14 April 2006

International Association for the Health and Ageing Study of Insurance Economics Research Programme on Health and Productive Ageing

I. GUEST EDITORIAL 2 Depression in middle age and old age – Geneva consequences for the future Mike Martin and Elke Voss write on affective disorders, in particular depression, that affect more and more people at Association middle age, and address what ageing and mental health will look like in old age in the very near future. Information II. ARTICLE I 6 ewsletter The Effects of quality reporting in U.S. healthcare markets N - Kyna Fong adresses “report cards” on healthcare quality, designed to aid purchasers and consumers in making better decisions. How and to what extent those report cards are effective remains to be seen.

III. ARTICLE II 8 Living without disability - François Herrmann, Jean-Marie Robine and Jean-Pierre Michel write on the concept of disability and the trends in disability free life expectancy.

IV. ARTICLE III 11 Caring for their parents - Paula C. Mateus de Albuquerque Mateus discusses the link between living arrangements of the elderly and the number of children from a game theory point of view.

V. CONFERENCES SUMMARY 13 Summary of the third Health and Ageing Geneva Association conference on “Longevity – A Medical and Actuarial Challenge”

VI. CALL FOR PARTICIPATIONS 15 Fourth Health and Ageing Geneva Association conference on “Chronic conditions and insurance”

VII. EDUCATION IN HEALTH ECONOMICS 16

VIII. HEALTH CONFERENCES 17

IX. PUBLICATIONS ON HEALTH ISSUES 18

X. GENEVA ASSOCIATION PUBLICATIONS 19

XI. GENEVA ASSOCIATION CONFERENCES 21

The Geneva Association • General Secretariat • 53 route de Malagnou • CH - 1208 Geneva Tel. +41-22-707 66 00 • Fax +41-22-736 75 36 • [email protected] • www.genevaassociation.org The Geneva Association Health and Ageing N° 14/April 2006

RESEARCH SUMMARY

Major concerns are generally directed at the rising health costs resulting from technological advances and the changing demographic structure whereby the population aged over 60 largely exceeds that of other age groups in most developed countries. Importance is placed on two major issues. First, the change in demographic structures leading to the perceived “ageing society”. And, second, technological advances, which are thought to result in increasing health costs. It is important to view these issues from the proper perspective. We are not ageing as a society but benefiting from an extended period of good health, which is largely a consequence of technological advances and healthier life styles. It is not the increased spending on health that should be the concern but what it is spent on. It is crucial that the nature of spending is well analyzed and the benefits clearly understood.

Current health systems in almost all countries are mainly non-funded pay-as-you-go systems with more or less pronounced intergenerational redistribution. Faced with a shrinking tax base and an increase in health costs, they are bound to experience greater and greater difficulties. Private systems and funded systems that allow accumulation of funds are slowly appearing as alternatives. This evolution raises many unknowns, especially in terms of financing and participation but also of solidarity and equity.

As the life cycle is getting longer, people have the opportunity to be productive for a longer period of time than before, which will therefore extend the period of wealth accumulation. This can allow funds or premiums to build up over a long period in order to cover the cost of care in the later stages of life. A majority of countries have already combined both public and private schemes in a bid to create a health financing system that could cope with the increasing difficulties it faces.

The Geneva Association Research Programme on Health and Ageing seeks to bring together facts, figures and analyses linked to issues in health. The key is to test new and promising ideas, linking them to related studies and initiatives in the health sector and trying to find solutions for the future financing of healthcare.

We are particularly interested in:

- The impact of an ageing population in health insurance systems. - The effect of technology on health insurance. - Development of health care systems and the capitalization issue. - The interaction of public and private systems in health provision. - Performance of health systems. - Health issues for an ageing population in the workplace. - Factors that influence health status. - Factors responsible for the increase in health spending. - Factors that contain the increase in health cost.

The Geneva Association Information Newsletter – Health and Ageing is linked to the Research Programme on Health and Productive Ageing and is published biannually in April and October. Download the electronic version from: http://www.genevaassociation.org/health_and_ageing.htm

Printed copies: 1000. Unrestricted circulation. Free of charge. Editor: Dr Christophe Courbage, The Geneva Association

For information and suggestions, please write to the Editor at the Geneva office. © Copyright 2006. The International Association for the Study of Insurance Economics. ISSN:1605-8283

1 The Geneva Association Health and Ageing N° 14/April 2006

I. GUEST EDITORIAL

Depression in middle and old age - consequences for the future

By Mike Martin* & Elke Voss+

Mental health problems severely decrease the quality of life of the persons affected and their environment. What makes data on the age-related changes in depression so important is that recent studies on prevalences of psychiatric disorders in middle age suggest a high and worldwide increasing rate of mental disorders in middle aged adults. In addition, a 2002 WHO study on the most recent Executive Summary of the Global Burden of Disease and Injury Series indicates that the burden of psychiatric conditions in middle age is frequently underestimated, and most likely undertreated. According to this report, five of the ten leading causes of disability worldwide (measured in years lived with disability), were psychiatric conditions (Hogan, 2000; WHO, 2002).

As one can see from current demographic data, the largest age group currently growing into old age are the middle-aged, that is, persons between 40 and 65. This large age group will determine what aging and what mental health will look like in old age in the very near future. Why should this age group be at risk for depression? Recent work has speculated that the high rate of psychiatric disorders in middle age could be due to (1) the high level of demands from work and family at middle age, i.e., between age 40 and 50, (2) the fact of being a member of the large birth cohorts of the baby boomers and/or witness of social change processes like globalization, or (3) the influence of midlife crises (cf. Willis & Martin, 2005).

Looking at data from an ongoing longitudinal study in Germany, the Interdisciplinary Longitudinal Study of Adult Development (ILSE), one may examine a representative sample of middle-aged 40+-year-olds and older 60+-year-olds (Voss et al., in press). One main area of data collection are measures of mental and physical health. The intake sample consisted of 1000 persons in the two age groups, with slightly more men than women (based on the fact of lower life expectancy of men and an anticipated longitudinal follow-up of 20 years). The sample consisted of 895 persons at the second measurement occasion, and this return rate of close to 90% can be considered excellent. Although the sample is slightly better educated and has a slightly higher income, it is generally representative of their age groups. That is why data from this study can serve as a basis for quasi-epidemiological examinations concerning the frequency of affective disorders (Martin & Zimprich, 2005).

