findings End-of-life costs during the final 4 months of life were about $10,000 higher for Medicaid cancer patients than for those without cancer. Medicaid cancer patients are more intensive users of inpatient and ambulatory services than are Medicaid patients without cancer. Medicaid cancer patients who die soon after diagnosis have higher costs of care and use inpatient services more intensely than do Medicaid patients without cancer. Conclusions Medicaid cancer patients incur substantially higher EOL costs than noncancer patients. This increased cost may reflect the cost of palliative care. Future studies should assess the types and timing of services provided to Medicaid cancer patients at the EOL. [ABSTRACT FROM AUTHOR]

Background Recent studies have suggested that vaccination of nursing home staff members may reduce the incidence of influenza among nursing home residents. Current national estimates of employee vaccination rates (around 50%) indicate that residents may be at an unnecessarily high risk of contracting influenza. This article reports on the influenza vaccination rates and attitudes toward the vaccine among employees in 37 nursing homes in 3 states. Methods Nursing home employees were surveyed at nursing homes in Florida, Georgia, and Wisconsin in 2011-2012. Completed surveys were received from a total of 1,965 employees. Results Approximately 54% of the employees surveyed received the vaccination during the 2010-2011 and 2011-2012 influenza seasons. Nursing home–level staff vaccination rates varied widely, from 15%-97%. Black and younger employees were less likely to receive the vaccine. Employee vaccination rates in nursing homes that used incentives were 12 percentage points higher than those that did not use incentives ( P = .08). Conclusion Low vaccination rates among nursing home workers may put residents at increased risk for influenza-related morbidity and mortality. The Centers for Medicare and Medicaid Services may consider employee vaccination rates as a quality indicator in addition to resident vaccination rates. Our findings support the use of a trial to test the use of incentives to increase employee vaccination rates. [ABSTRACT FROM AUTHOR]

In 2011, Bristol-Myers Squibb set the price of its newly approved melanoma drug ipilimumab-brand name Yervoy-at $120,000 for a course of therapy. The drug was associated with an incremental increase in life expectancy of four months. Drugs like ipilimumab have fueled the perception that the launch prices of new anticancer drugs and other drugs in the so-called 'specialty' pharmaceutical market have been increasing over time and that increases are unrelated to the magnitude of the expected health benefits. In this paper, we discuss the unique features of the market for anticancer drugs and assess trends in the launch prices for 58 anticancer drugs approved between 1995 and 2013 in the United States. We restrict attention to anticancer drugs because the use of median survival time as a primary outcome measure provides a common, objective scale for quantifying the incremental benefit of new products. We find that the average launch price of anticancer drugs, adjusted for inflation and health benefits, increased by 10 percent annually-or an average of $8,500 per year-from 1995 to 2013. We argue that the institutional features of the market for anticancer drugs enable manufacturers to set the prices of new products at or slightly above the prices of existing therapies, giving rise to an upward trend in launch prices. Government-mandated price discounts for certain classes of buyers may have also contributed to launch price increases as firms sought to offset the growth in the discount segment by setting higher prices for the remainder of the market. [ABSTRACT FROM AUTHOR]

Medicare beneficiaries do not have to pay for screening colonoscopies but must pay coinsurance if a polyp is removed via polypectomy. Likewise, beneficiaries do not have to pay for fecal occult blood tests but are liable for cost-sharing for diagnostic colonoscopies after a positive test. Legislative and regulatory requirements related to colorectal cancer screening are described, and on the basis of Medicare claims, it is estimated that Medicare spending would increase by $48 million annually if Medicare were to waive cost-sharing requirements for these services. The economic impact on Medicare if beneficiaries were not responsible for any cost-sharing requirements related to colorectal cancer screening services is described. Cancer 2014;120:3850-3852. © 2014 American Cancer Society. [ABSTRACT FROM AUTHOR]

