HEALTH ECONOMICS

Health economics lies at the interface of economics and medicine and applies the discipline of economics to the topic of health. There are several reasons why it is important to look at the economics in health.

1. Applications of Health Economics.

A. Effective Utilization of Resources

Health (and most) resources are finite. A choice has to be made about which resource to use for which activity. By choosing to use scarce resources for one activity, the opportunity of using those resources for alternative activities is given up. Economics attempt to provide an information framework for maximizing benefits within available resources while pursuing the objectives of efficiency and equity.

B. Analysing Cost-Effectiveness of Health Expenditure

Health economics provides an application of economic principles to analyse how different economic incentives affect the efficient behavior, policy makers, health administrators, patients and insurers in the delivery of health services. Predominant economic concerns about the health care system have historically revolved around problems of cost

Some of the most useful work in health economics employs only elementary economics concepts but requires detailed knowledge of health technology, health institutions and health service systems..

2. Evolution of Health Economics

The real beginning of health economics, as it is known today, can be traced to Kenneth Arrow who emphasised the importance of uncertainty. It is understood intuitively that medical treatments do not always produce the desired results and hence, the production of health itself involves a substantial amount of uncertainty. Uncertainty also pervades the structure of health insurance. A wide range of regulatory interventions in the health market such as licensure and new drug testing are directly linked to uncertainty.

Health care markets display a collection of unusual economic features that include: (i) the extent of government involvement; (ii) the dominant presence of uncertainty at all levels of health dare, ranging from randomness of an individual’s illnesses to how well medical treatments work and for whom; (iii) the large difference in knowledge between doctors and other providers and their patients, and (iv) Externalities –actions by individuals that impose costs or create benefits for others.

3.Scope of Health Economics

Williams (1987) provided and useful schematic structure of health economics, The four principal topics instrumental in analysis of health care issues are described in Table17.4. However, it is the inter-linkages across and within these topics that make the subject relevant

4. Empirical Fields of Application

A. Market Analysis

This deals with the ways in which markets operative specially in countries where there is substantial dependence on market institutions for the provision of health care insurance and delivery of health care. Even where there are no formal markets, the health care system operates as a kind of quasi-market. For example, contracts between physicians and hospitals, between non-profit public sector agencies and for-profit institutions, and, pseudo-prices (time prices) being paid.

Key issues Money prices, time-prices, waiting lists, time for admission to hospital

B. Micro-economic Appraisal.

This is more specifically evaluative and normative. There is an immense variety of topics, technologies and mechanisms that have been evaluated.

Key issues Cost-effectiveness, cost-benefit, and cost-utility analysis of alternative ways of delivering care at all phases (detection, diagnosis, treatment and aftercare)

C. Planning, Budgeting, Regulation and Monitoring Mechanisms

The need for this arises largely because of the great variety of health care delivery institutions, insurance and reimbursement mechanisms, and the diverse roles played by central and state agencies.

Key Issues Inter-play of budgeting, manpower allocations, regulation, incentive structures.

D. Systems Evaluation

This is concerned with the highest level of evaluation and appraisal across systems countries. The internationally observed differences between technologies, mechanisms, expenditure rates, and the outcomes are phenomena needing explanation but they also raise difficult questions of how best to make comparisons (for what purposes), and how best to infer lessons from one system for another.

Key Issues Inter-regional and international comparisons of performance, financing methods.

5. Application of Economic Analysis in Health Sector

It has been argued that it is unethical to apply economic analysis to the health sector. This argument is based on the reasoning that human life has no price. In reply, it can be pointed out that it may not be universally possible to state what should be the value of life, but that within a given budget one should strive to preserve as many lives, and reduce as much morbidity as possible.

In public health care, in the present context, the issue is not the ethics of behavior, but the ethics of decision-making. A decision is made in an ethical way when the decision-maker views all arguments for and against a decision. Thus, duty to the individual may conflict with the duty to the group and helping more people may conflict with helping those most in need. Health economics can contribute in making an optimal choice on the basis of available data with the application of techniques such as cost-effectiveness analysis of alternate interventions.

6. Limitations of Health Economics

Health economics has made substantial strides in theory and has had immense applications in recent years. However, many unanswered (and as many unasked) questions remain. Health economists are well aware of the limits of economics analysis. There are a number of important variables that are difficult to translate into economic terms; for example, non-monetary costs such as physical discomfort or psychological pain or loss. The contribution of health economics is in informing the consequences of various alternatives rather than in making choices that will always remain essentially value based.

ASSESSMENT OF PSYCHIATRIC DISABILITY AND REHABILITATION NEEDS

As in developing any other treatment, a thorough assessment is the first step in planning rehabilitation.

