Predictability of drug expenditures: An application using morbidity data

The growth of pharmaceutical expenditure and its prediction is a major concern for policy makers and health care managers. This paper explores different predictive models to estimate future drug expenses, using demographic and morbidity individual information from an integrated healthcare delivery organization in Catalonia for years 2002 and 2003. The morbidity information consists of codified health encounters grouped through the Clinical Risk Groups (CRGs). We estimate pharmaceutical costs using several model specifications, and CRGs as risk adjusters, providing an alternative way of obtaining high predictive power comparable to other estimations of drug expenditures in the literature. These results have clear implications for the use of risk adjustment and CRGs in setting the premiums for pharmaceutical benefits.Drug expenditure, risk-adjustment, morbidity, clinical risk groups

Specializing nurses as an indirect education program for stoma patients

Education programs are beneficial for patients with different chronic conditions. Prior studies have examined direct education, where information is transferred directly to patients. In contrast, in this program, information is transferred directly to nurses who become specialists and transfer education individually to patients. Hence, this paper evaluates the impact of having specialist nurses for stoma patients at hospitals, as those nurses provide healthcare to patients but also inform and educate patients about their condition and needs. The analysis uses an observational study with ostomized patients in Spain at hospitals with and without specialist nurses, and measures health service utilization and health-related quality of life (HRQL), besides performing a cost analysis and a cost-effectiveness analysis at both types of hospitals. The results show that patients with access to specialist nurses self-manage better, present lower adverse events and a better evolution of HRQL, and significantly demand more consultations with specialist nurses and less to A&E, primary care or specialists, resulting in important savings for the health system. Consequently, specializing or hiring nurses to provide indirect education to stoma patients is cost-effective and highly beneficial for patients. This type of indirect education strategy might be considered for specific conditions with low incidence or difficulties in identifying target patients or delivering information directly to them

Population based resource allocation: The use of hybrid risk adjustment

The emphasis on integrated care implies new incentives that promote coordination between levels of care. Considering a population as a whole, the resource allocation system has to adapt to this environment. This research is aimed to design a model that allows for morbidity related prospective and concurrent capitation payment. The model can be applied in publicly funded health systems and managed competition settings. Methods: We analyze the application of hybrid risk adjustment versus either prospective or concurrent risk adjustment formulae in the context of funding total health expenditures for the population of an integrated healthcare delivery organization in Catalonia during years 2004 and 2005. Results: The hybrid model reimburses integrated care organizations avoiding excessive risk transfer and maximizing incentives for efficiency in the provision. At the same time, it eliminates incentives for risk selection for a specific set of high risk individuals through the use of concurrent reimbursement in order to assure a proper classification of patients. Conclusion: Prospective Risk Adjustment is used to transfer the financial risk to the health provider and therefore provide incentives for efficiency. Within the context of a National Health System, such transfer of financial risk is illusory, and the government has to cover the deficits. Hybrid risk adjustment is useful to provide the right combination of incentive for efficiency and appropriate level of risk transfer for integrated care organizations.Health expenditures, hybrid risk-adjustment, morbidity, clinical risk groups

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Pathways towards chronic-care focused healthcare systems: evidence from SpainPathways towards chronic-care focused healthcare systems: evidence from Spai

Innovative reimbursement tools for cancer treatments. Analyzing the feasibility of single price versus indication based pricing in multi indication products. The case of Spain

