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Mollyann Brodie
1995, Political Analysis
Current Position: Vice President, Director of Public Opinion and Media Research
Current Employer: The Henry J. Kaiser Family Foundation
Thesis Title: Political Institutions, Participation, and Media Evaluations: Influence on Health Care Policy
Committee Members: Blendon, Feldman, Verba
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ABSTRACT: This thesis is composed of three distinct papers. Paper one explores the potential for a sensitization effect in research evaluations. This refers to the methodological phenomenon of a pre-event interview sensitizing the respondent such that the post-event measure is different than it would have been without the pre-measure experience. I find evidence for a substantial sensitization effect for panel respondents in an evaluation of a two-hour NBC News special on health care reform. The panel respondents, interviewed both before and after the special, scored consistently higher on health care reform knowledge scales as compared to an independent sample interviewed only after the special, even after accounting for other factors that influence the scores. I conclude that those evaluating the impact of media events on an average audience would be well advised to use an alternative research design than only a panel sample.
Paper two explores whether variation across states' political institutions and culture help to explain variation in the health policies states adopt. Using quantitative analysis, I find that state resources, needs, and ideology help to explain variation in health policy outcomes, particularly whether states adopt comprehensive health care reform or consider single payer proposals. Political institutions and culture significantly help to explain the number of incremental health policies aimed at covering the uninsured or controlling costs and the number of mandated health insurance benefits states adopt. Overall, states with more liberal ideologies are more likely to engage in publicly visible comprehensive health reform strategies; whereas political institutions exert more influence on those policies decided away from the public sphere.
Paper three explores who the participants were in the 1993-94 national health care reform debate. I find evidence that those active on health care reform were more likely to have more education, to be male, African-American, self-identified conservatives, associated with the health care industry, and engaged in the health care issue. Those with a policy preference for an employer mandate were considerably less active in the health reform debate. Furthermore, the presence of a single payer ballot initiative in California did not disproportionately mobilize self-identified liberals. Overall, legislators heard messages disproportionately from those opposed to comprehensive reform as proposed by President Clinton.
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Shoo Kim Lee
1996, Economics
Current Position: Scientific Director, iCARE, Professor of Pediatrics, and Canada Research Chair (Tier 1) in Knowledge Translation & Healthcare Improvement
Current Employer: University of Alberta
Thesis Title: The Infant Mechanical Ventilator: Time to Kill The Technology Overkill?
Committee Members: Newhouse, McCormick, Richardson
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ABSTRACT: Background. As a result of advances in medical treatment, fewer infants with respiratory distress syndrome (RDS) now require positive pressure mechanical ventilation (PPV), while an increasing number require continuous positive airway pressure (CPAP) support.
Objectives. To determine (1) the feasibility of substituting inexpensive CPAP devices for mechanical ventilators in the NICU without reduction in care, (2) whether SNAP (illness severity score) is predictive of ventilator use, (3) whether non-physician health providers affect practice variations and resource consumption in the NICU.
Methods. We prospectively studied the CPAP and PPV needs of infants admitted to the 16 bed level II/III NICU at Boston's Beth Israel Hospital and to 45 bed level II/III NICU at the Brigham and Women's Hospital during the ten month period form March to January 1995, and surveyed the infant mechanical ventilator needs of the greater Hartford region in Connecticut.
Results. Assuming the pattern of CPAP utilization at the Beth Israel NICU is generally applicable, CPAP devices could be substituted for 46% of all infant mechanical ventilators in the Northern Connecticut region without reduction of care. A strategy of substituting CPAP devices for infant mechanical ventilators where suitable will result in approximate cost savings of $13.5 million annually (sensitivity analysis range $8.5 million to $14.1 million) in the U.S. alone. SNAP is predictive of mechanical ventilator use in the NICU. There exists variation in ventilator use between the Beth Israel, and Brigham and Women's NICUs which cannot be accounted for by differences in patient characteristics, illness severity or physician differences.
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Aaron A. Stinnett
1996, Decision Sciences
Current Position: formerly Associate Professor, Department of Health Care Organization and Policy (UAB), Associate Scholar (LHCHP), Director of Economic Evaluation and Modeling Unit (UAB-CORE)
Current Employer: formerly University of Alabama at Birmingham, Lister Hill Center for Health Policy, UAB Center for Outcomes Research and Education
Thesis Title: Issues in the Economic Evaluation of Health Interventions
Committee Members: Weinstein, Paltiel, Siegel
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ABSTRACT: The objective of this thesis is to shed light on unresolved issues in the economic evaluation of health interventions. The opening paper addresses the use of constrained optimization techniques for health resource allocation, demonstrating that a general mathematical programming framework can accommodate much more complex information regarding returns to scale, indivisibilities, and program independence than previously has been considered.
The second paper presents a new framework for evaluating uncertainty in cost-effectiveness analysis (ECA). This method expresses the results of an evaluation in terms of the Net Health Benefit (NHB) conferred, where a program's NHB measures the health gain expected to result from implementing that program, compared to implementing its comparator and investing any cost differential in a marginally cost-effective program. This framework offers theoretical and practical advantages over the statistical analysis of cost-effectiveness (C/E) ratios.
The third paper evaluates two methods that have been proposed for estimating C/E ratios under second-order uncertainty. One method estimates a mean ratio of cost to effect, and the other estimates a ratio of mean cost to mean effect. It is demonstrated that the "ratio of means" approach follows from the theoretical foundations of CEA and is consistent with an intuitively appealing vector algebra approach to the problem; in contrast, the "mean ratio" approach is internally inconsistent and can prescribe economically inefficient choices.
The final paper investigates the cost-effectiveness of diet-and drug-based clinical strategies for cholesterol reduction in men and women at various degrees of risk for coronary heart disease (CHD). A computer simulation model is used to estimate the costs and health effects of strategies employing various combinations of a low-fat diet, niacin, and lovastatin. The results indicate that cholesterol reduction for the prevention of CHD can be relatively cost-effective in a variety of risk factor groups, but that some strategies are significantly more cost-effective than others. Strategies based on diet, niacin therapy, and stepped care (in which patients begin with niacin therapy and switch to lovastatin if they cannot tolerate niacin) tend to be relatively cost-effective. In contrast, nearly all strategies that employ lovastatin as a first-line medication are dominated.
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Jack Ven Tu
1996, Evaluative Science & Statistics
Current Position: Senior Scientist (ICES), Canada Research Chair in Health Services Research and Staff Physician (SWCHSC), Professor of Medicine, Public Health Sciences, Health Policy, Management, and Evaluation (UT)
Current Employer: Institute for Clinical Evaluative Sciences, Sunnybrook and Women's College Health Sciences Centre, University of Toronto
Thesis Title: Quality of Cardiac Surgical Care in Ontario, Canada
Committee Members: McNeil, MOrris, Newhouse, Weinstein
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ABSTRACT: In this dissertation, a comprehensive study was undertaken to study a number of issues related to the quality of cardiac surgical care in Ontario, Canada.
