Search

Background In 2003, national disability-associated health care expenditures (DAHE) were $398 billion. Updated estimates will improve our understanding of current DAHE. Objective The objective of this study was to estimate national DAHE for the US adult population and analyze spending by insurance and service categories and to assess changes in spending over the past decade. Research design Data from the 2013-2015 Medical Expenditure Panel Survey were used to estimate DAHE for noninstitutionalized adults. These estimates were reconciled with National Health Expenditure Accounts (NHEA) data and adjusted to 2017 medical prices. Expenditures for institutionalized adults were added from NHEA data. Measures National DAHE in total, by insurance and service categories, and percentage of total expenditures associated with disability. Results DAHE in 2015 were $868 billion (at 2017 prices), representing 36% of total national health care spending (up from 27% in 2003). DAHE per person with disability increased from $13,395 in 2003 to $17,431 in 2015, whereas nondisability per-person spending remained constant (about $6700). Public insurers paid 69% of DAHE. Medicare paid the largest portion ($324.7 billion), and Medicaid DAHE were $277.2 billion. More than half (54%) of all Medicare expenditures and 72% of all Medicaid expenditures were associated with disability. Conclusions The share of health care expenditures associated with disability has increased substantially over the past decade. The high proportion of DAHE paid by public insurers reinforces the importance of public programs designed to improve health care for people with disabilities and emphasizes the need for evaluating programs and health services available to this vulnerable population.

Introduction Demonstrating the validity of a public health simulation model helps to establish confidence in the accuracy and usefulness of a model’s results. In this study we evaluated the validity of the Prevention Impacts Simulation Model (PRISM), a system dynamics model that simulates health, mortality, and economic outcomes for the US population. PRISM primarily simulates outcomes related to cardiovascular disease but also includes outcomes related to other chronic diseases that share risk factors. PRISM is openly available through a web application. Methods We applied the model validation framework developed independently by the International Society of Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making modeling task force to validate PRISM. This framework included model review by external experts and quantitative data comparison by the study team. Results External expert review determined that PRISM is based on up-to-date science. One-way sensitivity analysis showed that no parameter affected results by more than 5%. Comparison with other published models, such as ModelHealth, showed that PRISM produces lower estimates of effects and cost savings. Comparison with surveillance data showed that projected model trends in risk factors and outcomes align closely with secular trends. Four measures did not align with surveillance data, and those were recalibrated. Conclusion PRISM is a useful tool to simulate the potential effects and costs of public health interventions. Results of this validation should help assure health policy leaders that PRISM can help support community health program planning and evaluation efforts.

Objective Given the growth in national disability-associated health care expenditures (DAHE) and the changes in health insurance–specific DAHE distribution, updated estimates of state-level DAHE are needed. The objective of this study was to update state-level estimates of DAHE. Methods We combined data from the 2013-2015 Medical Expenditure Panel Survey, 2013-2015 Behavioral Risk Factor Surveillance System, and 2014 National Health Expenditure Accounts to calculate state-level DAHE for US adults in total, per adult, and per (adult) person with disability (PWD). We adjusted expenditures to 2017 prices and assessed changes in DAHE from 2003 to 2015. Results In 2015, DAHE were $868 billion nationally (range, $1.4 billion in Wyoming to $102.8 billion in California) accounting for 36% of total health care expenditures (range, 29%-41%). From 2003 to 2015, total DAHE increased by 65% (range, 35%-125%). In 2015, DAHE per PWD were highest in the District of Columbia ($27 839) and lowest in Alabama ($12 603). From 2003 to 2015, per-PWD DAHE increased by 13% (range, −20% to 61%) and per-capita DAHE increased by 28% (range, 7%-84%). In 2015, Medicare DAHE per PWD ranged from $10 067 in Alaska to $18 768 in New Jersey. Medicaid DAHE per PWD ranged from $9825 in Nevada to $43 365 in the District of Columbia. Nonpublic–health insurer per-PWD DAHE ranged from $7641 in Arkansas to $18 796 in Alaska. Conclusion DAHE are substantial and vary by state. The public sector largely supports the health care costs of people with disabilities. State policy makers and other stakeholders can use these results to inform the development of public health programs that support and provide ongoing health care to people with disabilities.

