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The Cost of Arterial Hypertension and
its Impact on Health Spending in Mexico
Villarreal Ríos, Enrique; Mathew Quiroz, Alvaro
Instituto Mexicano del Seguro Social, Monterrey, Nuevo León , México
Introduction: Actually the health systems are in the economic dynamic, for this reason inputs, high cost, spending and budget are very important. In this context cardiovascular problems and specially hypertension are very important.
Objective: To determine the hypertension medical care cost and its impact on the health care expenditure and the gross national product of Mexico.
Material and Methods: The study included 4 parts, use of health services, costs, quantity of hypertension and identification of spend in health. A sample of medical charts with hypertension was chosen at random. Utilization of health services was counted
up and the unitary cost per service utilized was estimated. The cost per service and per patient with hypertension was calculated adjusting the unitary cost for the mean utilization of health services and also for an extreme scenario. The figure then was projected to the total population of hypertension patients and compared to the annual health care expenditure of Mexico
Results: In the standard scenario the annual cost per patient with hypertension was $1,067 and $3,913, on an extreme scenario. The annual expenditure of hypertension corresponded to 13.95% of the budget designated for health care at the national level and to 0.71%, of the gross national product of Mexico. These figures are modified to 51.17% and 2.62% on the extreme scenario, respectively.
Discussion: The study included a different moment of the natural history of the hypertension, then, the results apply to all the population of this group.
Conclusions: Hypertension medical care consumes a good deal of resources. This should be analyzed by interdisciplinary health teams in search of more efficient alternatives.
Health care systems are embedded in the dynamics of health care economics. Consequently, resource shortages, high costs and health care budgets become relevant.
With the increase of life expectancy we have observed the emergence of chronic degenerative illnesses demanding extensive health care services. The most outstanding among them are cardiovascular diseases, with high blood pressure at the top of the list. Fifty million cases are reported in the United States (1), while Canada and Mexico have rates of 25% (2) and 26.6% (3), respectively. In 1999, 321,387 new cases (4) were reported in Mexico, which does not include the fact that for each high blood pressure patient diagnosed, there are 1.3 who have not been detected3. Indications also show the annual cost of ambulatory high blood pressure patient care ranges from 57 to 450 dollars (5).
This proves the magnitude of the disease and its impact not only in the area of epidemiology and public health, but the financial consequence specifically in relation to available resources in the health care sector.
The objective of this work was to determine the cost of high blood pressure health care, its impact on the health care budget and on Mexico's GDP.
MATERIAL & METHODS
The methodology utilized included four sections: Intensity of health care service use, unit cost estimate, definition of high blood pressure patient population and identification of health care costs.
FREQUENCY OF HEALTH CARE SERVICE USE
The type and intensity of health care service use (outpatient consultation, hospitalization, laboratory, radiology and other specialized procedures) were identified using the information contained in clinical files. These were selected randomly from five Family Medical Units. Additionally, use of second and third level health care services were analyzed within this group. As the inclusion criterion, cases with reports of high blood pressure and under observation for more than one year were analyzed.
The size of the sample (N = 214) was established by making use of the ratio formula for infinite population, considering .15% or more of the general population has high blood pressure: P = 0.15; Z = 1.64; d = .04.
UNIT COST ESTIMATE
To estimate the cost of medical care, a Family Medical Unit and a General Hospital were chosen, estimating unit health care costs at each by using the per capita budget model(6). To estimate unit fixed costs, this model identified general and final services, and considered each of the following assets: Material resources (land & building); physical resources (furniture, equipment & instruments); human resources (managers, secretaries, physicians, nurses and assistant personnel); basic utilities (power, water, gas, telephone); and office supplies.
The expense of general services assigned to final services was identified by statistical information. This expense, in addition to the final service itself, is adjusted for productivity of the analyzed service, in the order defined by the fixed unit costs. The variable unit cost for each service was determined by identifying the average consumption of input (medication and cleansing materials) for a typical case as defined by experts in each field of study.
The sum of the unit fixed cost and the unit
variable cost became the unit cost per reason for service demand.
