A reassessment of suicide measurement.

BACKGROUND: Concern with suicide measurement is a positive, albeit relatively recent, development. A concern with "the social loss from suicide" requires careful attention to appropriately measuring the phenomenon. This paper applies two different methods of measuring suicide data: the conventional age-standardized suicide (count) rate; and the alternative rate, the potential years of life lost (PYLL) rate. AIMS: The purpose of applying these two measures is to place suicide in Queensland in a historical and comparative (relative to other causes of death) perspective. METHODS: Both measures are applied to suicide data for Queensland since 1920. These measures are applied also to two "largish" causes of death and two "smaller" causes of death, i.e., circulatory diseases, cancers, motor vehicle accidents, suicide. RESULTS: The two measures generate quite different pictures of suicide in Queensland: Using the PYLL measure, suicide is a quantitatively larger issue than is indicated by the count measure. CONCLUSIONS: The PYLL measure is the more appropriate measure for evaluation exercise of public health prevention strategies. This is because the PYLL measure is weighted by years of life lost and, thus, it incorporates more information than the count measure which implicitly weights each death with a somewhat partial value, viz. unity.

Policy-appropriate measurement of suicide: headcount vs. potential years of life lost, Australia, 1907-2005.

We reconsider conventional suicide measurement. First, a headcount of suicide is examined relative to some other causes of death (circulatory diseases, cancer, and motor vehicle accidents). We then construct a time-series data set of an alternative measure of suicide, the potential years of life lost (PYLL) for males and females. Suicide PYLLs average 4.57% of all male PYLLs and 2.44% of female PYLLs for 1907-2005. The comparable "count" percentages are 1.85 and 0.65, respectively. These differences are widening through time. In 2005, suicide represented 3.25% of all male deaths and 0.90% of female deaths using the count measure and, using PYLLs, 11.0% and 4.96%, respectively. The two measures produce quite different indications of suicide.

The Australian mental health system: An economic overview and some research issues.

This article is concerned with the key economic characteristics of Australia's mental health system. First, some brief conceptual and empirical descriptions are provided of Australia's mental health services, both as a total system, and of its two principal components, viz. public psychiatric institutions and private psychiatry services. Expenditures on public psychiatric hospitals clearly demonstrate the effect of deinstitutionalisation. Data from 1984 on private practice psychiatry indicate that per capita utilisation rates peaked in 1996 and have since fallen. Generally, since 1984 gross fees have not risen. However, for both utilisation and fees, there is evidence (of a statistical kind) that there are significant differences between the states of Australia, in these two variables (utilisation and fees). Emphasis is also placed on the economic incentives that arise from health insurance and the heterogeneous nature of mental illness. The effects of these incentives are regarded as by-products of the health insurance mechanism; and another effect, "unmet need" and "met non-need", is a somewhat unique problem of an informational kind. Discussion of many of these issues concludes on a somewhat negative note, e.g. that no empirical results are available to quantify the particular effect that is discussed. This is a manifestation of the lacunae of economic studies of the mental health sector.

Financial incentives and psychiatric services in Australia: an empirical analysis of three policy changes.

Australia has a national, compulsory and universal health insurance scheme, called Medicare. In 1996 the Government changed the Medicare Benefit Schedule Book in such a way as to create different financial incentives for consumers or producers of out-of-hospital private psychiatric services, once an individual consumer had received 50 such services in a 12-month period. The Australian Government introduced a new Item (319) to cover some special cases that were affected by the policy change. At the same time, the Commonwealth introduced a 'fee-freeze' for all medical services. The purpose of this study is two-fold. First, it is necessary to describe the three policy interventions (the constraints on utilization, the operation of the new Item and the general 'fee-freeze'.) The new Item policy was essentially a mechanism to 'dampen' the effect of the 'constraint' policy, and these two policy changes will be consequently analysed as a single intervention. The second objective is to evaluate the policy intervention in terms of the (stated) Australian purpose of reducing utilization of psychiatric services, and thus reducing financial outlays. Thus, it is important to separate out the different effects of the three policies that were introduced at much the same time in November 1996 and January 1997. The econometric results indicate that the composite policy change (constraining services and the new 319 Item) had a statistically significant effect. The analysis of the Medicare Benefit (in constant prices) indicates that the 'fee-freeze' policy also had a statistically significant effect. This enables separate determination of the several policy changes. In fact, the empirical results indicate that the Commonwealth Government underestimated the 'savings' that would arise from the 'constraint' policy.