The increase in pharmaceutical spending and more specifically in pharmaceutical spending in hospitals is a growing concern for policy makers. The main determinant of this increase is the adoption of healthcare technology, with innovative pharmaceutical treatments accounting for a significant part of this increase in spending, and among these, cancer treatments being of the most important. At the same time, it is increasingly common to have in the market multi-indication oncology treatments, which do not normally offer the same clinical benefit across indications, and as a consequence, it is not possible to reflect the real value of the medicine under a single cross-indication price, constituting a challenge for pricing and reimbursement responsible agents. The health economics literature and the international experience have explored different approaches to bear this challenge, such as indication based pricing, multi year multi indication agreements, or the use of specific funds. The goal of this report is to analyse the practical feasibility of the implementation in Spain of two of them: indication based pricing (with different listed prices per indication for multi-indication products), or a unique listed price for all of them. We perform this analysis through the composition of a multidisciplinary Expert Panel that met twice during 2021 in directed discussions. By explicit request of the Members in the Expert Panel, this report does not endorse any specific recommendation for one or another alternative but just make an analysis of advantages and disadvantages of each system. The alternative of a unique single price for all the indications of a product is in principle easier to manage, and in terms of regulation, it would not need major modifications to be operative and reduces the risk of arbitrage. However, it moves away from the valuebased pricing and may result in strategic behaviour in companies that may derive in delay in access for some patients. If pursued, a weighted average taking into account the added therapeutic value and the expected number of patients that could be benefitted per indication is recommended, always avoiding the only use of a price-volume agreement. The price should be revised every time that there is a new indication approved and periodically to check new clinical evidence on the indications as well as possible deviations in the estimation of the demand. The alternative of indication based pricing (IBP) promotes value-based pricing, through a different price, based on the value evidenced in the economic evaluation exercise to each approved indication, and in the long run, it improves social welfare and provides the right incentives for innovation and a higher degree of competition in markets. However, its implementation would need some normative modifications, may result in incentives for arbitrage, greater administrative costs in the purchasing and payment process, and also in monitoring and registering the specific use per indication. At the same time, it can produce some reluctance to the change in local and regional providers and payers who are already negotiating (and should continue to do so) indication-specific discounts. As in the case of single price, prices under IBP should also be revised periodically. Both alternatives may admit exceptions in order to improve their results. IBP is unfeasible for agnostic tumours or when the administration of the medicine is not independent by indications. Single price is problematic when differences in added value may derive in lack of incentives for commercialization of a new indication, with the loss of access to the medicine for affected patients. Interestingly, both alternatives share some common challenges for the appropriate implementation. They both rely on the existence of regulation promoting systematic, rapid and homogeneous economic evaluations or at least the characterization of the therapeutic value for all innovative products and all the new indications of them and periodic revisions, and on the existence of a structure capable of performing in a timely manner. That is a major challenge in Spain, where economic evaluation has not yet been implemented in a precise, sophisticated and transparent manner (in the simpler situation of only one listed price per product). It will become much more complicated in the case of indication specific economic evaluations. REvalMed is a new network launched in 2020 by the Ministry of Health to solve this gap, with the goal of adding economic evaluation to therapeutic positioning reports (IPTs). However, it is still too early to determine its success with a low number of economic evaluations published so far. Another common challenge shared by both alternatives is the need of a Registry of Clinical Data, which should include specific and as complete as possible information regarding the indication for which the product is purchased, and monitor its use for patients per indication, the added value and health outcomes obtained, or adverse effects. That registry should help to the development of economic evaluations to set and revise prices, to identify any deviation from the expected volume in previous budget impact analysis, or to update assessment of added value with new clinical information. That registry should be as homogeneous as possible for all Autonomous Communities. The initial investment for composing that registry may be costly. The question of whether the cost of this registration should be shared between the companies and the regulator or the provider, or whether it should be borne entirely by one of these parties, is a matter to be debated. Furthermore, the main goal of that registry should be its use for improving clinical benefits for patients and not for price setting (also). If the main objective were price setting, this could increase resistance to the implementation of this register from various stakeholders at the local and regional level, as they already negotiate prices. In order to attain an appropriate implementation of any of the two alternatives, Spain should provide a regulatory and structural framework in which a registry of clinical data be operative and help the performance of systematic, rapid and homogeneous economic evaluation exercises for all new indications in order to help in their price setting, and periodically, in their revisions. Both alternatives could be used together with other complementary methodologies such as budget impact analysis, the analysis of the degree of competition at the different indications, or even multi criteria decision analysis or cancer specific funds that have hardly been presented in this report

Mental Illness Inequalities by Multimorbidity, Use of Health Resources and Socio-Economic Status in an Aging Society

Background: Mental illness, multi-morbidity, and socio-economic inequalities are some of the main challenges for the public health system nowadays, and are further aggravated by the process of population aging. Therefore, it is widely accepted that health systems need to focus their strategies for confronting such concerns. With guaranteed access to health care services under universal coverage in many health systems, it is expected that all services be provided equally to patients with the same level of need. Methods: In this paper, we explore the existence of inequalities in the access to services of patients with mental illness taking into account whether they are multimorbid patients, their socioeconomic status, and their age (...

Estimates of patient costs related with population morbidity: Can indirect costs affect the results?