Taking the Social Security cost as a basis, costs were estimated for the open population serviced by the State and population serviced by Private Medical Institutions.
POPULATION OF HIGH BLOOD PRESSURE PATIENTS
To define the total of high blood pressure patients in the country, Chronic Disease National Survey (3) criteria were used, showing prevailing high blood pressure among individuals older than 20 in Mexico (27.9% in the North, 26.9% in the South and 23.8% in Mexico City). This information was compared with the entire population of the Mexican Republic (94,962,160) (7).
To define the amount of population per type of institution providing the medical service, the information used was that of the Mexican Health Services market structure8, 54% for Social Security, 27% for Open Population serviced by the State and 19% for Private Medical Institutions.
EXPENSE IN HEALTH CARE
To identify the health care expense and the GDP, information from the National Health Accounts (9) was used This information indicated $128,706 and $2'523,648 million pesos were spent respectively, for 1996.
Two scenarios were compared for use of health care services. The first was based on average use. The second, classified as an extreme scenario, included the average amount and the standard deviation. Within each scenario, total costs per care level and institution were estimated and adjusted to the amount of population serviced. The appropriate amount represented the total cost of high blood pressure health care. To conclude, this was compared with the total budget allocated to health care and the GDP.
Family Medicine was the most utilized service, with 8.43 consultations per year on average per high blood pressure patient, ± 2.96; glycemia was the most popular test at the first level of care, averaging 1.16, ± 1.69; and 0.372 ± 0.53 thorax X-ray tests were taken per patient. shows the annual average use per service and its corresponding value in the extreme scenario.
|Table 1a,b,c: Unitary cost, utilization and annual cost per patient and Institution. Family Medicine|
The number of cardiology consultations was 0.172 ± 0.59; with average hospital stays of second level service at 0.014 ± 0.205 bed-days per year per high blood pressure patient, while third level was 0.163 ± 1.194. The remaining services utilized and their use per patient are shown in.
|Table 2a,b,c: Unitary cost, utilization and annual cost per patient and Institution. Second level|
The highest unit cost in Social Security was due to: cardiac catheter use at $3,362; the bed-day in third level cardiology (highest specialty) and second level at $1,249 and $917, respectively; and specialty outpatient consultations amounting to $111.and show the unit cost for the remaining utilized services.
|Table 3a,b,c: Unitary cost, utilization and annual cost per patient and Institution. Third level|
The average scenario shows the most costly service per high blood pressure patient per year was Family Medicine, with $1,554, followed by the bed-day in third level cardiology (highly specialized) for $547. This service was also the most expensive in the extreme scenario for $4,557. The annual cost per service per type of Institution is shown on
In Social Security, the annual cost of health care for the high blood pressure patient in the average scenario was $1,064; $699 in State Institutions and $2,860 in Private Medical Institutions. These numbers changed in the extreme scenario to $3,878; $2,497 and $10,424, respectively, per Institution indicated.shows the cost per level of service and scenario.
|Table 4a,b: Annual cost per patient and total number of patients, adjusted per institution, by scenarios.|
The total cost of high blood pressure in Mexico for the average scenario is $17.903 billion, according to an estimated high blood pressure patient population of 13'704,573 (14.43 prevailing per 100 individuals). For the extreme scenario, the cost changed to $65.081 billion pesos.shows the percentage of health care budget and appropriate GDP for the two proposed scenarios.
|Table 5: Total spend in hypertension, percent of the spend in health and in PIB per scenarios.|
According to our research the most utilized service was Family Medicine. This is a logical conclusion considering this service is responsible for the primary control of the high blood pressure population. However, upon comparing the average number of consultations per high blood pressure patient per year in Family Medicine, we found it higher than that reported for the population in general (2.60). Contrary to this, the average number of hospital days per high blood pressure patient was lower than the number for the population in general (0.39 hospitalization days per user)(10).
