2nd Conference of the Swiss Society of Health Economics

Session D: Methodological issues / equity in healthcare

Are There Side Effects of Prescription Drug Monitoring Programs?

To curtail prescription drug abuse, US states have implemented electronic Prescription Drug Monitoring Programs (PDMPs). In this paper, we study the direct and indirect effects deriving from the introduction of electronic PDMPs. Our results highlight how supply side restrictions aimed at curtailing prescription drug abuse inadvertendly exacerbated the opioid crisis. Using administrative claims data from the largest commercial insurance association in the US, we find that PDMPs reduce the number of opioid prescriptions, high-dose/long-duration scripts and pharmacies’ order volume of oxycodone and hydrocodone. Prescribers respond only on the extensive margin and do not adjust dosages. However, reductions in prescriptions do not translate into meaningful health improvements. Aggregate mortality is unaffected. We uncover a composition change in both mortality and hospitalizations: Reductions in prescriptions cause drug users to substitute heroin and illicit fentanyl for prescription drugs. This drug substitution causes a surge in heroin overdoses but reduces prescription drug mortality. The changing consumption patterns also affect health care utilization, reducing hospitalizations due to abuse of opioid medication while increasing hospitalizations due to heroin abuse. The most affected demographics are among the middle-aged, white, and commercially insured. The composition change is not cost-neutral: hospitalization costs increase by 3%. Overall, the drug substitution effects are of first-order magnitude and not constrained to the short-run. 

Simone Balestra, University of St. Gallen

Comparing the preferences of people with different levels of education and health literacy with regard to future outpatient healthcare systems - Results of a discrete choice experiment

Educational inequalities in health outcomes are reported in all western countries. Additionally, studies show that educational levels and health literacy are related to different preferences regarding healthcare systems. To address these educational inequalities in health outcomes, it is important to understand the differences in preferences by educational level and health literacy in relation to emerging healthcare models. For this purpose, this study measures the preferences of the Swiss population with regard to future outpatient healthcare and compares the preferences of people with different levels of education and health literacy by means of subgroup analyses.

In a representative online survey with a discrete choice experiment, 3,500 adults in Switzerland will be surveyed. The experiment comprises attributes that are currently under discussion in outpatient healthcare. Additionally, questions on educational background and health literacy (HLS-EU-Q6) will be asked to enable subgroup analyses.

Data from an online pretest with 800 people show preliminary results of a conditional logit regression. Regarding differences in preferences by educational level, people with a lower educational background are less likely to accept new technologies when contacting healthcare professionals, are less willing to make their own decisions about their treatment, and place more emphasis on already knowing the person treating them than people with a higher educational background.

Zora Föhn, University of St. Gallen

COVID-19: When physical distancing becomes impossible. A physical distancing index based on access to essential infrastructure

The effectiveness of governmental regulations of physical distancing to reduce the spread and contain pockets of transmission with coronavirus disease 2019 (COVID-19) and other infectious diseases might be limited in many low- and middle-income (LMICs) countries because of difficulties for their populations to keep enough physical distance to others in day-to-day livelihoods.

We develop a physical distancing index (PDI) for 34 sub-Saharan African countries based on the share of households without access to private toilets, water, space (measured as people per room used for sleeping), transportation and communication technology. We provide high-resolution risk maps (5 x 5 km) based on Bayesian distributional regressions that show which regions are most limited in following current World Health Organization (WHO) guidelines of keeping a minimum of 1-m distance and isolation of sick people.

Our results show that countries with the highest PDI are concentrated in the western part of Africa , whereas the risk of a rapid increase of disease transmission due to a lack of private infrastructure is lower in the southern part of Africa.

Governments and public health specialists should pay particular attention to areas with high PDI, thereby allocating limited resources most cost-effectively. It is essential to address this infrastructure crisis to mitigate negative health outcomes of current COVID-19 pandemic and future epidemics.

Kenneth Harttgen, ETH Zurich

Cream Skimming by Health Care Providers and Inequality in Health Care Access: Evidence from a Randomized Field Experiment

To study whether structural differences in reimbursement rates lead to structural differences in health care system access. Specifically, to study whether outpatient specialists cream-skim the more profitable privately insured patients in the German health care system. Wait times and equity in health care access are standard performance indicators to rate health care systems.

A randomized field experiment for which we selected 36 representative German counties. The same test person called a total of 991 outpatient specialists twice in time intervals of at least two weeks to make appointments for elective medical treatments. The insurance status was randomized between the two calls.

The likelihood to be offered an appointment was a highly significant 7% larger for privately insured patients. Moreover, conditional on being offered an appointment, the wait times for publicly insured patients were more than twice as long, and on average 13 weekdays longer. We also find that access differences are not as pronounced when the reimbursement rate differential is smaller.

Structural differences in reimbursement rates create structural differences in health care access, both on the extensive and the intensive margin. Although our research identifies drivers of structural inequalities in health care access, we deliberately abstain from drawing welfare conclusions.

Nicolas Ziebarth, Cornell University

Timing Matters: The Impact of Response Measures on COVID-19-Related Hospitalization and Death Rates in Germany and Switzerland

We assess the impact of the timing of lockdown measures implemented in Germany and Switzerland on cumulative COVID-19-related hospitalization and death rates. Our analysis exploits the fact that the epidemic was more advanced in some regions than in others when certain lockdown measures came into force, based on measuring health outcomes relative to the region-specific start of the epidemic and comparing outcomes across regions with earlier and later start dates. When estimating the effect of the relative timing of measures, we control for regional characteristics and initial epidemic trends by linear regression (Germany and Switzerland), doubly robust estimation (Germany), or synthetic controls (Switzerland).  We find for both countries that a relatively later exposure to the measures entails higher cumulative hospitalization and death rates on region-specific days after the outbreak of the epidemic, suggesting that an earlier imposition of measures is more effective than a later one. For Germany, we further evaluate curfews (as introduced in a subset of states) based on cross-regional variation.  We do not find any effects of curfews on top of the federally imposed contact restriction that banned groups of more than 2 individuals.

Henrika Langen, University of Fribourg