Esta dissertação é composta por dois ensaios sobre economia da saúde. O primeiro ensaio tem como objetivo analisar o ambiente regulatório no mercado de medicamentos para doenças raras. Essas doenças são caracterizadas por afetar um pequeno número de indivíduos em uma determinada população e por serem crônicas, progressivas, degenerativas, 80% são de origem genética, 50% afetam as crianças, das quais 30% morrem antes dos 5 anos de idade. Elas representam risco de morte e um custo socioeconômico alto para o paciente e sua família. Devido à raridade, a indústria farmacêutica tem não demonstra interesse em desenvolver novos medicamentos órfãos. Apesar de individualmente raras, estima-se que o número de casos de alcançar 420 a 560 milhões de pessoas. Para a referida análise foi utilizado o modelo econômico desenvolvido por DeBrock (1985), que consiste na determinação simultânea de esforço de inovação e extensão de patentes, estabelecendo a trajetória ótima de proteção como resultado de um jogo não cooperativo entre o regulador e a empresa inovadora. Foram identificados individualmente os principais incentivos e instrumentos de regulação econômica. Eles são compostos por assistência à protocolos, procedimento centralizado de análise, reduções de taxas, o acesso de pesquisa financiado e exclusividade de mercado. Conclui-se que o instrumento regulatório mais importante foi a exclusividade de mercado, pois garante lucros extraordinários para a empresa inovadora, tornando o desenvolvimento de novas drogas tornou-se economicamente viável. No entanto, ressalta-se que todos os mecanismos tem um papel importante no sistema de incentivos e que cada um deles deve ser considerado para o desenvolvimento de políticas públicas para doenças raras. O segundo ensaio tem como objetivo medir o impacto do Diabete Melito nos rendimentos dos trabalhadores brasileiros no ano de 2008. Essa doença é caracterizada pelo elevado nível de glicose no sangue, problema que pode desencadear desencadeia má cicatrização, ataque cardíaco, acidente vascular cerebral, insuficiência renal, problemas de visão e amputação de membros. Dados do Ministério da Saúde indicam que, no Brasil, em 2010, havia cerca de 10 milhões de casos da doença, sendo a quarta principal causa de morte no país. Dados da WHO estimam que a prevalência da doença no Brasil é de 10,2% da população, cerca de 20 milhões de pessoas. A hipótese a ser testada é que o estado de saúde interfere nos rendimentos por meio de três mecanismos distintos: (i) na decisão de participar no mercado de trabalho, mensurado por meio de um Probit binário, (ii) na quantidade de horas trabalhadas e (iii) a produtividade por hora, ambos mensurados por meio do método de dois estágios de Heckman. Cada modelo é estimado separadamente para indivíduos com e sem doenças, sendo tomada a diferença do valor esperado de ambos para capturar o efeito contrafactual. Os resultados obtidos indicaram a existência de perdas progressivas, que incidem com maior intensidade entre a população feminina e que, no agregado, podem chegar ao valor de R$ 8.064.408.441.99 (USD 3.450.709.518,02 e EUR 2.490.436.905,56), correspondendo a cerca de 0,54% dos rendimentos totais e 0,20% do PIB do referido ano. Concluiu-se que o Diabete Melito gera perdas significativas na renda dos trabalhadores brasileiros, especialmente em relação à sua participação no mercado de trabalho. Os resultados indicam que as políticas públicas devem ser direcionadas para a prevenção da doença, uma vez que o desenvolvimento de comorbidades amplifica o efeito de perdas. Por fim, visando a manter a inter-relação entre os temas e a estabelecer a unidade do trabalho, foram abordadas na última seção as conclusões a respeito da dissertação. / This dissertation consists of two essays on health economics. The aim of the first essay is to analyze the regulatory environment for medicinal products for rare diseases. These diseases are characterized by to affect a small number of individuals in a given population and to be chronic, progressive, degenerative, 80% are genetic in origin, 50% affect children, of which 30% die before the age of 5. They represent death risk and a high socioeconomic cost to the patient and his family. Due to the rarity, pharmaceutical industry has not shown interest in developing new orphan drugs. Although individually rare, estimatives show that the number of cases to reach 420 million to 560 million people. For this analysis the economic model developed by DeBrock (1985), which consists of the simultaneous determination of innovation effort and extension of patents, establishing the optimal path protection as a result of a non-cooperative