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Prior literature has documented improvements in cancer survival over time. However, ambiguity remains over the relative contributions of improved treatment and earlier detection to survival gains. Using registry data, we developed a novel framework to estimate the relative contributions of advances in treatment and detection. Our approach compares changes in the probability of early detection, which we interpret as the effects of advances in detection, to improvements in stageconditional survival, which we interpret as the effects of treatment. We applied this methodology using SEER data to estimate probabilities of early detection and stage-conditional survival curves for several cancers, by race, between 1988 and 2000. Survival increased for all of the cancers we examined, with blacks experiencing larger survival gains than whites for all cancers combined. Our baseline analysis found that treatment advances account for the vast majority of survival gains for all the cancers examined: breast cancer (83%), lung cancer (85%), colorectal cancer (76%), pancreatic cancer (100%), and non-Hodgkin's lymphoma (96%). Compared to whites, treatments appear to explain a lower percentage of survival gains for blacks for all cancers combined; breast cancer, NHL, and pancreatic cancer show a higher percentage of survival gains than lung cancer; and roughly the same percentage for the colorectal cancer. These results are robust to sensitivity analyses examining potential length and lead time bias. Overall, our results suggest that while improved treatment and early detection both contributed to the recent gains in survival, the majority of gains from 1988 to 2000 appear to have been driven by better treatment, manifested by improved stage-conditional survival. These results have important policy implications regarding investment in research and development and the evaluation of efforts to improve cancer screening. [ABSTRACT FROM AUTHOR]

Background: Although cancer mortality has been decreasing since 1991, many cancers are still not detected until later stages with poorer outcomes. Screening for early-stage cancer can save lives because treatments are generally more effective at earlier than later stages of disease. Evidence of the aggregate benefits of guideline-recommended single-site cancer screenings has been limited. This article assesses the benefits in terms of life-years gained and associated value from major cancer screening technologies in the United States., Methods: A mathematical model was built to estimate the aggregate benefits of screenings for breast, colorectal, cervical, and lung cancer over time since the start of US Preventive Services Task Force (USPSTF) recommendations. For each type, the full potential benefits under perfect adherence and the benefits considering reported adherence rates were estimated. The effectiveness of each screening technology was abstracted from published literature on the life-years gained per screened individual. The number of individuals eligible for screening per year was estimated using US Census data matched to the USPSTF recommendations, which changed over time. Adherence rates to screening protocols were based on the National Health Interview Survey results with extrapolation., Results: Since initial USPSTF recommendations, up to 417 million people were eligible for cancer screening. Assuming perfect adherence to screening recommendations, the life-years gained from screenings are estimated to be 15.5-21.3 million (2.2-4.9, 1.4-3.6, 11.4-12.3, and 0.5 million for breast, colorectal, cervical, and lung cancer, respectively). At reported adherence rates, combined screening has saved 12.2-16.2 million life-years since the introduction of USPSTF recommendations, ~ 75% of potential with perfect adherence. These benefits translate into a value of $8.2-$11.3 trillion at full potential and $6.5-$8.6 trillion considering current adherence. Therefore, single-site screening could have saved an additional 3.2-5.1 million life-years, equating to $1.7-$2.7 trillion, with perfect adherence., Conclusions: Although gaps persist between the full potential benefit and benefits considering adherence, existing cancer screening technologies have offered significant value to the US population. Technologies and policy interventions that can improve adherence and/or expand the number of cancer types tested will provide significantly more value and save significantly more patient lives., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objectives: This article provides systematic evidence on the share of the value of health generated by drugs and other healthcare goods and services that accrue to patients on the demand side versus the manufacturers on the supply side., Methods: We exploit a large data set with > 9000 cost-effectiveness measures for various interventions, which we convert into measures of the shares of the value of improved health appropriated by the supply side using literature estimates of how patients value gains in health., Results: We find that if patients value a quality-adjusted life-year at $450 000 the median share appropriated for drugs on the supply side is approximately 6% and has declined at 0.1% per year between 1997 and 2019. This compares with other healthcare interventions, such as screenings or medical procedures, which have a median value of 9% but decline at 0.3% per year over the same period. If patients value a quality-adjusted life-year at $150 000, the median share appropriated for drugs and other healthcare interventions on the supply side is approximately 18% and 27%, respectively. Our estimates of appropriations are upper bounds, partly due to QALYs not capturing full producer value., Conclusions: Many policy debates center on the idea that the supply side is capturing too much of the value of the medical innovation that they generate. We find that, for these interventions, a large share of the value of medical innovation accrues to patients on the demand side given that the revenue to innovators is often far less than the patient's value of these medical innovations., (Copyright © 2023. Published by Elsevier Inc.)