BACKGROUND Although state Medicaid programs cover cancer screening, Medicaid beneficiaries are less likely to be screened for cancer and are more likely to present with tumors of an advanced stage than are those with other insurance. The current study was performed to determine whether state Medicaid eligibility and reimbursement policies affect the receipt of breast, cervical, and colon cancer screening among Medicaid beneficiaries. METHODS Cross-sectional regression analyses of 2007 Medicaid data from 46 states and the District of Columbia were performed to examine associations between state-specific Medicaid reimbursement/eligibility policies and receipt of cancer screening. The study sample included individuals aged 21 years to 64 years who were enrolled in fee-for-service Medicaid for at least 4 months. Subsamples eligible for each screening test were: Papanicolaou test among 2,136,511 patients, mammography among 792,470 patients, colonoscopy among 769,729 patients, and fecal occult blood test among 753,868 patients. State-specific Medicaid variables included median screening test reimbursement, income/financial asset eligibility requirements, physician copayments, and frequency of eligibility renewal. RESULTS Increases in screening test reimbursement demonstrated mixed associations (positive and negative) with the likelihood of receiving screening tests among Medicaid beneficiaries. In contrast, increased reimbursements for office visits were found to be positively associated with the odds of receiving all screening tests examined, including colonoscopy (odds ratio [OR], 1.07; 95% confidence interval [95% CI], 1.06-1.08), fecal occult blood test (OR, 1.09; 95% CI, 1.08-1.10), Papanicolaou test (OR, 1.02; 95% CI, 1.02-1.03), and mammography (OR, 1.02; 95% CI, 1.02-1.03). Effects of other state-specific Medicaid policies varied across the screening tests examined. CONCLUSIONS Increased reimbursement for office visits was consistently associated with an increased likelihood of being screened for cancer, and may be an important policy tool for increasing screening among this vulnerable population. Cancer 2014;120:3016-3024. © 2014 American Cancer Society. [ABSTRACT FROM AUTHOR]

Background: Special events are common community-based strategies for health promotion. This paper presents findings from a systematic literature review on the impact of special events to promote breast, cervical or colorectal cancer education and screening. Methods: Articles in English that focused on special events involving breast, cervical, and/or colorectal cancer conducted in the U.S. and published between January 1990 and December 2011 were identified from seven databases: Ovid, Web of Science, CINAHL, PsycINFO, Sociological Abstract, Cochrane Libraries, and EconLit. Study inclusion and data extraction were independently validated by two researchers. Results: Of the 20 articles selected for screening out of 1,409, ten articles on special events reported outcome data. Five types of special events were found: health fairs, parties, cultural events, special days, and plays. Many focused on breast cancer only, or in combination with other cancers. Reach ranged from 50–1732 participants. All special events used at least one evidence-based strategy suggested by the Community Guide to Preventive Services, such as small media, one-on-one education, and reducing structural barriers. For cancer screening as an outcome of the events, mammography screening rates ranged from 4.8% to 88%, Pap testing was 3.9%, and clinical breast exams ranged from 9.1% to 100%. For colorectal screening, FOBT ranged from 29.4% to 76%, and sigmoidoscopy was 100% at one event. Outcome measures included intentions to get screened, scheduled appointments, uptake of clinical exams, and participation in cancer screening. Conclusions: Special events found in the review varied and used evidence-based strategies. Screening data suggest that some special events can lead to increases in cancer screening, especially if they provide onsite screening services. However, there is insufficient evidence to demonstrate that special events are effective in increasing cancer screening. The heterogeneity of populations served, event activities, outcome variables assessed, and the reliance on self-report to measure screening limit conclusions. This study highlights the need for further research to determine the effectiveness of special events to increase cancer screening. [ABSTRACT FROM AUTHOR]

Objective To describe trends in the use of percutaneous coronary intervention ( PCI) following the COURAGE trial, which found that medical therapy is as effective as PCI for patients with stable angina. Data Sources We used the National Hospital Discharge Survey; inpatient and outpatient discharge data from Florida, Maryland, and New Jersey; and the English Hospital Episode Statistics database. Study Design We report trends in PCI volume by diagnosis (stable angina vs. unstable angina or AMI) before and after publication of the COURAGE trial. Principal Findings The number of PCIs in patients without a diagnosis of AMI or unstable angina in Florida, Maryland, and New Jersey declined from 48,000 in 2006 to 40,000 in 2008 (−17 percent). There was no change in the number of PCIs in patients with a diagnosis of AMI. We observed similar patterns in U.S. community hospitals. PCI volume did not decline in England. Conclusions PCI volume declined after publication of the COURAGE trial. The experience of the COURAGE trial suggests that comparative effectiveness research can lead to cost-saving changes in medical practice patterns. However, there are many patients with stable coronary disease who continue to receive PCI post- COURAGE. [ABSTRACT FROM AUTHOR]