In the first paper, "Coronary artery bypass mortality rates in Ontario: A Canadian approach to quality assurance in cardiac surgery", a study was undertaken to assess the overall in-hospital mortality rate and the amount of inter-hospital variation in risk-adjusted mortality rates following coronary artery bypass graft (CABG) surgery in Ontario between 1991 and 1993. The overall mortality rate was 3.01%, and no hospitals had risk-adjusted mortality rates significantly higher than expected during the three-year study period. The outcomes in this study are probably attributable to regionalization of CABG surgery and a very low prevalence of low-volume cardiac surgeons in Ontario.
In the second paper, "Coronary artery bypass surgery in Ontario and New York State: Which rate is right?", the clinical characteristics of patients and rates of CABG surgery in Ontario and New York State in 1993 were compared. Patients in New York were more likely to be older, female, and have had a recent myocardial infarction while patients in Ontario were more likely to have had left ventricular dysfunction and severe coronary artery disease. It was concluded that there is no single right rate of CABG surgery but rather trade-offs between higher rates of surgery and the clinical severity of patients receiving the procedure.
In the third paper, "Predicting mortality after coronary artery bypass surgery: What do artificial neural networks learn?", artificial neural networks (ANNs) and logistic regression (LR) statistical models were developed for predicting in-hospital mortality after CABG surgery in Ontario. The predictions from the ANN model were very highly correlated (r=0.95) with those of a main effects LR model with both models having similar areas under the receiver operating characteristic curve. The results of this study suggest that ANNs do not offer any significant advantages over LR modeling techniques since both methods "learn" similar relationships between patient characteristics and mortality after CABG surgery.
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Angela Man-Wei Cheung
1997, Decision Sciences
Current Position: Associate Professor, Faculty of Medicine, Director, Osteoporosis Program, and Associate Director, Women's Health Program
Current Employer: University of Toronto
Thesis Title: The Economic Impact of Primary Prevention: Methods and Applications of Cost- Effectiveness Analysis
Committee Members: Weinstein, Cook, Gillman, Tosteson
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ABSTRACT: This thesis examined the methodologies and applications of cost-effectiveness analyses in primary prevention. It is presented in the form of three papers. The first paper examined the lipid-mediated cardioprotective effects of long-term hormone replacement therapy in postmenopausal women using lipid profile changes observed in the PEPI trial, a multicenter randomized controlled trial of various hormone regimens. Our results showed that the lipid-mediated effects of long-term treatment with various hormone regimens in a 50 year-old postmenopausal woman yield average coronary risk reductions of 12-18%, and average gains in life expectancy of 0.19-0.28 years.
The second paper examined the cost-effectiveness of long-term hormone replacement therapy in postmenopausal women. This paper used age-specific incidences of coronary heart disease, breast cancer and hip fractures, and evaluated the balance of the costs and the effects of these diseases in postmenopausal women of different ages. The results of the first paper were used to set the most conservative estimate for the effect of hormone replacement therapy on coronary heart disease. We found that the cost-effectiveness ratio for long-term unopposed estrogen replacement therapy is $27,800 per year of life gained for 50 year-old women without a uterus (discounted at 3% and expressed in 1996 US dollars), and $42,200 for long-term combination therapy for 50 year-old women with a uterus. In general, the cost-effectiveness ratios of long-term hormone replacement therapy for older postmenopausal women are more attractive than for younger postmenopausal women.
The third paper examined the cost-effectiveness of blood pressure screening in children. We used longitudinal tracking correlations to predict adult blood pressures from childhood blood pressures, and modeled the effects and costs of various screening and intervention strategies. We found that blood pressure screening strategies for 15 year-old children are more cost-effective than population-wide interventions ($76,000-$131,000 compared with $120,000-$187,000 per discounted year of life gained for boys, and $120,000-$216,000 compared with $212,000-$330,000 per discounted year of life gained for girls). In general, boys have lower (more attractive) cost-effectiveness ratios than girls. Overall, when compared to no screening or intervention, the most cost-effective strategy for the control of blood pressure is screening plus dietary sodium reduction for those who are hypertensive ($76,000 and $120,000 per discounted year of life gained for boys and girls, respectively.) However, neither blood pressure screening nor population-wide interventions are very cost-effective.
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Yiing-Jenq Chou
1997, Economics
Current Position: Professor, Department of Social Medicine and Institute of Public Health
Current Employer: School of Medicine, National Yang Ming University, Taiwan
Thesis Title: Social Health Insurance and Saving in Taiwan; Health Insurance and Female Labor Supply; and Fertility and the Cost of Having a Child: Can the Government Influence Fertility Rate Through Incentives
Committee Members: Newhouse, Hsiao, Staiger
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ABSTRACT: In this thesis, three important health policy issues in Taiwan were studied in three papers.
In the first paper, "Social Health Insurance and Saving in Taiwan", a study was undertaken to assess the change in private saving behavior after the introduction of social health insurance in Taiwan. The special features of "Farmer Health Insurance" allowed design of a "natural experiment" for this study. The results show that only farmer families with elderly members responded to the introduction of health insurance by moderately increasing consumption expenditures. The magnitude of the consumption change can be partially explained by the government subsidy, providing some evidence in support of the theory of life-cycle saving. However, the small estimated change in consumption implies that previous studies that stressed the importance of precautionary motives for savings may have been overstated.
The second paper, "Health Insurance and Female Labor Supply", examines the impact of employment-linked health insurance on the female's labor participation decision, using natural experiments in Taiwan area to evaluate the importance of the availability of health insurance on female's employment decision. The findings show that an alternative health insurance policy for government employees' wives reduced their probability of being hired as an employee, and decreased their labor participation rate. Implementation of the Universal National Health Insurance Act in 1995 provided a "reverse experiment" that confirms these findings. Consistent results form the two natural experiments imply that the availability of health insurance is an important determinant of Taiwanese women's labor market participation.
The third paper is entitled, "Fertility and the Cost of Having a Child: Can the Government Influence Fertility Rate through Incentives? " This paper uses a natural experiment in Taiwan to estimate the effect of incentives on fertility behavior. A change in the government employee benefit plan in July 1993 provides a good instrument for identifying the relationship between the cost of raising a child and the fertility decision. The primary result is that the incentive embodied in the policy change had a positive and significant effect on the birth rate. Government employees indeed responded to the incentive by increasing their fertility rate after the benefit plan change.
