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Rose Gagnon,1,2 Kadija Perreault,1,2 Jason R Guertin,3,4 Simon Berthelot,4– 6 Bertrand Achou,7 Luc J Hébert1,2,8 1Centre for Interdisciplinary Research in Rehabilitation and Social Integration (Cirris), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de La Capitale-Nationale, Quebec City, Quebec, Canada; 2Department of Rehabilitation, Université Laval, Quebec City, Quebec, Canada; 3Department of Social and Preventive Medicine, Université Laval, Quebec City, Quebec, Canada; 4Centre de recherche du CHU de Québec – Université Laval, Quebec City, Quebec, Canada; 5Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, Quebec, Canada; 6CHU de Québec – Université Laval, Quebec City, Quebec, Canada; 7HEC Montreal, Montreal, Quebec, Canada; 8Department of Radiology and Nuclear Medicine, Université Laval, Quebec City, Quebec, CanadaCorrespondence: Luc J Hébert, Cirris, CIUSSS de la Capitale-Nationale, 525 Boulevard Wilfrid-Hamel, H-1410, Quebec City, Quebec, G1M 2S8, Canada, Tel +1 418 529-9141 ext 6579, Email lucj.hebert@fmed.ulaval.caBackground: Musculoskeletal disorders (MSKDs) are among the most disabling and costly non-fatal health conditions. They may lead to long-term consequences such as chronic pain, physical limitations, and poorer quality of life. They also account for a significant proportion of emergency department visits, representing between 18% and 25% of all visits, depending on country.Purpose: To assess the health-related quality of life of patients presenting to the emergency department with a MSKD, to convert their answers to utility scores and to explore the association between diverse socio-demographic and clinical variables and patients’ health-related quality of life.Patients and Methods: This is an analysis of cross-sectional data obtained during the baseline assessment performed as part of a 6-month pragmatic randomized controlled trial conducted in an academic emergency department. We included patients aged 18– 80 years with a minor MSKD. The main outcome measures were health-related quality of life (five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and utility scores (− 0.148 – worse than death, 0 – dead, 0.949 – perfect health) measured with the EQ-5D-5L. Possible associations were explored by comparing scores across subgroups based on certain socio-demographic (eg, age, gender, triage score) and clinical factors (eg, pain interference on function, pain intensity) and with reference values using descriptive statistics (mean, median), rankFD ANOVAs, and χ2 tests.Results: Sixty-nine participants completed the EQ-5D-5L. Mean and median utility scores were, respectively, 0.536 (95% CI: 0.479– 0.594) and 0.531 (IQR: 0.356– 0.760). Participants with higher levels of pain (< 4/10: 0.741, 95% CI: 0.501– 0.980; 4– 7/10: 0.572, 0.500– 0.644; > 7/10: 0.433, 0.347– 0.518) or pain interference on function (< 4/10: 0.685, 95% CI: 0.605– 0.764; 4– 7/10: 0.463, 0.394– 0.533; > 7/10: 0.294, 0.126– 0.463) presented significantly lower utility scores. No significant differences were found for other socio-demographic characteristics.Conclusion: In patients with MSKDs who present to the emergency department, higher levels of pain or pain interference are associated with decreased health-related quality of life. These findings need to be confirmed on a larger scale.Keywords: EQ-5D-5L, quality of life, pain, emergency services, musculoskeletal disorders

In this article, the authors address concerns about the impact that the aging of Canada's population over the coming decades could have on economic growth and, consequently, growth in government revenues. They explore how revenue-neutral changes in the tax mix today could mitigate those concerns and raise more revenue than is projected in current forecasts with a status-quo scenario. Using data for Quebec, the authors show that a shift in the relative share of total revenues from personal income taxes to consumption taxes could be quite effective over the next four decades. A revenue-neutral shift equivalent to 1 percent of the province's consumption tax revenues today would result in an increase in revenues ranging between 0.3 percent and 1.0 percent by 2060, while a shift equivalent to 25 percent of consumption tax revenues would generate additional revenues of 1.4 percent to 4.8 percent.