Purpose: Episiotomy is one of the most commonly performed procedures among women of childbearing age in the United States. In 2005, a major systematic review conducted by Hartmann and colleagues recommended against routine use of episiotomy and was widely covered in the media. We assessed the impact of the Hartman et al. study on episiotomy trend. Methods: Based on 100 % hospital discharge data from eight states in 2003–2008, we used interrupted time series regression models to estimate the impact of the Hartman et al. review on episiotomy rates. We used mixed-effects regression models to assess whether interhospital variation was reduced over time. Results: After controlling for underlying trend, episiotomy rates dropped by 1.4 percentage points after Hartman et al. publication ( p < 0.01 for spontaneous delivery; p < 0.1 for operative delivery). The publication has smaller effect on government hospitals as compared to private hospitals. Mixed effects models estimated negative correlation between cross-time and cross-hospital variations in episiotomy rates, indicating reduced cross-hospital variation over time. Conclusions: Our results suggested that there has been a gradual decline in episiotomy rates over the period 2003–2008, and that synthesis of evidence showing harms from routine episiotomy had limited impact on practice patterns in the case of episiotomy. The experience of episiotomy illustrates the challenge of using comparative effectiveness and evidenced-based medicine to reduce use of unnecessary procedures. [ABSTRACT FROM AUTHOR]

Transplantation is notable for the degree to which resources are allocated via administrative rather than market mechanisms. However, non-monetary incentives still permeate the system. Using instrumental variable regression, we estimate the substitution patterns between cadaveric and living kidney donations in the United States from 1988 to 2008. On average, a decrease of two to five cadaveric donations causes living kidney donations to increase by one. Disaggregating living donors into blood-related and non-blood-related donors, the strongest effect is found among non-blood-related donors known to the organ recipient. A 1% increase of cadaveric donations decreases living donations from this group by 1.54%. ( JEL D62, D64, I1) [ABSTRACT FROM AUTHOR]

Kidney transplant candidates can obtain organs immediately from living donors or wait for deceased donor organs. I hypothesize that as waiting time for deceased donor organs increases, more patients will seek living donors. I estimate the impact of the availability of deceased donor organs on the use of living donor transplantation. The model, which is identified using within-region variation in the demand for and supply of kidneys, shows evidence of a substitution effect. A five unit increase in the supply of deceased donor kidneys will result in one fewer living donor transplant for a net increase of four transplants. ( JEL I18, H44, D45) [ABSTRACT FROM AUTHOR]

Most studies of competition in health care focus on prices and costs, but concerns about quality play a central role in policy debates. If demand is inelastic to quality, then competition may reduce patient welfare. This study uses a dataset of patient registrations for kidney transplantation in conjunction with a mixed logit model to gauge consumers' responsiveness to quality when choosing hospitals. Results indicate that at the hospital level, a one-standard deviation increase in the graft-failure rate is associated with a 6% decline in patient registrations. Privately-insured patients are more responsive to quality than Medicare patients, suggesting that insurers consider quality when contracting with providers. [ABSTRACT FROM PUBLISHER]

Comparisons of alternative liver allocation policies often begin by assuming that patients are either urgent or nonurgent, ignoring the process by which patients become urgent in the first place. This article employs a simulation model to study how patients’ health changes between listing and transplant as a function of the rationing rule and the ratio of liver demand to supply. Compared to a first-come first-served queue or random assignment, a “sickest-first” policy results in worse patient outcomes when the demand-to-supply ratio is high. A substantial portion of this differential may be attributed to the fact that under the sickest-first rule, many patients are listed in a nonurgent state but transplanted only once they have reached the sickest patient category. The sickest-first rule is equitable, however, in that patients placed on the waiting list in the sickest category are not disadvantaged relative to patients listed in healthier states. [ABSTRACT FROM PUBLISHER]

The article focuses on personal saving behavior and the rate of inflation. Personal saving rates, that is the ratios of personal saving to personal disposable income, in many industrialized countries have risen dramatically in recent years. A number of attempts to explain the phenomenon of rising saving rates coinciding with price inflation have drawn upon the work of economist George Katona, who has stressed the feeling of uncertainty and pessimism about the future caused by inflation that, in turn, encourages saving. In this study a general model of aggregate household saving behavior has been formulated. Data on Canada, Germany, Japan, Great Britain, and the U.S. are used to estimate the personal saving function in each of the countries and the results are used to test various hypotheses about personal saving behavior. This article has two major objectives, which includes a test for a direct influence of inflation on personal saving after taking into account the influence of other relevant factors.

