In this paper we extend the Box-Cox indirect censoring model (Chaze, 2005) in order to simultaneo... more In this paper we extend the Box-Cox indirect censoring model (Chaze, 2005) in order to simultaneously analyze healthcare consumption and insurance deductible choice in Switzerland. One original feature of this study is the focus on both the in- surance deductible eect on healthcare demand and role played by GP density in the formation of this demand. We nd that health
With its extensive, homogeneous and compulsory Social Health Insurance (SHI) program, Switzerland... more With its extensive, homogeneous and compulsory Social Health Insurance (SHI) program, Switzerland offers a unique setting to measure the effect of deductible choice on healthcare demand. Indeed, identical SHI cover is provided over the whole country with free deductible choice in a set ranging from CHF 300 to CHF 2500, which notably gives the opportunity to study high deductible plans.
Patients with advanced cancer often have to make difficult decisions, such as how much to spend o... more Patients with advanced cancer often have to make difficult decisions, such as how much to spend on moderately life-extending treatments. This and other end-of-life decisions are also influenced by their informal caregivers. Understanding the relative value that patients and their caregivers place on various aspects of end-of-life care can help clinicians tailor treatments to best meet the preferences of their patients. To quantify willingness to pay of patients with advanced cancer and their caregivers to extend the patients' life by 1 year and to compare this result to their willingness to pay for other end-of-life improvements. Cross-sectional survey using a discrete choice experiment. A total of 211 patients with stage IV cancer and their informal caregivers. The willingness to pay of patients to extend their life by 1 year (S$18,570; 95% confidence interval: S$6687-S$30,542) was not statistically different from their willingness to pay to avoid severe pain (S$22,199; S$11,64...
We debunk three likely misperceptions about childhood obesity: (1) the epidemic thereof is caused... more We debunk three likely misperceptions about childhood obesity: (1) the epidemic thereof is caused by poverty, (2) information campaigns alone would be effective at reducing childhood obesity rates, and (3) obesity-reducing interventions would necessarily save money. We then discuss policies that could be effective at reducing childhood obesity rates and propose a tax/subsidy strategy that would provide the right incentives for governments, schools, and households to make appropriate investments in obesity prevention efforts.
Non-communicable diseases (NCDs) are emerging as the predominant global health challenge of this ... more Non-communicable diseases (NCDs) are emerging as the predominant global health challenge of this century. Physical inactivity is one of the primary risk factors for NCDs. Therefore, increasing physical activity levels is a public health imperative. The arrival of affordable wearable technologies, such as wireless pedometers, provides one strategy for encouraging walking. However, the effectiveness of these technologies in promoting sustained behavior change has not been established. Insights from economics suggest that incentives may be a useful strategy for increasing maintenance and effectiveness of behavior change interventions, including physical activity interventions that rely on wearable technologies. The aim of this trial is to test the effectiveness of a common wireless pedometer with or without one of two types of incentives (cash or donations to charity) for reaching weekly physical activity goals. We present here the design and baseline characteristics of participants of this four arm randomized controlled trial. 800 full-time employees (desk-bound office workers) belonging to 15 different worksites (on average, 53 (sd: 37) employees at each worksite) were successfully randomized to one of four study arms. If shown to be effective, wearable technologies in concert with financial incentives may provide a scalable and affordable health promotion strategy for governments and employers seeking to increase the physical activity levels of their constituents.