Housing is mostly exempted from Medicaid and Supplemental Social Insurance means tests. Reforms of this special treatment have been debated, but little is known about its costs, benefits, and redistributive implications. I estimate a life cycle model of single retirees accounting for this exemption. It shows that the homestead exemption explains important patterns of Medicaid recipiency and that it is highly valued. It also shows that estate recovery could cover most of its costs with possibly limited negative welfare consequences. Finally, the model predicts that removing the homestead exemption or enforcing estate recovery programs would reduce redistribution toward lower-income retirees. (JEL D15, G51, H51, I13, I18, I38, J26)

The coronavirus disease 2019 (COVID-19) pandemic surged in early March 2020, with unemployment reaching historic levels in April 2020. This study paints an early portrait of the pandemic’s impact on the finances of households in Quebec, one of the hardest-hit provinces in terms of COVID-19 cases as well as unemployment levels. The article also provides an understanding of how government emergency benefit programs may have helped households get by during the early period of the pandemic. Finally, we draw on expectations data collected in a survey of 3,009 respondents living in Quebec to illustrate what households can expect for the rest of 2020.

The market for long-term care (LTC) insurance is much smaller than economic theory predicts. One reason is that premium markups are prohibitively high. We aim at quantifying markups for LTC insurance due to mortality and morbidity risk. To this end, we model a shareholder value maximising insurance company that is subject to solvency regulation. Because liabilities from LTC insurance (which depend on future morbidity and mortality) are more volatile than liabilities from annuities (which only depend on future mortality), capital provisions to ensure compliance with regulatory solvency requirements are higher if an insurance company offers LTC insurance instead of annuities. At the same time, a higher volatility in the LTC insurance segment also implies a higher expected payoff to the insurance company’s shareholders. To quantify which effect prevails and which product policy is optimal, we conduct an empirically calibrated simulation study with stochastic mortality and LTC needs. Our results show that offering LTC insurance increases the upside potential to shareholders, but that effect is more than offset by a higher need for external capital. Consequently, if shareholders are to accept an LTC insurance segment, holders of an LTC insurance policy need to pay considerable markups. The more LTC insurance contracts the insurer has sold, the higher the markups.

OBJECTIVES The objective was to evaluate the effects of direct-access physiotherapy on patients presenting with a musculoskeletal disorder (MSKD) to the emergency department (ED) on clinical outcomes and use of health care resources. METHODS We conducted a randomized controlled trial in an academic ED in Quebec City, Canada. We included patients aged 18 to 80 years with minor MSKD. The intervention group had direct access to a physiotherapist (PT) in the ED immediately after triage and prior to physician assessment, and the control group received usual care by the emergency physician without PT intervention. The key variables included clinical outcomes (pain, interference of pain on function) and resources use (ED return visit, medications, diagnostic tests, additional consultations). They were analyzed using descriptive statistics and compared between groups using two-way analyses of variance, log-linear analysis, and chi-square tests. RESULTS Seventy-eight patients suffering from MSKDs were included (40.2 ± 17.6 years old; 44% women). For the primary clinical outcome, participants in the PT group (n = 40) had statistically lower levels of pain and pain interference at 1 and 3 months. In terms of resource use, participants in the PT group returned significantly less often to the ED. At baseline and 1 month, less prescription medication was used, including opioids, but there were no differences at 3 months. Although over-the-counter medication was recommended more at baseline in the PT group, there were no differences in use at 1 month, and the PT group had used them less at 3 months. There were no differences between groups at follow-up for imaging tests, other professionals consulted, and hospitalization rates. CONCLUSION Patients presenting with a MSKD to the ED with direct access to a PT had better clinical outcomes and used less services and resources than those in the usual care group after ED discharge and up to 3 months after discharge.

In theory, illiquid housing may substitute for long-term care insurance (LTCI) as retirees decumulate housing wealth mainly when moving to long-term care facilities. In this paper, I build and estimate a rich life-cycle model of single retirees in order to evaluate whether the impact of housing liquidity on LTCI demand is large. Overall, I find that the prospects of increasing LTCI demand by making housing more liquid are quite limited, as even large increases in housing liquidity generate modest increases in LTCI demand. I also find a limited impact of housing liquidity on the demand for life annuities. Finally, I show that the types of bequest motives used to rationalize the low take-up of reverse mortgages are generally inconsistent with the low demand for LTCI, suggesting that other factors may play a role in this low take-up of reverse mortgages.