With respect to the laboratory, one possible explanation for the high number of glycemia tests performed is the presence of diabetes mellitus as a concomitant disease. But discussion here must be directed to clarify whether it is necessary to consider this type of test part of the set of examinations utilized by the high blood pressure patient.
Conversely, more specific tests for high blood pressure patient assessment such as the thorax X-ray and electrocardiogram reported lower utilization, not quite one test per patient per year on average. Health care providers could interpret this as an inadequate utilization of health care services.
The analysis of unit cost per service reported a low number for Family Medicine consultations. However, its high utilization renders it as consuming the most resources. In contrast, despite the unit cost of third level service as the highest, this prevailing rate did not show up when conducting the analysis of cost per service used per high blood pressure patient. For this specific case, its utilization was low and consequently, so was the average cost per high blood pressure patient. This same pattern is evident in the second level of health care.
In Mexico, as reported by Hernández & col.(9), the health care budget per capita for the population in general is $1,390, a number higher than budgeted for high blood pressure patient in the average scenario for Social Security and State Institutions. But if its high prevailing rate and chronic nature is considered, then servicing this health care need must be associated with a high consumption of resources.
Declaring the annual average cost of health care for the high blood pressure patient in Social Security amounts to $1,064 may generate criticism and disqualification of what is herein presented. This criticism may be utilized with the appropriate information to Open Population Institutions. However, using this number on the entire high blood pressure patient population and conducting the analysis based on the percentage allotted to Health and the GDP is cause for concern. The result of this comparison becomes more dramatic when evaluating the extreme scenario, orienting criticism toward the fact that there will be no budget deep enough to solve the health care needs of the population. Thus the importance of the rational use of resources assigned to Health Care Systems.
1 National Health and Nutrition Examination Survey III, 1988-91 CDS/NCHS.
2 Joffres, MR. "Awarness, treatment and control of hypertension in Canada" Amer JJ Hypertens, 1997; 10:1097-102.
3 Encuesta Nacional de Enfermedades Crónicas. Secretaría de Salud. Tercera Edición, México D.F. 1996.
4 Sistema Único de Información. Epidemiología. Sistema Nacional de Vigilancia Epidemiológica. Número 52, Vol 16, Semana 52, del 26 de diciembre de 1999 al 1 de enero del 2000.
5 Calvo VC, "Nuevos retos del control de la hipertensión arterial". Revista Medica del IMSS, 1998; 36(3)199-201.
6 Villarreal Ríos E., Cavazos Galván RH., Garza Elizondo ME., Guzmán Padilla JE., Montalvo Almaguer G., Salinas Martínez AM., Tovar Castillo NH. Estimación de costos en salud: Una propuesta metodológica. "Modelo de presupuesto capitado" Instituto Mexicano del Seguro Social, Dirección Regional Norte, Coordinación Regional de Comunicación Social. México, D.F. 1997
7 Secretaría de Salud. Boletín de Información Estadística. Recursos y Servicios, Nº 16, vol 1. Sistema Nacional de Salud. México 1996.
8 Villarreal Ríos E, Salinas Martínez A, Garza Elizondo ME, Nuñez Rocha GM, Estructura del Mercado de los Servicios de Salud en México, Revista Médica del IMSS 2000, 38(5): 365-369.
9 Hernández P., Zurita B., Ramírez R., Álvarez F., Cruz C. Las cuentas nacionales de salud. 1995. Fundación Mexicana para la Salud (FUNSALUD), México, D. F. 1997.
10 Instituto Mexicano del Seguro Social. Compendio estadístico anual de oferta y demanda, servicios médicos otorgados y morbi-mortalidad en Nuevo León. Coordinación Delegacional de Informática Médica. Jefatura Delegacional de Prestaciones Médicas. Delegación Regional Nuevo León. Instituto Mexicano del Seguro Social. Monterrey, N.L. 1998.
11 McMurray J., The health economics of the treatment of hyperlipidemia and hypertension. Am J Hypertens 1999, (12) 99-104.
12 Shepard D., Hodgkin D. Cost effectiveness of intensive treatment of hypertension. AM J Manag Care 1998, 765-769
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