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Haiden Ashby Huskamp
1997, Economics
Current Position: Associate Professor of Health Economics, Department of Health Care Policy
Current Employer: Harvard Medical School
Thesis Title: The Economics of Managed Behavioral Health Care Benefit Carve-Outs
Committee Members: Frank, McGuire, Newhouse
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ABSTRACT: In the past few years, managed behavioral health care (MBHC) carve-outs have become one of the dominant methods of organizing and financing mental health and substance abuse (MHSA) services. Under a MBHC carve-out, a payer of health care benefits separates the MHSA risk from the health insurance benefit packages it sponsors and enters into a contractual arrangement with a specialty vendor to manage the MHSA benefit only. This dissertation examines the payment arrangements used in managed behavioral health care (MBHC) carve-out contracts, the incentives such arrangements create, and the impact of contract features on the utilization and cost of care.
The first essay is an applied theoretical analysis of the agency problem in MBHC contracting which examines optimal risk sharing and the use of an imperfect or "noisy" signal of quality for these contracts. Given certain assumptions, I find that the use of a soft capitation arrangement by the payer is not sufficient to influence the level of quality provided by the vendor. The payer can influence the level of quality by contracting on a noisy signal of quality.
The second and third essays use claims and enrollment data to assess the impact on MHSA expenditures and treatment patterns of a MBHC carve-out program adopted by the Massachusetts Group Insurance Commission (GIC) in 1993. The GIC carve-out program used a soft capitation arrangement with weak incentives for controlling costs, contracted on several noisy signals of quality by creating financial incentives based on imperfect quality measures, expanded the MHSA benefit, and implemented a care management process for MHSA services. The financial incentives in the contract were tightened slightly at the end of the first year after implementation of the carve-out program.
Adoption of the GIC carve-out program was associated with a substantial decrease in the probability of receiving any MHSA services, a dramatic drop in total costs per MHSA treatment episode, and a shift away from the use of facility care towards the use of outpatient care for MHSA treatment. Individuals with certain severe MHSA conditions received fewer services on average after the carve-out program was adopted. The tightening of the financial incentives at the end of the first year was associated with a further decrease in the probability and level of MHSA expenditures. The magnitude of the vendor's response to the weak financial incentives and the further decline in the probability and level of expenditures after the incentives were tightened slightly suggest that MBHC vendors are very sensitive to the financial incentives they face.
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John Norman Lavis
1997, Evaluative Science & Statistics
Current Position: Associate Professor, Dept. of Clinical Epidemiology and Biostatitics (MU), Assoc. Member, Dept. of Political Science (MU), Member, Center for Health Economics and Policy Analysis (MU), and Canada Research Chair in Knowledge Transfer and Exchange (CIAR)
Current Employer: McMaster University, and Canadian Institute for Advanced Research
Thesis Title: An Inquiry Into the Links Between Labour-Market Experiences and Health
Committee Members: Newhouse, Cleary, Pierson, Tarlov
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ABSTRACT: In the first of three papers I developed a research framework with which to conceptualize and plan research on the health consequences of labour-market experiences. The first half of the framework comprises a typology of labour-market experiences and the second half comprises the range of possible health and economic outcomes of these experiences. Using the framework I identified the most serious gaps in the research literature: limited attention to interactions between experiences and between experiences and the context for these experiences; limited or no attention to some increasingly prevalent experiences; and no simultaneous measurement of health and economic outcomes.
In the second paper I examined the relationship between unemployment and mortality in 2868 male household heads followed for up to 25 years and 2676 male household heads followed for up to 16 years as part of the Panel Study of Income Dynamics. I used annual measures of unemployment as time-varying variables in Cox regression analyses and controlled for annual measures of potential confounders (race, marital status, income, education, and employment grade). Men who were unemployed one or more times on the day of the annual survey had a higher hazard of death while in the labour force than men who were working on the day of the survey (hazard ratio 3:23 [1.61-6.48]). Men who experienced longer unemployment spells died earlier while in the labour force or retirement than those who experienced shorter (or no) unemployment spells (hazard ratio1.03 [1.00-1.05] for a one week change in the duration of unemployment). No clear relationship emerged between the number of unemployment spells and mortality.
In the third paper I developed a conceptual framework to identify institutional innovations or policy changes in Canada and the United Kingdom which may have come about, at least in part, because of the determinants-of-health synthesis and to determine the role that these ideas played in the politics associated with these developments. Elite interviews and reviews of primary and secondary sources suggested that the policy-relevant ideas embodied in the determinants-of-health synthesis played strategic, rather than instrumental, roles in any institutional innovation or policy change.
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LTC Thomas Vincent Williams
1997, Organizational Behavior
Current Position: Director, Center for Health Care Management Studies
Current Employer: TRICARE Management Activity, Department of Defense
Thesis Title: Physician Experiences and Evaluations of Managed Care Organizations: Perceived Organizational Support in Health Care
Committee Members: Cleary, Ayanian, Soumerai
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ABSTRACT: Physicians are increasingly working in managed care organizations. At the same time these organizations apply some combination of regulatory, financial, or normative mechanisms to influence clinical decisions of physicians within them. The outcome of this management on the job attitudes of physicians is most important for its effect on the core content of their work. Physician satisfaction with managed care plans and their recommendations of it to others may indicate a high level of support to quality of care and management that allows independent judgement and clinical freedoms to treat in ways they view as appropriate.
The first empirical study of this thesis asked physicians to evaluate the resources and procedures of one of the managed care plans they worked with and to assess the extent to which the management strategies used by that plan influence their clinical behavior and the quality of care available to their patients. Physicians said that use of education and peer influence as management strategies had greater influence over their clinical behavior and facilitated the provision of high quality care more than the use of rules and regulations or financial incentives. Plans with the most positive evaluations were plans that physicians said used educational strategies more and that used rules and regulations and financial incentives less.
The second empirical study of this thesis investigates the association of participation in more than one managed care organization and reported autonomy. The increasing participation of physicians in managed care has led to increasing involvement in managed care plans and greater numbers of managed care contracts. It was felt that complexity of managing more than one health care contract would compound the administrative burden of patient care and practice management. The second study did not indicate an association between autonomy and participation for the sample of physicians. It did establish the important nature of organizational support to essential features of a physician's task environment. The number of denials and lower reports of administrative support were strong predictors of lower reports of clinical autonomy.