Objective: Determine workplace productivity losses attributable to breast cancer progression., Methods: Longitudinal analysis linking 2005 to 2012 medical and pharmacy claims and workplace absence data in the US patients were commercially insured women aged 18 to 64 diagnosed with breast cancer. Productivity was measured as employment status and total quarterly workplace hours missed, and valued using average US wages., Results: Six thousand four hundred and nine women were included. Breast cancer progression was associated with a lower probability of employment (hazard ratio [HR] = 0.65, P < 0.01) and increased workplace hours missed. The annual value of missed work was $24,166 for non-metastatic and $30,666 for metastatic patients. Thus, progression to metastatic disease is associated with an additional $6500 in lost work time (P < 0.05), or 14% of average US wages., Conclusions: Breast cancer progression leads to diminished likelihood of employment, increased workplace hours missed, and increased cost burden.

Objectives: To determine the lifetime social value of using the guideline-recommended vaccines for children born in the United States in 2009., Study Design: This study utilized an economic model with parameter values sourced from clinical and observational data, as well as the literature., Methods: The model quantified the health effects of routine vaccination for 14 diseases in terms of quality-adjusted life-years (QALYs) saved. The health effects were then valued by applying an economic value of a QALY. Producers' profits were estimated using data on vaccine prices, profit margins, and the number of vaccines administrated in the 2009 US birth cohort. The costs of producing the vaccines were subtracted from the value of the health effects to yield the total social value of vaccination. The producers' and consumers' shares of this social value were calculated. Sensitivity analyses were conducted to determine how results depend on underlying parameter assumptions., Results: Estimates indicated that vaccination of this cohort will save 1.2 million QALYs, relative to no vaccination. Of those health gains, 88% stemmed from reduced mortality and 12% from reduced morbidity. We estimated a social value of $184.1 billion from these gains, of which $3.4 billion accrues to manufacturers as profits, while $180.7 billion accrues to the rest of society. In sensitivity analysis, the total social value ranged from $40 billion to $675 billion, and the manufacturers' share ranged from 0.3% to 11.5%., Conclusions: Policy makers should account for this social value when considering policies affecting incentives to vaccinate and develop new vaccines.

As real-world data (RWD) in health care begin to cross over to the Big Data realms, a panel of health economists was gathered to establish how well the current US policy environment further the goals of RWD and, if not, what can be done to improve matters. This report summarizes these discussions spanning the current US landscape of RWD availability and usefulness, private versus public development of RWD assets, the current inherent bias in terms of access to RWD, and guiding principles in providing quality assessments of new RWD studies. Three main conclusions emerge: (1) a business case is often required to incentivize investments in RWD assets. However, access restrictions for public data assets have failed to generate a proper market for these data and hence may have led to an underinvestment of public RWDs; (2) Very weak empirical evidence exist on for-profit entities misusing public RWD data entities to further their own agendas, which is the basis for supporting access restrictions of public RWD data; and (3) perhaps developing standardized metrics that could flag misuse of RWDs in an efficient way could help quell some of the fear of sharing public RWD assets with for-profit entities. It is hoped that these discussions and conclusions would pave the way for more rigorous and timely debates on the greater availability and accessibility of RWD assets.

Introduction: There have been significant improvements in both treatment and screening efforts for many types of cancer over the past decade. However, the effect of these advancements on the survival of cancer patients is unknown, and many question the value of both new treatments and screening efforts., Methods: This study uses a retrospective analysis of SEER Registry data to quantify reductions in mortality rates for cancer patients diagnosed between 1997 and 2007. Using variation in trends in mortality rates by stage of diagnosis across cancer types, we use logistic regression to decompose separate survival gains into those attributable to advances in treatment versus advances in detection. We estimate the gains in survival due to gains in both treatment and detection overall and separately for 15 of the most common cancer types., Results: We estimate that 3-year cancer-related mortality of cancer patients fell 16.7% from 1997 to 2007. Overall, advances in treatment reduced mortality rates by approximately 12.2% while advances in early detection reduced mortality rates by 4.5%. The relative importance of treatment and detection varied across cancer types. Improvements in detection were most important for thyroid, prostate and kidney cancer. Improvements in treatment were most important for non-Hodgkins lymphoma, lung cancer and myeloma., Conclusion: Both improved treatment options and better early detection have led to significant survival gains for cancer patients diagnosed from 1997 to 2007, generating considerable social value over this time period.