The explanatory factors of individual healthcare consumption are studied by means of healthcare e... more The explanatory factors of individual healthcare consumption are studied by means of healthcare expenditures from the 2000–2005 Swiss Household Income and Expenditure Survey (SHIES). In order to tackle the issues of large number of null expenditures and skewed distribution of positive outcomes, the family of Box-Cox censoring models (Chaze, 2005) is applied. The results show that the use of SHIES
Promoting universal health coverage (UHC) has been an important part of Singapore's overall 14 de... more Promoting universal health coverage (UHC) has been an important part of Singapore's overall 14 development strategy, with a strong policy focus on the promotion, prevention and treatment of non-15 communicable diseases. The health care system is buttressed by a financing structure comprising the national 16 medical savings scheme (Medisave), health insurance scheme (MediShield), and government subsidies to 17 protect against unpredictable high expenditures. 18 While Singapore does not have a UHC monitoring framework per se, indicators on accessibility, quality and 19 affordability of healthcare are tracked. They include tracer indicators for health-related Millennium 20 Development Goals, and chronic conditions and injuries (CCI) recommended by the WHO and World Bank. 21 Measures of disease burden, effective coverage, and affordability are also reported. Data sources include the 22 42 OPEN ACCESS PLOS Medicine | www.plosmedicine.org 2 Part of the UHC Measurement Collection system. Indicators on accessibility, quality and affordability of healthcare for Singaporeans are regularly 1 tracked and reported to Parliament as part of the Key Performance Indicators for the Ministry of Health. 2 Equity-related considerations are incorporated into these indicators. 3 3. In the last two decades, life expectancy and health-adjusted life expectancy have improved. Cross-4 sectionally, service coverage and outcomes for individuals with diabetes and high blood cholesterol are 5 better for the lower educated. For hypertension, service coverage was better for the lower-educated but 6 outcomes performed worse. For asthma, there was an uneven SES gradient. For cancer, knowledge and 7 utilisation of screening increases with education attainment. 8 4.
Ghana has been institutionalizing a set of coordinated mechanisms to measure and monitor progress... more Ghana has been institutionalizing a set of coordinated mechanisms to measure and monitor progress in health coverage. These periodic assessments have over time shown significant country progress towards achieving a fifty--percent reduction in childhood morality rate by 2015 and a two--thirds reduction in maternal deaths within the same period. However, a lot more effort remains for Ghana to actually attain these Millennium Development Goals targets post 2015. The push for universal health coverage is now more important than ever and has necessitated the adoption of a systematic set of measurement and monitoring tools that will overtime depict effective country progress towards improved health outcomes, consolidating optimum health coverage. Ghana is working towards developing a system that is comparable with those in other countries of similar population structure and economic status particularly in Sub--Saharan Africa, to ensure more meaningful analysis of desired national health goals and outcomes. The purpose of this review is to determine whether Ghana as a country endorses universal health coverage and how well Ghana is positioned to achieve universal health coverage as well as which existing policies can or should be developed to achieve this. The review examines the systems operational for measuring universal health coverage in Ghana, strategies for identifying and addressing relevant gaps as well as which indicators will most appropriately assess progress towards universal health coverage. The review is contributing to the World Summary Points: 13 1. Ghana has an elaborate range of indicator to measure and monitor its health outcomes, however, there is 14 need for greater clarity on which indicators sufficiently measure true coverage and which ones measure 15 impact or output 16 2. Policy--wise, success of Ghana achieving universal health coverage will depend to a large extent on 17 Government leadership in promoting its key initiatives of community--based health care and services 18 (CHPS), NHIS and Decentralization to increase focus on preventive and promotive health actions rather 19 than large capital investments on hospital--based care in order to contain cost.
Objective-To test whether overweight or obese employees who achieve clinically significant weight... more Objective-To test whether overweight or obese employees who achieve clinically significant weight loss of 5% or greater have reduced medical expenditures, absenteeism, presenteeism, and/ or improved Health-Related Quality Of Life (HRQOL).
Non-communicable diseases, including cardiovascular diseases, cancers, respiratory diseases, diab... more Non-communicable diseases, including cardiovascular diseases, cancers, respiratory diseases, diabetes, and mental disorders, and injuries have become the major causes of morbidity and mortality in Pakistan. Tobacco use and hypertension are the leading attributable risk factors for deaths due to cardiovascular diseases, cancers, and respiratory diseases. Pakistan has the sixth highest number of people in the world with diabetes; every fourth adult is overweight or obese; cigarettes are cheap; antismoking and road safety laws are poorly enforced; and a mixed public-private health-care system provides suboptimum care. Furthermore, almost three decades of exposure to sociopolitical instability, economic uncertainty, violence, regional conflict, and dislocation have contributed to a high prevalence of mental health disorders. Projection models based on the Global Burden of Disease 2010 data suggest that there will be about 3·87 million premature deaths by 2025 from cardiovascular diseases, cancers, and chronic respiratory diseases in people aged 30-69 years in Pakistan, with serious economic consequences. Modelling of risk factor reductions also indicate that Pakistan could achieve at least a 20% reduction in the number of these deaths by 2025 by targeting of the major risk factors. We call for policy and legislative changes, and health-system interventions to target readily preventable non-communicable diseases in Pakistan.