Figure 1. Prevalence and incidence rates for affective disorders in 41-43 (Born 1950/52) versus 61-63-year- olds (Born 130/31) 1930/32)

30 25

20 20.2 15

In % 10 9.5 10.3 5 5.1 3.4 6.3 0 Lifetime 4-year Prevalence Incidence Prevalence

Born 1930/32 Born 1950/52

* Professor for the Psychology of Aging and Director of the Institute of Gerontology at The University of Zurich, Switzerland. Email: [email protected]. + Senior research fellow Institute of Gerontology at The University of Heidelberg, Germany. 2 The Geneva Association Health and Ageing N° 14/April 2006

Data from this study suggest that in all three measures, the younger cohort of 40+-year-olds reports significantly higher prevalences for the lifetime, over a four-year longitudinal period and current level of incidence. This suggests that the findings from other countries can be replicated and that middle aged adults show higher rates of affective disorders (Voss et al, in press).

Figure 2. Lifetime prevalence rates for several affective disorders in 41-43- (Born 1950/52) versus 61- 63-year-olds (Born 1930/32)

cohort 1930/32 cohort 1950/52 cohort Mental disorders % (n) (N=483) (N=494) differences Chi-Square

ssd manifest ssd manifest Lifetime prevalence at T1

Any affective disorder 4,0 (19) 9,1 (44) 5,1 (25) 19,2 (95) 22,1 *** Major depressive disorder 3,5 (17) 7,7 (37) 4,9 (24) 17,6 (87) 23,7 *** Any anxiety disorder 5,6 (27) 12,4 (60) 8,1 (40) 7,7 (38) 7,8 * Panic disorder 0,8 (4) 1,0 (5) 0,8 (4) 2,0 (10) 2,5 Agoraphobia without pd 1,5 (7) 4,6 (22) 1,2 (6) 2,0 (10) 6,2 Simple Phobia 1,9 (9) 4,6 (22) 7,1 (35) 2,0 (10) 21,7 *** Social Phobia 4,0 (19) 4,0 (19) 1,8 (9) 1,0 (5) 13,1 ** Any substance use disorder 1,5 (7) 2,1 (10) 3,6 (18) 6,1 (30) 15,1 ***

Significance: *p≤0.05; **p≤0.01; ***p≤0.001

If analyses are conducted in more detail, it is again striking that rates of disorders are higher in middle aged, not older adults. This is true for all affective disorders combined, clearly depression, and substance disorders. Only anxiety disorders seem to be more frequent in the older adults. Applying very strict criteria show the same picture: The younger cohort born 1950-1952 is significantly more frequently clinically depressed. What is more, the ILSE data suggest that in the younger, middle-aged cohort not only depression is more frequent, also the age at which it occurs the first time is increasingly early in life. This trend is also worldwide and is stable even after controlling for potential memory effects in the older adults (Voss et al., 2006).

120

100

80

60

40

depressive episodes (%) 20

major of frequency cumulative 0 14-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60

age of first onset (in years) K 30/32 K 50/52

For comparative purposes, we used data from the American National Comorbidity Survey (Kessler et al., 1994) and selected the participants that were exactly the same age and exactly as representative for the US as the ILSE participants. In addition, both studies used exactly the same measurement instruments. In both studies, mental disorders were obtained with structured face-to- face interviews according to DSM-III-R.

3 The Geneva Association Health and Ageing N° 14/April 2006

Despite a seemingly general increase in particular psychiatric disorders in different countries, it is not well known how cultural differences or differential risk factors might influence the prevalence of the major psychiatric disorders. Countries might differ with respect to environmental pressure vs. protecting factors and the likelihood of providing adequate treatment options for persons at risk for mental illnesses. Furthermore, the awareness and openness and/or willingness to report psychiatric problems or to be sensitive enough to perceive particular symptoms as psychiatric may be higher in some cultures. In general, the comparison suggests that for the most mental health problems examined, the prevalence rates are very similar in both countries. That is also comparable to data from Japan and Canada.

Figure 3. Prevalences of mental disorders in middle aged adults from the U.S. (NCS; N=707) and Germany (ILSE; N = 496)

45

40 44 35 37 30 Any disorder 25 Affective disorders

In % 20 22 21 23 23 Depression 20 15 Anxiety disorders 15 10 5

0 USA Germany

Consequences for the future

What consequences does this have for the future of mental health? As data from Switzerland suggest, about 5% of the middle-aged abd 2.6% of the older adults receive treatment for mental health problems. Considering the rates of depression and other affective disorders, on one hand this suggests that mental health problems are undertreated (Martin, Voss & Schmitt, 2005). That is, not everyone who would profit from the treatment seeks or receives it. On the other hand it suggests that if the more frequently ill middle-aged persons stay depressed, a much larger treatment need than is currently observed might be needed. In addition: since the number of older persons will increase and the rate of depression increases we must expect a much larger need for mental health care in the near future (cf. Willis & Martin, 2005)

Figure 4. Heart/Circulatory system problems in healthy, depressed, and comorbid depressed (Depression+) ILSE participants

100 90 100 80 70

60 Healthy 50 Depression In % 40 45 40.9 Depression+ 30 35.2 20 10 20.8 10.7 0 Born 1930/32 Born 1950/52 4 The Geneva Association Health and Ageing N° 14/April 2006

Finally, another reason why depression should be treated early on is the effect it might have on the development of physical health. The comparison data from the ILSE study clearly suggest that the risk for heart problems or failures of the circulatory system are substantially higher in persons with depression and other mental health problems. On the basis of longitudinal analyses, we have also determined that depression leads to heart problems, and rarely the other way around. This suggests that untreated depression is causing physical health problems (Martin et al., 2002). This means that a treatment in middle age would potentially help to prevent a stronger deterioration of health across the life span. Overall, affective disorders, in particular depression, affect more and more people at middle age. If untreated, depression in midlife is likely to increase the risk of chronification and multimorbidity. However, depression in many countries is clearly underdiagnosed and undertreated, and investing in mental health in middle age should have long- term positive consequences for individual and public health.

References

Hogan, M. (2000). The Executive Summary of The Global Burden of Disease and Injury Series. Retrieved August 2002, from the Harvard School of Public Health Web site http://www.hsph.harvard.edu/organizations/bdu/summary.html). Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., Wittchen, H. U., & Kendler, K. S. (1994). Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States. Archives of General Psychiatry, 51, 8-19. Martin, M., & Zimprich, D. (2005). Cognitive development in midlife. In S. L. Willis & M. Martin (Eds.), Middle adulthood: A lifespan perspective (pp. 179-206). Thousand Oaks, CA: Sage. Martin, M., Voss, E., Barth, S., Rott, C., Kliegel, M., & Sperling (2002). Depression im mittleren, höheren und höchsten Alter: Prävalenzen und Konsequenzen. [Depression in middle, older and oldest age: Prevalences and consequences]. Zeitschrift der Betrieblichen Krankenversicherung, 90, 20-23. Voss, E., Barth, S., Martin, M., Pantel, J., Schmitt, M., & Schröder, J. (in press). Age differences in prevalence and course of major depression: A longitudinal population-based study of two birth cohorts in Germany. Psychiatry Research. Voss, E., Martin, M., Stegmann, A., Schmitt, M., & Wethington, E. (2006). Mental illness in middle- aged adults in Germany and the United States: A cross-national comparison of the Interdisciplinary Longitudinal Study on Adult Development (ILSE) and the National Comorbidity Survey (NCS). Manuscript submitted for publication (Culture, Medicine and Psychiatry). WHO, 2002. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva, Switzerland. Willis, S. L. & Martin, M. (2005). Middle adulthood: A lifespan perspective. Thousand Oaks, CA: Sage.