A number of health economics works require patient cost estimates as a basic information input. However the accuracy of cost estimates remains in general unspecified. We propose to investigate how the allocation of indirect costs or overheads can affect the estimation of patient costs in order to allow for improvements in the analysis of patient costs estimates. Instead of focusing on the costing method, this paper proposes to highlight changes in variance explained observed when a methodology is chosen. We compare three overhead allocation methods for a specific Spanish population adjusted using the Clinical Risk Groups (CRG), and we obtain different series of full-cost group estimates. As a result, there are significant gains in the proportion of the variance explained, depending upon the methodology used. Furthermore, we find that the global amount of variation explained by risk adjustment models depends mainly on direct costs and is independent of the level of aggregation used in the classification system.Patient costs, Clinical Risk Groups, Variation explained, Overhead allocation

FINGER (Forming and Identifying New Groups of Expected Risks): Developing and Validating a New Predictive Model to Identify Patients With High Healthcare Cost and at Risk of Admission

Objective Predictive statistical models used in population stratification programmes are complex and usually difficult to interpret for primary care professionals. We designed FINGER (Forming and Identifying New Groups of Expected Risks), a new model based on clinical criteria, easy to understand and implement by physicians. Our aim was to assess the ability of FINGER to predict costs and correctly identify patients with high resource use in the following year. Design Cross-sectional study with a 2-year follow-up. Setting The Basque National Health System. Participants All the residents in the Basque Country (Spain) >= 14 years of age covered by the public healthcare service (n=1 946 884). Methods We developed an algorithm classifying diagnoses of long-term health problems into 27 chronic disease groups. The database was randomly divided into two data sets. With the calibration sample, we calculated a score for each chronic disease group and other variables (age, sex, inpatient admissions, emergency department visits and chronic dialysis). Each individual obtained a FINGER score for the year by summing their characteristics' scores. With the validation sample, we constructed regression models with the FINGER score for the first 12 months as the only explanatory variable. Results The annual FINGER scores obtained by patients ranged from 0 to 57 points, with a mean of 2.06. The coefficient of determination for healthcare costs was 0.188 and the area under the receiver operating characteristic curve was 0.838 for identifying patients with high costs (>95th percentile); 0.875 for extremely high costs (>99th percentile); 0.802 for unscheduled admissions; 0.861 for prolonged hospitalisation (>15 days); and 0.896 for death. Conclusion FINGER presents a predictive power for high risks fairly close to other classification systems. Its simple and transparent architecture allows for immediate calculation by clinicians. Being easy to interpret, it might be considered for implementation in regions involved in population stratification programmes.Manuel Garcia-Goni thanks the Ramon Areces Foundation for financial support under the research project 'Envejecimiento y sistema sanitario y social. El gasto publico y sus efectos en igualdad, dependencia y aseguramiento en Espana'. All authors thank this project for funding publishing charges

The green future of electricity: the cases of Uruguay and the European Union

We are grateful for the financial support of the Inter-American Development Bank (IDB) for part of this work. All shortcomings and limitations are our responsibility.El objetivo de este trabajo es entender los cambios de política y regulación en Uruguay y la Unión Europea que llevaron a la adopción de fuentes de energía renovable no convencionales en un corto período de tiempo. Uruguay es uno de los 3 países del mundo con más del 90% de la electricidad proveniente de fuentes renovables (98% en Uruguay) y donde las renovables no convencionales aportan una contribución significativa. Uruguay también ha lanzado recientemente la primera ruta eléctrica de América Latina, con 500 km y estaciones de carga a intervalos de 60 km. La Unión Europea es una referencia internacional en la promoción del crecimiento económico sostenible y del desarrollo sostenible. Por lo tanto, también examinaremos la experiencia de la Unión Europea en el desarrollo de una agenda verde en la que las fuentes de energía renovables son una parte fundamental.The objective of this paper is to understand the policy and regulation changes in Uruguay and the European Union that led to the adoption of non-conventional renewable sources of energy in a short time span. Uruguay is one of only 3 countries in the world with more tan 90% of the electricity coming from renewable sources (98% in Uruguay) and where nonconventional renewables provide a significant contribution to it. Uruguay has also recently launched the first electric route in Latin America, with 500 Km and charging stations at 60 Km intervals. The European Union is an international reference in the promotion of sustainable economic growth and sustainable development. Therefore, we will also look at the experience of the European Union in the development of a green agenda where renewable sources of energy are a fundamental part of it.DecanatoFac. de Ciencias Económicas y EmpresarialesTRUEpu