Using a rich Italian cross-sectional dataset, we estimate the effect of a neighborhood problems a... more Using a rich Italian cross-sectional dataset, we estimate the effect of a neighborhood problems aggregate (including pollution, crime, and noise) on self-assessed health, presence of chronic conditions and limitations in daily activities. We address the self-selection of the residents in their neighborhoods, as well as the possible endogeneity of income with respect to health, through instrumental variable methods and several endogeneity tests. The main novelty is the sound estimation of the neighborhood effect on health using observational data, which has the advantage of providing general results that are not dependent on any experimental design. This allows us to fully compare the neighborhood effect with the traditional socioeconomic determinants of health. Our main findings are that low quality neighborhoods are strongly health damaging. This effect is comparable to the primary/upper secondary education health differential and is even higher than the impact that poor economic circumstances have on health.
Using the 2006 Homescan panel, we estimate the changes in energy, fat and sodium purchases result... more Using the 2006 Homescan panel, we estimate the changes in energy, fat and sodium purchases resulting from a tax that increases the price of sugar-sweetened beverages (SSBs) by 20% and the effect of such a tax on body weight. In addition to substitutions that may arise with other beverages, we account for substitutions between SSBs and 12 major food categories. Our main findings are that the tax would result in a decrease in store-bought energy of 24.3kcal per day per person, which would translate into an average weight loss of 1.6 pounds during the first year and a cumulated weight loss of 2.9 pounds in the long run. We do not find evidence of substitution to sugary foods and show that complementary foods could contribute to decreasing energy purchases. Despite their significantly lower price elasticity, the tax has a similar effect on calories for the largest purchasers of SSBs.
When fitting an econometric model, it is well known that we pick up part of the idiosyncratic cha... more When fitting an econometric model, it is well known that we pick up part of the idiosyncratic characteristics of the data along with the systematic relationship between dependent and explanatory variables. This phenomenon is known as overfitting and generally occurs when a model is excessively complex relative to the amount of data available. Overfitting is a major threat to regression analysis in terms of both inference and prediction. We start by showing that the Copas measure becomes confounded by shrinkage or expansion arising from in-sample bias when applied to the untransformed scale of nonlinear models, which is typically the scale of interest when assessing behaviors or analyzing policies. We then propose a new measure of overfitting that is both expressed on the scale of interest and immune to this problem. We also show how to measure the respective contributions of in-sample bias and overfitting to the overall predictive bias when applying an estimated model to new data. We finally illustrate the properties of our new measure through both a simulation study and a real-data illustration based on inpatient healthcare expenditure data, which shows that the distinctions can be important.
Background: There is extensive evidence that regular physical activity confers numerous health be... more Background: There is extensive evidence that regular physical activity confers numerous health benefits. Despite this, high rates of physical inactivity prevail among older adults. This study aimed to ascertain if incentives could be effective in motivating physical activity through improving uptake of walking programs, either with or without an enrolment fee to cover corresponding costs.
Explaining the rationale of preventive care underuse is a difficult task considering its great be... more Explaining the rationale of preventive care underuse is a difficult task considering its great benefits for health. Underuse is even more difficult to explain in countries like Italy where preventive care can be obtained for free. In this article we investigate the determinants of prevention underuse with an empirical model based on human capital theory which also includes three factors to which little attention has been paid so far: role played by the General Practitioner (GP), nonmonetary barriers to access and health beliefs. We apply a recursive probit model explaining both recourse to prevention and to the GP which allows us to adequately measure the effect of the latter on the former and to quantitatively compare the determinants of curative and preventive care. We find that the GP plays a minor role in prevention use but that nonmonetary barriers to access and health beliefs are strong determinants of preventive care demand. Finally, we also find support for both Grossman's capital depreciation theory (at younger ages) and Cropper's shorter pay-off period theory (at older ages).
In recent years, economic research on the socio-economic determinants of health has significantly... more In recent years, economic research on the socio-economic determinants of health has significantly;grown given the importance of health for individual wellbeing. Most of the work up to now;has focused on the effects of individual socio-economic conditions, whereas, more recently, the view that even socio-economic characteristics of the place in which individual live can influence health status autonomously is gaining consensus.