Figures are taken from:

Martin, M., & Kliegel, M. (2005). Psychologische Grundlagen der Gerontologie [Psychological foundations of gerontology]. In C. Tesch-Römer, H.-W. Wahl, S. Weyerer, & S. Zank (Series Eds.), Grundriss Gerontologie: Band 3. Stuttgart: Kohlhammer. Martin, M., Voss, E. & Schmitt, M. (September 2005). Depression in middle and old age: consequences for the future. Paper presented at the 1st World Ageing and Generations Congress in St. Gallen, Switzerland.

5 The Geneva Association Health and Ageing N° 14/April 2006

II. INVITED ARTICLE I

The effects of quality reporting in U.S. healthcare markets

By Kyna Fong*

The U.S. is rare amongst highly developed countries to depend on private market mechanisms to fund and provide healthcare for its non-elderly citizens. Americans have the opportunity to choose many aspects of their care, ranging from health plans to insurance coverage to specific hospitals and doctors. Recently, a series of articles have documented the disturbing frequency of poor- quality healthcare and the adverse effects such care exerts on health outcomes and costs (IOM, Wennberg). The general consensus is that people need to be made more aware of quality and the variation in quality so that they can make better-informed decisions and thereby raise the overall quality of care. Participants in both the for-profit and non-profit sectors have responded by producing a slough of “report cards” on healthcare quality, designed to aid purchasers and consumers in making better decisions (Vara). How and to what extent those report cards are effective remains to be seen.

The two direct avenues through which report cards can improve quality of care are (1) shifting consumers towards higher-quality sources of healthcare and (2) inducing competition amongst those sources to improve quality. In this report, following some background discussion on report cards, we review studies that look for evidence of those two developments.

The Design of Report Cards

An important factor in effective quality reporting lies in the design of the report cards themselves. First, what should be the unit of comparison? Healthcare decisions in which quality differentiation can play a role cover a wide range: examples include health plans, multi-specialty physician groups, hospitals, surgery centers, outpatient clinics, specialists and primary care doctors. Few of those healthcare sources currently compete based on quality directly and report cards can serve to fix that. The eventual units of comparison and thus the structure of market competition will be determined by what consumers care about and how capable they are of processing information.

Next, what quality measures should be used and how should they be presented? Most will agree that, since a goal of quality reporting is to raise the overall quality of care, quality should be measured on a vertically differentiable (ranked) scale. But there are many aspects to quality: outcomes, best practices, limited medical errors, service, consumer satisfaction. Which will consumers respond to? Information overload is an important concern – how can the information be transmitted efficiently? (Hibbard et al.) Notice that there is an underlying tension here between providing information that consumers actually care about and providing information that consumers should care about, according to experts. This is an issue that may explain why many report card attempts have not elicited the desired responses.

To get an idea of the sorts of ratings that are currently available, we provide a few brief examples. The NCQA (National Committee for Quality Assurance) is an independent, nonprofit agency that collects data on health plans nationwide (HMO’s and POS’s) and reports both clinical quality information (such as rates for breast cancer screening, diabetic eye exams, and child immunization) as well as consumer satisfaction measures. PacifiCare Health Systems, a for-profit health insurance carrier, releases measures on clinical quality, service quality, and consumer satisfaction to rate its physician groups. The Leapfrog group, a consortium of more than 100 private and public sector organizations, provides public reporting on hospital-level outcome, clinical and safety measures. Finally, a plethora of for-profit websites have sprung up that provide information on specific doctors and hospitals, with attempts to compile consumer satisfaction reports (Vara).

* Doctoral candidate in Economics at the Stanford Graduate School of Business. Email: [email protected]

6 The Geneva Association Health and Ageing N° 14/April 2006

Demand-Side Responses

Most studies analyzing healthcare report cards have looked the effect on consumers. Have consumers changed their decision-making patterns based on quality reporting? If even consumers are not affected by report cards, there is little reason to believe that healthcare providers will take notice.

Overall, the evidence has been largely negative or insignificant. One of the most glaring results is a survey of patients undergoing cardiac surgery (Schneider 1998). Despite the availability of prominent public performance reports on risk-adjusted mortality ratings, only 12% of patients reported awareness of the reports and fewer than 1% could both identify the correct rating of their surgeon or hospital and say that the rating had at least a moderate impact on their choice of provider. It is concerning that consumers don’t respond to public report cards even for a procedure so important as cardiac surgery.

Studies that analyze consumer responses to health plan quality information have mostly shown small if any effects (Marshall, Scanlon, Beaulieu). Often, the findings confirm the positive value of information, but suggest that much of the information is already known (Dafny) or that the number of consumers actually affected is very small (Jin). A recent study on choices of physician groups shows some positive response, but these are mostly on the part of new enrollees who do not have switching costs and often have no prior information other than the reports (Rosenthal).

Overall, consumers have not responded significantly to provider report cards. The main issues cited include (1) insufficient dissemination of reports, (2) lack of support and encouragement from providers, (3) switching costs and inertia, and (4) insufficient patient education about the importance and credibility of reports. Although there is evidence that consumers having access to quality information contributes positively to making better choices, the effects thus far have been very limited.

Supply-Side Responses

Given that there is little demand-side response to quality reporting, it is unsurprising that there is no compelling evidence that report cards have induced providers to improve their quality significantly. In cases of glaring deficiencies, providers have responded (Schneider 1996), but visible competition amongst providers to improve scores has not been observed.

The theory that doctors’ and hospitals’ pride in their work will sufficiently motivate them to improve their scores has a limited application. In order for consistent investments in quality improvement to be undertaken, providers must have financial incentive to do so. The lack of demand-side response to report cards, however, and the resulting implication that consumers don’t value quality as measured by report cards has dulled the motivation.

On the contrary, instead of the positive possibility of providers working to improve quality directly, studies have discovered a negative reaction: some providers work to improve quality ratings instead by cherry-picking or avoiding bad risks. In the case of cardiac surgeons, after public disclosure they became less willing to perform surgery on high-risk cases, since deaths in those cases would affect their mortality ratings (Dranove). In this sense, public quality reporting may in fact provide negative value to consumers as a result of changes in supply-side behavior (Dranove).

