The public view of private health insurance, CHERE Discussion Paper No 45

Until the 1996 Federal election, the Liberal Party remained committed to the repeal of Medicare. In that election the Liberal platform endorsed the continuation of Medicare, and support for private health insurance. Since then the Government has pursued a strategy of support for private health insurance involving three stages: one, rebates for the poor and penalties for the well-off; two, universal rebates; and three, departure from community rating to what has been described as ?lifetime health cover?. This paper reviews the coverage by the quality media of the private health insurance issue from the beginning of 1996 (prior to the beginning of the formal election campaign) to the end of 1999 (after the announcement of lifetime health cover). Over 500 articles were reviewed. Federal elections and budgets are most likely to trigger articles on private health insurance. The topic has become newsworthy, with stories now appearing which report only changes in insurance coverage. Most articles report differing perspectives on the issue; however, opposing views are frequently given little column space and appear at the end of the article. While many articles report events in a factual way, there are a significant number which provide only one perspective or viewpoint. The media rely heavily on authoritative experts and these are usually spokespersons for the private sector and the organised medical profession. When independent figures are quoted, there has been no disclosure of any financial or other links with the private health sector. The story angle was generally conflict between the various stakeholders, although the politics of health policy was also a major theme. The editorials, in contrast, urged a view of what was good for the country, rather than the winners/losers in a political conflict. The Age and the Sydney Morning Herald (SMH) took quite different stances on the issue of access, hospital costs and the importance of community rating. Clearly, the media has a role to inform. Many articles are a means of disseminating new policies, or explaining their detail, or advising individuals of the implications for them. However, the media has also defined what and why private health insurance is a problem, floated unpopular policy responses, defined the solution and popularised it. For those concerned to see public debate on private health insurance, to promote information and evidence as a basis for policy, and to see community values inform health policy, there is little here to encourage.Private health insurance, media, Australia

Can we design a market for competitive health insurance? CHERE Discussion Paper No 53

The topic of this paper is whether it is possible, given the current state of knowledge and technology, to design the appropriate market structure for managed competition. The next section reviews market failure in the private health insurance market. The subsequent two sections describe the principles of managed competition and its development and application in other countries. Then, the paper outlines recent developments in private health insurance policy in Australia, and proposals to apply managed competition in this country. The required design of the managed competition market place is described, and four major issues, risk adjustment, budget holding, consumer behaviour, and insurer behaviour, are identified. The final sections of the paper review the evidence on these four issues to determine if managed competition can be implemented, given current knowledge.Health Insurance, Managed competition, Australia

Municipal services: organisations, companies and alternatives

A review of the impact of international institutions and multinational companies on municipal services worldwide, and of campaigns for alternatives

Australian health services research and its contribution to the international literature, CHERE Discussion Paper No 41

This study was prompted by the findings of Butler et al (1998) that the Australian contribution to the international health services research literature accounted for 5.6% in 1993-1994. First, the methodology used in that study is critically appraised, and second, to identify the extent to which Health Services Research (HSR) is published in the journals identified by Butler et al, and to assess the contribution of Australian HSR, an alternative search strategy is used. Findings indicate that Australian HSR is far from out-performing other medical research fields in international publication.Health services research, Australia, Comparison

Variation in the costs of healthcare for chronic disease in Australia: The case of asthma, CHERE Working Paper 2008/7

Objectives Individuals with chronic conditions represent a high healthcare cost group and understanding the cost variation among individuals is important for developing appropriate policy. This study aimed to investigate the sources of variation in the cost of healthcare for a cohort of people with asthma. It examines the costs to the health system and patient out-of-pocket costs. Methods A longitudinal observational study of asthma-related healthcare costs in a cohort of people with asthma (n=252). Participants were followed for three years using six-monthly postal surveys and individual administrative data. The factors associated with health system and patient out-of-pocket costs were investigated using generalised linear mixed models. Results There was substantial variability around the average costs of healthcare for asthma which were associated with asthma-related health measures and socio-demographic variables. The health system costs were less for those living in regional areas relative to Sydney residents and both the health system and patient out-of-pocket costs were highest in the oldest age group and lowest for children. The health system and patient out-of-pocket costs were highest for the high income group while the middle income group had the lowest total cost. Conclusions Our findings suggest that variations should be explored in developing strategies for chronic disease management and that Australia has achieved reasonable equity in access. However, out-of-pocket costs may be a deterrent for the middle income group, which should be a general concern for policies targeting the most disadvantaged group to the exclusion of concern with universal access.asthma, out-of-pocket costs, Australia

The provision of informal care in terminal illness: An analysis of carers? needs using a discrete choice experiment

