Willingness to Pay for Drug Rehabilitation: Implications for Cost Recovery

Objectives: This study estimates the value that clients place on drug rehabilitation services at the time of intake and how this value varies with the probability of success and availability of social services. Methods: We interviewed 241 heroin users who had been referred to, but had not yet entered, methadone maintenance treatment in Baltimore, Maryland. We asked each subject to state a preference among three hypothetical treatment programs that varied across 3 domains: weekly fee paid by the client out of pocket ($5 to$100), presence/absence of case management, and time spent heroin-free (3 to 24 months). Each subject was asked to complete 18 orthogonal comparisons. Subsequently each subject was asked if they likely would enroll in their preferred choice among the set of three. We computed the expected willingness to pay (WTP) as the probability of enrollment times the fee considered in each choice considered from a multivariate logistic model that controlled for product attributes. We also estimated the price elasticity of demand. Results: We found that 21% of clients preferred programs that were logically dominated by other options. The median expected fee subjects were willing to pay for a program that offered 3 months of heroin-free time was $7.30 per week, rising to$17.11 per week for programs that offered 24 months of heroin-free time. The availability of case management increased median WTP by $5.64 per week. The fee was the most important predictor of the self-reported probability of enrollment with a price elasticity of -0.39 (SE 0.042). Conclusions: Clients' median willingness to pay for drug rehabilitation fell short of the average program costs of$82 per week, which reinforces the need for continued subsidization as drug treatment has high positive externalities. Clients will pay more for higher rates of treatment success and for the presence of case management.

Editorial: Enabling local health departments to save more lives: A public health perspective

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Algorithms for purchasing AIDS vaccines

The authors delineate two different algorithms for the purchase of AIDS vaccines, to show how differences in policy objectives can greatly affect projections of the number of courses of vaccine that will be needed. They consider a hypothetical vaccine costing ten dollars to produce, and offering sixty percent, seventy five percent, and ninety percent reductions in the risk of HIV for ten years. For each of the world's ten major geographic divisions, they sue published estimates of the risk of AIDS, the value of medical costs averted, and the value of potential productivity losses. Under the"health sector"algorithm - in which purchases are made to minimize the impact of AIDS/HIV on government health spending - 766 million courses of vaccine would be purchased. Under the"societal"algorithm - in which purchases are made to minimize the impact of AIDS/HIV on health spending and GDP - more than 3.7 billion courses of vaccine would be purchased. Under an"equity"model - allocating vaccines to everyone in the world at high risk, as if they had the financial resources of Western Europeans - vaccine would be offered to 4.7 billion people. For a Western European man, reducing the risk of AIDS/HIV would be a $789 concern; in Africa,the comparable risk would be a$48,577 crisis. The authors conclude that financing AIDS vaccines solely on the fixed budget of a ministry of health, means large vulnerable populations wouldn't receive the vaccine. Allocating the vaccine based on society's ability to pay would still exclude many poor infants who would probably be immunized if they were born in more developed regions. Policymakers concerned about equity in health care must redouble efforts to making the financing of development, and distribution of AIDS vaccines, a global, not a regional concern.Disease Control&Prevention,Public Health Promotion,Health Monitoring&Evaluation,Early Child and Children's Health,HIV AIDS,HIV AIDS,Health Monitoring&Evaluation,Health Economics&Finance,Adolescent Health,Environmental Economics&Policies

Are infant mortality rate declines exponential? The general pattern of 20th century infant mortality rate decline