Looking Forward

Many factors confound the effectiveness of quality reporting, and the field is still very much in a trial-and-error stage. One important concern looking forward is that, if quality reporting reaches the point where consumers respond and shift market share to high-performers, quality as a vertical differentiator will inevitably lead to the productization of quality. In particular, the healthcare market may become tiered by quality, with higher quality demanding higher prices. The U.S. healthcare market is already criticized widely for its vast inequalities – the performance of healthcare markets infused by quality differentiation will be an interesting and important development to keep our eyes on.

7 The Geneva Association Health and Ageing N° 14/April 2006

References

Beaulieu N. “Quality Information and Consumer Health Plan Choices.” Journal of Health Economics 2002; 21(1): 43-63. Dafny, L.S., Dranove, D. “Do Report Cards tell consumers anything they don’t already know? The case of Medicare HMO’s.” NBER Working Paper 11420. 2005 June. Dranove, D., Kessler, D., McClellan, M., Satterthwaite M. “Is more information better? The effects of ‘report cards’ on health care providers.” Journal of Political Economy 2003 Jun 3; 111: 555- 588. Hibbard, J.H., et al. “Choosing a Health Plan: Do Large Employers Use the Data.” Health Affairs November/December 1997; 16(6): 172-180. Institute of Medicine. Crossing the Quality Chasm. National Academy Press, Washington DC. 2001. Jin G.Z., Sorensen A.T. “Information and consumer choice: The value of publicized health plan ratings.” Journal of Health Economics 2006; 25: 248-275. Marshall, M.N. et al. “The Public Release of Performance Data: What do we expect to gain? A review of the evidence.” JAMA 2000 April 12; 1866-1874. Rosenthal M.B., Li, Elena, Epstein, A.M. “The Impact of Provider Performance Reporting on Consumer and Physician Group Behavior.” Harvard School of Public Health Working Paper. 2006. Scanlon D.P., Chernew M., McLaughlin C., Solon G. “The Impact of Health Plan Report Cards on Managed Care Enrollment.” Journal of Health Economics 2002; 21(1): 19-41. Schneider E.C., Epstein A.M. “Influence of Cardiac-surgery Performance Reports on Referral Practices and Access to Care – A Survey of Cardiovascular Specialists.” NEJM 1996 July 25; 335(4): 251-256. Schneider E.C., Epstein A.M.. “Use of public performance reports: a survey of patients undergoing cardiac surgery.” JAMA 1998 May 27; 279(20): 1638-42. Vara, V. “Sites Offering Data, Reviews of Doctors.” Wall Street Journal. 23 November 2005. Wennberg, John. Dartmouth Atlas Project. www.dartmouthatlas.org.

III. INVITED ARTICLE II

Living without Disability

By François R. Herrmann*, Jean-Marie Robine+* and Jean-Pierre Michel*

The Wikipedia definition of the term 'disability' as it is applied to humans, refers to any condition "that impedes the completion of daily tasks using traditional methods. National governments and global humanitarian agencies have narrowed this definition for their own purposes, only pledging aid to those with specific disabilities of a certain severity". Whereas proponents of the social model of disability define handicap as the social and economic consequences of disability.

Disability can be broken down into a number of broad subcategories, which include physical impairments affecting movement (such as muscular dystrophy, post-polio syndrome, spina bifida and cerebral palsy), sensory impairments (such as visual or hearing impairments), cognitive impairments (such as autism or Down syndrome) and psychiatric conditions such as depression and schizophrenia. Before interventions can be developed, it is necessary to know how the disablement process works in older people.

Three major models of the disablement process have been developed. The first model proposed by Nagi begins with disease, (Nagi 1964; Nagi 1976; Nagi and Marsh 1980) leading to

* Department of Rehabilitation and Geriatrics, Geneva Medical School and University Hospitals, Switzerland. + INSERM Démographie et Santé, CRLC, Université de Montpellier 1, France

8 The Geneva Association Health and Ageing N° 14/April 2006 impairment, functional limitation, and finally, disability. The second model developed by Wood also begins with disease, leading to impairment and functional limitation but from there to activity restriction and finally handicap. (Wood and Holt 1980) The third ICIDH-model leads from disease to impairment, to disability and finally to handicap. (Wood 1980) Many similarities can be noted between the three models (for instance the role of disease and impairment on the process), but they disagree as to the definition of disability. The Wood model has the advantage that it differentiates the role of functional limitations from activity restriction. The cascade of consequences begins with a chronic disease that leads to functional limitation, followed by disability, dependency and loss of autonomy.

Disability is an important condition as it is associated with suffering and with an increase in healthcare cost, at the same time, it can be considered as an indicator of the severity of morbid states and an indicator of the quality of years lived. It can also be integrated with life expectancy, yielding disability-free life expectancy (DFLE), which measures the number of remaining years that a person of a certain age is still supposed to live without disability.

Over a long period of time, increases in life expectancy at birth have corresponded to improvements in the health of populations. However, now that chronic diseases have replaced, or are progressively replacing, infectious diseases, and the risk of becoming ill is not solely associated with the risk of dying, monitoring the increase in life expectancy is no longer sufficient to infer population health. Indeed, with a constant recovery rate, when the risk of dying diminishes more than the risk of becoming ill, the risk of being ill increases. In other words, the prevalence of chronic disease in the population usually increase as a result of longer survival: when the decrease in fatality is not compensated for by an equivalent decrease in incidence.

Without pertinent data on the change in morbidity, the relationships between the changes in these risks have been theoretically debated, gradually focusing on three theories. The first anticipates an improvement in the state of health or a compression of morbidity (Fries 1980; Fries 2002; Fries et al. 1989; Hubert et al. 2002) the second a decline or an expansion of morbidity, (Gruenberg 1977; Kramer 1980; Kramer 1983) and the third, a dynamic equilibrium, a kind of status quo, (Manton 1982) where, though the prevalence of morbidity increases as mortality falls, the prevalent states are on average less severe (see Figure 1).