In this work we introduce a general equilibrium model with landlords, indebted owner-occupiers and renters to study housing markets' dynamics. We estimate it by using standard Bayesian methods and match the US data of the last decades. This framework is particularly suited to explain current trends on housing markets. We highlight the crucial relationship between interest rates, house prices and rents, and argue that it helps understanding the main driving forces. Our analysis suggests that current developments on housing markets can play a role for a recovery from the Covid pandemic as they have an expansionary effect on aggregate output. Moreover, we account for the heterogeneous impact of crisis-induced policies depending on agents' status on the housing market. We show how, despite an increase in housing prices, the welfare of landlords has been negatively hit. This is associated to the joint decrease in returns on housing and financial assets that reduces their financial incomes.

COVID-19 outbreaks at nursing homes during the recent pandemic, which received ample media coverage, may have lasting negative impacts on individuals’ perceptions regarding ursing homes. We argue that this could have sizable and persistent implications for savings and long-term care policies. We first develop a theoretical model predicting that higher nurs- ing home aversion should induce higher savings and stronger support for policies subsidizing home care. We further document, based on a survey on Canadians in their 50s and 60s, that higher nursing home aversion is widespread: 72% of respondents are less inclined to enter a nursing home because of the pandemic. Consistent with our model, we find that the latter are much more likely to have higher intended savings for older age because of the pandemic. We also find that they are more likely to strongly support home care subsidies.

ObjectivesThe purpose of this study was to assess utility scores of patients presenting to the emergency department (ED) with a musculoskeletal disorder and to explore the influence of diverse factors on health-related quality of life.DesignSecondary analysis of data obtained before randomization during a pragmatic randomized controlled trialSettingAcademic ED in Quebec City (Canada)ParticipantsParticipants aged 18-80 years old presenting with a minor MSKD.Main Outcome MeasuresHealth-related quality of life (five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and utility scores (0 – dead, 100 – perfect health), measured with the EQ-5D-5L, were compared between subgroups and with reference values using descriptive statistics (mean, median), rankFD ANOVAs, and χ2 tests.ResultsSixty-nine participants completed the EQ-5D-5L. Mean and median utility scores were respectively 0.536 (95% CI: 0.479-0.594) and 0.531 (IQR: 0.356-0.760). Participants with higher levels of pain (7/10: 0.433) or pain interference on function (7/10: 0.294) presented significantly lower utility scores. No significant differences were found for other socio-demographic characteristics. The mean overall VAS score was 58.1 (95% CI: 52.2-64.0).ConclusionsIn patients with MSKDs presenting to the ED, higher levels of pain and pain interference on function may influence perceived health-related QoL. These findings need to be confirmed on a larger scale.Trial RegistrationThis trial was registered at the US National Institutes of Health (ClinicalTrials.gov) #NCT04009369 on July 5, 2019

ContextIn several countries, physiotherapists (PT) have been integrated within emergency departments (EDs) to help manage patients with musculoskeletal disorders (MSKDs). Still, research on the effects of such initiatives is scarce.ObjectivesTo evaluate the effects of direct access PT on MSKD patients consulting the ED in terms of clinical outcomes and use of health care resources.Design, Setting, ParticipantsRandomized controlled trial, academic ED in Quebec City (Canada), participants 18-80 years presenting with a minor MSKD.InterventionDirect access PT at the EDControlEmergency Physicians lead management (EP).Main Outcome MeasureClinical outcomes (pain, interference of pain on function) and use of resources (ED return visit, interventions, diagnostic tests, consultations) were compared between groups at ED discharge and after 1 and 3 months using two-way ANOVAs, log-linear analysis and χ2 tests.ResultsSeventy-eight patients suffering from MSKDs were included (40.2 ± 17.6 years old; 44% women). Participants in the PT group (n=40) had statistically lower levels of pain and pain interference at 1- and 3-months. They were recommended fewer imaging tests (38% vs. 78%; pConclusionPatients presenting with a MSKD to the ED with direct access to a PT had better clinical outcomes and used less services and resources than those in the usual care group after ED discharge and up to 3 months after discharge. The results of this study support the implementation of such models of care for the management of this population.Trial RegistrationThis trial is registered at the US National Institutes of Health (ClinicalTrials.gov) #NCT04009369Ethical approvalThis trial was approved by the Research Ethics Committee of the CHU de Québec - Université Laval #MP-20-2019-4307