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Nancy Beaulieu
1998, Economics
Current Position: Visiting Assistant Professor
Current Employer: Sloan School of Management, Massachusetts Institute of Technology
Thesis Title: Quality Information and Quality Competition In the Managed Care Health Insurance Market
Committee Members: Cutler, Green, Newhouse
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ABSTRACT: This thesis explores three aspects of quality information and quality competition in the managed care health insurance market. In the first chapter, economic theories of non-price competition and insurance market competition are combined to develop a theoretical model of the managed care health insurance market. This model generalizes previous models of insurance markets and identifies the inefficiencies of the private market in promoting social welfare. The results of the model suggest the development of non-market mechanisms to improve quality and highlight the importance of risk-adjustment. In the second chapter, another model is developed to understand the impact of overlapping provider networks on quality competition between health plans. Overlapping provider networks imply a shared set of inputs for health plans competing in the same market. This organizational phenomenon is shown to generate an externality that leads to lower equilibrium levels of quality and reduced incentives for quality improvement. The results of the model have implications for the economic evaluation of exclusive provider networks; it is found that exclusivity may lead to improvements in quality and that these improvements should be weighed against potential losses from reductions in price competition. The findings of the model also suggest an important role for non-market mechanisms in stimulating the development and diffusion of new technologies to improve quality. The third chapter is an empirical analysis of the effect of information about quality on consumers' health plan choices. A natural experiment was created when employees of Harvard University were given quality information on the health plans in which they could enroll. Panel data on employees and health plans were analyzed to assess the effect of the information. The results of an econometric analysis indicate that some employees did respond to the information by choosing a health plan with a higher quality rating. The analyses also found that employees differed in their responsiveness to the information according to characteristics such as age, employment tenure, and previous health plan enrollment. The primary policy implication of this analysis is that the provision of quality information, if improperly managed, may lead to distortion in the allocation of resources.
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Audiey Kao
1998, Organizational Behavior
Current Position: Clinical Associate Professor, Department of Medicine (UCH), and Vice-President for Ethics Standards (AMA)
Current Employer: The University of Chicago Hospital, and American Medical Association
Thesis Title: Trust and Agency: The Patient-Physician Relationship in the Era of Managed Care
Committee Members: Cleary, Bradach, Marsden
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ABSTRACT: Trust is essential in social life. Interpersonal relationships are complex and often unpredictable, and as such, trust minimizes the cognitive and emotional hesitancy of individuals, groups, and communities to engage in mutually beneficial exchanges. Without some degree of trust, joint action and cooperation are limited by explicit contracts, while potentially beneficial social relationships fail to develop altogether, due to prohibitively high transaction and monitoring costs. Therefore, trust serves as an "efficient" catalyst that increases the likelihood of joint action and broadens the possibilities of social cooperation.
Due to the central importance of trust as a social catalyst, it has been the focus of considerable scholarly interest among sociologists, psychologists, and economists. Despite this academic interest in the social value of trust, few attempts have been made to investigate, either conceptually or empirically, the "epidemiology" of this social good. Conceptual clarity and empirical research is especially lacking in social relationships where trust is seen as a fundamental component of a good dyad. One such social dyad is that between patients and their physicians, and the lack of academic inquiry into trust is that it has been taken for granted.
In Paper One of my thesis, the goal is to shed light on the complexities and nuances of interpersonal trust, with particular emphasis on the therapeutic relationship between patients and their physicians. Moving beyond the precepts offered by perspectives that characterize persons as self-interested agents or embedded moral beings, a dynamic model of interpersonal trust that does not characterize trust as an all or none phenomenon based on either a "market-based" or a "virtue-based" ethic is developed. In this model, patients and physicians are participants in an interdependent, but inherently asymmetric social dyad, where patients' trust in physicians is dependent on a "role-based" ethic of the medical professional.
In Paper Two, and following my explication of a more complete model of interpersonal trust, the development of a reliable and valid measure that is designed to assess patients' trust in their physicians is presented. Patient trust directly stems from the physician's role-based obligations to his or her patient. As a physician-confidant, I feel obligated to keep patient information confidential. As a physician-informant, I feel impelled to reliably inform patients of all relevant medical information. As a physician-craftsman, I feel accountable to provide patients with competent advice and care. As a physician-advocate, I feel bound to act in the patient's best interest, even at the risk of forgoing personal interests. Therefore, a scale of patient trust should capture these role-based aspects of a physician-professional.
In Paper Three, the goal here is to use the Patient Trust Scale in order to evaluate the impact of significant organizational changes in the health care system on trust in the patient-physician relationship. In this era of managed care, the influence of third parties, and more specifically the direct financial incentives imposed by health plans and insurers, on clinical decision making has raised concerns about physicians serving as double agents who have conflicting obligations to patients and health care organization. Therefore, the relationship between methods of physician reimbursement and patient trust is examined.
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Felicia Eugenia Mebane
1998, Political Analysis
Current Position: Clinical Assistant Professor, Department of Health Policy and Administration, and Assistant Dean for Students
Current Employer: School of Public Health, University of North Carolina- Chapel Hill
Thesis Title: The Politics of Medicare Policy
Committee Members: Blendon, Feldman, Reeves, Staiger
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ABSTRACT: This thesis includes three studies that further illuminate various aspects of a key political determinant of Medicare policy: public opinion. For the first study, I use data provided by the Kaiser Family Foundation to examine media coverage of Medicare during the 1995 federal budget debates. Using descriptive statistics, I link changes in the level of critical coverage of President Clinton and the Republican leadership to changes in the public's support for their ability to address Medicare's problems. I also use probit regressions to show that coverage of policy-related topics tended to be less critical of these newsmakers. I conclude that policymakers concerned with how the public will receive future efforts to reform Medicare should continually evaluate their coverage and seek ways to focus on policy-related topics.
For the second study, I use a public opinion survey conducted in 1995 and provided by Professor Robert J. Blendon to explore whether or not knowledge of the Medicare program affects preferences for Medicare policy. I reveal that knowledge has small, significant impacts on the likelihood of support for five of six Medicare policy options. I also find large, significant information effects for subsets of the population. Finally, I find that the effect of information varies with the type of information tested. I conclude that educating the public about the Medicare program matters primarily for interest groups that may benefit from activating particular segments of the population.
Finally, participation in the election process is one manifestation of public opinion about campaign issues. For this study, I use American National Election Studies data to compare political participation and mobilization of older and younger Americans in 1996 with the corresponding rates of participation and mobilization in 1988 and 1992. I find that the political environment in 1996 (in which Medicare was a prominent campaign issue) did seem to stimulate different rates of political participation among older Americans. The results were mixed for mobilization efforts. I conclude that this likely link between issues salient for older Americans and political participation will become increasingly important with the aging of the "baby boom" cohort.
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Meredith B. Rosenthal
1998, Economics
Current Position: Associate Professor of Health Economics and Policy, Department of Health Policy and Management
Current Employer: Harvard School of Public Health
Thesis Title: Risk Sharing in Managed Care
Committee Members: Frank, Cutler, Newhouse, Zeckhauser
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ABSTRACT: Managed care continues to evolve in the pursuit of sustainable cost savings. In its early form, the industry relied on "command and control" mechanisms to influence physician practice style and reduce the cost of care. In response to the backlash from physicians and patients against the encroachment of managed care into the doctor-patient relationship, health plans are seeking alternative ways of containing costs. This dissertation explores one of these alternatives that is increasingly prevalent and controversial: risk sharing with providers. There is concern that putting physicians at risk for the cost of treating patients compromises ethical principles and may lead to reductions in the quality of care. To help inform the debate about risk sharing in managed care, the three papers that comprise my thesis explore issues related to the design of risk sharing contracts as well as their impact in an outpatient mental health setting.