Figure 1: Life expectancy and disability

Healthy LE = DFLE Present LE

Expansion of disability

Dynamic equilibrium Disability free

PostponementDisability of disability

Compression of disability

0 20406080100

The life expectancy at the age of 65 is the average number of years a person at the age of 65 could live if, for the time period, the observed age specific mortality rates remain constant. In Switzerland a man aged 65 has an average life expectancy of 17.6 years and a woman of 21.0. (2006) Life expectancy at 65 differs consistently when calculated without severe or without moderate to severe activity restrictions. Healthy life expectancy at age 65 varies from about 2 years in Portugal or Finland to more than 8 years in Belgium for men or in the Netherlands for women. On the other side there are important differences in the life expectancy in bad health, e.g. for man from one year in Sweden to 7.5 years in Portugal. (Robine et al. 2005) 9 The Geneva Association Health and Ageing N° 14/April 2006

Although the trends in life expectancy (LE) in the EU show small variations between the 14 analyzed EU-countries analyzed by European health expectancy monitoring unit (EHEMU) and a constant linear increase between 1995 and 2003, the Disability Free Life Expectancy (DFLE) and the DFLE in percent of the LE show a blurry picture. There is a large variation in DFLE among the countries with trends over 1995 - 2003 varying from reduction to stagnation or increase in the proportion of life with reported disability at age 65. There are also gender differences in the trends. Trends in the proportion of life spent disability-free at age 65 show a gain of more than 5% for men living in Austria, Belgium, Finland, Germany, Italy and Spain as well as for women in Italy and Sweden. On the contrary a loss of 5% or more was calculated for men living in Denmark, Sweden and in the UK and for women in Germany, Greece, Ireland, Netherlands and Portugal. (Robine et al. 2004 (revised July 2005))

Disability can be prevented in part by decreasing the prevalence of modifiable risk factors, such as the avoidance of disease and accident, vaccination, engagement in regular physical exercise, having a healthy diet, avoiding smoking, drinking a little wine, benefiting of education, and eventually, taking specific medication such as statin and aspirin.

References

Disability. Accessed on 25.3.2006. http://en.wikipedia.org/wiki/Disability Espérance de vie. Office fédéral de la statistique Accessed on 23.3.2006. http://www.bfs.admin.ch/bfs/portal/fr/index/themen/gesundheit/uebersicht/blank/panorama/leben serwartung.html Fries, J. F. Aging, natural death, and the compression of morbidity. N Engl J Med (1980) 303(3):130-5. Fries, J. F. Aging, natural death, and the compression of morbidity. 1980. Bull World Health Organ (2002) 80(3):245-50. Fries, J. F., Green, L. W., and Levine, S. Health promotion and the compression of morbidity. Lancet (1989) 1(8636):481-3. Gruenberg, E. M. The failures of success. Milbank Mem Fund Q Health Soc (1977) 55(1):3-24. Hubert, H. B., Bloch, D. A., Oehlert, J. W., et al. Lifestyle habits and compression of morbidity. J Gerontol A Biol Sci Med Sci (2002) 57(6):M347-51. Kramer, M. The rising pandemic of mental disorders and associated chronic diseases and disabilities. Acta Psychiatrica Scandinavica (1980) 62(Suppl. 285):282-297. Kramer, M. The increasing prevalence of mental disorders: a pandemic threat. Psychiatr Q (1983) 55(2-3):115-43. Manton, K. G. Changing concepts of morbidity and mortality in the elderly population. Milbank Mem Fund Q Health Soc (1982) 60(2):183-244. Nagi, S. Z. A Study in the Evaluation of Disability and Rehabilitation Potential: Concepts, Methods, and Procedures. Am J Public Health Nations Health (1964) 54:1568-79. Nagi, S. Z. An epidemiology of disability among adults in the United States. Milbank Mem Fund Q Health Soc (1976) 54(4):439-67. Nagi, S. Z., and Marsh, J. Disability, health status, and utilization of health services. Int J Health Serv (1980) 10(4):657-76. Robine, J., Jagger, C., Clavel, A., et al. Disability-Free Life Expectancy (DFLE) in EU Countries from 1991 to 2003 (Technical report 1, available at http://www.hs.le.ac.uk/reves/ehemutest/pubs.html.) European health expectancy monitoring unit (EHEMU), 2004 (revised July 2005). Robine, J., Jagger, C., Clavel, A., et al. Différentes estimations des espérances de santé dans les pays de l’Union européenne en 2002 : Calculs réalisés à partir des données d’Eurobaromètre 58 (EHEMU Technical report 3, available at http://www.hs.le.ac.uk/reves/ehemutest/pdf/techrep30507.pdf). European health expectancy monitoring unit (EHEMU), 2005. Wood, P. International classification of impairments, disabilities and handicaps (ICIDH). World Health Organization, 1980. Wood, P. H., and Holt, P. J. The development of strategic guidelines for regional planning of rehabilitation services. Int Rehabil Med (1980) 2(3):143-52. 10 The Geneva Association Health and Ageing N° 14/April 2006

IV. ARTICLE III

Parental care for the elderly

By Paula C. Mateus de Albuquerque*

The ageing population of the developed world brings with it its own specific set of problems, one of these being the need for assistance for an ever-increasing percentage of the population - the elderly. Many elderly people who live alone feel, not only unsafe, but also lonely. Furthermore, they are often physically incapable of taking care of themselves, thus in need of long-term care.

The elderly population of today tends to have fewer children per capita than previous generations and this means that the accommodating of an elderly and lonely parent is becoming more of a concern to each and every child. Although we cannot establish an immediate link between the type of living arrangement and the level of well being, it seems clear that living arrangements widely influence the daily lives of the elderly and their well-being. Several characteristics relating to the elderly and their children have been referred to in the literature as explanations for decisions made about living arrangements. A factor often considered a determinant of living arrangements is that of the number of children. Although many studies in the literature have identified a negative and significant effect between the number of children and the odds of living alone, as opposed to living with others, the empirical literature is not unanimous on this subject.

Several studies in the literature identify the negative and significant effect of the number of children on the odds of living alone, relative to living with others (see e.g. Burr and Mutchler (1992), Crimmins and Ingegneri (1990), and Spitze and Logan (1990)) However, Aquilino (1990) finds that the number of children is not significant in explaining parent-child co-residence. In this study, the likelihood of co-residence is evaluated given that there is at least one unmarried child. Some other studies that analyse the probability of transitions from one living arrangement to another find that the effect of the number of children is not significant when other factors such as health, income and demographic characteristics are controlled (see Worobey and Angel (1990), Speare et al. (1991), and in part Spitze et al. (1992)). Wolf and Soldo (1988) conclude that the composition of the kin network holds more relevance in explaining the choice of living arrangements than that of its size. Hoerger et al. (1996) find that the probability of institutionalising a parent is not influenced by the number of children, nor by whether or nor by children living close to their parents. However, a childless person is much more likely to end up in a nursing home.