game between the regulator and the innovator was used. The main incentives and instruments of economic regulation were individually identified. They are protocols assistance, centralized analysis procedure, fee reductions, access to funded research and market exclusivity. We conclude that the most important regulatory tool was market exclusivity, because it ensures extraordinary profits for the innovator, making the development of new drugs become economically viable. However, it is noteworthy that all the mechanisms have an important role in the incentive system and that each of them should be considered for the development of public policies for rare diseases. The second essay aims to measure the impact of diabetes mellitus on the income of Brazilian workers in 2008. The main disease characteristic is high blood glucose, a problem that can trigger scarring troubles, heart attack, stroke, failure kidney, vision problems and limbs amputation. Ministry of Health data indicate that, in Brazil, in 2010, there were about 10 million cases of the disease, making it the fourth leading cause of death in the country. WHO data estimate that the disease prevalence is 10.2% of the Brazilian population, about 20 million people. The hypothesis to be tested is that the health status interfere in worker income through three distinct mechanisms: (i) in the decision to participate in the labor market, measured by means of a binary Probit, (ii) in the amount of hours worked and (iii) in the productivity per hour, both measured by the Heckman two-stage method. Each model is estimated separately for individuals with and without disease, and taking the difference of the expected value of both to capture the counterfactual effect. The results indicated the existence of progressive losses, which focus more strongly among women and that, in the aggregate, may reach R$ 8.064.408.441.99 (3,450,709,518.02 USD and EUR 2,490,436,905, 56), corresponding to about 0.54% of the total income and 0.20% of GDP in that year. It was concluded that diabetes mellitus causes significant losses in Brazilian workers income, especially in relation to their participation in the labor market. The results indicate that public policies should be directed to the prevention of disease, since the development of comorbidities amplifies the losses effect. Finally, to keep the inter-relationship between the issues and to establish the unity of the work, have been addressed in the last section the conclusions regarding the dissertation.

No presente estudo realizou-se a análise custo-efetividade das terapias antineoplásicas IFL (irinotecano, 5-fluorouracil e leucovorin) e IFL+BV (IFL associado ao bevacizumabe) empregado no tratamento do câncer colorretal metastático em primeira linha. Estimou o custo direto de medicamentos, materiais e recursos humanos. A efetividade dos protocolos foi medida pela proporção de pacientes livre de progressão de doença. Os dados relativos aos custos de materiais e medicamentos foram obtidos a partir de tabelas de preços que regulamentam o mercado hospitalar. Os dados concernentes à efetividade foram obtidos através da literatura científica. Utilizou-se o modelo de análise de decisão para estimar o custo total da terapia antineoplásica. Os resultados mostraram que o protocolo IFL apresentou a melhor relação custo-efetividade durante todo o tempo de seguimento, ou seja, o menor custo por unidade de efetividade, que no 10º mês foi de R$ 180.619,46. A análise de sensibilidade mostrou que esta conclusão foi robusta. Essas análises farmacoeconômicas apontaram que a seleção do protocolo antineoplásico depende do custo e efetividade, mas, sobretudo da relação custo-efetividade que permite saber o custo estimado por unidade de sucesso. / In this paper a cost–effectiveness analyses was done of the antineoplasics therapies IFL (irinotecan, 5- fluorouracil and leucovorin) and IFL + BV (IFL associated to bevacizumab) used as metastatic colorectal cancer as first line treatment. It has estimated the cost of medications, materials and human resources. The effectiveness of the protocols was measured through the proportion of patients that were free from the illness progression. Data regarding material cost and medication were obtained by price tables that regulate Hospital market. Data relating to effectiveness were obtained through scientific literature. We utilized the decision analysis model to estimate the total cost of the antineoplasics therapy. The results showed that the IFL protocol presented a better cost–effectiveness relationship during the whole period following, that is, the lowest cost per effectiveness units, that on the 10th Month was R$ 180.619,46. The sensitivity analysis showed that this conclusion was strong. These pharmacoeconomic analyses pointed to the fact that antineoplasics protocol selection depends on cost and effectiveness, but, above all on the cost–effectiveness relation which allows us to know the estimated cost per successful unit.