The first paper presents an economic model of physician contracting in which physicians affect multiple dimensions of health care utilization. The objective of the paper is to investigate whether the variation in risk sharing contracts observed in managed care may be explained in part by the need for health plans to give incentives to physicians to practice efficiently while minimizing unnecessary risk exposure. My results support the idea that contractual form may be selected so that physicians bear risk only on the margin where they exert substantial control.
The second and third papers of my dissertation evaluate the impact of a natural experiment in which a managed behavioral health plan changed from a fee-for-service to a case-rate system for reimbursing behavioral health groups for outpatient mental health care. The second paper demonstrates that the case-rate reimbursement system reduced visits per episode by approximately 15 percent. In addition, there was evidence that visits that were likely to be of lower value were more likely to be eliminated. Finally, the response to the case rate varied according to how heavily invested in managed care the group was (share of revenue from risk contracts) and how intensively they monitored member clinicians.
In the third paper, I explore whether the reduction in utilization associated with the introduction of the case rate was associated with measurable differences in quality of care. Looking at the process of care, I found that case-rate patients were more likely to be referred to community and self-help programs, perhaps as substitutes for therapy. In addition, they were more likely to be medicated than fee-for-service patients. Finally, in terms of the best measure available in the data of health status improvement from treatment, change in global assessment of functioning (GAF), no difference could be detected.
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Jennifer Prah Ruger
1998, Decision Sciences
Current Position: Assistant Professor of Global Health
Current Employer: Department of Epidemiology and Public Health, Yale University School of Medicine
Thesis Title: Aristotelian Justice and Health Policy: Capability and Incompletely Theorized Agreements
Committee Members: Sen, Greeen, Newhouse
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ABSTRACT: The dissertation focuses on the implications for health policy of Aristotelian/Capability lines of reasoning to social justice and efficiency. The monograph draws on philosophical and economic analysis and social choice theory in the examiniation of health capabilities as: (i) a central focal variable for the assessment of equality and efficiency in health policy; (ii) the product of health and other public policies; and (iii) the object of social choice.
Drawing on moral and political philosophy, the Aristotelian/Capability lines of reasoning provide the basis for the special moral importance of health capabilities as the central focal variable for assessing equality and efficiency in health policy. These lines of thought take a universal view of humans' capability to flourish as an end of political activity and provide an analytical framework to address questions of justice and efficiency in public policy in a way that other philosophical schools do not.
Drawing on economic analysis, the monograph makes a case for focusing attention in health economics and health policy on the economics of health, per se, as differentiated from the economics of medical care, and as such emphasizes the analysis of empirical evidence on the instrumental effectiveness and cost-effectiveness of the various determinants of health and the public policies associated with these determinants. Further investigations of the determinants and consequences of variations in health capabilities is necessary to fully understand the patterns and public policies associated with health production.
And finally, drawing on social choice literature, this monograph identifies and defends a particular approach to collective decision making in public policy – incompletely theorized agreements (ICTA). In matters of social decision making about health capabilities in health policy, the ICTA framework is particularly useful and complementary to the capability approach. Health, and thus health capabilities, is a multidimensional concept about which different people have different, and sometimes, conflicting, views. Since no unique view of health capabilities exists and is ideal for all evaluative purposes, the pragmatism of both the incomplete ordering of the capability approach and the incompletely theorized agreement on that ordering of the ICTA approach allow for reasoned public policy decision making and analysis in particular situations in the face of plural goods and different, even conflicting, views.
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Alyce Sophia Adams
1999, Evaluative Science & Statistics
Current Position: Assistant Professor, Department of Ambulatory Care and Prevention
Current Employer: Harvard Medical School and Harvard Pilgrim Health Care
Thesis Title: How Tribes Choose Between Tribal and Indian Health Service Management of Health Care Resouces; Drug Coverage and Drug Use by Medicare Beneficiaries; Bias in Measures of Guideline Adherence
Committee Members: Kalt, Frank, Rubin, Soumerai
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ABSTRACT: This dissertation is composed of three separate studies. The first paper is entitled "The Road Not Taken: How Tribes Choose Between Tribal and Indian Health Service Management of Health Care Resources". It examines trends in tribal management of health care resources since passage of the American Indian Self-Determination and Education Assistance Act of 1975 (PL 638). Administrative data were used to identify characteristics of tribes that chose to take over management of health care service units from the Indian Health Service between 1980 and 1995. An unresponsive local Indian Health Service, a large tribal bureaucracy, and greater tribal financial resources were all predictive of tribal management. In order to fulfill the promise of the 1975 legislation, Congress should address issues of inequity in Indian Health Service responsiveness and inadequate funding for health care services.
The second paper, "The Use of Prescription Drugs by Medicare Beneficiaries with Hypertension: Does Drug Coverage Matter?", explores the relationship between coverage for outpatient prescription drugs and the use of essential medications by Medicare beneficiaries with hypertension. Controlling for demographic and health status characteristics, we found a significant and positive association between drug coverage and consumption of anithypertensives. We also explored the use of a propensity score to control for selection bias due to adverse selection and eligibility rules. Given what we know of the life-saving potential of antihypertensive agents, we have a moral and ethical obligation to ensure that all persons with hypertension have coverage for these essential medications.
The final paper, "Evidence of Self-Report Bias in Assessing Adherence to Guidelines", examines trends in the use of self-report measures in research on adherence to practice guidelines and the impact of response bias on the validity of these measures. The use of self-report measures increased from 18% of studies in 1980 to 41% of studies in 1985. Further, in 87% of 37 comparisons, self-reported adherence rates exceeded the objective rates, resulting in a median over-estimation of adherence of 27% (absolute difference). Given evidence of response bias, we recommend that self-reports be used only in conjunction with objective measures in studies of guideline adherence.
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Amber Batata
1999, Economics
Current Position: Assistant Director in the Economics and Policy Research Group
Current Employer: Worldwide Public Affairs and Policy, Pfizer, Inc.