This paper presents a general proof of a fundamental proposition of rationing theory and demonstrates that it applies to some basic postulates of macroeconomic theory, including the consumption function. The approach used is to study individual consumer behavior under conditions of quantity constraints. In so doing, the choice-theoretic foundations of the household sector's excess demand functions, as well as the functions themselves, in a general disequilibrium model are developed. These functions include quantities as well as prices as arguments. The response to a change in an effective quantity constraint is shown to depend on the substitutability between the goods involved. Responses to price changes are also determined. The results are then related to the literature on macroeconomic disequilibrium. [ABSTRACT FROM AUTHOR]

This article presents the author's response to comments about his paper on the application of the Barro-Grossman disequilibrium model to the Soviet Union. In the empirical work reported in my 1976 article, I found that the disequilibrium model performed well in that the Soviet data were consistent with the model's predictions. Comparison of the growth in the stock of savings with the growth in the flow of income or consumption is misleading and uninteresting. For example, a constant marginal propensity to save and a constant income imply an increase in the stock of savings and, of course, no change in income or consumption. Joyce Pickersgill has examined data on average and marginal propensities to save in the Soviet Union during 1955 to 1971. She concludes that her results do not support the view that Soviet households are saving larger and larger proportions of their increased incomes. However, the course of variables such as the average propensity to save is irrelevant to the question at hand since examination of such variables omits the influence of other factors. The disequilibrium model involves several factors and options operating on and open to the household when faced with a quantity constraint and proper evaluation of the model involves examination of all of them. At the outset I should state that my paper assumes the existence of repressed inflation in the sense that the controlled prices of at least some consumer goods are below market-clearing levels. Therefore my tests are of a joint hypothesis of the presence of this particular kind of repressed inflation and the disequilibrium model. My results do not contradict this joint hypothesis, but they do not constitute a direct test of the existence of repressed inflation in the Soviet Union.

This article discusses the disequilibrium model in a controlled economy in the Soviet Union. Robert Clower has presented a hypothesis of household behavior under conditions of involuntary unemployment; in his analysis, Clower contends that a constraint in labor supply implies a decrease in demand for consumer goods. Robert Barro and Herschel Grossman generalized Clower's analysis to include the case where the quantity of consumer goods available is less than the demand at the going price. The Barro-Grossman disequilibrium model provides a framework for analyzing the effects of repressing inflation by means of price controls. The model predicts that such a policy will lead to increased saving and, more importantly, a reduction in labor supply. The latter response will have a multiplier effect on output. Given the potential importance of the implications of these effects, particularly the labor supply response, it would seem of utmost importance to test this model empirically. The disequilibrium model predicts that if the amount of goods available on the state and cooperative retail market decreases then labor supply decreases, demand on the collective farm market and other free markets increases and saving increases. These predictions are tested here using time-series data for the years 1955 to 1967.

This article discusses various issues related to the economic policy adopted by the U.S. government concerning the account deficit of the country in 1988. In 1988, the U.S. recorded a deficit of about $135 billion on the current account of its balance of payments with the rest of the world. This sum amounted to roughly 2.75 percent of its gross national product. The recent path of the U.S. current account deficit and the consequent accumulation of external debts have raised many interesting economic and policy questions. Based on current policies, mainstream assumptions about the U.S. and foreign growth rates, and limited further currency realignments, many observers expect that within a few years the U.S. current account deficit will resume widening. The consensus forecast seems to be that a U.S. current account balance in the neighborhood of zero is not even a remote possibility in the near or not-so-near future. The implications of a current account deficit depend in part on what caused the deficit in the first place and how the economy adjusts in response.

The article discusses the adverse effects of limiting provider networks on the health care system of the U.S. Topics covered include the nominal goals of the Patient Protection and Affordable Care Act (ACA) as well as the need for all U.S. people to have health insurance. Also mentioned is the aim to make health insurance affordable to consumers.

The author offers insights on the patient-assistance programs being offered by pharmaceutical manufacturers. Topics explored include the annual spending of drug companies on these programs, the benefits of these programs to concerned firms in terms of product demand and public relations, and the cost of participating in these programs for patients. Also addressed are the possible subsidization of program participation for patients and the legal concerns raised with regard to remuneration.