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-07-15T13:31:10Z No. of bitstreams: 1 glauciaposasdamotta.pdf: 1127197 bytes, checksum: 4839d7d88ea8408f7ff1e8c962c5e174 (MD5) / Approved for entry into archive by Diamantino Mayra (mayra.diamantino@ufjf.edu.br) on 2016-07-19T15:53:24Z (GMT) No. of bitstreams: 1 glauciaposasdamotta.pdf: 1127197 bytes, checksum: 4839d7d88ea8408f7ff1e8c962c5e174 (MD5) / Made available in DSpace on 2016-07-19T15:53:24Z (GMT). No. of bitstreams: 1 glauciaposasdamotta.pdf: 1127197 bytes, checksum: 4839d7d88ea8408f7ff1e8c962c5e174 (MD5) Previous issue date: 2011-12-14 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / A população brasileira vem sofrendo, nas últimas décadas, transições decorrentes de mudanças nos níveis de mortalidade e fecundidade, o que pode ser atribuído a melhorias nas condições de vida, devido a avanços econômicos, ambientais, assim como na saúde pública e medicina. Uma das implicações desse processo é o aumento da expectativa de vida, que reflete diretamente no padrão de consumo dos indivíduos. Neste contexto, a presente dissertação teve por objetivo principal analisar o impacto de alterações nas preferências das famílias em direção a bens e serviços de saúde, e consequentemente, do consumo desses bens e serviços sobre a produção setorial, indicadores macroeconômicos, como PIB, Emprego, Saldo Comercial Externo, Investimento e Bem Estar, diante desse novo cenário de transição demográfica. Para tanto, utilizou-se um modelo de Equilíbrio Geral Computável, calibrado com dados da Matriz Insumo-Produto para o Brasil e das Contas Nacionais em Saúde, relativos ao ano de 2005. Destacam-se os seguintes resultados: i) para sustentar o aumento do consumo de bens saúde, o PIB deve ser mais elevado em relação ao cenário base; ii) para consumir mais saúde os agentes reduziriam o consumo de todos os outros tipos de produtos; e iii) a análise de bem estar para a saúde mostra que mudanças das preferências e dos preços em direção a esses bens implicam em uma elevação na renda para compensar o consumidor pelas variações de preços, ou seja, ele precisará de uma renda mais elevada para consumir mais saúde. / The Brazilian population has suffered in recent decades transitions arising from changes in levels of mortality and fertility, which can be attributed to improvements in living conditions, due to advances in economic, environmental, and public health and medicine. One implication of this process is the increase in life expectancy, which directly reflects the consumption pattern of individuals. In this context, the present work was aimed at analyzing the impact of changes in household preferences toward goods and health services, and consequently the consumption of these goods and services on the production sector, macroeconomic indicators such as GDP, employment, Trade Balance, Investment and Welfare, before this new scenario of demographic transition. For this purpose we used a Computable General Equilibrium Model, calibrated with data from the Input-Output Matrix for Brazil and the National Health Accounts, for the year 2005. We highlight the following results: i) to support the increased consumption of healthgoods, GDP should be higher compared to the baseline scenario, ii) to consume more health, agents reduce the consumption of all other types of products; and iii) the analysis of well-being to health shows that changes in prices and preferences toward these assets imply a rise in income to compensate the consumer for price changes, i.e.. it needs a higher income for consume more health.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-09-26T18:15:53Z No. of bitstreams: 1 grazielaliebel.pdf: 1243606 bytes, checksum: e56da84b10382a3266b42bdc42faa2e2 (MD5) / Approved for entry into archive by Diamantino Mayra (mayra.diamantino@ufjf.edu.br) on 2016-09-26T20:17:33Z (GMT) No. of bitstreams: 1 grazielaliebel.pdf: 1243606 bytes, checksum: e56da84b10382a3266b42bdc42faa2e2 (MD5) / Made available in DSpace on 2016-09-26T20:17:33Z (GMT). No. of bitstreams: 1 grazielaliebel.pdf: 1243606 bytes, checksum: e56da84b10382a3266b42bdc42faa2e2 (MD5) Previous issue date: 2016-03-29 / FAPEMIG - Fundação de Amparo à Pesquisa do Estado de Minas Gerais / Com a criação e instituição do Sistema Único de Saúde a insuficiência de recursos, bem como a