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The impact of the Dept of Defense's CHAMPUS reform initiative on government expenditures for health care offered to Armed Forces personnel is discussed. Additional information on the new structure of CHAMPUS is included.

Using data from the National Health Interview Survey and the RAND Health Insurance Experiment, we estimated the external costs (costs borne by others) of a sedentary life-style. External costs stem from additional payments received by sedentary individuals from collectively financed programs such as health insurance, sick-leave coverage, disability insurance, and group life insurance. Those with sedentary life-styles incur higher medical costs, but their life expectancy at age 20 is 10 months less so they collect less public and private pensions. The pension costs come late in life, as do some of the medical costs, and so the estimate of the external cost is sensitive to the discount rate used. At a 5 percent rate of discount, the lifetime subsidy from others to those with a sedentary life style is $1,900. Our estimate of the subsidy is also sensitive to the assumed effect of exercise on mortality. The subsidy is a rationale for public support of recreational facilities such as parks and swimming pools and employer support of programs to increase exercise., The financial costs that a sedentary lifestyle imposes on others were measured. External costs result from additional payments that sedentary persons receive from collectively financed health benefit programs such as health insurance, sick-leave coverage, disability insurance, and group life insurance. Although sedentary people incur higher medical costs, their life expectancy at age 20 is 10 months less than that of active individuals, so they collect less in pensions. Because pension and medical costs occur late in life, the estimate of the external cost is affected by the discount rate used. If costs are discounted by 5 percent per year, the lifetime subsidy from other people to each sedentary person is $1,900 dollars. This estimate of the subsidy depends on the assumed effect of exercise on death rates. This subsidy effect justifies public expenditure on such things as parks and swimming pools and employer expenditure on programs to increase exercise.

Poor health habits, such as smoking and heavy drinking, result in high costs for society as a whole. Society is believed to subsidize the cost of smoking and drinking. Concern about these costs has prompted proposals to increase both federal and state excise taxes on cigarettes and alcohol. Researchers attempted to assess the economically efficient level of taxation (i.e., the "sin tax") imposed on cigarettes and alcoholic beverage purchases in order to cover the costs of alcohol and tobacco use absorbed by the general society. Over a lifetime, smokers and drinkers impose costs on others through the greater use of collectively-financed health insurance, a higher incidence of involvement in fires, a greater likelihood of involvement in motor-vehicle accidents, and a higher rate of involvement in the criminal justice system. However, researchers found that while nonsmokers subsidize smokers' medicare care and group life insurance, smokers subsidize nonsmokers' pensions and nursing home payments (they are more likely to die before collecting their benefits): on balance, smokers probably pay their way with the current level of excise taxes on cigarettes. By contrast, drinkers do not pay their way; for example, the present legal system can not reasonably make drunk drivers bear the full costs of their actions suffered by others., ABSTRACT: We estimate the lifetime, discounted costs that smokers and drinkers impose on others through collectively financed health insurance, pensions, disability insurance, group life insurance, fires, motor-vehicle accidents, and the criminal justice system. Although nonsmokers subsidize smokers' medical care and group life insurance, smokers subsidize nonsmokers' pensions and nursing home payments. On balance, smokers probably pay their way at the current level of excise taxes on cigarettes; but one may, nonetheless, wish to raise those taxes to reduce the number of adolescent smokers. In contrast, drinkers do not pay their way: current excise taxes on alcohol cover only about half the costs imposed on others.

Attempts to estimate the lifetime, discounted costs that smokers and drinkers impose on others through collectively financed health insurance, pensions, disability insurance, group life insurance, fires, motor-vehicle accidents, and the criminal justice system in the U.S. Excise taxes on cigarettes and alcohol; Internal and external costs of smoking and alcohol drinking.

An association between cigarette smoking and menstrual disorders was observed during 1981 in a sample of 1367 women between the ages of 18 and 44 years in selected communities of Los Angeles County. Relevant questions were asked as part of a survey conducted to investigate the general health status of women living in these communities. The five-year period prevalence of physician-attended menstrual disorders, as reported in the survey, was 20.3%; the prevalence of menstrual disorders was higher among smokers (25.1%) than among nonsmokers (1 8.6%). Women who smoked 1½ packs of cigarettes or more per day were twice as likely to report past menstrual disorders as women who were nonsmokers. The results, though inconclusive, warrant further investigation. [ABSTRACT FROM PUBLISHER]

Recently, the U.S. Department of Defense replaced its traditional fee-for-service insurance plan for military health care beneficiaries with an HMO/PPO hybrid. Using survey and claims data, a comparison is made of changes in costs over two years at sites that implemented this CHAMPUS Reform Initiative (CRI) with changes at matched control sites. Results indicate that CRI substantially raised per beneficiary government costs for providing benefits (as compared to predicted costs in the absence of CRI). This difference is attributed to the higher overhead of managed care and the increased expenditures by HMO participants. [ABSTRACT FROM AUTHOR]

Replies to the comments of a reader concerning the authors' article about the effect to infants of smoking in pregnant women.

The U.S. Department of Defense (DoD) strives to maintain a physically and psychologically healthy, mission-ready force, and the care provided by the Military Health System (MHS) is critical to meeting this goal. Attention has been directed to ensuring the quality and availability of programs and services for posttraumatic stress disorder (PTSD) and depression. This study is a comprehensive assessment of the quality of care delivered by the MHS in 2013-2014 for over 38,000 active-component service members with PTSD or depression. The assessment includes performance on 30 quality measures to evaluate the receipt of recommended assessments and treatments. These measures draw on multiple data sources including administrative encounter data, medical record review data, and patient self-reported outcome monitoring data. The assessment identified strengths and areas for improvement for the MHS. In particular, the MHS excels at screening for suicide risk and substance use, but rates of appropriate follow-up for service members with suicide risk are lower. Most service members received at least some psychotherapy, but less than half of psychotherapy delivered was evidence-based. In analyses focused on Army soldiers, outcome monitoring increased notably over time, yet preliminary analyses suggest that more work is needed to ensure that services are effective in reducing symptoms. When comparing performance between 2012-2013 and 2013-2014, most measures demonstrated slight improvement, but targeted efforts will be needed to support further improvements. RAND provides recommendations for strategies to improve the quality of care delivered for these conditions.

The U.S. Department of Defense (DoD) strives to maintain a physically and psychologically healthy, mission-ready force, and the care provided by the Military Health System (MHS) is critical to meeting this goal. Given the rates of posttraumatic stress disorder (PTSD) and depression among U.S. service members, attention has been directed to ensuring the quality and availability of programs and services targeting these and other psychological health (PH) conditions. Understanding the current quality of care for PTSD and depression is an important step toward improving care across the MHS. To help determine whether service members with PTSD or depression are receiving evidence-based care and whether there are disparities in care quality by branch of service, geographic region, and service member characteristics (e.g., gender, age, pay grade, race/ethnicity, deployment history), DoD's Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) asked the RAND Corporation to conduct a review of the administrative data of service members diagnosed with PTSD or depression and to recommend areas on which the MHS could focus its efforts to continuously improve the quality of care provided to all service members. This study characterizes care for service members seen by MHS for diagnoses of PTSD and/or depression and finds that while the MHS performs well in ensuring outpatient follow-up following psychiatric hospitalization, providing sufficient psychotherapy and medication management needs to be improved. Further, quality of care for PTSD and depression varied by service branch, TRICARE region, and service member characteristics, suggesting the need to ensure that all service members receive high-quality care.