In this paper we extend the Box-Cox indirect censoring model (Chaze, 2005) in order to simultaneo... more In this paper we extend the Box-Cox indirect censoring model (Chaze, 2005) in order to simultaneously analyze healthcare consumption and insurance deductible choice in Switzerland. One original feature of this study is the focus on both the in- surance deductible eect on healthcare demand and role played by GP density in the formation of this demand. We nd that health
With its extensive, homogeneous and compulsory Social Health Insurance (SHI) program, Switzerland... more With its extensive, homogeneous and compulsory Social Health Insurance (SHI) program, Switzerland offers a unique setting to measure the effect of deductible choice on healthcare demand. Indeed, identical SHI cover is provided over the whole country with free deductible choice in a set ranging from CHF 300 to CHF 2500, which notably gives the opportunity to study high deductible plans.
Patients with advanced cancer often have to make difficult decisions, such as how much to spend o... more Patients with advanced cancer often have to make difficult decisions, such as how much to spend on moderately life-extending treatments. This and other end-of-life decisions are also influenced by their informal caregivers. Understanding the relative value that patients and their caregivers place on various aspects of end-of-life care can help clinicians tailor treatments to best meet the preferences of their patients. To quantify willingness to pay of patients with advanced cancer and their caregivers to extend the patients' life by 1 year and to compare this result to their willingness to pay for other end-of-life improvements. Cross-sectional survey using a discrete choice experiment. A total of 211 patients with stage IV cancer and their informal caregivers. The willingness to pay of patients to extend their life by 1 year (S$18,570; 95% confidence interval: S$6687-S$30,542) was not statistically different from their willingness to pay to avoid severe pain (S$22,199; S$11,64...
We debunk three likely misperceptions about childhood obesity: (1) the epidemic thereof is caused... more We debunk three likely misperceptions about childhood obesity: (1) the epidemic thereof is caused by poverty, (2) information campaigns alone would be effective at reducing childhood obesity rates, and (3) obesity-reducing interventions would necessarily save money. We then discuss policies that could be effective at reducing childhood obesity rates and propose a tax/subsidy strategy that would provide the right incentives for governments, schools, and households to make appropriate investments in obesity prevention efforts.
Non-communicable diseases (NCDs) are emerging as the predominant global health challenge of this ... more Non-communicable diseases (NCDs) are emerging as the predominant global health challenge of this century. Physical inactivity is one of the primary risk factors for NCDs. Therefore, increasing physical activity levels is a public health imperative. The arrival of affordable wearable technologies, such as wireless pedometers, provides one strategy for encouraging walking. However, the effectiveness of these technologies in promoting sustained behavior change has not been established. Insights from economics suggest that incentives may be a useful strategy for increasing maintenance and effectiveness of behavior change interventions, including physical activity interventions that rely on wearable technologies. The aim of this trial is to test the effectiveness of a common wireless pedometer with or without one of two types of incentives (cash or donations to charity) for reaching weekly physical activity goals. We present here the design and baseline characteristics of participants of this four arm randomized controlled trial. 800 full-time employees (desk-bound office workers) belonging to 15 different worksites (on average, 53 (sd: 37) employees at each worksite) were successfully randomized to one of four study arms. If shown to be effective, wearable technologies in concert with financial incentives may provide a scalable and affordable health promotion strategy for governments and employers seeking to increase the physical activity levels of their constituents.