ineficiência e a ineficácia de sua utilização, tem estado em debate constantemente. Sendo evidente a fragilidade do financiamento, pois condiciona muitas vezes a eficiência esperada do sistema. Dentro do atual modelo de gestão do SUS existem os níveis de assistência, os quais devem estar ajustados hierarquicamente, descentralizados e regionalizados para melhor atender as demandas da população. Neste sentido acreditamos existir fatores associados à produção e aos gastos ambulatoriais em média complexidade. Objetivo: Avaliar a associação entre os gastos com a produção ambulatorial em média complexidade e os fatores associados. Metodologia: A população do estudo foram os 853 municípios do estado de Minas Gerais agregados por microrregiões no ano de 2014. Este será foi um estudo ecológico, analítico - observacional, com uma análise bivariada e multivariada, avaliando algumas variáveis relevantes, como o gasto com a produção em média complexidade, e variáveis explicativas sócio demográficas e econômicas, cobertura da Estratégia Saúde da Família, número de médicos especialistas e de Atenção Básica, e oferta (equipamentos) dos serviços em média complexidade, Resultados: Encontramos correlação positiva entre a produção ambulatorial em média complexidade e as variáveis: Produto Interno Bruto, Renda Média Domiciliar, Índice de Desenvolvimento Humano Municipal, Condição de habitação, Sexo Feminino, Médicos especialistas e de atenção básica e correlações negativas entre a produção ambulatorial em média complexidade e as variáveis Taxa de Analfabetismo e Cobertura da Estratégia Saúde da Família, sendo que todas as correlações se mostraram significativas (p < 0,05). O mesmo resultado foi encontrado na correlação dos gastos com produção ambulatorial em média complexidade e as demais variáveis. Na análise de regressão linear múltipla nem todas as variáveis contribuíram significativamente para explicação das variâncias a um intervalo de 95% de confiança, apresentaram maior valor preditivo as variáveis condição de habitação e médicos especialistas. Considerações finais: Acreditamos que o nosso estudo pode contribuir para compreender e racionalizar o uso dos recursos disponíveis em média complexidade. / After the Unified Health System establishment, the lack of health resources and the its inefficient use have been constantly debated. These debates have exposed the SUS's incapability of funding the Health System, which could compromise its expected efficiency. In the current Unified Health System management model, there are levels of assistance, which should be set hierarchically, decentralized and regionalized to better meet the population needs. In this sense, we believe there are associated factors between the production and the outpatient spending of medium complexity. Objective: Therefore, the aim of this research was to measure the association between spending on outpatient services of medium complexity and other associated factors. Methodology: Thus, we considered the 853 counties, from Minas Gerais State, aggregated in micro-regions to the year of 2014. This research consisted in an ecological and analytical-observational study, with a bivariate and multivariate analysis, which allowed us to analyze some relevant variables, such as the spending associated with production of medium complexity, and other explanatory variables, like demographic and economic factors, Family Health Strategy coverage, number of medical specialists, number of doctors from primary care, and supply services (equipment) in medium complexity. Results: Regarding the results, we found a positive correlation between outpatient treatment of moderate complexity and the following variables: Gross Domestic Product, the households with Middle-Income, the Municipal Human Development Index, housing condition, Female Genre, medical specialists and doctors from primary care. We also found a negative correlation between outpatient services of moderate complexity and the variables: Illiteracy rate and Coverage of Family Health Strategy. All correlations were statistically significant (p < 0.05). The same result was found to the correlation between spending on outpatient services of moderate complexity and other variables. When analyzing the models with multiple linear regressions, with a range of confidence of 95%, we have noted that some variables have not contributed significantly to explain the variance. The housing condition and the number of medical specialists were the variables with the best predictive values. Conclusion: Therefore, we believe our study helps to understand and rationalize the use of available resources in moderate complexity.

