Main Conclusion
 Paper
p provides
p
a very
y informative review of the
comparative effectiveness of different providers of
anesthesia services and clearly demonstrates the
economic advantages of an approach that focuses on
CRNAs
Details of the argument
•
Authors have made the following argument
–
–
CRNAs and anesthesiologists provide similar quality of care
(regardless of the level of supervision for the CRNA)
A CRNA acting alone is…
is
•
the least expensive way to provide the level of care
–
•
–
•
for society and for a private insurer
the most profitable way to provide the level of care
CRNAs are much less costly to train
As a result of these points we should train CRNAs and
allow them to practice in more settings
Key Unanswered Questions
 Why
y do we not seem to have a mix of CRNAs and
anesthesiologists that would reflect allocative
efficiency?
 Not just making the product with the least expensive
resources but having the right mix of products
 What else might need to be done to achieve allocative
efficiency?
Some Methodological
Issues
•
Standardization will help to make research more
understandable and more useful and more recognizable by
policy makers
•
Points
–
–
–
Use of the term “cost-effectiveness”
Importance of elaboration on discounting,
discounting inflation,
inflation and
regression analysis
Importance of sensitivity analyses varying perspective,
quantity of demand for services,
services certainty of demand for
services, settings, and other parameters
Use of the Term CostCostEffectiveness
•
In popular discussions
–
•
In academic discussions
–
–
–
•
the
h term cost-effective
ff i is
i often
f
confused
f d with
i h cost saving
i
if all options yield similar outcomes
outcomes, we can talk about cost
minimization
of cost-effectiveness the results/outcomes/quality of care can vary quite
a bit between and among alternatives.
when cost-effectiveness is used we are most commonly comparing two or
more alternatives with different costs and outcomes and asking whether
the one is less costly and more expensive or whether the one that is more
expensive and more costly is worth the extra cost
This work could be interpreted as a cost minimization study
Elaboration on Discounting
•
Paper mentions that when discounting was applied the costs
i
increased
d by
b 4% but
b t the
th qualitative
lit ti conclusion
l i does
d
nott
change
•
In reality,
reality discounting rarely makes a big difference—
difference
especially over a decade or less
•
Most commonly, discounting is like taking a stream of
payments and translating it from a cash flow to how much
money would be needed at the start and results in cost
reductions.
–
I don’t doubt that what was done is correct but it would be
nice to see details to make sure it matches with expectations
Inflation
•
Paper
p mentions that all costs were inflated to 2008 dollars
•
Adjusting for inflation is always important as decision
makers need to know what things cost today and not when
they were reported in the literature
•
What we need to know is a bit more about the process of
inflation adjustment since the costs of medical education
(and higher education more generally) have generally
increased at a much higher rate than the general consumer
price index
Regression
 The regression
g
is not described in detail
 Differences are reported as percentages
 Thi
This probably
b bl implies
i li taking
t ki a logarithm
l
ith off the
th
dependent variable or using a log-link function but more
p
details would be helpful
 Making assumptions about what an author did can
sometimes result in misinterpretation
Sensitivity Analysis
•
Well done and extremely important
–
–
–
–
–
•
Costs to the
C
h hospital
h i l
Costs to the insurer
Costs to society
Diff
Different
settings
i
Different levels of demand
A few questions
–
–
What about costs to the patient?
Mentions varying parameters by +/-10%
•
•
–
One at a time or all at once?
Why only 10%?
What is meant by least likely to result in negative net revenue?
Final Economic Point
 Referringg to somethingg as inefficient in the context of
pure economic jargon means not being produced at the
lowest cost
 However, cost alone is not all important when we are
y
in which the price
p
does not
workingg with a system
necessarily bear any relationship to the marginal cost
Conclusion
 Economics is an important
p
tool but usingg the standard
economic theory is difficulty in health care
 Jargon is confusing but using it consistently and in
standardized ways will help everyone interested in
performingg and interpreting
p
p
g the results for policy
p
y and
decision making