<p>Abstract</p> <p>Background</p> <p>Time trends in infant mortality for the 20^thcentury show a curvilinear pattern that most demographers have assumed to be approximately exponential. Virtually all cross-country comparisons and time series analyses of infant mortality have studied the logarithm of infant mortality to account for the curvilinear time trend. However, there is no evidence that the log transform is the best fit for infant mortality time trends.</p> <p>Methods</p> <p>We use maximum likelihood methods to determine the best transformation to fit time trends in infant mortality reduction in the 20^thcentury and to assess the importance of the proper transformation in identifying the relationship between infant mortality and gross domestic product (GDP) per capita. We apply the Box Cox transform to infant mortality rate (IMR) time series from 18 countries to identify the best fitting value of lambda for each country and for the pooled sample. For each country, we test the value of <it>λ </it>against the null that <it>λ </it>= 0 (logarithmic model) and against the null that <it>λ </it>= 1 (linear model). We then demonstrate the importance of selecting the proper transformation by comparing regressions of ln(IMR) on same year GDP per capita against Box Cox transformed models.</p> <p>Results</p> <p>Based on chi-squared test statistics, infant mortality decline is best described as an exponential decline only for the United States. For the remaining 17 countries we study, IMR decline is neither best modelled as logarithmic nor as a linear process. Imposing a logarithmic transform on IMR can lead to bias in fitting the relationship between IMR and GDP per capita.</p> <p>Conclusion</p> <p>The assumption that IMR declines are exponential is enshrined in the Preston curve and in nearly all cross-country as well as time series analyses of IMR data since Preston's 1975 paper, but this assumption is seldom correct. Statistical analyses of IMR trends should assess the robustness of findings to transformations other than the log transform.</p

Far above rubies: the association between bride price and extramarital sexual relations in Uganda

The custom of bride price involves the payment of goods or cash from the groom's family to the bride's family at the time of marriage. We present a theory that views bride price as a payment in hedonic markets for marital fidelity. Data from a household survey in Uganda are used to test the theoretical prediction that payment of bride price will be associated with fewer non-marital sexual relationships for women. The data show a robust association between bride price payment and lower rates of non-marital sexual relationships for women but not for men

Cost-effectiveness of traffic enforcement: case study from Uganda

BACKGROUND: In October 2004, the Ugandan Police department deployed enhanced traffic safety patrols on the four major roads to the capital Kampala. OBJECTIVE: To assess the costs and potential effectiveness of increasing traffic enforcement in Uganda. METHODS: Record review and key informant interviews were conducted at 10 police stations along the highways that were patrolled. Monthly data on traffic citations and casualties were reviewed for January 2001 to December 2005; time series (ARIMA) regression was used to assess for a statistically significant change in traffic deaths. Costs were computed from the perspective of the police department in $US 2005. Cost offsets from savings to the health sector were not included. RESULTS: The annual cost of deploying the four squads of traffic patrols (20 officers, four vehicles, equipment, administration) is estimated at$72,000. Since deployment, the number of citations has increased substantially with a value of $327 311 annually. Monthly crash data pre- and post-intervention show a statistically significant 17$603 per death averted or $27 per life year saved discounted at 3$300 GDP per capita). CONCLUSION: The costs of traffic safety enforcement are low in comparison to the potential number of lives saved and revenue generated. Increasing enforcement of existing traffic safety norms can prove to be an extremely cost-effective public health intervention in low-income countries, even from a government perspective

Economic Recessions and Infant Mortality in the U.S., 1999-2008

Objectives: Prior studies of US data from the 1990s have shown that economic growth is associated with higher all cause mortality. This paper updates prior findings to more recent data on US infant mortality for blacks and whites. Methods: We analyzed data from 50 US states from 1999 to 2008 using state fixed-effects regression models stratified to identify the racially disparate impact of each state’s economic performance on infant mortality, controlling for state policy-related variables, reflecting population,% black, % on TANF, % on Medicaid, and alcohol consumption. Results: Economic recessions are significantly associated with lower post-neonatal mortality for white infants, but not black infants. Each 1% decrement a state’s gross state product, would be associated with an approximately 2.3 fewer infant deaths (95% CI: -0.294-4.894) in an average state with 64,000 total births. Results were robust to the inclusion of state trends, national trends, state fixed effects, lagged gross state product, and the inclusion of measures of unemployment and state policy variables. Conclusions: This study in combination with studies from the 1990s reflects growing evidence that economic growth in the US can be harmful to child health. Policy makers need to be informed and mindful about the “side effects” of economic growth on health

Modeling the cost effectiveness of injury interventions in lower and middle income countries: opportunities and challenges