Submitted by Daniely Januário (daniely.januario@gmail.com) on 2018-03-02T12:31:14Z No. of bitstreams: 1 joseresendedecastrojunior.pdf: 3078753 bytes, checksum: f22309c68ef54befb8ce6682fdfa7d3e (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2018-03-14T18:29:39Z (GMT) No. of bitstreams: 1 joseresendedecastrojunior.pdf: 3078753 bytes, checksum: f22309c68ef54befb8ce6682fdfa7d3e (MD5) / Made available in DSpace on 2018-03-14T18:29:39Z (GMT). No. of bitstreams: 1 joseresendedecastrojunior.pdf: 3078753 bytes, checksum: f22309c68ef54befb8ce6682fdfa7d3e (MD5) Previous issue date: 2016-09-30 / PROQUALI (UFJF) / A fibrilação atrial é a arritmia cardíaca sustentada mais comum, acometendo principalmente idosos e aumenta o risco de acidente vascular cerebral. É atualmente um problema de saúde pública pela sua elevada morbimortalidade e custos crescentes. A varfarina é o anticoagulante que se mostrou efetivo na prevenção deste evento, contudo apresenta limitações que contribuem para a sua baixa aderência e subutilização. O surgimento de novos anticoagulantes, como a rivaroxabana, evidenciou que esta medicação pode ser tão efetiva quanto à varfarina, mas, com menores taxas de complicações hemorrágicas graves, principalmente cerebrais, não havendo necessidade de exames de monitorização, porém com um custo maior. O objetivo deste estudo foi avaliar a custo-utilidade da rivaroxabana comparada à varfarina nesta arritmia, ou seja, comparar o custo da intervenção com sua efetividade medida como ganho em anos de vida ajustada pela qualidade. Inicialmente foi realizada uma revisão sistemática de estudos econômicos sugerindo que a rivaroxabana pode ser uma opção custo-efetiva, principalmente em países desenvolvidos. Houve apenas um estudo realizado em país em desenvolvimento que mostrou resultado divergente. Posteriormente, foi desenvolvido um modelo econômico de Markov, na perspectiva do Sistema Único de Saúde, que permitiu simular a evolução de uma coorte de idosos com fibrilação atrial, em ciclos trimestrais durante toda a vida. Os resultados evidenciaram que os custos incrementais da rivaroxabana foram superiores à varfarina (R$ 7.135,48), com um discreto aumento de utilidade, resultando numa razão de custo-utilidade incremental de R$ 206.816,45/anos de vida ajustada pela qualidade. Este valor encontra-se acima do limiar proposto pela Organização Mundial da Saúde, podendo não ser uma opção custo-efetiva. Apesar das limitações, este trabalho conseguiu reunir as evidências disponíveis e mostrou a necessidade de se ajustar os protocolos clínicos e diretrizes para uma prática clínica que possa conciliar os princípios de integralidade do cuidado à sustentabilidade do sistema de saúde. / Atrial fibrillation is the most common sustained cardiac arrhythmia, affecting mainly the elderly and increases the risk of stroke. It is currently a public health problem because of its high morbidity and mortality and increasing costs. Warfarin is an anticoagulant that was effective in preventing this type of stroke, but has limitations that contribute to its low adhesion and underutilization. The emergence of new anticoagulants such as rivaroxaban, suggest that this drug may be as effective as warfarin, but with lower rates of major bleeding complications, mainly brain. Also, with this drug, there is no need for monitoring tests, but is more expensive. The aim of this study was to evaluate