Objectives: Organs for transplantation are scarce, but new medical therapies can prevent organ failure and the need for transplants. We sought to describe the unique value created by treatments that spare organs from failure and thus conserve donated organs for transplant into others, using hepatitis C virus (HCV) as a case study., Study Design: Epidemiologic-economic model., Methods: Using data on trends in chronic liver disease, liver disease progression, and liver transplant allocation models, as well as the effectiveness of new HCV treatments, we estimate the potential effects of systematic HCV screening and treatment on the demand for liver transplants in the United States. We estimate the spillover benefits to patients with all-cause liver disease in terms of increased availability of transplants and life-years gained., Results: We estimated that systematic HCV screening and treatment could spare 10,490 liver transplants to HCV-infected patients from 2015 to 2035. An estimated 7321 transplants would accrue to patients with end-stage liver disease without HCV and 3169 transplants to those with uncured HCV, providing approximately 52,700 and 22,800 additional life-years, respectively., Conclusions: Treatment advances for HCV have the potential to generate considerable spillover benefits to patients awaiting transplants for non-HCV-mediated liver failure. For other diseases in which organ transplants are in short supply, our study provides a novel pathway by which positive spillovers may accrue from treatments that prevent end-stage organ disease.

Disease-associated malnutrition (DAM) is a well-recognized problem in many countries, but the extent of its burden on the Chinese population is unclear. This article reports the results of a burden-of-illness study on DAM in 15 diseases in China. Using data from the World Health Organization (WHO), the China Health and Nutrition Survey, and the published literature, mortality and disability-adjusted life years (DALYs) lost because of DAM were calculated; a financial value of this burden was calculated following WHO guidelines. DALYs lost annually to DAM in China varied across diseases, from a low of 2248 in malaria to a high of 1 315 276 in chronic obstructive pulmonary disease. The total burden was 6.1 million DALYs, for an economic burden of US$66 billion (Chinese ¥ 447 billion) annually. This burden is sufficiently large to warrant immediate attention from public health officials and medical providers, especially given that low-cost and effective interventions are available., (© 2014 APJPH.)

Aim: This study aims to analyze the impacts of a range of clinical evidence generation scenarios associated with comparative effectiveness research (CER) on pharmaceutical innovation., Materials & Methods: We used the Global Pharmaceutical Policy Model to project the effect of changes in pharmaceutical producer costs, revenues and timings on drug innovation and health for the age 55+ populations in the USA and Europe through year 2060 using three clinical scenarios., Results: Changes in producer incentives from widespread CER evidence generation and use had varied but often large predicted impacts on simulated outcomes in 2060. Effect on the number of new drug introductions ranged from a 81.1% reduction to a 45.5% increase, and the effect on population-level life expectancy ranged from a 15.6% reduction to a 11.4% increase compared to baseline estimates., Conclusion: The uncertainty surrounding the consequences of increased clinical evidence generation and use on innovation calls for a carefully measured approach to CER implementation, balancing near-term benefits to spending and health with long-term implications for innovation.

Technology drives both health care spending and health improvement. Yet policy makers rarely see measures of cost growth that account for both effects. To fill this gap, we present the quality-adjusted cost of care, which illustrates cost growth net of growth in the value of health improvements, measured as survival gains multiplied by the value of survival. We applied the quality-adjusted cost of care to two cases. For colorectal cancer, drug cost per patient increased by $34,493 between 1998 and 2005 as a result of new drug launches, but value from offsetting health improvements netted a modest $1,377 increase in quality-adjusted cost of care. For multiple myeloma, new therapies increased treatment cost by $72,937 between 2004 and 2009, but offsetting health benefits lowered overall quality-adjusted cost of care by $67,863. However, patients with multiple myeloma on established first-line therapies saw costs rise without corresponding benefits. All three examples document rapid cost growth, but they provide starkly different answers to the question of whether society got what it paid for., (Project HOPE—The People-to-People Health Foundation, Inc.)