Carbon offset programs, such as that overseen by the California Air Resources Board (CA ARB), have emerged as a strategy for climate change mitigation. Offset projects sequestering carbon earn credits that can be traded on the Cap-and-Trade market to compensate for carbon emissions. The carbon stock embodied in harvested wood products can make up a substantial portion of the sequestered carbon in forest offset projects. In this paper we investigate the sensitivity of the calculations for the number of credits allocated to a forest offset project in the California system. We also examine how alternative models for the decay of harvested wood products might better reflect the dynamics of both the lifetime and cascade chain progression of the products and how this might change the amount of credits earned. The results suggest improved data collection and refinement in methodology would help to improve accuracy and reduce uncertainty in a large and important carbon stock. We conclude with offering suggestions on how an understanding of the dependence of harvested wood product stocks on life cycle parameters might affect the economics of offset programs and assist targeted mitigation efforts.

Vaccinations are recommended to prevent serious morbidity and mortality. However, providers' concerns regarding costs and payments for providing vaccination services are commonly reported barriers to adult vaccination. Information on the costs of providing vaccination is limited, especially for adults.We recruited 4 internal medicine, 4 family medicine, 2 pediatric, 2 obstetrics and gynecology (OBGYN) practices, and 2 community health clinics in North Carolina to participate in a study to assess the economic costs and benefits of providing vaccination services for adults and children. We conducted a time-motion assessment of vaccination-related activities in the provider office and a survey to providers on vaccine management costs. We estimated mean cost per vaccination, minimum and maximum payments received, and income.Across all provider settings, mean cost per vaccine administration was $14 with substantial variation by practice setting (pediatric: $10; community health clinics: $15; family medicine: $17; OBGYN: $23; internal medicine: $23). When receiving the maximum payment, all provider settings had positive income for vaccination services. When receiving the minimum reported payments for vaccination services, pediatric and family medicine practices had positive income, internal medicine, and OBGYN practices had approximately equal costs and payments, and community health clinics had losses or negative income.Overall, vaccination service providers appeared to have small positive income from vaccination services. In some cases, providers experienced negative income, which underscores the need for providers and policymakers to design interventions and system improvements to make vaccination services financially sustainable for all provider types.

INTRODUCTION: Vaccination coverage among adults remains low in the United States. Understanding the barriers to provision of adult vaccination is an important step to increasing vaccination coverage and improving public health. To better understand financial factors that may affect practice decisions about adult vaccination, this study sought to understand how costs compared with payments for adult vaccinations in a sample of U.S. physician practices. METHODS: We recruited a convenience sample of 19 practices in nine states. We collected data on the time and material costs of the vaccination work flow using a management survey and a time-motion study. We collected data on payments received for vaccine doses and vaccine administration for different payer types using a finance survey. We received complete cost and payment data from 13 of the 19 practices. We compared payments for vaccines to prices paid for vaccines. We calculated annual net revenue from vaccination services by combining payments received for vaccine doses and vaccine administration with estimated costs. RESULTS: The extent to which vaccine payments exceeded vaccine prices varied by payer type, with per-dose payments from Medicare exceeding prices paid for 5 out of 5 vaccines , from Medicaid for 9 out of 14 vaccines, and from private health plans for 16 out of 21 vaccines. The median annual total net revenue from vaccination services was $90,343 at family medicine practices (range: $3,968 to $249,628), $28,267 at internal medicine practices (−$32,659 to $141,034) and $2,886 at obstetrics and gynecology practices (−$73,451 to $23,820). CONCLUSIONS: Payments received generally exceeded prices paid for most vaccines. Adult vaccination was profitable at the median of our sample, but there is wide variation in profitability due to differences in costs and payment rates across practices. This study provides evidence on the economic viability of adult vaccination that can help inform practices’ decisions whether to provide adult vaccines and contribute to keeping adults up-to-date with the recommended vaccination schedule.