Measuring inequality: tools and an illustration.

BACKGROUND: This paper examines an aspect of the problem of measuring inequality in health services. The measures that are commonly applied can be misleading because such measures obscure the difficulty in obtaining a complete ranking of distributions. The nature of the social welfare function underlying these measures is important. The overall object is to demonstrate that varying implications for the welfare of society result from inequality measures. METHOD: Various tools for measuring a distribution are applied to some illustrative data on four distributions about mental health services. Although these data refer to this one aspect of health, the exercise is of broader relevance than mental health. The summary measures of dispersion conventionally used in empirical work are applied to the data here, such as the standard deviation, the coefficient of variation, the relative mean deviation and the Gini coefficient. Other, less commonly used measures also are applied, such as Theil's Index of Entropy, Atkinson's Measure (using two differing assumptions about the inequality aversion parameter). Lorenz curves are also drawn for these distributions. RESULTS: Distributions are shown to have differing rankings (in terms of which is more equal than another), depending on which measure is applied. CONCLUSION: The scope and content of the literature from the past decade about health inequalities and inequities suggest that the economic literature from the past 100 years about inequality and inequity may have been overlooked, generally speaking, in the health inequalities and inequity literature. An understanding of economic theory and economic method, partly introduced in this article, is helpful in analysing health inequality and inequity.

Medicare, fee-for-service subsidies, and market outcomes: a partial description of Australia's health care financing labyrinth.

In Australia, both in-hospital and out-of-hospital services are subsidized via a national, social health insurance scheme, referred to as "Medicare." Revenue for the scheme is raised via general taxation and an earmarked "tax," which is presently 1.5 percent of taxable income. Members are entitled to the subsidized consumption of a broad range of medical practitioner services provided on both an in-hospital and an out-of-hospital basis, in both private and public facilities. Moreover, the range of services subsidized by the Australian scheme is broad, and includes the types of medical care that are available only to those U.S. Medicare patients who have opted for the Supplementary Medical Insurance Program. The purpose of this article is to provide a descriptive account of the Australian Medicare arrangements, particularly those that pertain to private, fee-for-service, medical practice. This article emphasizes the fact that, although the provisions are nationally uniform in application, these arrangements do not give rise to homogeneity of consumer payments and medical practitioner revenue. The article's theme is that, just as the simple terms "Medicare" and "Medicaid" belie the complexity of U.S. social health insurance, the Australian application of the term "Medicare" also describes a health care financing labyrinth.

Substitutability of a process innovation in medical diagnosis: some empirical results.

The health sectors in many countries have been increasing in relative size, and medical innovations have been identified by some as a factor contributing to the rise in health expenditures. This paper begins by reviewing the various approaches that economists have employed to determine the connection, if any, between rising health expenditures and new medical technologies. It is then argued that another way to approach the issue is to determine if innovations have substituted for previously existing technologies. Thus this method cannot be applied to product innovations: it is restricted to process innovations. This procedure is applied to the innovation of fibre optic colonoscopy, a procedure for diagnosing diseases/conditions in the lower gastrointestinal tract. The data relate to private medical practice in Australia which operates on a fee-for-service basis. The empirical results indicate no evidence of substitution of the 'new' for the 'old' technology. Thus, there is some reason to believe that this innovation will have contributed to rising health expenditures for diagnosis of the lower gastrointestinal tract. The paper concludes by considering policy options that could address the issue.

A note on nutrition and economics.