Theoretically, the relationship between the number of children and the likelihood of the different living arrangements is not entirely clear, nor has it been explored. Wolf (1994) mentions that the number of available kin can create constraints on the set of living arrangements. Engers and Stern (2002)1 write that the number of children “determines the number of options in the choice set and it interacts with other explanatory variables”. Also, in Hiedemann and Stern (1999), the estimated model points to an increase in the chance that a parent receives care from a child or lives in an institution with a larger number of children. The other alternative would be to live independently. In an attempt to find a rationale to the relation between the number of children and the likelihood of each type of living arrangement, we propose the building of a game-theoretic model with discrete payoffs, where we consider the existence of n children. We use this model to

* Correspondence should be sent to [email protected] or to ISEG, Technical University of Lisbon, Rua Miguel Lupi, 20, Gab. 604, 1200 Lisboa, Portugal. 1 Engers and Stern (2002) present one of a few very interesting theoretical models that incorporates strategic behaviour and consider the role of n children when modelling the decision about the living arrangements. Hiedemann and Stern (1999), Checkovich and Stern (2002), and Byrne et al. (2004) are others. Although they obtain relevant results when they estimate the models, their main purpose is not to examine the rationale for the effect of the number of children on the living arrangements of an elderly parent. 11 The Geneva Association Health and Ageing N° 14/April 2006 investigate the influence of the number of children on the living arrangement of an elderly parent who cannot live alone, including the probability of his institutionalisation. It is assumed that there are three alternative living arrangements: a) the parent is institutionalised, b) the parent spends some time with each child, and c) the parent lives with only one child. The parent’s preferences are known: he prefers c) to b) and b) to a). We include three types of costs to the children associated to each living arrangement: costs of effort and time, financial costs, and the emotional cost of disappointing the parent by not being able to offer him the solution he hopes for.

It can be shown that when only costs of effort and time are taken into account, the number of children does not change the condition for full time institutionalisation, and the effect of the number of children on the probabilities of full time co-residence and of division among all children is indeterminate. When financial costs are considered, a large number of children act in favour of full-time institutionalisation as compared to the full time co-residence arrangement. Only the third type of cost goes in a different direction. And a larger number of children reinforces the negative influence of the disappointment effect on the chances of the full time institutionalisation arrangement.

It happens that a parent with many children who would rather live with the same child all the time is not safely closer to obtaining what he wants than a parent with fewer children. A parent with many children is more likely to avoid being institutionalised, but only if the disappointment effect surpasses the other cost effects, which is not very realistic.

Therefore, using the ageing of the population as a motive for reducing the number of children to each parent does not necessarily imply that the unmarried elderly person with adult children will have to rely more on institutions when they need long-term care.

To conclude, we argue that the ageing of the population generates a larger demand for formal care for the elderly, but only to the extent that it is accompanied by a larger incidence of childlessness. An elderly person with no kin in a position to care for them and who is incapable of living alone, is only left with the option of being institutionalised/benefiting from formal care. But, if the dominant rule was to have the elderly live with children, the number of children should not matter. One child should be enough to guarantee the co-residence outcome, even if the costs of care-giving are assumed by just one household.

References

Aquilino W (1990) The likelihood of parent-adult child coresidence: effects of family structure and parental characteristics, Journal of Marriage and the Family 52: 405-419 Burr, J. and J. Mutchler (1992) The Living Arrangements of Unmarried Elderly Hispanic Females, Demography 29(1):93-112 Byrne D, Goeree M, Hiedemann B, Stern S (2004) Formal home health care, and family decision making, draft Checkovich T Stern S (2002) Shared caregiving responsibilities of adult siblings with elderly parents. The Journal of Human Resources 37(3):441-478 Crimmins E and Ingegneri D (1990) Interaction and Living Arrangements of Older Parents and Their Children. Research on Aging 12(1):3-35 Engers M and Stern S (2002) Long Term Care and Family Bargaining. International Economic Review 43(1):1-44 Hiedemann B and Stern S (1999) Strategic Play among Family Members when Making Long-term Care Decisions. Journal of Economic Behavior and Organization 40(1): 29-57 Hoerger T, Picone G, Sloan F (1996) Public subsidies, private provision of care and living arrangements of the elderly. The Review of Economics and Statistics 78(3):428-439 Mutchler J, Burr J (1991) A Longitudinal Analysis of Household and Nonhousehold Living Arrangements in Later Life. Demography 28: 375-390 Speare A, Avery R, Lawton L (1991) Disability, residential mobility, and changes in living arrangements. Journal of Gerontology: Social Sciences 46(3):S133-S142 Spitze G, Logan J (1990) Sons, daughters and intergenerational support, Journal of Marriage and the Family, 52: 420-430

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Spitze G, Logan J, Robinson J (1992) Family structure and changes in living arrangements among elderly nonmarried persons. Journal of Gerontology: Social Sciences 47(6):S289-S296 Wolf D (1994) The Elderly and Their Kin: Patterns of Availability and Access. In: Martin L, Preston S (eds) Demography of Aging. National Academy Press, Washington D.C. 146-194 Wolf D, Soldo B (1988) Household composition choices of older unmarried women. Demography 25(3):387-403 Worobey J, Angel R (1990) Functional capacity and living arrangements of unmarried elderly persons. Journal of Gerontology: Social Sciences 45:S95-S101

V. CONFERENCE SUMMARY

Summary of the third Health and Ageing Geneva Association conference on “Longevity – A Medical and Actuarial Challenge”

By Christophe Courbage

On November 24, 2005, the third Health and Ageing Geneva Association conference graciously hosted by GE Insurance Solutions took place in Munich. The theme was “Longevity – A Medical and Actuarial Challenge” and the conference was attended by 32 persons, coming mainly from European countries but also from China, Japan and the U.S..

The increase in longevity is one of the main improvements of our modern societies. Not only do people in industrialised countries live longer, but they also live healthier. This has, of course, consequences for the coverage of health and longevity risks, and in particular on the provision needed to cover these risks. Based on these premises, the conference focused on two issues: first it addressed the determinants of longevity, and whether they are linked to technological and medical advancements, pharmaceutical advances, or social factors. Second, it dealt with the ways of covering the longevity risk, either via insurance and reinsurance companies, or via securitisation.

The first speaker, Caspar Sieger, Head of medical department at GE Insurance Solutions, addressed the impact of technological and medical improvements on longevity. He presented the most important medical innovations in the 20th century, whether vaccination, disinfection, hormone replacement, antibiotics, anti-tumor therapy or cardiac therapy. He also addressed the influence of various new therapies on morbidity and mortality. According to Caspar Sieger, future progress in medicine will affect three main areas: cancer, heart disease and brain disorder.

Nicolas Pangher, medical director IT and R&D at ITA TBS SpA, looked at the specific area of micro and nano technologies and how these technologies will improve care and its delivery. He presented new techniques obtained from micro and nano technologies such as smart surgery, in vivo diagnostics, DNA chip, drug delivery, implant, home care and tele-medicine. These techniques might revolutionise the way we practise medicine. It might also have a positive impact on quality of life and longevity. Yet, it seems to be that these cares will be at a very high cost, which raises the question of its coverage by insurance companies.

Stephan Mumenthaler, Head of Economic Affairs at Novartis, addressed the role of pharmaceuticals on advances in longevity. New pharmaceuticals have contributed significantly to the increase in life expectancy since the eighties, with some studies suggesting that it accounts for 40% of the increase. He introduced cost-saving illustrations of pharmaceutical and stressed the need for pharmaceutical innovation. Finally, he raised the importance of the four-pillar concept as crucial to the sustainability of social systems.