the cost-utility of rivaroxabana compared to warfarin in this arrhythmia, or compare the cost of a health intervention with effectiveness measured as a gain in years of life adjusted for quality. Initially, a systematic review of economic studies was performed that suggest that rivaroxaban can be a cost-effective option compared to warfarin, especially in developed countries. There was only one study in a developing country which showed divergent results. Later, it was developed an economic model of Markov was developed with the Unified Health System perspective, which allowed simulation of the evolution of a cohort of elderly patients with Atrial fibrillation in quarterly cycles throughout life. The results showed that the incremental costs of rivaroxaban was superior to warfarin (R$ 7.135,48), with a slight increase of utility, resulting in incremental cost-utility ratio of R$ 206.816,45/years of life adjusted for quality. This value is above the threshold proposed by the Wolrd Health Organization, may not be a cost-effective option. Despite the limitations, this study brought together the available evidence and showed the need to adjust the clinical protocols and guidelines for clinical practice that can reconcile the principles of comprehensive care to the sustainability of the health system.

Chapter 1: Patents and Entry Competition in the Pharmaceutical Industry: The Role of Marketing Exclusivity Effective patent length for innovation drugs is severely curtailed because of extensive efficacy and safety tests required for FDA approval, raising concern over adequacy of incentives for new drug development. The Hatch-Waxman Act extends patent length for new drugs by five years, but also promotes generic entry by simplifying approval procedures and granting 180-day marketing exclusivity to a first generic entrant before the patent expires. In this paper we present a dynamic model to examine the effect of marketing exclusivity. We find that marketing exclusivity may be redundant and its removal may increase generic firms' profits and social welfare. Chapter 2: Why Authorized Generics?: Theoretical and Empirical Investigations Facing generic competition, the brand-name companies some-times launch generic versions themselves called authorized generics. This practice is puzzling. If it is cannibalization, it cannot be profitable. If it is divisionalization, it should be practiced always instead of sometimes. I explain this phenomenon in terms of switching costs in a model in which the incumbent first develops a customer base to ready itself against generic competition later. I show that only sufficiently low switching costs or large market size justifies launch of AGs. I then use prescription drug data to test those results and find support. Chapter 3: The Merger Paradox and R&D Oligopoly theory says that merger is unprofitable, unless a majority of firms in industry merge. Here, we introduce R&D opportunities to resolve this so-called merger paradox. We have three results. First, when there is one R&D firm, that firm can profitably merge with any number of non-R&D firms. Second, with multiple R&D firms and multiple non-R&D firms, all R&D firms can profitably merge. Third, with two R&D firms and two non-R&D firms, each R&D firms prefer to merge with a non-R&D firm. With three or more than non-R&D firms, however, the R&D firms prefer to merge with each other.