Use of symptom assessment to choose pharamacological and behavioral methods to decrease symptoms is considered insufficient today. Currently, the mainstay of assessment in rehabilitation psychiatry is the functional assessment. Increasingly focus is being directed towards cognitive and dynamic assessment and on assessment of recovery

Functional assessment is the evaluation of the manner in which people perform in real life situations. The client assessment for strength, interests and goals (CASIG) is one of the commonly used measures for functional assessment. It is administered as a structured interview to assess ten areas:

i. Personal medium term goals and roles.

ii. Quality of life.

Iii. Unacceptable community behaviors

iv. Medication practices.

v. Functional living skills.

vi. Symptoms.

vii. Cognitive functioning.

viii. Quality of treatment.

ix. Spiritual and religious aspects

x. Patient rights.

It is a specific patient-based tool to assess psychiatric disability and recovery. However, it is most useful for outpatients and higher functioning inpatients who are clearly able to articulate realistic goals and whose behavior approximates community standards.

For most patients in log-term residential settings, performance based and observational measures are more appropriate. Maryland Assessment of Social Competence (MASC) is such a structured role play for assessing social skills. Other comprehensive, observational assessments systems with demonstrated utility are Time Sample Behavior Checklist (TSBC), Clinical Frequencies Recording System (CFRS) and Staff Resident Interaction Chronograph (SRIC).

The rationale for cognitive assessment is clear in most MIs including Schizophrenia but most of the traditional assessments are confounded by multiple cognitive processes, are not strongly correlated to theories of cognition, and cannot aid in determin ing the cause of poor performance. Recent measures like Schizophrenia cognition rating scale (SCORS) provides an assessment of patients cognitive functioning based on interviews both with patients and their caregivers. Other useful neuropsychological batteries are Repeatable Battery for the Neuropsychological Assessment of Schizophrenia (RBANS), the brief assessment of cognition in Schizophrenia (BACS), and the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) and Consensus Cognitive Battery (MCCB).

Dynamic assessment is assessment of the learning potential. This is accomplished by incorporating sensitive methods for assessing the ability to improve with instructions

and or practice into the testing conditions. The micro module learning test (MMLT) is a brief brief measure of responsiveness to the three core components involved in skills training-verbal instruction, modeling and role play.

INTERVENTIONS IN REHABILITATION

Psychiatric rehabilitation comprises of two intervention strategies. Individual-centerd strategies are aimed at developing patient skills in interacting with stressful environment while ecological strategies are directed towards developing environmental resources to reduce potential stressors. Those with SMI are likely to need both approaches.

There are, fortunately, numerous interventions available for rehabilitation services. Needless to say, mot all may ne required in a given individual. Further, any particular objective may be achieved by multiple interventions either used at tandem or in combinations. It is important for patients ‘felt-needs’ to be addressed rather than providing prefabricated packages (Nagaswami et al., 1985). Some of these interventions are briefly outlined below

A. Cognitive behavior therapy: Cognitive behavior interventions can be used for a variety of purposes. Irrespective of the diagnosis, it may be used for anxiety management, activity scheduling and assuring treatment compliance (Tarrier, 1992). In addition, it has been used for those with schizophrenia with an intention to help patients re-evaluate their psychotic symptoms including their hallucination and delusions (Fowler et al., 1995). The therapist, working in close alliance with patients, helps to improve their coping ability, rationalize their beliefs and reduce their distressing experiences of anxiety and suspiciousness. Direct confrontation is counterproductive and hence is avoided. Systemic studies have found that cognitive therapies not only reduce targeted symptoms but can also reduce nontargeted symptoms like formal thought disorders (Turkington et al., 2006). These improvements, however, are evident only on intensive intervention and do not appear to benefit in the long term (Tarrier et al., 1999; Tarrier et al., 2000). With regard to treatment adherence, cognitive techniques have shown to improve compliance and reduce risk of relapse (odds ratio 2;1) when compared with supportive therapy (Kemp et al., 1996).

B. Cognitive remediation: Cognitive impairment has been found to be the single most important determinant of functioning in work, social relationships and independent living Cognitive remediation involves the use of various ‘exercises’ to improve different cognitive functions like attention, memory and other executive functions. The technique was originally developed for those with cognitive impairment due to

neurological damage like stroke, head injury or postoperative states. Interventions include attention training, abstraction training, memory training, training using self- talk, errorless training, social cognition exercise and many others. These interventions can be provided programs manually or in a computerized form. Computer programs have also been developed (Cogpack, CogReHab, Captain’s log) that provide these interventions in various combinations and may also include other methods. A recent meta-analysis (McGurk et al., 2007) concludes that cognitive remediation causes robust improvement in cognitive impairment across a variety of programs and patient conditions. Interestingly, other reviews accept that cognitive remediation helps modest improvement in neuropsychological testing (Krabbendam and Aleman, 2003; Twamley et al., 2003) but has no impact on functional outcomes. It appears that practice rather than cognitive remediation accounts for observed improvement (Szoke et al., 2008).