Health care spending and health outcomes vary markedly across countries, but the association between spending and outcomes remains unclear. This inevitably raises questions as to whether continuing growth in spending is justified, especially relative to the rising cost of cancer care. We compared cancer care across sixteen countries over time, examining changes in cancer spending and two measures of cancer mortality (amenable and excess mortality). We found that compared to low-spending health systems, high-spending systems had consistently lower cancer mortality in the period 1995-2007. Similarly, we found that the countries that increased spending the most had a 17 percent decrease in amenable mortality, compared to 8 percent in the countries with the lowest growth in cancer spending. For excess mortality, the corresponding decreases were 13 percent and 9 percent. Additionally, the rate of decrease for the countries with the highest spending growth was faster than the all-country trend. These findings are consistent with the existence of a link between higher cancer spending and lower cancer mortality. However, further work is needed to investigate the mechanisms that underlie this correlation., (Project HOPE—The People-to-People Health Foundation, Inc.)

We analyzed the effect of oral nutritional supplement (ONS) use on 30-day readmission rates, length of stay (LOS), and episode costs in hospitalized Medicare patients (≥65), and subsets of patients diagnosed with acute myocardial infarction (AMI), congestive heart failure (CHF) or pneumonia (PNA). Propensity-score matching and instrumental variables were used to analyze ONS and non-ONS episodes from the Premier Research Database (2000-2010). ONS use was associated with reductions in probability of 30-day readmission by 12.0% in AMI and 10.1% in CHF. LOS decreases of 10.9% in AMI, 14.2% in CHF, and 8.5% in PNA were associated with ONS, as were decreases in episode costs in AMI, CHF and PNA of 5.1%, 7.8% and 10.6%, respectively. The effect on LOS and episode cost was greatest for the Any Diagnosis population, with decreases of 16.0% and 15.8%, respectively. ONS use in hospitalized Medicare patients ≥65 is associated with improved outcomes and decreased healthcare costs, and is therefore relevant to providers seeking an inexpensive, evidence-based approach for meeting Affordable Care Act quality targets.

Improving medication adherence has been identified as a crucial step towards improving health outcomes for patients with chronic disease and has provided the motivation for many changes in our health care system. Despite the volume of research done on this topic, however, we still lack important basic information about how to improve adherence in a cost-effective way. There is a need for a better understanding of what areas of research are most likely to produce advances that could be used by policymakers, providers, payers, or other stakeholders to generate real improvements in medication adherence. To address this, we developed a set of research priorities designed to improve understanding about whom to target for adherence interventions and which particular interventions to employ for specific subpopulations. To produce this research agenda, we synthesized information from the existing literature with a series of stakeholder interviews and expert panel meetings. We identified 6 key areas for research: (1) predicting nonadherence, (2) behavioral factors affecting nonadherence, (3) measuring the impact of nonadherence on health and cost outcomes, (4) effectiveness of existing interventions, (5) misaligned incentives between payers and providers, and (6) provider training and coordination of care. We provide detailed descriptions and example topics within each area.  As the health care system continues to embrace reforms designed to improve the value of care, more and better information is needed to guide efforts designed to improve medication adherence. Addressing the topic areas identified here will be an important step towards accomplishing this goal.

Despite the goal of comparative effectiveness research (CER) to inform patient-centered care, most studies fail to account for the patient-centeredness of care that already exist in practice, which we denote as passive personalization (PP). Because CER studies describe the average effectiveness of treatments rather than heterogeneity in how individual patients respond to therapies, clinical or coverage policies that respond to CER results may undermine PP in clinical practice and generate worse outcomes. We study this phenomenon empirically in the context of use of antipsychotic drugs in Medicaid patients with schizophrenia using novel instrumental variable methods. We find strong support for PP in clinical practice and demonstrate that the average effects from a CER study cannot be replicated in practice because of the presence of PP. In contrast, providing physicians with evidence to further personalize treatment can produce significant benefits., (Copyright © 2013 John Wiley & Sons, Ltd.)

Personalized medicine - the targeting of therapies to individuals on the basis of their biological, clinical, or genetic characteristics - is thought to have the potential to transform health care. While much emphasis has been placed on the value of personalized therapies, less attention has been paid to the value generated by the diagnostic tests that direct patients to those targeted treatments. This paper presents a framework derived from information economics for assessing the value of diagnostics. We demonstrate, via a case study, that the social value of such diagnostics can be very large, both by avoiding unnecessary treatment and by identifying patients who otherwise would not get treated. Despite the potential social benefits, diagnostic development has been discouraged by cost-based, rather than value-based, reimbursement.