Amid provider reports of financial barriers as an impediment to adult immunization, this study explores the time and costs of vaccination in adult provider practices. Both a Vaccination Time-Motion Study and Vaccine Practice Management Survey were conducted (March – October 2017) in a convenience sample of 19 family medicine (FM), internal medicine (IM), and obstetrician-gynecology (OBGYN) practices, in nine states. Practices were directly observed during a one week period; estimates were collected of time spent on activities that could not be directly observed. Cost estimates were calculated by converting staff time for performed activities. In the time-motion study, FM and IM practices spent similar time conducting vaccination activities (median = 5 min per vaccination), while OBGYN practices spent more time (median = 29 min per vaccination). Combining results from the time-motion study and the practice management survey, the median costs of vaccination remained similar for FM practices and IM practices at $7 and $8 per vaccination, respectively, but was substantially higher for OBGYN practices at $43 per vaccination. Factors that contributed to higher costs among OBGYN practices were the increased time to counsel patients, administer vaccines, and to plan and manage vaccine supplies. In addition, 68% of OBGYN patients who were offered and counseled to receive vaccines declined to receive them. Counseling patients who ultimately do not go on to receive a vaccine may be an important cost factor. Lower costs of vaccination services may be achieved by increasing efficiencies in workflow or the volume of vaccinations.

In the forest offset program, sequestration of carbon from the atmosphere has quite a number of factors that are uncertain or pose a risk. The uncertainty among the different factors can vary by region or by project. The uncertainty can also be reduced using a variety of strategies. The risks may be different under a variety of circumstances and may be reduced by one of several actions.

Calculating forest offset credits under the California Forest Offset Protocol is heavily dependent on data from the U.S. Forest Service (USFS) and on methodologies developed by the USFS. The USFS data include both archived data and continuing data compilations. They include both published and unpublished data. The driving data source for calculating forest offset credits is, in fact, the U.S. Forest Service. The Forest Inventory and Analysis (FIA) program (USDA Forest Service 2016) within the Forest Service, employs a multi-phase inventory of U.S. forest attributes, with each phase contributing to the subsequent phase. To quote from the FIA web site: “The Forest Inventory and Analysis (FIA) Program of the U.S. Forest Service provides the information needed to assess America’s forests. As the Nation’s continuous forest census, our program projects how forests are likely to appear 10 to 50 years from now. This enables us to evaluate whether current forest management practices are sustainable in the long run and to assess whether current policies will allow the next generation to enjoy America’s forests as we do today. FIA reports on status and trends in forest area and location; in the species, size, and health of trees; in total tree growth, mortality, and removals by harvest; in wood production and utilization rates by various products; and in forest land ownership.” USFS historic and continuing data and methods compilations are integral to the calculations in the ARB offset protocol and many are directly linked from the California Air Resources Board web site (California ARB 2015a).

With considerable reliance on somewhat qualitative judgments, estimates, models, and assumed factors, the quality of a forest carbon accounting system can be reviewed by examining the extent to which the processes, procedures, and methods prescribed by the offset protocol adhere to its underlying accounting principles. We can examine the extent to which increased adherence to one principle results in a tradeoff of diminished adherence to another principle, and consider how the implementation of these underlying principles impacts achievement of the offset protocol’s stated objective.

The Forest Offset Protocol lays out the requirements and methods for quantifying the net GHG emission and removals resulting from voluntary project activities undertaken on forested land. The ARB’s compliance offset protocol was built off of the Climate Action Reserve’s Forest Project Protocol Version 3.2 (CAR 2010). The Forest Offset Protocol covers three types of project activities, the carbon pools included in each project type, and requirements for project eligibility, monitoring, and commitments.

There are many ideas presented in this document but here we highlight some of the major points. There is much still to be learned for implementing a forest offset program and what works for one market is likely to be emulated or adapted in other markets. Goldstein and Nayland (2015) note that “there are a few key compliance carbon-pricing policies to watch” and “California represents the most certain source of demand for forest carbon in the next few years.” Challenges that are met can be modified and improved in other markets and in new iterations of existing markets. A key objective is to maintain fungibility among markets and between emissions and offsets (Lee et al. 2013).

Calculation of offset credits requires a chain of measurements, estimates, and modeling exercises. It requires measuring what did happen, estimating what likely happened, and modeling what might have happened. It requires dealing with uncertainty and risk. It differs importantly from conventional inventory processes in that it deals with some things that can be counted and some that cannot. And the California offset program deals with these calculations in a conservative way so that errors are on the side that credits are unlikely to be given for offsets not produced but there are likely to be offsets created for which credit is not given. This section describes the core details of what goes into the calculation process and indicates some of the ancillary data that are required. It does not discuss the physical measurements required to document the amount of carbon actually stored on site in the forest ecosystem as these have been widely discussed and the California requirements are consistent with popularly accepted procedures.