Although the interest of economists in food has a long tradition, mainly from the work of Malthus, it is only since 1945 that a more microeconomic approach has been applied. Recently attention has shifted from food, per se, to nutrition and its role as a determinant of health status. The purpose of this note is to comprehend how nutritional research, and nutritional advice, can be understood in an economic framework. For this purpose the "new" characteristics theory associated with Lancaster is appropriate. Such economic research is relevant to the policy concern of the relative emphasis on curative vs preventive health services.

Health outcome and higher medical qualifications: an economic conception and notes on implementation.

A major policy issue in the health sector is the relationship between the outcomes of a medical procedure provided by differently qualified medical personnel, and in which the medical service supplied by the different groups of providers are differently priced. This problem, which exists in health systems which have providers' remuneration based on either fee-for-service or salaries, has not been explicitly considered by economists. Although this question has been indirectly treated in the economic literature on occupational regulation, and directly in the medical literature on quality assessment, both literatures are deficient in different respects. This paper applies the characteristics theory of consumer demand to the problem. A procedure for establishing the nature of the relationship between levels of qualifications and health outcome in an illustrative case of discrete choice is outlined. It is emphasised that the nature of this relationship must be established empirically. It is shown that in this illustrative situation there are four distinct cases that can arise and that under certain circumstances the analysis of the problem can be appropriately conducted in terms of a single dimension of health status. Different prices for the medical service are introduced and the conditions under which a higher price for a service provided by a medical practitioner with higher qualifications can be justified in terms of consumer welfare are considered. The paper concludes with a discussion of some issues associated with an empirical application of the conceptual framework.

The temporal use of diagnostic tests of the colon: some results for fee-for-service medicine in Australia.

In the context of rising health expenditures it is relevant to consider the behavior of those who, in large part, determine what medical procedures are performed on patients. The purpose of this paper is to describe the utilization of diagnostic tests of the colon in Australia. The study is restricted to private medical practitioners operating on a fee-for-service basis. Diagnosis of the gastrointestinal tract is of some interest because the new technology of fiber optic endoscopy has provided an alternative means of diagnosing diseases or conditions. The results presented here indicate rising per capita utilization rates for both the "new" technology and the "old" techniques of barium enema radiology and sigmoidoscopy. There is no evidence of the "new" technology displacing the "old" in terms of per capita use. The data may be consistent with the hypothesis that process innovations in medicine do not displace alternative products: rather they are "added on" to the existing products.

Cimetidine and ulcer surgery. Some results for Queensland men and women by ulcer type.

Although numerous clinical trials have demonstrated that cimetidine is efficacious in the treatment of peptic ulcer, fewer studies have examined whether cimetidine reduces the need for surgical therapy when it is prescribed in the noncontrolled environment of clinical medicine. This study reports on the surgical experience in the State of Queensland which has an excellent data set for investigating this matter. The results suggest that cimetidine therapy has led to a reduction in the rates of surgical interventions for gastric ulcers, but has had no effect on the rates of surgery for duodenal ulcers. This conclusion holds both for male and for female patients.

Cost-benefit analysis of water fluoridation in Townsville, Australia.

The purpose of this paper is to quantify the economic costs and benefits of water fluoridation in the city of Townsville, Australia. The study has been undertaken in such a way as to overcome the problems associated with hypothetical cohort analysis in the economic analysis of health projects. The method utilised involves analysing the economic effects on the total population subject to water fluoridation, through the systematic disaggregation and valuation of demographic, dental and economic data. The study indicates that significant economic benefits will accrue to the Townsville community through water fluoridation, under a wide range of conditions and assumptions.

A rehabilitation of health outcome in quality assessment.

The purpose of this paper is to outline a conceptual framework for analysing the quality of health care. This framework brings together the dominant notions within the medical literature and an approach taken in economics, specifically, the 'characteristics' or 'wants satisfaction' theory of consumer demand. It is suggested that this 'new' theory of consumer demand can provide an operational definition of the quality of health services. We give an account of how the relationship between patient satisfaction, cost and outcome may be synthesized and we discuss how this synthesis relates to assumptions, in the medical literature, of a relationship between structure, process and outcome factors of the quality of care.