BACKGROUND: This paper estimates the cost-effectiveness of five interventions that could counter injuries in lower and middle income countries(LMICs): better traffic enforcement, erecting speed bumps, promoting helmets for bicycles, promoting helmets for motorcycles, and storing kerosene in child proof containers. METHODS: We adopt an ingredients based approach to form models of what each intervention would cost in 6 world regions over a 10 year period discounted at both 3% and 6% from both the governmental and societal perspectives. Costs are expressed in local currency converted into US $2001. Each of these interventions has been assessed for effectiveness in a LMIC in limited region, these effectiveness estimates have been used to form models of disability adjusted life years (DALYs) averted for various regions, taking account of regional differences in the baseline burden of injury. RESULTS: The interventions modeled in this paper have cost effectiveness ratios ranging from US$5 to $556 per DALY averted depending on region. Depending on local acceptability thresholds many of them could be judged cost-effective relative to interventions that are already adopted. Enhanced enforcement of traffic regulations is the most cost-effective interventions with an average cost per DALY of$64 CONCLUSION: Injury counter measures appear to be cost-effective based on models. More evaluations of real interventions will help to strengthen the evidence basis

Lifecycle Changes in the Rate of Time Preference: Testing the Theory of Endogenous Preferences and its Relevance to Adolescent Substance Abuse

Economic theory indicates that because one's activities to improve health reward one in the future, persons who value the future more highly will be more prone to healthy activity. Without measures of time preference we can neither test this theory nor understand what makes people value future events more highly. Progress in this area requires a method to infer measures of time preference from the secondary datasets used in public health and economic research. Time preference in its econometric expression is the measurable forfeiting of additional goods in the present to enjoy goods in the future. The rate of time preference varies from 0 for individuals who are indifferent between present and future consumption to infinity for individuals who have place no value on future consumption. When subjects decide to forego higher wages in the present by taking safer jobs that increase their chance of future survival they send signals about their time preference (mixed with signals about risk aversion, other job prospects, family pressures, etc.). These wage-risk tradeoffs offer scholars interested in measuring time preference the convenience of a secondary dataset, but the drawback of needing to control for the confounding and endogenous factors. This study applies econometric techniques to the National Longitudinal Survey of Youth (NLSY) to derive estimates of the levels of time preference for each labor force participant in each of 15 waves of data from 1979 to 1994. With these estimates I describe the evolution of time preference over the life course. I test the following hypotheses suggested by Becker and Mulligan (Becker and Mulligan 1997)in their theory of endogenous time preferences: 1)Age and Education reduce the rate of time preference; 2)Female gender and Father's Presence in the Home at age 14 reduce the rate of time preference; 3) Religious participation reduces the rate of time preference. Finally I show that subjects with a more immediate time preference are more likely to drink alcohol and conditional upon drinking are more more likely to drink heavily. A policy maker with a better understanding of the determinants of time preference can design better policies that empower children to value their future well-being and thereby increase present healthy behavior

Advancing the application of systems thinking in health: why cure crowds out prevention

INTRODUCTION: This paper presents a system dynamics computer simulation model to illustrate unintended consequences of apparently rational allocations to curative and preventive services. METHODS: A modeled population is subject to only two diseases. Disease A is a curable disease that can be shortened by curative care. Disease B is an instantly fatal but preventable disease. Curative care workers are financed by public spending and private fees to cure disease A. Non-personal, preventive services are delivered by public health workers supported solely by public spending to prevent disease B. Each type of worker tries to tilt the balance of government spending towards their interests. Their influence on the government is proportional to their accumulated revenue. RESULTS: The model demonstrates effects on lost disability-adjusted life years and costs over the course of several epidemics of each disease. Policy interventions are tested including: i) an outside donor rationally donates extra money to each type of disease precisely in proportion to the size of epidemics of each disease; ii) lobbying is eliminated; iii) fees for personal health services are eliminated; iv) the government continually rebalances the funding for prevention by ring-fencing it to protect it from lobbying. The model exhibits a “spend more get less” equilibrium in which higher revenue by the curative sector is used to influence government allocations away from prevention towards cure. Spending more on curing disease A leads paradoxically to a higher overall disease burden of unprevented cases of disease B. This paradoxical behavior of the model can be stopped by eliminating lobbying, eliminating fees for curative services, and ring-fencing public health funding. CONCLUSIONS: We have created an artificial system as a laboratory to gain insights about the trade-offs between curative and preventive health allocations, and the effect of indicative policy interventions. The underlying dynamics of this artificial system resemble features of modern health systems where a self-perpetuating industry has grown up around disease-specific curative programs like HIV/AIDS or malaria. The model shows how the growth of curative care services can crowd both fiscal and policy space for the practice of population level prevention work, requiring dramatic interventions to overcome these trends.DFI