Thesis Title: Economic Analyses of Medicare HMOs
Committee Members: Staiger, Cutler, Newhouse
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ABSTRACT: My dissertation consists of three essays, all of which attempt to broaden our knowledge of the economic implications of managed care, particularly for the elderly, in the market for health insurance. Managed care insurance combines physician and insurer behavior in such a way that is thought to reduce inefficiency in medical care and improve access to and delivery of preventive medicine. The first essay estimates how responsive Medicare managed care (or HMO) enrollment is to prices and finds that a $100 increase in monthly capitation payments led to a 3.8 percentage point increase in Medicare HMO enrollment in 1997. The second essay determines that the elderly who join HMOs cost approximately $1100 less than the average cost of those remaining in the traditional Medicare sector and this selection is leading to significant overpayments to managed care plans, particularly in the first year of enrollment. The third essay (joint with Ellen Meara) tries to shed light on the quality implications of managed care and finds that higher HMO enrollment leads to later diagnosis of lung cancer (which is largely untreatable) and, to a lesser extent, later diagnosis of colon, breast and cervical cancers, all of which have proven benefits for early diagnosis and treatment.
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Johanna Birckmayer
1999, Evaluative Science & Statistics
Current Position: Division Director of State Support Systems
Current Employer: Pacific Institute for Research and Evaluation
Thesis Title: The Role of Alcohol and Firearms in Youth Suicide and Homicide in the United States
Committee Members: Hemenway, Soumerai, Howland
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ABSTRACT: Homicide and suicide are, respectively, the second and third leading cause of death for young Americans. The following three papers address two risk factors for suicide and homicide, alcohol and gun availability. Two studies examine the association between an alcohol policy designed to reduce youth access to alcohol -- minimum legal drinking ages -- and youth suicide and homicide. The third paper explores the relationship between suicide rates and levels of household gun ownership by age of the victim.
Since 1970, numerous state legislatures have enacted changes in the legal drinking age creating a natural experiment to test the effects of these law changes. Available data suggest that MLDAs affect the quantity of alcohol, especially beer, consumed by youth. The first two studies in this dissertation use pooled cross sectional time series mortality data from the 48 contiguous states from 1970 to 1990 to examine the association between varying MLDAs and youth suicide and homicide. In the first paper, a significant association is identified between the minimum legal drinking age and youth suicide. The analysis suggests that the suicide rate of 18 to 20 year olds living in states with an 18 year old MLDA was 8% higher than the suicide rate among 18 to 20 year olds in states with a 21 year old drinking age. In the second paper, no association is found between the MLDA and homicide rates.
The third paper explores the hypothesis that the availability of firearms may have a differential effect on suicide rates, depending on the age of the potential victim. Suicide rates and levels of household gun ownership are analyzed in the nine census regions for the years 1979 to 1994. Levels of gun ownership are highly correlated with suicide rates among 15 to 24 year olds and 45 to 84 year olds, but not among 25 to 44 year olds.
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Scott Gazelle
1999, Decision Sciences
Current Position: Professor of Radiology (HMS), Professor, Department of Health Policy and Management (HSPH), Director, Partners Radiology, and Director, Institute for Technology Assessment (MGH)
Current Employer: Harvard Medical School & Harvard School of Public Health & Massachusetts General Hospital
Thesis Title: Cost-Effectiveness of Imaging and Surgery in Patients with Colorectal Cancer Liver Metastases
Committee Members: Weinstein, Kuntz, Hunink
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ABSTRACT: This study examines options for diagnostic imaging and surgical management of patients with hepatic metastases from colorectal carcinoma (CRC). The objective of the study was to better understand the cost, effectiveness, and cost-effectiveness of hepatic resection ("metastasectomy") in these patients, and to investigate the impact of different pre- and post-operative diagnostic imaging regimens on the costs and effectiveness of therapy. In order to perform the analysis, we developed and validated a series of state-transition (Markov) decision models. These models were used to investigate: 1) the likelihood of missing liver metastases, given certain assumptions concerning test sensitivity, operative threshold, and the number of metastases present; 2) the cost-effectiveness of hepatic metastasectomy in patients with limited hepatic metastases; and 3) the impact of diagnostic imaging on the cost-effectiveness of therapy. Our principal findings were as follows: 1) hepatic metastasectomy, within the general bounds established for the analysis, appears to be a relatively cost-effective procedure for the management of patients with limited hepatic metastases from colorectal carcinoma; 2) more aggressive approaches to imaging and resection should be preferred over less aggressive approaches in this patient population; 3) there appears to be a survival benefit, at a reasonable cost, even in patients who ultimately develop post-operative recurrences following metastasectomy; and, 4) when considering the cost and effectiveness of a variety of management strategies, across a population of patients with hepatic metastases, the benefits associated with more frequent pre- and post-operative imaging and more sensitive imaging tests are sufficient to justify their increased cost. Our results strongly support an aggressive approach to imaging and treatment in patients with potentially resectable metastases from colorectal carcinoma. From a cost-effectiveness perspective, it appears that hepatic metastasectomy should be encouraged, and that all surgeons and oncologists should be encouraged to expand their criteria for patient selection for this procedure. However, it is critical that the results of our studies be confirmed by actual clinical experience, and also by detailed and prospective collection of data concerning the costs and outcomes associated with imaging and surgery in this patient group.
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Elizabeth Richardson Vigdor
1999, Economics
Current Position: Research Scholar
Current Employer: Center for Health Policy, Sanford Institute of Public Policy, Duke University
Thesis Title: Measuring Health and Assessing the Impact of Health System Change
Committee Members: Cutler, Frank, Newhouse
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ABSTRACT: This thesis explores each of the steps in the process linking health system change to output: changes in access, changes in health, and the valuation of health.
The first chapter derives an economic framework for measuring and valuing health and presents estimates of the change in population health over the past 40 years. We define "health capital" as the discounted value of the current and future utility associated with individual health. We measure health capital empirically using data on mortality and morbidity from chronic disease. Our estimates suggest that health capital at birth increased by about $100,000 between 1970 and 1990, and health capital at age 65 increased by about $169,000. The increase in health capital at birth and age 65 are both greater than the increase in average medical spending over that time period.
Chapter 2 examines the relationship between managed care penetration growth and change in the number of hospitals and emergency rooms. I find that growth in managed care penetration can explain between 19 and 37 percent of the decrease in hospitals and between 0 and 56 percent of the decline in emergency rooms in low income areas between 1984 and 1994. None of the decline in hospitals or emergency rooms in higher income areas can be attributed to managed care. I also find that distance to the nearest hospital in California cities increased by 22 percent for the poor and 16 percent for the non-poor over this period. I estimate that this would lead to a one percent drop in inpatient utilization by the poor and a 0.8 percent decline for people in higher income areas.
The third chapter examines the impact of hospital closings on health outcomes. I look at the effect of hospital closures on rates of admission for avoidable hospitalizations. I also examine differences in mortality and length of stay for two urgent conditions. I find weak evidence that people experience adverse health outcomes when an urban hospital closes, and that this effect increases with poverty status. Overall, the results are inconclusive but suggest that further study is necessary.