Dans l’ensemble de la thèse, nous avons appliqué des techniques de ‘mesure des variations spatiales’ pour l'étude des variations géographiques de taux d'hospitalisation en France. La thèse est composée de 4 études :Étude 1 : « Variation géographique des recours aux procédures chirurgicales en France en 2008-2010 et comparaison avec les États-Unis et la Grande-Bretagne ».Étude 2 : « Variation géographique des admissions pour les prothèses du genou, de la hanche et la fracture de la hanche en France : existence d’une demande induite dans le secteur des hôpitaux à but lucratif et dans les hôpitaux public et privés à but non-lucratif »Étude 3 : « Caractéristiques et tendances des admissions non urgentes à but lucratif et sans but lucratif hôpitaux en France en 2009 et 2010 ». Étude 4 : « Taux d'admission pour des ’hospitalisations évitables par le système ambulatoire’ (ACSC) en France en 2009-2010 : tendances, variation géographique, coûts et comparaison internationale ». / For all of this work, we applied ‘small-area variation’ techniques to the study of geographic variations in hospitalization rates in France. We conducted four studies:Study 1: Geographic variation in rates of common surgical procedures in France in 2008-2010 and comparison to the US and BritainStudy 2: Geographic variation in admissions for knee replacement, hip replacement, and hip fracture in France: evidence of supplier-induced demand in for-profit and not-for profit hospitalsStudy 3: Characteristics and patterns of elective admissions to for-profit and not-for-profit hospitals in France in 2009 and 2010Study 4: Rates of admission for ambulatory care sensitive conditions in France in 2009-2010: trends, geographic variation, costs, and an international comparison

This diploma thesis deals with the question of whether do public subsidies cause wasteful use of pharmaceuticals, and if so then to what extent. The hypothesis is tested on the Czech republic data for the years 2005-2012. The biggest contributions are defining the health system as an intra-temporal problem, which tells us that lower values of discount rate implies higher level of wasteful use. I express the environmental issues, which are caused by unprofessional pharmaceutical disposal. You can find the price (-0,11), the income (-0,2) and the cross-price (-0,14) elasticity of demand for pharmaceuticals in the empirical part. These estimates are obtained with the help of the Kuhn-Tucker method. Using the 2OLS method Model 2 comes with the major findings. With 10% increase of public subsidies, consumers tend to waste 13,2% more pharmaceuticals.

Pharmaceutical expenditures are an important part of the entire hospital operating budget, and inpatient pharmaceuticals denote one of the highest costs in hospital care. Predictions for medication budgets based on the types of patients have been largely undertaken in medical hospitals and not psychiatric facilities. According to several previous studies, gender, age, diagnosis, comorbidity and length of stay (LOS) affect the general inpatient treatment expenditures. However, whether or not the impact of these factors differs in psychiatric hospitals remains to be investigated. To that end, the current study examines medication costs for mental and behavioral health disorder as well as the primary chronic diseases commonly comorbid with mental and behavioral health disorders that suggest formulary management control might be helpful. Multiple regression models were developed to determine the leading drivers associated with the growing inpatient hospital medication costs among patients admitted to an acute psychiatric hospital. We also analyzed LOS using a Poisson model in order to determine whether it is a proxy for psychiatric inpatient medication costs. Our finding selected 51 medications (14% of the 364 total medications consumed 90% of the total medication cost) under A category (AV, AE, and AN) and B category (BV, BE, and BN) in order to develop a medication list (MUC, medication under control) that suggested cost control measures based on cost and clinical criticality could be important. This study demonstrated that comorbidity, principal and secondary diagnoses, LOS, and MUC are associated with higher inpatient medication costs than other factors, including age, gender, insurance type, and month admitted. Our study also observed that the principal ICD-10-CM codes F10 (Alcohol related disorders) is associated with high inpatient medication cost. Secondary diagnosis related groups (DRGs) 203 (Bronchitis & asthma), 192 (Chronic obstructive pulmonary disease, COPD), 201 (pneumothorax), 639 (Diabetes), 642 (Inborn and other disorders of metabolism), 645 (Endocrine disorders), 641 (Nutritional & miscellaneous metabolic disorders), 690 (Kidney & urinary tract infections), 675 (Other kidney & urinary tract procedures), 699 (Other kidney & urinary tract diagnoses), and 700 (Other kidney and urinary tract diagnoses), 305 (Hypertension), 310 (Cardiac arrhythmia & conduction disorders), 303 (Atherosclerosis), 293 (Heart failure & shock), and 316 (Other circulatory system diagnoses) were found to be associated with higher inpatient medication costs. In addition, LOS can be used as an indicator (proxy) for inpatient medication cost when patients present with a secondary DRG 639 (diabetes) and 690 (kidney & urinary tract infections) in an acute psychiatric hospital. Viewed collectively, this study would enable executives of acute psychiatric hospitals to identify the most important factors that are associated with high inpatient medication costs, thereby assisting in the development of the hospital pharmaceutical budget using a novel and scientific approach.