Objectives: To assess the effect of inpatient oral nutritional supplement (ONS) use on length of stay, episode cost, and 30-day readmission probability., Study Design: Eleven-year retrospective study (2000 to 2010)., Methods: Analyses were conducted using the Premier Perspectives Database, which contained information on 44.0 million adult inpatient episodes. Using a matched sample of ONS and non-ONS episodes for any inpatient diagnosis, instrumental variables regression analysis was performed to quantify the effect of ONS use on length of stay, episode cost, and probability of approximate 30-day readmission. For the readmission outcome, the matched sample was restricted to episodes where the patient was known to be at risk of readmission. The fraction of a hospital's episodes in a given quarter involving ONS was used as an instrumental variable., Results: Within the database, 1.6% of 44.0 million adult inpatient episodes involved ONS use. Based on a matched sample of 1.2 million episodes, ONS patients had a shorter length of stay by 2.3 days (95% confidence interval [CI] - 2.42 to -2.16), from 10.9 to 8.6 days (21.0% decline), and decreased episode cost of $4734 (95% CI - $4754 to - $4714), from $21,950 to $17,216 (21.6% decline). Restricting the matched sample to the 862,960 episodes where patients were readmitted at some point, ONS patients had a reduced probability of early readmission (within 30 days) of 2.3 percentage points (95% CI - 0.027 to - 0.019), from 34.3% to 32.0% (6.7% decline)., Conclusions: Use of ONS decreases length of stay, episode cost, and 30-day readmission risk in the inpatient population.

We analyze the problem of incentivizing research and development (R&D) into developing world disease from an economic efficiency perspective. We view the problem as how to best promote R&D into goods with positive external effects in the sense that medicines that directly affect the health of the poor also indirectly affect the utility of the altruistic "rich." We demonstrate why existing policy proposals - such as price concessions by manufacturers - adversely impact the poor by placing the burden of R&D only on innovators rather than all altruists in the rich world. We offer policy solutions that are based on economic efficiency and therefore rely on a broad sense of how the world values the treatment of developing world disease. We estimate that global altruism toward those with malaria is, at a minimum, valued between $835 million and $2.4 billion annually and for HIV/AIDS, between $9.1 billion and $26.6 billion annually. We argue that future policies toward neglected diseases need to better incorporate how efficient R&D meets the need of this global altruism.

Increased health care spending has placed pressure on public and private payers to prioritize spending. Cost-effectiveness (CE) analysis is the main tool used by payers to prioritize coverage of new therapies. We argue that reimbursement based on CE is subject to a form of the "Lucas critique"; the goals of CE policies may not materialize when firms affected by the policies respond optimally to them. For instance, because 'costs' in CE analysis reflect prices set optimally by firms rather than production costs, observed CE levels will depend on how firm pricing responds to CE policies. Observed CE is therefore endogenous. When CE is endogenously determined, policies aimed at lowering spending and improving overall CE may paradoxically raise spending and lead to the adoption of more resource-costly treatments. We empirically illustrate whether this may occur using data on public coverage decisions in the United Kingdom., (Copyright © 2012 Elsevier B.V. All rights reserved.)

We develop a conceptual framework for estimating the value of personalized medicines. We show that personalizing medicines generates value from two sources. The first is a market-expansion effect by persons who initiate treatment due to reduced pre-treatment uncertainty about the effectiveness or side effects of treatment. The second is a market-contraction effect due to discontinuation of treatment by persons unresponsive to treatment. We apply the conceptual framework to evaluate the value of a predictive test to assess whether patients are at elevated risk for cardiac complications from COX-2 inhibitors. We find that this predictive test would yield an overall value to patients of about $16 billion per year or $1284 per likely patient.

Recent evidence suggests that the economic value of increased health has been enormous, with most of these gains being driven by medical R&D. The R&D process for pharmaceuticals is particularly expensive and time consuming, with well-known studies from the Tufts Center for the Study of Drug Development suggesting that developing a single successful drug costs around $1 billion and takes roughly 12 years. We argue that these estimates are incomplete because they do not incorporate the social costs imposed by the regulatory process, namely the costs to producers in terms of forgone profits and the costs to consumers in terms of delayed access to drugs. In this article, we develop a framework to estimate the social costs imposed by the regulatory process. Under this framework, delays in drug development are socially costly because of reduced consumer surplus (due to delayed access to beneficial therapies), reduced producer variable profits, and increased R&D expenditures. We apply this framework to the case of therapies aimed at treating AIDS, non-Hodgkin's lymphoma, and breast cancer. In each case, we find that the effects of drug delays on consumer surplus and variable producer profits are far larger than the effects on R&D costs. These findings suggest that patients, not firms, would be the primary beneficiaries from any improvements in streamlining the drug development process.