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Melinda Beeuwkes Buntin
2000, Economics
Current Position: Health Economist and Co-Director, Center for Health Care Organizations, Economics, and Financing
Current Employer: RAND Corporation
Thesis Title: Risk Selection in the Medicare Program
Committee Members: Newhouse, Frank, Swartz
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ABSTRACT: Risk selection is a major impediment to the functioning of health insurance markets and a serious problem for those who seek to introduce more competition into the Medicare program. Ideally, health care providers should compete on the basis of cost and quality. Whenever providers are paid a fixed amount per patient or per service, however, they have an incentive to compete to attract patients who are healthier (and hence more profitable) than the population as a whole—a practice known as "risk selection." This dissertation investigates the determinants of risk selection among competing Medicare plans, examines econometric issues involved with modeling health care costs and risk selection, and seeks better ways to compensate Medicare plans that experience favorable or adverse selection.
Chapter one investigates whether or not standardizing Medicare HMOs’ benefits packages would reduce risk selection. Policymakers have expressed the hope that standardization would reduce health plans’ ability to risk select by constructing benefits packages that are differentially attractive to healthy beneficiaries. I find evidence that plans’ relative copayment levels, physician network sizes, and quality all influence risk selection among plans. Thus, the standardization of benefits packages would restrict consumers’ choices without preventing risk selection. Given this finding, in chapter two I look for ways in which Medicare payments to plans could be "risk adjusted" to reflect the expected costs of plan enrollees. I focus on decedents since they have high costs. I find that while Medicare payment systems could be improved by paying more for beneficiaries with certain terminal illnesses, incentives would remain to select against the terminally ill. Chapter three focuses on methodological issues. It presents and evaluates alternative econometric methods of modeling risk selection and predicted health care cost measures such as the selection measure used in chapter one.
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Susan Busch
2000, Economics
Current Position: Associate Professor
Current Employer: Department of Epidemiology and Public Health, Yale University School of Medicine
Thesis Title: Measuring Productivity and Quality in Mental Health Care
Committee Members: Frank, Berndt, Huskamp
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ABSTRACT: The treatment of mental illness has undergone significant organizational and technological change in the past decade. Spending continued to grow at rates above changes in general price in the 1990s. Are increased mental health expenditures due to price increases, quantity increases or some combination? What has been the effect of these recent changes on quality of care? This thesis addresses these questions.
Mental health carve-outs separate the insurance risk of mental health care from that of general medical care and are increasingly common in both the public and private sector. In the first chapter I focus on the quality of treatment for depression in one mental health carve-out. Comparing treatment patterns in the pre- and post-carve-out period, I find that although quality declined over the course of the time period studied, implementation of the carve-out was associated with an increased probability of receiving guideline-level treatment.
Although broad trends in medical spending have received widespread attention from policymakers, very little attention has focused on the components of those changes. In the second chapter, colleagues and I make use of results from clinical literature, and identify therapeutically similar treatment bundles that are then linked and weighted to construct price indexes for the treatment of major depression. In doing so, we construct medical price indexes that deal with prices of treatment episodes rather than discrete inputs, that are based on transaction prices, that take quality changes and expected outcomes into account, and that employ current, time-varying expenditure weights in the aggregation computations.
We find that over the 1991-1995 time period this treatment price index has hardly changed, remaining at 1.00 or falling slightly to around 0.97. This index grows considerably less rapidly than the various official PPIs. A hedonic approach to price index measurement yields broadly similar results. In the third chapter I reported on additional analysis that indicate this bias is due to either between-item-strata substitution (63 percent) or failure to account for quality change (37 percent). This suggests recent modifications to BLS methodology will have little effect on the bias in official price indexes in so far as treatment for depression is a representative condition.
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Phaedra S. Corso
2000, Decision Sciences
Current Position: Associate Professor in Health Policy
Current Employer: Department of Health Policy Administration, Biostatistics, and Epidemiology, College of Public Health, University of Georgia
Thesis Title: Evaluating Preferences for Health Risks
Committee Members: Graham, Dicker, Goldie, Hammitt
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ABSTRACT: This thesis considers different methods used to elicit individual preferences for health and safety issues in a series of three papers developed from an empirical analysis of a large national survey. The first paper explores the use of contingent valuation (CV), as elicited through willingness-to-pay (WTP), as a method for valuing mortality-risk reductions. Previous empirical work suggests that CV estimates of WTP are invalid because WTP estimates are insensitive to the quantity (or magnitude) of the good being valued. In a test of alternative visual aids to communicate magnitude of risk, we found that WTP was statistically sensitive to the magnitude of risk reduction for all groups receiving a visual aid, but not for the group that did not receive an aid. These results suggest that CV can provide valid estimates of WTP for mortality-risk reduction if appropriate methods are used to communicate the risk change to respondents. The second paper explores the underlying axiomatic assumptions that allow one to use quality-adjusted life years (QALYs) as a health outcome measure. In an assessment of risk-neutrality and consistency in risk posture for longevity, we found that risk posture appears to depend on remaining life expectancy and other dimensions of the choice, including the difference in risk, the asymmetry of probabilities, and whether one choice alternative included a certain outcome. These results suggest that the use of QALYs as an outcome measure may be jeopardized since individual preferences for remaining longevity are not consistent. In a third paper, we compare the use of cost-benefit analysis (CBA) and direct democracy for allocating scarce resources between prevention and treatment interventions. We found that two methods for measuring social benefits, WTP and voting, yield dissimilar policy implications, with the former suggesting that treatment programs be funded, and the latter suggesting that prevention programs be funded. Our data also indicate that general opinions about the costs and effectiveness of prevention versus treatment significantly influence voting choices, in addition to such other non-normative factors such as a bias for action. These results indicate that relying on one method for eliciting preferences for use in resource-based decisions for prevention or treatment may not be adequate.
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Jill Morris Ferdinands
2000, Decision Sciences
Current Position: Principal Investigator, Influenza Genomics Initiative, Influenza Division; and Commander (USPHS)
Current Employer: Centers for Disease Control and Prevention; and US Public Health Service, Air Pollution & Respiratory Branch, Nat'l Center for Environmental Health
Thesis Title: Methods for Modeling and Valuing Life Expectancy Gains
Committee Members: Graham, Hammitt, Kuntz
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ABSTRACT: Over the past decade, there has been increasing concern over the inability of society to afford the growing number of health-related interventions. Decision-makers have turned to the tools and techniques of economic analysis to illuminate the trade-offs associated with different policy decisions. This thesis presents three studies that contribute to the improvement of methods for the economic evaluation of interventions that extend human lives.