The explanatory factors of individual healthcare consumption are studied by means of healthcare e... more The explanatory factors of individual healthcare consumption are studied by means of healthcare expenditures from the 2000–2005 Swiss Household Income and Expenditure Survey (SHIES). In order to tackle the issues of large number of null expenditures and skewed distribution of positive outcomes, the family of Box-Cox censoring models (Chaze, 2005) is applied. The results show that the use of SHIES
Promoting universal health coverage (UHC) has been an important part of Singapore's overall 14 de... more Promoting universal health coverage (UHC) has been an important part of Singapore's overall 14 development strategy, with a strong policy focus on the promotion, prevention and treatment of non-15 communicable diseases. The health care system is buttressed by a financing structure comprising the national 16 medical savings scheme (Medisave), health insurance scheme (MediShield), and government subsidies to 17 protect against unpredictable high expenditures. 18 While Singapore does not have a UHC monitoring framework per se, indicators on accessibility, quality and 19 affordability of healthcare are tracked. They include tracer indicators for health-related Millennium 20 Development Goals, and chronic conditions and injuries (CCI) recommended by the WHO and World Bank. 21 Measures of disease burden, effective coverage, and affordability are also reported. Data sources include the 22 42 OPEN ACCESS PLOS Medicine | www.plosmedicine.org 2 Part of the UHC Measurement Collection system. Indicators on accessibility, quality and affordability of healthcare for Singaporeans are regularly 1 tracked and reported to Parliament as part of the Key Performance Indicators for the Ministry of Health. 2 Equity-related considerations are incorporated into these indicators. 3 3. In the last two decades, life expectancy and health-adjusted life expectancy have improved. Cross-4 sectionally, service coverage and outcomes for individuals with diabetes and high blood cholesterol are 5 better for the lower educated. For hypertension, service coverage was better for the lower-educated but 6 outcomes performed worse. For asthma, there was an uneven SES gradient. For cancer, knowledge and 7 utilisation of screening increases with education attainment. 8 4.
Ghana has been institutionalizing a set of coordinated mechanisms to measure and monitor progress... more Ghana has been institutionalizing a set of coordinated mechanisms to measure and monitor progress in health coverage. These periodic assessments have over time shown significant country progress towards achieving a fifty--percent reduction in childhood morality rate by 2015 and a two--thirds reduction in maternal deaths within the same period. However, a lot more effort remains for Ghana to actually attain these Millennium Development Goals targets post 2015. The push for universal health coverage is now more important than ever and has necessitated the adoption of a systematic set of measurement and monitoring tools that will overtime depict effective country progress towards improved health outcomes, consolidating optimum health coverage. Ghana is working towards developing a system that is comparable with those in other countries of similar population structure and economic status particularly in Sub--Saharan Africa, to ensure more meaningful analysis of desired national health goals and outcomes. The purpose of this review is to determine whether Ghana as a country endorses universal health coverage and how well Ghana is positioned to achieve universal health coverage as well as which existing policies can or should be developed to achieve this. The review examines the systems operational for measuring universal health coverage in Ghana, strategies for identifying and addressing relevant gaps as well as which indicators will most appropriately assess progress towards universal health coverage. The review is contributing to the World Summary Points: 13 1. Ghana has an elaborate range of indicator to measure and monitor its health outcomes, however, there is 14 need for greater clarity on which indicators sufficiently measure true coverage and which ones measure 15 impact or output 16 2. Policy--wise, success of Ghana achieving universal health coverage will depend to a large extent on 17 Government leadership in promoting its key initiatives of community--based health care and services 18 (CHPS), NHIS and Decentralization to increase focus on preventive and promotive health actions rather 19 than large capital investments on hospital--based care in order to contain cost.
Objective-To test whether overweight or obese employees who achieve clinically significant weight... more Objective-To test whether overweight or obese employees who achieve clinically significant weight loss of 5% or greater have reduced medical expenditures, absenteeism, presenteeism, and/ or improved Health-Related Quality Of Life (HRQOL).
Non-communicable diseases, including cardiovascular diseases, cancers, respiratory diseases, diab... more Non-communicable diseases, including cardiovascular diseases, cancers, respiratory diseases, diabetes, and mental disorders, and injuries have become the major causes of morbidity and mortality in Pakistan. Tobacco use and hypertension are the leading attributable risk factors for deaths due to cardiovascular diseases, cancers, and respiratory diseases. Pakistan has the sixth highest number of people in the world with diabetes; every fourth adult is overweight or obese; cigarettes are cheap; antismoking and road safety laws are poorly enforced; and a mixed public-private health-care system provides suboptimum care. Furthermore, almost three decades of exposure to sociopolitical instability, economic uncertainty, violence, regional conflict, and dislocation have contributed to a high prevalence of mental health disorders. Projection models based on the Global Burden of Disease 2010 data suggest that there will be about 3·87 million premature deaths by 2025 from cardiovascular diseases, cancers, and chronic respiratory diseases in people aged 30-69 years in Pakistan, with serious economic consequences. Modelling of risk factor reductions also indicate that Pakistan could achieve at least a 20% reduction in the number of these deaths by 2025 by targeting of the major risk factors. We call for policy and legislative changes, and health-system interventions to target readily preventable non-communicable diseases in Pakistan.