Standard techniques of cost effectiveness analysis measure a technology's benefits in terms of expected life years (or quality-adjusted life years) gained at today's life expectancies. However, this approach ignores the gains which derive from the possibility that a health technology allows an individual to survive long enough to benefit from other technological innovations which raise life expectancy (and quality of life) in the future. Borrowing a term from the finance literature, we refer to this source of value as the "option value" of innovation. We explain where this value comes from and how to calculate it in a variety of standard cost effectiveness analysis contexts. We provide a proof-of-concept using the example of the drug tamoxifen, which delayed the onset of breast cancer for some patients until more effective adjuvant treatment was available. We find that incorporating option value can increase the conventionally estimated value of tamoxifen with better adjuvant treatment by nearly a quarter (from $200,000 to $248,000 for those who initiated tamoxifen in 1999). We expect similar results for other drugs in therapeutic areas of rapid technological advancement.

Comparative effectiveness research (CER) is thought to identify what works and does not work in health care. We interpret CER as infusing evidence on product quality into markets, shifting the relative demand for products in CER studies. We analyze how shifts in demand affect health and health care spending and demonstrate that CER may raise or lower overall health when treatments have heterogeneous effects, but payers respond with product-specific coverage policies. Among patients with schizophrenia, we calibrate that subsidy policies based on the clinical trial CATIE may have reduced overall health by inducing some patients to switch away from schizophrenia treatments that were effective for them towards winners of the CER., (Copyright © 2011 Elsevier B.V. All rights reserved.)

This paper reviews the evidence on external costs of risky behaviors in the U.S. and provides a framework for estimating them. External costs arise when a person does not bear all the costs of his or her behavior. They provide one of the strongest rationales for government interventions. Although the earlier estimates of external costs no longer have policy relevance, they demonstrated that the existence of external costs was an empirical question. We recommend that the estimates of external costs be updated as insurance structures, environments, and knowledge about these behaviors change. The general aspects of external costs may apply to countries other than the U.S. after taking into account differences in institutional, policy and epidemiological characteristics.

For decades, the US public and private sectors have committed substantial resources towards cancer research, but the societal payoff has not been well-understood. We quantify the value of recent gains in cancer survival, and analyze the distribution of value among various stakeholders. Between 1988 and 2000, life expectancy for cancer patients increased by roughly four years, and the average willingness-to-pay for these survival gains was roughly $322,000. Improvements in cancer survival during this period created 23 million additional life-years and roughly $1.9 trillion of additional social value, implying that the average life-year was worth approximately $82,000 to its recipient. Health care providers and pharmaceutical companies appropriated 5-19% of this total, with the rest accruing to patients. The share of value flowing to patients has been rising over time. In terms of economic rates of return, R&D investments against cancer have been a success, particularly from the patient's point of view.

Objectives: To examine how cost sharing for prescription drugs affects compliance with antiplatelet therapy and subsequent health outcomes among patients with acute coronary syndrome (ACS)., Study Design: Retrospective outcomes study using administrative data from medical and pharmaceutical claims of patients enrolled at health plans offered by 26 large employers drawn from all regions of the country., Methods: A total of 14,325 patients were diagnosed as having ACS and underwent coronary stent implantation between 2002 and 2005. Each patient was followed up for a maximum of 2 years. Primary outcomes measures were adoption of outpatient antiplatelet therapy, adherence to outpatient therapy, hospital admissions, and healthcare expenditures., Results: Patients with ACS who face higher coinsurance are less likely to adopt outpatient antiplatelet therapy within the first month after stent implantation and are more likely to discontinue treatment in the first year after stent implantation (P <.01). Higher coinsurance is also associated with an increased number of ACS rehospitalizations (P <.01). For patients in health plans with higher coinsurance rates, expected costs from ACS hospitalizations are $2796 (38%) higher in the first year after stent implantation (P <.01)., Conclusions: Higher copayments for prescription drugs are associated with lower utilization of antiplatelet therapy and with higher likelihood of rehospitalization among patients with ACS. As a consequence, total healthcare spending for patients with ACS increases by approximately $615 in the first year after stent implantation.