There is an increasing expectation that families will provide care at home for those with chronic, acute and terminal illness. There is a range of services available to support the home care of these patients. Carers of those in the terminal phase of illness face different demands and challenges than those caring for the chronically ill, disabled or aging; the patient?s health is deteriorating, often rapidly, and death is imminent. Yet the needs and requirements of this group of carers has been far less studied than those caring for people with chronic and continuing conditions. We argue that considering the reciprocal nature of relationships is important in understanding the provision of informal care. Carers? feelings for which tasks and responsibilities are most difficult are not the same as their preferences for additional support services. Carers preferences are influenced by their relationship with the patient. This study investigates carers? preferences for services to support their caregiving role. Carer preferences were investigated using a discrete choice experiment, in which 168 carers were asked first to choose between two packages of care and then between the chosen package and their current support. Data were analysed using mixed logit. The DCE results showed that the support most wanted was palliative care nursing, general nursing, and telephone advice available 24 hours. Carers providing high levels of care wanted respite care provided at home and help with the patient?s personal care. Where the care-giving need was relatively low, carers wanted help with household tasks, transport and a case co-ordinator. Overall, carers appeared to be satisfied with the support they received from palliative care services, but this varied with the personal circumstances of the carer. This study provides useful insights for those who plan and deliver palliative care in the community. It supports the view that effective support for carers must recognise the differing needs of individual carers. While our results do not provide any insight into how the pre-existing relationship between carer and recipient may affect preferences for care, it points to the need to explore further differences in preferences across respondents both in discrete choice work in general, and in designing services to support rather than replace informal carers.Informal care; carer's perspective; discrete choce experiment

Evidence for funding, organising and delivering health care services targeting secondary prevention and management of chronic conditions. CHERE Working Paper 2009/6

This paper is designed as an issues paper. Its aim is to set out what evidence is available regarding the effectiveness and efficiency of funding, organisation and delivery of services directed at preventing and managing chronic conditions, and identify what further information is required. The latter will then be used as a means of identifying gaps in information which can be addressed by research. The information is not presented as a comprehensive review of all available evidence but as a preliminary scoping of the results of the most recent literature.chronic conditions, prevention, funding

Economic analysis of psychotherapy for borderline personality disorder patients, CHERE Project Report No 9

Economic evaluation, mental health

Economic evaluation of the proposed surgical scheme at Auburn Hospital: Final report, CHERE Project Report No 19

Background Public hospitals have experienced budget constraints but as demand for admissions has been growing at the same time, occupancy levels have been increasing. As emergency and urgent admissions are given priority, the effect has been not just longer waiting times and larger waiting lists for non-urgent admissions, but also frequent cancellations of elective surgery, thus adding to patients? waiting time. Consequently, there have been a number of attempts to reduce elective surgical waiting lists. The Auburn Elective Surgical Program (AESP) was a pilot program funded by the NSW Health Department, to improve elective surgery for patients in Western Sydney Area Health Service (WSAHS). The program commenced 19th July 2001 and ended 15th November 2001. Initially, the program targeted three specific surgical procedures, laparoscopic cholecystectomy, hernia repair, and haemorrhoidectomy, and was expanded to include thyroidectomy, ligation and stripping of varicose veins and endoscopy. The program sought to improve the effectiveness and efficiency of administrative and clinical aspects of elective surgery by: > Using spare operating theatre capacity at Auburn Hospital; > the use of a new booking and waiting list system, managed by a nurse co-ordinator, which offered suitable patients a definite date for surgery; > increasing surgical sessions by paying participating surgeons on a fee for service basis; > however, surgery could be performed by a surgeon other than their treating surgeon; > re-structuring elective surgical sessions to eliminate meal breaks; > planning post discharge care so that surgery could be performed on a day only basis. The Centre for Health Economics Research and Evaluation (CHERE) was commissioned to undertake an independent evaluation of the AESP. This study has examined the throughput, health outcomes, costs and patient satisfaction. Throughput data on the program were defined as time spent on the waiting list, number of failures to attend planned surgery, average length of stay, and number of surgical interventions. Health consequences were defined as complications, unplanned readmissions to hospital, wound infection after surgery, mortality, percentage of same day admissions and conversion rate to open cholecystectomy. Costs were estimated from a health service perspective. Patient acceptability was assessed by the proportion of eligible patients having their surgery under the AESP, and patient satisfaction by questionnaire.Economic evaluation, waiting times, hospitals

Properties of principal component methods for functional and longitudinal data analysis

The use of principal component methods to analyze functional data is appropriate in a wide range of different settings. In studies of ``functional data analysis,'' it has often been assumed that a sample of random functions is observed precisely, in the continuum and without noise. While this has been the traditional setting for functional data analysis, in the context of longitudinal data analysis a random function typically represents a patient, or subject, who is observed at only a small number of randomly distributed points, with nonnegligible measurement error. Nevertheless, essentially the same methods can be used in both these cases, as well as in the vast number of settings that lie between them. How is performance affected by the sampling plan? In this paper we answer that question. We show that if there is a sample of $n$ functions, or subjects, then estimation of eigenvalues is a semiparametric problem, with root-$n$ consistent estimators, even if only a few observations are made of each function, and if each observation is encumbered by noise. However, estimation of eigenfunctions becomes a nonparametric problem when observations are sparse. The optimal convergence rates in this case are those which pertain to more familiar function-estimation settings. We also describe the effects of sampling at regularly spaced points, as opposed to random points. In particular, it is shown that there are often advantages in sampling randomly. However, even in the case of noisy data there is a threshold sampling rate (depending on the number of functions treated) above which the rate of sampling (either randomly or regularly) has negligible impact on estimator performance, no matter whether eigenfunctions or eigenvectors are being estimated.Comment: Published at http://dx.doi.org/10.1214/009053606000000272 in the Annals of Statistics (http://www.imstat.org/aos/) by the Institute of Mathematical Statistics (http://www.imstat.org