The first study focuses on methods used to predict life expectancy gains. We use a novel combination of observed epidemiological relationships and disease simulation to infer knowledge about the underlying effects of aspirin use on colorectal cancer. We find that aspirin likely acts at multiple points in the disease process by exerting a strong influence early in the disease and a relatively weaker influence later in the disease, a result with implications for the effectiveness (and cost-effectiveness) of aspirin as a chemopreventive agent for colorectal cancer. From a methodological perspective, this study illustrates the ability of simulation modeling to generate important new insights about the disease process.
The second paper focuses on estimating the monetary value of life expectancy gains by using stated willingness to pay for two life-extending interventions. Our analysis reveals a troubling disparity between estimates of the value of a statistical life year derived from the two goods. That the disparity cannot be explained suggests that the value of a statistical life year may not be a readily generalizable metric for monetizing life expectancy gains.
The third study focuses on examining alternative methods for communicating the benefits of interventions that extend human lives. We find that survey respondents valued benefits expressed as a life expectancy gain more highly than identical benefits expressed as a reduction in annual mortality risk. Using sensitivity to scope as a validity test, we find that the life expectancy format demonstrates greater validity, implying that the monetary value of longevity benefits may be more likely to reflect true preferences if elicited using a life expectancy format.
In summary, the three studies presented herein contribute to the ongoing search for methods to credibly estimate the magnitude and value of life expectancy gains. Enhancing the validity of these methods will help us more efficiently allocate society’s scarce resources among the growing number of competing programs that extend human lives.
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David Howard
2000, Economics
Current Position: Associate Professor, Department of Health Policy and Management
Current Employer: Rollins School of Public Health, Emory University
Thesis Title: The Economics of Organ Allocation
Committee Members: Newhouse, Frank, Swartz
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ABSTRACT: Unlike most goods and services, organs are distributed according to an administratively-determined point formula. This formula must balance competing goals, including the need to minimize organ wastage, the maximization of human life, and the equitable distribution of resources. This dissertation examines the current system for allocating livers in light of these goals.
When an organ becomes available, wait-listed patients are ranked in order of medical urgency and the organ is offered to the surgeon of the first patient on the waiting list. Surprisingly, 45 percent of livers are rejected by the first surgeon to whom they are offered. The first chapter shows, using data from the national organ allocation registry, that surgeons’ behavior is consistent with an optimal stopping problem; surgeons reject poor quality organs for healthy patients in the hope that they will receive a better organ offer in the future. A structural model shows that surgeons’ willingness to use poor-quality organs is responsive to technological change and organ availability.
One criticisms of the current allocation system is that many patients are placed on the waiting list in a healthy state but only receive a transplant once they reach the sickest urgency category, at which point their ability to survive the transplant operation is diminished. The rest of the dissertation examines this aspect of the allocation system. Chapter 2 presents estimates of the effect of waiting time on the probability of transplant success. Using blood type as an instrument, waiting time is found to have a clinically and statistically significant effect on outcomes. Chapter 3 presents a simulation model of patient outcomes under various allocation rules. The current sickest-first rule results in a large loss of health between listing and transplant, and this loss is directly related to the ratio of organ demand to supply. The fourth and final chapter presents three principles by which to evaluate organ allocation rules. Unlike the standard ethical criteria, these take account of the fact that patient urgency is endogenously determined; a rule that prioritizes patients by urgency will cause more patients to become urgent in the first place.
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Lisa Alison Prosser
2000, Decision Sciences
Current Position: Research Scientist, Center for Health Services Research
Current Employer: Henry Ford Health System
Thesis Title: Patient Preferences and Economic Considerations in Treatment Decisions for Multiple Sclerosis
Committee Members: Weinstein, Kuntz, Newhouse
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ABSTRACT: This thesis explores the role of patient preferences in treatment decisions and in the cost-effectiveness of three treatments for patients with multiple sclerosis (MS). The first chapter reports the results of a survey conducted to measure utilities for six health states and three treatment states in multiple sclerosis. Patients assign high utilities to milder MS health states and disutility is associated with the treatment health states. Mean utilities for the treatment health states were lower than those for the milder MS health states. These results provide support for a hypothesis that a patient’s decision to discontinue treatment is rational.
The second chapter examines the role of risk attitude and treatment choice in patients with multiple sclerosis. Patients’ risk profiles regarding health and money were assessed using standard-gamble questions. The main finding of this chapter is that risk attitude is related to treatment choice for patients with MS. As patients become more risk seeking, they are more likely to forgo treatment. Treatment discontinuation, however, is not associated with risk attitude. Patients who discontinue do so because they have experienced moderate or severe side effects, regardless of risk preference. An additional finding of this paper is that risk attitude varies across domains. While respondents were, on average, risk averse with respect to money, they were risk neutral on health. Therefore, risk attitude regarding money may not be an appropriate proxy for risk attitude regarding health.
The third chapter evaluates the cost-effectiveness of interferon beta-1a, interferon beta-1b, and glatiramer acetate in patients with multiple sclerosis. A computer simulation to model the effects and costs of treatments in multiple sclerosis was developed. Cost-effectiveness ratios for all three treatments are unfavorable under most assumptions, unless the cost of the drug is substantially reduced. All three treatment strategies are strongly dominated in the base case analysis; for treatment duration of five years or less, benefits are not large enough to overcome disutility associated with the treatments. Using alternative assumptions, cost-effectiveness ratios are still greater than $1,000,000/QALY in most cases. Under favorable assumptions, cost-effectiveness ratios may be as low as $460,000/QALY for IFNB-1a.
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Eve Wittenberg
2000, Evaluative Science & Statistics
Current Position: Senior Scientist
Current Employer: Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University
Thesis Title: Health Risk Behaviors, Preferences and Policies
Committee Members: Graham, Goldie, Light, Newhouse
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| ABSTRACT: : This dissertation address health behavior in response to risk, and public preferences regarding risk. Health behavior is explored in two papers on the topic of child seating behavior in motor vehicles. Seating position is the behavior of interest, in response to the health risk to children posed by passenger air bags. Paper #1 is an empirical study of child seating behavior in vehicles traveling in New England. From a sample of 503 drivers observed and interviewed in 1998, we found that the presence of passenger air bags in vehicles was independently associated with a decreased chance of children being seated in the front seat. This result suggests that drivers were adjusting their behavior in response to the hazard posed by air bags to children.
Paper #2 reports on an accompanying study that analyzed trends in child seating behavior from 1990 through 1998 in vehicles involved in fatal crashes. Using a national database of fatal crashes to identify predictors of child front seating, we found that while the frequency of front seating declined in all vehicles over this period, greater declines were associated with the presence of both a passenger air bag and younger children in the vehicle. These results confirmed and extended our New England findings, implying that the behavioral response to the air bag hazard was greater for younger children.
Public preferences regarding risk were explored in the context of the role that risk characteristics play in preferences regarding health policies. Papers #3 and 4 p |
Mollyann Brodie
,
1995