Critics of me-too innovation often argue that follow-on drugs offer little incremental clinical value over existing pioneer products, while at the same time increasing health care costs. We examine whether consumers view follow-on and pioneer drugs as close substitutes or distinct clinical therapies. For five major classes of drugs, we find that large reductions in the price of pioneer molecules after patent expiration-which would typically lead to decreased consumption of strong substitutes-have no effect on the trend in demand for follow-on drugs. Our findings are likely unaffected by health insurance, competitive pricing of me-toos, marketing, and switching costs.

GDP per capita is usually used to proxy for the quality of life of individuals living in different countries. Welfare is also affected by quantity of life, however, as represented by longevity. This paper incorporates longevity into an overall assessment of the evolution of cross-country inequality and shows that it is quantitatively important. The absence of reduction in cross-country inequality up to the 1990s documented in previous work is in stark contrast to the reduction in inequality after incorporating gains in longevity. Throughout the post–World War II period, health contributed to reduce significantly welfare inequality across countries. This paper derives valuation formulas for infra-marginal changes in longevity and computes a "full" growth rate that incorporates the gains in health experienced by 96 countries for the period between 1960 and 2000. Incorporating longevity gains changes traditional results; countries starting with lower income tended to grow faster than countries starting with higher income. We estimate an average yearly growth in "full income" of 4.1 percent for the poorest 50 percent of countries in 1960, of which 1.7 percentage points are due to health, as opposed to a growth of 2.6 percent for the richest 50 percent of countries, of which only 0.4 percentage points are due to health. Additionally, we decompose changes in life expectancy into changes attributable to 13 broad groups of causes of death and three age groups. We show that mortality from infectious, respiratory, and digestive diseases, congenital, perinatal, and “ill-defined” conditions, mostly concentrated before age 20 and between ages 20 and 50, is responsible for most of the reduction in life expectancy inequality. At the same time, the recent effect of AIDS, together with reductions in mortality after age 50--due to nervous system, senses organs, heart and circulatory diseases--contributed to increase health inequality across countries.

This paper analyzes the forces contributing to the worldwide long-run rise in obesity and the role of public interventions in affecting its continued growth. A growth in obesity in a population must result from the growth of calorie consumption outpacing the growth of physical activity. Yet historically in developed countries, obesity has grown with modest rises in calorie consumption and with a substantial increase in both exercise and dieting. We consider the economic incentives that give rise to the long-run growth in obesity by stimulating intake of calories at the same time as discouraging the expending of calories on physical activity, whether in work or leisure. We argue that technological change provides a natural interpretation of the long-run growth in obesity, that it predicts that the effect of income on obesity changes from positive to negative with economic development, and that it implies that technological change may not continue to raise weight. We discuss the positive and normative impacts of direct and indirect public interventions to reduce obesity.

Objective: To evaluate whether immunization against a vaccine-preventable disease is sought to avoid the naturally occurring disease itself, we hypothesized that the rate of "on-time" measles immunization would increase during an epidemic of that disease. If such an effect occurred, we wondered whether it would have an impact on on-time administration of other recommended immunizations., Design: Retrospective evaluation of immunization rates of children at their second birthday with the use of computerized health records of children entering kindergarten in an 8-year interval spanning the onset of epidemic measles in Chicago, Ill, in 1989 and 1990., Setting: Children entering Chicago public schools., Main Outcome Measures: Rates of receipt of measles-containing vaccine (MCV), 1 to 4 doses of a diptheria toxoid-tetanus toxoid-pertussis (DTP) or diphtheria toxoid-tetanus toxoid (DT) vaccine, 1 to 3 doses of oral or inactivated polio vaccine (OPV/IPV), and the full series of these vaccines (4:3:1) that are required to be "up-to-date" by the second birthday., Results: The rate of on-time MCV receipt increased from 56% to 58% in the years prior to 70% during the epidemic (1989 and 1990). A similar increase did not occur to DTP/DT 4 or OPV/IPV 3. Moreover, among older children delayed in MCV receipt, evidence of catch-up immunization also occurred during the epidemic years; similar catch-up for delayed DTP/DT 4 or OPV/IPV 3 immunization did not occur., Conclusions: Dramatic increases in one-time and catch-up MCV receipt occurred during the Chicago measles epidemic of 1989 and 1990. The lack of similar increases in DTP/DT 4 and OPV/IPV 3 suggests MCV receipt was not associated with receipt of other recommended immunizations during that time.