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Other Patient-Level Economic Outcomes


... (African American, Chinese, Filipino, Latino, and white) and four languages ... Forward and back translation into non-English languages. WTP Question ... – PowerPoint PPT presentation

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Title: Other Patient-Level Economic Outcomes

Other Patient-Level Economic Outcomes
  • Todd Wagner, PhD
  • August 8th, 2007

Outline of Talk
  • Willingness to pay
  • Employment and (lost) productivity

Economic Theory
  • A persons happiness is dependent on
  • her consumption of non-health goods (X)
  • her health (H)
  • where consumption is limited by income and time
  • Without mammogram V(Y,Px,H)
  • Getting a mammogram costs time and money
  • Trade off for a mammogram -- WTP
  • V(Y,Px,H) V(Y-WTPmam,Px,H)

Revealed Preferences
  • Analyses of consumption data provide information
    on revealed preferences
  • For example, consumers show a preference for
    iPods over other MP3 players
  • Economists can use this information to estimate
    social welfare in a cost-benefit analysis

Contingent Valuation
  • Hard to observe revealed preferences in health
    care because of market distortions.
  • Exceptions for travel costs
  • Clarke, P. M. (1998). JHE, 17(6), 767-787.
  • Kessler, D. (2005) NBER Working Paper 11419
  • If preferences are not observable, perhaps they
    can they be elicited
  • Contingent valuation

Willingness to Pay
  • WTPcv can be used as an alternative to utility
    and QALYs
  • Hereafter I use WTP to refer to WTPcv
  • WTP can be used in a cost-benefit analysis or as
    preference measure

  • What would I be willing to pay to avoid x or
    gain y?
  • Academic research roots in environmental
  • Also used in marketing

Benefits of WTP
  • People understand the concept
  • Explicit tradeoff
  • Adheres to neoclassical economic theory
  • Many people pay for health care
  • Dollar an easy to understand unit as opposed to
  • May be responsive to small effect not detected
    with utilities

Drawbacks of WTP
  • Insurance obscures charges and reduces risk
  • Correlation with income makes many practitioners
  • Validity is extremely dependent on framing of
    question and response scale
  • Vulnerable to social desirability
  • No limit on willing to pay
  • Never willing to pay

What to Ask
  • User based ex-post vs. insurance based ex-ante
  • Who pays public versus private
  • Results certainty or uncertain
  • Framing
  • Realism of task
  • Extent of description

Who to Ask
  • Everybody that could potentially benefit
  • Only those that directly benefit

Mode of Administration
  • In person interviewing
  • can positively bias responses through social
  • Allows for probes and potentially greater
  • Paper and web surveys
  • May avoid social desirability
  • Any confusion may not be resolved

Response Categories
  • Preferred
  • Payment cards/scales
  • Maximum amount is WTP
  • This method biases estimates of variation
  • Dichotomous response
  • Randomly assign price, person asked yes or no
  • Requires large sample
  • WTP is estimated in a maximum likelihood logit
  • Avoid
  • Open ended
  • Bidding games
  • NOAA. (1992). Report of the National Oceanic and
    Atmospheric Administration. Federal Registry,
    58(10), 4601-4614.

Question Development
  • WTP question must be tailored for each study
  • No standard WTP question
  • Pre-testing is highly recommended
  • Dillman method
  • Modify the question
  • Identify the response scale range
  • Assess validity
  • Correleted with income
  • Scope WTP should vary by scope of benefits
  • Dillman, D. (2000). Mail and Internet Surveys
    The Tailored Design Method (Second ed.). New
    York John
  • Wiley and Sons, Inc.

  • Pathfinders NCI funded behavioral intervention
    that sought to improve cancer screening among
    ethnically diverse women in the SF. Bay Area.

Focus Groups
  • Conducted focus groups and individual interviews
    with low income women representing five race /
    ethnic groups (African American, Chinese,
    Filipino, Latino, and white) and four languages
    (English, Chinese, Spanish and Tagalog).
  • Focus group facilitators were women of
    approximately the same age and same
  • All focus groups were tape recorded with consent

Question Development
  • Discussed use of mammography, paying for health
  • Showed example WTP questions and had them discuss
  • Identified range of WTP responses
  • Forward and back translation into non-English

WTP Question
  • The next questions ask how important you think
    mammograms are. I am going to ask how much you
    would be willing to pay to get a mammogram.
    Please be assured that answering these questions
    will not increase the cost of any medical
    services. Your answer simply tells us what the
    mammogram is worth to you in dollars. Okay, here
    are the questions.
  • 1. Many women get mammograms free of charge. But
    suppose that there was no way to get a free
    mammogram. Would you get a mammogram if it cost
  • (PROBE) Considering what you can afford right
    now, would you be willing to pay 75 for a

Question Validation
  • The validity was tested with a random sample of
    52 low-income, ethnically diverse women in the
    San Francisco area.
  • Internal validity correlation with income
  • Construct validity correlation with past

Wagner, T. H., Hu, T.-w., Dueñas, G. V.,
Pasick, R. J. (2000). Willingness to pay for
mammography item development and testing among
five ethnic groups. Health Policy, 53(2), 105-121.
Pathfinders Intervention
  • Enrolled 1463 women
  • Collected baseline data, including WTP
  • Randomized to educational intervention and
    control (usual care)
  • 24 month follow-up

Baseline data
  • 1419 respondents as of early-April 2000

final ethnicity Freq.
Percent -----------------------------------------
----- Black/African American 499
35.17 Chinese 181
12.76 Filipina 142
10.01 Latina 297
20.93 White 300
21.14 -------------------------------------------
--- Total 1419
Wagner, T. H., Hu, T.-w., Dueñas, G. V., Kaplan,
C. P., Pasick, R. J., Nguyen, B. H. (2001).
Does willingness to pay vary by race/ethnicity?
An analysis of mammography among low-income
women. Health Policy, 58, 275-288.
Sample Characteristics
  • Survey in English 996 (70)
  • 39 of sample was foreign born
  • Proportion of life in US
  • Black/African American 0.99
  • Chinese 0.33
  • Filipina 0.40
  • Latina 0.52
  • White 0.97