This dissertation consists of three essays addressing different topics in health economics. In the first essay, we perform a systematic review of peer-reviewed articles examining consumer preference for the main electronic cigarette (e-cigarette) attributes namely flavor, nicotine strength, and type. The search resulted in a pool of 12,933 articles; 66 articles met the inclusion criteria for this review. Current literature suggests consumers preferred flavored e-cigarettes, and such preference varies with age groups and smoking status. Consumer preference for nicotine strength and types depend on smoking status, e-cigarette use history, and gender. Adolescents consider flavor the most important factor trying e-cigarettes and were more likely to initiate vaping through flavored e-cigarettes. Young adults prefer sweet, menthol, and cherry flavors, while non-smokers, in particular, prefer coffee and menthol flavors. Adults in general also prefer sweet flavors (though smokers like tobacco flavor the most) and dislike flavors that elicit bitterness or harshness. Non-smokers and inexperienced e-cigarettes users tend to prefer no nicotine or low nicotine e-cigarettes while smokers and experienced e-cigarettes users prefer medium and high nicotine e-cigarettes. Weak evidence exists regarding a positive interaction between menthol flavor and nicotine strength. In the second essay, we investigate U.S. adult consumer preference for three key e-cigarette attributes––flavor, nicotine strength, and type––by applying a discrete choice model to the Nielsen scanner data (Consumer Panel data combined with retail data) for 2013 through 2017, generating novel findings as well as complementing the large literature on the topic using focus groups, surveys, and experiments. We found that (adult) vapers prefer tobacco flavor, medium nicotine strength, and disposables, and such preference can vary over cigarette smoking status, purchase frequency, gender, race, and age. In particular, smokers prefer tobacco flavor, non-smokers or female vapers prefer medium strength, and infrequent vapers prefer disposables. Vapers also display loyalty (inertia) to e-cigarette brands, flavor, and nicotine strength. One key policy implication is that a flavor ban will likely have a relatively larger impact on adolescents and young adults than adults. The third essay employs a machine learning algorithm, particularly a random forest, to identify the importance of BMI information during kindergarten on predicting children most likely to be obese by the 4th grade. We use the Arkansas BMI screening program dataset. The potential value of BMI information during early childhood to predict the likelihood of obesity later in life is one of the main benefits of a BMI screening program. This study identifies the value of this information by comparing the results of two random forests trained with and without kindergarten BMI information to assess the ability of BMI screening to improve a predictive model beyond personal, demographic, and socioeconomic measures that are typically used to identify children at high risk of excess weight gain. The BMI z-score from kindergarten is the most important variable and increases the accuracy of the prediction by 14%. The ability of BMI screening programs to identify children at greatest risk of becoming obese is an important but neglected dimension that should be used in evaluating the overall utility. In the last essay, we use Nielson retail scanner dataset and apply a difference-in-differences (DID) approach and synthetic control method, and we test whether consumers in Utah reduced beef purchases after the 2009 Salmonella outbreak of ground beef products. The result of DID approach indicates that the Salmonella event reduced ground beef purchases in Utah by 17% in four weeks after the recall. Price elasticity of demand is also estimated to be -2.04; therefore, the reduction in ground beef purchases as a result of recall is comparable to almost 8.3% increase in the price of this product. Using the synthetic control method that allows us to use all of the control states to produce synthetic Utah, we found the effect of this event minimal compared to the DID effect.