Steve Wilson, Group Chief Actuary of Zurich Financial Services, looked at the impact of multifactor on longevity: gender, external environment, treatment advances, behavioural risk factors, genetic profile and random events. Longevity and mortality issues differ by type of insurance: life insurers 13 The Geneva Association Health and Ageing N° 14/April 2006 are more concerned with smoking, obesity and pandemics while general insurers rather focus on exposure to industrial diseases. Finally, Steve presented the two models that are used in the U.K. to measure annual mortality improvements.

Axel Boersch-Supan, Professor at the University of Mannheim, spoke about the socio-economic determinants of life expectancy, based on data collected through the SHARE network. While there exists a clear socio-economic gradient for morbidity and mortality, the direction of causality with evidence of moral hazard effect is still unclear. According to Professor Boersch-Supan, the detection of causality would require long-run longitudinal data.

The afternoon sessions were devoted to the coverage of risks linked to longevity. Lucie Taleyson, Head of the International Research and Development Center on Long-term Care Insurance at SCOR Vie, addressed the issue of insuring long-term care. Long-term care is one of the biggest threats for the wealth of elderly, and faced with insufficient state benefits, private long-term care insurance is an essential source of funding for long-term care. There exists two main markets of long-term care insurance with two claim models: France with the cash benefit model, and the US, with the reimbursement model. Lucie presented, in details, the risk modelling for the French model. She showed the importance of every stage of the product cycle: product design, medical approach, actuarial basis, statistical tools, claim management, reserving and risk monitoring.

David Paul, BUPA Group’s actuary, addressed the actuarial difficulties in modelising the longevity risk and presented various projections on future health spending in the UK, based on the Wanless Review, which is the first ever evidence-based assessment of the long-term resource requirements for the NHS. According to this report, in order to meet people’s expectations and to deliver the highest quality over the next 20 years, the UK will need to devote more resources to health care, and that this must be matched by reform to ensure that these resources are used effectively.

Florian Boecker, Head of the actuarial department of life and health at GE Insurance Solutions, wondered whether longevity is reinsurable. It seems that there is a need for longevity insurance, but the added value differs from Life and Living benefits. Suitable reinsurance products exist or can be developed. The question unanswered is whether there is a gap between customer requirements and interest of reinsurers.

Finally, Barbara Blasel, Senior marketer at BNP Paribas, closed the seminar by addressing the issue of longevity bond. This bond is a financial product that offers longevity protection by hedging the trend in longevity. She presented the way it is structured and how it can be placed on the market.

All in all, this seminar gave a broad overview of the medical and actuarial challenges that longevity raises, and the ways the longevity risk can be covered either via insurance or other mechanisms. This is a very important issue, as it happens that in many countries a trend towards private financing of health systems is taking place. Knowing more on the ability of insurance companies or other private entities to take part in the coverage of health and longevity risks gives information to the extent of what may be financed by public and/or private funds. The success of the conference undeniably called for a fourth health & Ageing Geneva Association conference. Thus, we are happy to announce that the fourth issue of the Geneva Health and Ageing conference will take place in Vienna on 6-7 November 2006 and will be hosted by Uniqa. The theme will be “chronic conditions and insurance”. We encourage you to participate in this conference and to suggest topics for presentation. For any further information, please refer to the following page of this newsletter. We look then forward to seeing you in Vienna.

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VI. CALL FOR PARTICIPATIONS

First Announcement

Conference

on

Chronic Conditions and Insurance

Fourth Geneva Association Conference on Health and Ageing

Vienna 6-7 November 2006

hosted and co-organised by UNIQA

The conference will deal with the following topics:

ƒ Chronic conditions and its characteristics

− What are chronic conditions? (cancer, LTC, HIV, arthritis, diabetes, spinal problems…)? − What are the drivers of chronic conditions? (illness, accident, lifestyle)? − What are the cares linked to chronic conditions? − What are the trends for the future?

ƒ Chronic conditions, financial and societal consequences

− What are the financial costs of chronic care for individuals, the society and insurance companies? − Cost of care versus investment in care − What are the life organisations to cope with chronic conditions?

ƒ Ways of preventing and overcoming chronic conditions

− How to prevent chronic conditions? − Health Promotion − The roles of public authorities − The roles of insurance companies

ƒ Organising the coverage of chronic conditions

− Insurance issues (assessment and provision, insurability, affordability, accessibility) − Various types of insurance (life insurance, health insurance, disability insurance, LTC insurance, accident insurance) − Other ways of coverage (securitisation of chronic risks)

Should you want to participate or to contribute, please contact Christophe Courbage, Head of the Health and Ageing Research Programme at: [email protected]

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VII. EDUCATION IN HEALTH ECONOMICS

Advanced Health Leadership Forum, Universitat Pompeu Fabra, Barcelona and University of California, Berkeley, Barcelona, Spain and San Franciso, California, USA. 14-21 July 2006 (Barcelona); 7-13 January (San Francisco)

The Advanced Health Leadership Forum is a certificate-based international health program focusing on key health policy and management issues, emphasizing the health economics and business perspective. Participants grapple in a practical manner with the health policy issues and options that have been converging internationally. They learn policies and management/leadership approaches that work, find out which approaches have been tried and have not been successful, and learn about current innovations. For any further information, please visit http://ahlf.berkeley.edu or contact [email protected]

The Marie Curie Training Programme In Applied Health Economics, 2006-2008

The aims of the programme are to introduce young researchers to the main econometric techniques used in applied health economics, to provide practical experience with the application of these techniques, and to instil a code of good practice in the analysis of health data. The programme consists of three types of event: A two-week training course that will impart the basic knowledge required for the practice of applied health economics. a 3-day “Master Classes” made up of practical workshops on data and software for applied health economics lead by internationally recognised econometricians and health economists, which will preceed, a 3-day international conferences on econometrics and health economics. The programme is aimed at PhD students and young European researchers who are expected to participate in all three types of event. For further information, please visit http://www.york.ac.uk/res/herc/APPHEC

Improving the Quality of Health Services, Harvard School of Public Health, Boston, Massachusetts, USA, August 21 - September 1, 2006

This two-week course will cover a number of topics related to improving the quality of care in health systems. While both theory and practice will be included, the emphasis will be on practical skill building. Topics to be are addressed: Health Sector Reform and Its Relationship to Quality, Management Reform, Overview of Quality, Accreditation, Ethical Issues: Resource Allocation, Professional Norms, Strategic Planning for Quality, Developing and Implementing Clinical Practice Guidelines, Human Resources, Organizational Change, Performance Contracting, Negotiation and Conflict Resolution. For further details, please visit http://www.hsph.harvard.edu/ihsg/training.html

Interdisciplinary Postgraduate Training in Mental Health Policy and Economics Research: ICMPE, Venice, Italy, July 2006 - March 2007