Baseline characteristics (cont.)
  • 1.14 had never heard of mammogram
  • 87 had a mammogram in their lifetime
  • 83 had mammogram in last 5 years
  • Stages of change
  • precontemplation 5
  • contemplation 30
  • action 12
  • maintenance 38
  • relapse 14

  • Average WTP 131 (SD 92 Range 0-500)

WTP by stages of change
Mother, daughter or sister with breast cancer
Thistles and Thorns
  • Refused to answer 4 (0.3)
  • Dont know 26 (1.8)
  • No limit 95 (6.7)
  • Pay nothing 55 (3.9)

  • Cost benefit analysis compares costs to monetized
  • CEA exists because people prefer QALYs over
    monetized benefits
  • WTP is a measure of monetized benefits
  • Net benefitWTP-Costs
  • Objective function net benefit gt0

Employment Outcomes
  • Employment outcomes are typically excluded from a
    CEA because these effects are included in the
    denominator (QALYs).
  • However, employment may be an important outcome
    in its own right or
  • CEA may be using another outcome that does not
    reflect employment (e.g., mortality)

Typical (Bad) Questions
  • Are you currently working at a paying job?
  • ? Full time
  • ? Part time
  • ? Not working
  • Please check one of the following
  • ? working full time
  • ? working part time
  • ? homemaker
  • ? student
  • ? unemployed
  • ? retired

BLS on Being Employed
  • Persons 16 years and over in the civilian
    noninstitutional population who, during the
    reference week, (a) did any work at all (at least
    1 hour) as paid employees worked in their own
    business, profession, or on their own farm, or
    worked 15 hours or more as unpaid workers in an
    enterprise operated by a member of the family
    and (b) all those who were not working but who
    had jobs or businesses from which they were
    temporarily absent because of vacation, illness,
    bad weather, childcare problems, maternity or
    paternity leave, labor-management dispute, job
    training, or other family or personal reasons,
    whether or not they were paid for the time off or
    were seeking other jobs. Excluded are persons
    whose only activity consisted of work around
    their own house (painting, repairing, or own home
    housework) or volunteer work for religious,
    charitable, and other organizations.

  • Persons aged 16 years and older who had no
    employment during the reference week, were
    available for work, except for temporary illness,
    and had made specific efforts to find employment
    sometime during the 4-week period ending with the
    reference week. Persons who were waiting to be
    recalled to a job from which they had been laid
    off need not have been looking for work to be
    classified as unemployed.

Out of Labor Force
  • People who are not employed and not actively

Class Exercise
  • For employment status, how does BLS classify
  • military personnel
  • veterans
  • prison inmates

Measuring Employment
  • Paid employment
  • Employer (self or company)
  • Hours of employment
  • Productivity / lost productivity
  • Absenteeism / presenteeism
  • Income / assets
  • Occupation (typically of little value)

Employment Matters
  • Diseases can affect overall employment
  • Depression
  • Arthritis
  • Stroke
  • Back pain
  • Diseases can affect willingness to start own
  • Depression

  • Many illnesses can affect productivity and
  • Migraine
  • Incontinence
  • Ulcers
  • Depression
  • Substance Use
  • Back pain

  • No gold standard exists for employment, assets,
    and income
  • Many people use questions from national surveys
  • PSID (Panel Study of Income Dynamics)
  • AHEAD (Asset and Health Dynamics Among the Oldest
  • HRS (Health and Retirement Survey)
  • Bureau of Labor Statistics (www.bls.gov/ers/home.h
  • Two measures of lost productivity

Example of Tailored Questions
  • Partners in Care (depression)
  • http//www.rand.org/health/projects/pic/measures/t
  • 23 pages of detailed questions on assets, income,
    wealth for respondent and family.
  • Based on Health and Retirement Survey.

Heath and Work Performance Questionnaire (HPQ)
  • http//www.hcp.med.harvard.edu/hpq/
  • How many hours does your employer expect you to
    work in a typical 7-day week?
  • In the past 4 weeks (28 days), how many days did
  • ...miss an entire work day because of problems
    with your physical or mental health?
  • ...miss part of a work day because of problems
    with your physical or mental health? (Please
    include only days missed for your own health, not
    someone elses health.)

Work and Health Interview
  • In the past 4 weeks, how many hours per week, on
    average, did you work? ______________ of
  • In the past 4 weeks, how many total, full days of
    work did you miss for health reasons? These would
    be days you did not go to work at
    all. ______________ days
  • For a number of reasons (illnesses, poor
    concentration, fatigue) people are not as
    productive as they can be at work all the time.
    In the past 4 weeks, how many hours per week, on
    average, were you not productive?
  • ______________ of hours
  • Note wording from earlier version and it may
    have changed
  • Stewart et al. Lost Productive Time Due to Common
    Pain JAMA 2003

Barriers to Measuring Employment
  • People who receive public benefits face a
    disincentive to work
  • Income from work must outweigh benefits
  • Incentives to work under the table
  • Incentives to bill years work in a month or two
  • These perverse incentives lead Congress to
    enact the 1996 welfare reforms
  • Veterans who receive means-tested public benefits
    also face a disincentive

Other Problems
  • For an outcome measure, avoid using labeled
    categories (e.g., full time or part time)
  • Measure hours of work
  • Other issues to consider
  • Unions
  • Worksite health programs
  • Childcare
  • Health of family members
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