There has been considerable speculation regarding the significance of the component competition in the race attitudes of Negroes and whites. However, empirical research in the field has neglected exploration of the significance of this factor. In the present report, attitudinal responses of 100 male Negro physicians, dentists, lawyers and public school teachers toward open competition reveal ambivalence about the matter. While they tend to accept the idea of open competition, they are considerably less than enthusiastic. [ABSTRACT FROM AUTHOR]

The aims of this study are to explore sexual adjustment before and during the honeymoon period and to examine postmarital consequences of premantal coitus with spouse during this period. The honeymoon represents a phase of marriage that has been the subject of much humor, of considerable morbid speculation, but of little research. Much of the existing knowledge concerning this early marital period is in the form of case materials which too often stress the more dramatic and anomalous factors influencing honeymoon sex adjustment. Some of the factors publicized as playing a central role in early marital sex adjustment are examined here. The universe of subjects for this study consisted of 190 married women, wives of students residing in three housing units on a midwestern university campus. Each subject was personally contacted and the nature of the research was briefly explained to her; she was then requested to complete a four page schedule. Information on the age and education of the respondents failed to show a significant relationship with premarital coitus with spouse.

This paper reports some of the more salient findings of the second study of a projected multi phase investigation of the relationship between social differentials and attitudes in the realm of intergroup relations. The first study, the field work for which was conducted in Indianapolis during 1950 involved the assessment of attitudes of Whites of varying socio economic status toward both Negroes and Whites of varying status. The present study, the data for which were gathered in Indianapolis during 1952, is to some extent a mirror image of the first phase. Virtually all relevant variables are the same as in the first investigation. This study is concerned with attitudes of Whites toward Negroes. The research dealing with attitudes of minority group members toward the majority makes a rather thin chapter in annals of sociological research, especially when compared to the volume of research on the other half of the intergroup relations picture. The inter group relations area has been traditionally handled within a social pathology framework and this orientation has been conducive not only to the espousal of values of the investigator, but has also lent itself to the assignment of blame and responsibility to particular individuals and groups for the society's failure to realize the investigator's values.

Estimates of the benefits of antifraud enforcement in health care typically focus on direct monetary damages. Deterrence effects are acknowledged but unquantified. We evaluate the impact of a Department of Justice investigation of hospitals accused of billing Medicare for unnecessary implantable cardiac defibrillator (ICD) procedures on their use. Using 100 % inpatient and outpatient procedure data from Florida, we estimate that the investigation caused a 22 % decline in ICD implantations. The present value of savings nationally over a 10 year period is $2.7 billion, nearly 10 times larger than the $280 million in settlements the Department of Justice recovered from hospitals. The investigation had a large and long-lasting effect on physician behavior, indicating the utility of antifraud enforcement as a tool for reducing wasteful medical care. [ABSTRACT FROM AUTHOR]

Background: Prebiopsy magnetic resonance imaging (MRI) of the prostate improves detection of significant tumors, while decreasing detection of less-aggressive tumors. Therefore, its use has been increasing over time. In this study, the use of prebiopsy MRI among Medicare beneficiaries with prostate cancer was examined. It was hypothesized that patients of color and those in isolated areas would be less likely to undergo this approach for cancer detection.Methods: Using cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) program linked to billing claims for fee-for-service Medicare beneficiaries, men with nonmetastatic prostate cancer were identified from 2010 through 2015 with prostate-specific antigen (PSA) <30 ng/mL. Outcome was prebiopsy MRI of the prostate performed within 6 months before diagnosis (ie, Current Procedural Terminology 72197). Exposures were patient race/ethnicity and rural/urban status. Multivariable regression estimated the odds of prebiopsy prostate MRI. Post hoc analyses examined associations with the registry-level proportion of non-Hispanic Black patients and MRI use, as well as disparities in MRI use in registries with data on more frequent use of prostate MRI.Results: There were 50,719 men identified with prostate cancer (mean age, 72.1 years). Overall, 964 men (1.9% of cohort) had a prebiopsy MRI. Eighty percent of patients with prebiopsy MRI lived in California, New Jersey, or Connecticut. Non-Hispanic Black men (0.6% vs 2.1% non-Hispanic White; odds ratio [OR], 0.28; 95% CI, 0.19-0.40) and men in less urban areas (1.1% vs 2.2% large metro; OR, 0.65; 95% CI, 0.44-0.97) were less likely to have prebiopsy MRI of the prostate.Conclusions: Non-Hispanic Black patients with prostate cancer and those in less urban areas were less likely to have prebiopsy MRI of the prostate during its initial adoption as a tool for improving prostate cancer detection. [ABSTRACT FROM AUTHOR]