C. Family intervention: Individuals with schizophrenia, where the family expresses high levels of criticism, hostility,or over-involvement are more likely to have frequent relapses compared to people with similar problems but from families that tend to be less expressive with emotions. Psychosocial intervention (family therapy), designed to reduce these levels of expressed emotions within families, have been conducted mostly in the UK. Other interventions include family group-counseling and home-based crisis intervention. Family therapy, in particular single family therapy, has shown to have preventive effects in terms of psychotic relapsed and readmission (Pilling et al., 2002), in addition to benefits in medication compliance

D. Social skills training:. The term ‘skills’ refers to acquired behaviors based on learning experiences (Kopelowicz et al., 2006). Social skills represent constituent behaviors which, when combined in appropriate sequences and used with others in appropriate ways and places, enables an individual to have success in daily living reflected by social competence (Bellack et al., 2004). Social competence can be defined as the ability to achieve legitimate personal goals through interacting with others in all situations: work, school, recreation, shopping, consumer services, medical and mental care, and legal agencies (Knapczyk and Rodes, 2001). Thus, social skills training are heterogeneous interventions aimed at improving activities of daily living, hygiene and grooming, basic communication skills, job-finding, and interpersonal problem solving, i.e. improving social competence.

Social skills and social competence can be viewed as protective factors in the

vulnerability-stress-protective factors model of schizophrenia (Kopelowicz et al., 2009). Strengtheniing social skills and competence of individuals with schizophrenia

can reduce the impact of cognitive deficits, stressful events and social maladjustment. Improved social competence confers protection not only against stress induced relapse but also improves interpersonal support, social affiliation and quality of life (kopelowicz et al., 2006).

Interventions involve simple advice while others require elaborate combination of operant conditioning and social learning models. Steps involved in social skills training are as follows:

1. Problem Identification: made in collaboration with patient by acknowledging ‘barries’ and ‘goals’ of the patient.

2. Goal setting: Short-term, near-approximation goal that patient and therapist find feasible.

3. Behavior rehearsal or role play: Patient demonstrates the verbal, nonverbal and paralinguistic skills required for successful social interaction.

4. Corrective feedback: Required for behavior exhibited in role play.5. Social modeling: Demonstration by the therapist of desired interpersonal behavior

in a form that can be learnt by the observing patient.6. Behavior practice: Facilitate its use in real-life situations.7. Positive social reinforcement: Contingent upon those behavior skills that showed

improvement.8. Homework assignments: To motivate the patient to implement the learned skill in

real-life situations.9. Positive reinforcement and problem solving: To address issues arising in patients

experience due to the use of acquired skills.

The onset of SMI usually occurs before adult social skills are learnt through natural process. This reason, combined with the fact that learning itself may be impaired in SMI (Harvey et al., 2004), skills training takes the form of special education and precision teaching. Hence, repeated practice or overlearning is essential to ensure assimilation and durability of social skills. Learning is facilitated when errors are minimized and correct responses are abundantly reinforced (Kopelowicz et al., 2006). To build up the social skills repertoire of an individual with SMI to a level of fluency, the therapist will have to provide broad range of skills.

Social skills training has now been used for more than three decades in developed nations. Studies on its efficacy in diverse treatment settings (inpatient, outpatient, residential continuum), diverse practitioners (psychiatrist, psychologist, mental health nurse, social worker) and covering a broad range of skills (illness management, smoking cessation, securing and retaining job) have shown gratifying results

(Kopelowicz et al., 2006). In the last decade there has been further refinement in the

delivery of social skills training. Firstly, it is now understood that social skills training is more effective when done in natural environment as opposed to classroom teaching (Glynn et al., 2002). Secondly, evidence is emerging that cognitive remediation potentiates skills training (Vauth et al., 2004). This has lead to integration of social

skills training as an essential element in comprehensive multidimensional programs.

E. Other approaches: Many ecological approaches have been developed with advancement in delivery of community mental health services. Supported housing, i.e. independent housing coupled with the provision of support services, offers flexible and individualized services depending on individual demands (Rog, 2004). Transitional employment, clubhouse and sheltered workshops provide prevocational training that enable competitive employment (Rossler, 2006). Supported employment involves placing an individual in competitive employment as soon as possible and then provide indefinite support to maintain that position (Salyers et al.,2004)