Using a rich Italian cross-sectional dataset, we estimate the effect of a neighborhood problems a... more Using a rich Italian cross-sectional dataset, we estimate the effect of a neighborhood problems aggregate (including pollution, crime, and noise) on self-assessed health, presence of chronic conditions and limitations in daily activities. We address the self-selection of the residents in their neighborhoods, as well as the possible endogeneity of income with respect to health, through instrumental variable methods and several endogeneity tests. The main novelty is the sound estimation of the neighborhood effect on health using observational data, which has the advantage of providing general results that are not dependent on any experimental design. This allows us to fully compare the neighborhood effect with the traditional socioeconomic determinants of health. Our main findings are that low quality neighborhoods are strongly health damaging. This effect is comparable to the primary/upper secondary education health differential and is even higher than the impact that poor economic circumstances have on health.
Using the 2006 Homescan panel, we estimate the changes in energy, fat and sodium purchases result... more Using the 2006 Homescan panel, we estimate the changes in energy, fat and sodium purchases resulting from a tax that increases the price of sugar-sweetened beverages (SSBs) by 20% and the effect of such a tax on body weight. In addition to substitutions that may arise with other beverages, we account for substitutions between SSBs and 12 major food categories. Our main findings are that the tax would result in a decrease in store-bought energy of 24.3kcal per day per person, which would translate into an average weight loss of 1.6 pounds during the first year and a cumulated weight loss of 2.9 pounds in the long run. We do not find evidence of substitution to sugary foods and show that complementary foods could contribute to decreasing energy purchases. Despite their significantly lower price elasticity, the tax has a similar effect on calories for the largest purchasers of SSBs.
When fitting an econometric model, it is well known that we pick up part of the idiosyncratic cha... more When fitting an econometric model, it is well known that we pick up part of the idiosyncratic characteristics of the data along with the systematic relationship between dependent and explanatory variables. This phenomenon is known as overfitting and generally occurs when a model is excessively complex relative to the amount of data available. Overfitting is a major threat to regression analysis in terms of both inference and prediction. We start by showing that the Copas measure becomes confounded by shrinkage or expansion arising from in-sample bias when applied to the untransformed scale of nonlinear models, which is typically the scale of interest when assessing behaviors or analyzing policies. We then propose a new measure of overfitting that is both expressed on the scale of interest and immune to this problem. We also show how to measure the respective contributions of in-sample bias and overfitting to the overall predictive bias when applying an estimated model to new data. We finally illustrate the properties of our new measure through both a simulation study and a real-data illustration based on inpatient healthcare expenditure data, which shows that the distinctions can be important.
Background: There is extensive evidence that regular physical activity confers numerous health be... more Background: There is extensive evidence that regular physical activity confers numerous health benefits. Despite this, high rates of physical inactivity prevail among older adults. This study aimed to ascertain if incentives could be effective in motivating physical activity through improving uptake of walking programs, either with or without an enrolment fee to cover corresponding costs.
Explaining the rationale of preventive care underuse is a difficult task considering its great be... more Explaining the rationale of preventive care underuse is a difficult task considering its great benefits for health. Underuse is even more difficult to explain in countries like Italy where preventive care can be obtained for free. In this article we investigate the determinants of prevention underuse with an empirical model based on human capital theory which also includes three factors to which little attention has been paid so far: role played by the General Practitioner (GP), nonmonetary barriers to access and health beliefs. We apply a recursive probit model explaining both recourse to prevention and to the GP which allows us to adequately measure the effect of the latter on the former and to quantitatively compare the determinants of curative and preventive care. We find that the GP plays a minor role in prevention use but that nonmonetary barriers to access and health beliefs are strong determinants of preventive care demand. Finally, we also find support for both Grossman's capital depreciation theory (at younger ages) and Cropper's shorter pay-off period theory (at older ages).
In recent years, economic research on the socio-economic determinants of health has significantly... more In recent years, economic research on the socio-economic determinants of health has significantly;grown given the importance of health for individual wellbeing. Most of the work up to now;has focused on the effects of individual socio-economic conditions, whereas, more recently, the view that even socio-economic characteristics of the place in which individual live can influence health status autonomously is gaining consensus.
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Papers by Marcel Bilger