The training offers to the different participants in the field of mental health policy and economics (clinicians, health economists, epidemiologists, health services and health policy researchers, sociologists) an interdisciplinary, rigorous, structured, introductory research training program combining coherently traditional face-to-face and internet-based training. For any further information, please contact [email protected] or visit http://www.icmpe.org

York Expert Workshops on Quality of Life, St. William's College, York University, June-July 2006

The 3-day Quality of Life Workshop provides a detailed introduction to the theory and practice of quality of life measurement with particular emphasis on its use in economic evaluation. For further information, please visit http://www.york.ac.uk/inst/che/training/expert.htm

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VIII. HEALTH CONFERENCES

2006

May 23-26 26th Conference of the Spanish Health Economics Association on "Health Care Production: More is Better?", Toledo, Spain. For further information, please visit http://www.aes.es/Jornadas/jornadas.php

May 31 Consultative Meeting to Achieve Improvements in Health Through a Health Systems Action Network, Washington, USA. For further information, please visit http://www.phrplus.org/hsan.html

June 4-7 American Society of Health Economists Inaugural Conference, Madison, USA. The main theme is on economics of population health. For further details, please visit: www.healtheconomics.us

June 9-11 7th European Network for Mental Health Service Evaluation (ENMESH)), Sweden. For further information, please contact [email protected]

June 10-14 5th International Conference on Health Economics, Management and Policy, Athens, Greece. For further information, please visit http://www.atiner.gr/

June 15 Economics, Ethics and Health Care Funding: UBC Faculty of Medicine and Vancouver Island Health Authority, Victoria, British Columbia, Canada. For any further information, please visit http://www.chii.ubc.ca/workshop

July 6 6th European Conference on Health Economics, Budapest, Hungary. For further information, please visit http://www.eche2006.com/index1.htm

August 21-25 11th world congress on public health, Rio de Janeiro, Brasil. For further information, please visit http://www.saudecoletiva2006.com.br/

August 24 Geneva Association session on “The financing of the longevity risk” at the 4th Congress of the European Union Geriatric Medicine Society, Geneva Switzerland. For further information, contact

September 27-29 The 5th international respite care conference : Take care of the caregivers – social innovation, Evry, France. For further information, please contact [email protected]

October 28-31 Regional Conference on Cost-effective Healthcare 2006 on “Health Systems”, Singapore. For further details, please visit http://www.cehealth2006.com/

November 6-7 4th Geneva Association Health and Ageing Conference on “Chronic conditions and insurance”, Vienna, Austria. For further information, please contact: [email protected]

November 23-24 18th Conference of French Health Economists, Dijon, France. For further information, please visit http://www.ces-asso.org

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IX. PUBLICATIONS ON HEALTH ISSUES

The impact of ageing on public expenditure: projections for the EU25 Member States on pensions, health care, long-term care, education and unemployment transfers (2004-2050), Economic Policy Committee and the European Commission (DG ECFIN) Publication, 2006. The full text of the report can be downloaded from: http://europa.eu.int/comm/economy_finance/publications/european_economy/2006/eesp106en.pdf

Primary Care in the Driver's Seat?, edited by Richard Saltman, Ana Rico, Wienke Boerma, Open University Press, 2005, ISBN 0335213650. Across western, central and eastern Europe, primary care is delivered through a wide range of institutional, financial, professional and clinical configurations. This book is a study of the reforms of primary care in Europe as well as their impacts on the broader co-ordination mechanisms within European health care systems. It also provides suggestions for effective strategies for future improvement in health care system reform.

The Elgar Companion to Health Economics, edited by Andrew M. Jones, Edward Elgar Publishing, 2006, ISBN 1 84542 003 9. This volume covers theoretical and empirical issues in health economics with a balanced range of material on equity and efficiency in health care systems, health technology assessment and issues of concern for low and middle income countries. It is organised into two broad sections. The first deals with the economics of population health and of health care systems, analysed with both equity and efficiency goals in mind. The second covers the conceptual and practical issues that arise in the evaluation of health care technologies: most often applied to pharmaceuticals but also relevant for other interventions.

Projecting OECD health and long-term care expenditures: what are the main drivers?, OECD Working Papers N°477, February 2006. The full report can be doawnloaded from http://europa.eu.int/comm/economy_finance/publications/european_economy/2006/eesp106en.pdf

Caring about Health, by Stan van Hooft, Ashgate Publications, 2006, ISBN 0 7546 5358 7. Presenting a philosophical exploration of the ideas central to health care practice, this book explores such concepts as caring, health, disease, suffering and pain from a phenomenological perspective. With deep philosophical insight this book draws out, not only the ethical demands that arise when one encounters these phenomena, but also the forms of ethical education that would help care workers respond to those demands.

Human Resources for Health in Europe, edited by Carl-Ardy Dubois, Ellen Nolte, Martin McKee, Open University Press, 2005, ISBN 0335218555. The book analyses how the current regulatory processes and practices related to key aspects of the management of the health professions may facilitate or inhibit the development of effective responses to challenges facing health care systems in Europe. The authors document how health care systems in Europe are confronting existing challenges in relation to the health workforce and identify the strategies that are likely to be most effective in optimizing the management of health professionals in the future.

The Status of the Family in Law and Bioethics – The Genetic Context, by Roy Gilbar, Ashgate Publication, 2005, ISBN 0 7546 4545 2. Where do a doctor’s responsibilities lie in communicating diagnostic and predictive genetic information to a patient’s family members? The patient may or may not wish to retain confidentiality, while the relative may either seek information or prefer to remain ignorant. This volume investigates the doctor’s professional legal and ethical obligations in the context of these familial tensions.

Health Policy and High-Tech Industrial Development, edited by Marco Tommaso and Stuart Schweitzer, Edward Elgar Publishing, 2005, ISBN 1 84376 757 0. By veawivng together the fields of health economics, industrial organisation and indistrual development, this book describes the benefit of promoting a country’s health industry as a way of stimulating its high-technology industrial capacity.

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X. GENEVA ASSOCIATION PUBLICATIONS

The Geneva Papers on Risk and insurance – Issues and Practice

Vol. 31, No. 1 / January 2006 CONTRIBUTIONS FROM THE 32ND GENERAL ASSEMBLY OF THE GENEVA ASSOCIATION, MAY 2005 New Markets, New Regulation New Markets, New Regulation: The Latin-American Experience, by Manuel Aguilera-Verduzco New Markets, New Regulation, by Filomeno Mira Candel New Markets, New Regulation and New Prospect—The Chinese Perspective, by Wu Dingfu External Forces Impacting the Insurance Industry External Forces Impacting the Insurance Industry: Threats from Regulation, by James J. Schiro External Forces Shaping the Future of the Insurance Industry, by Gregory V. Serio Our World, by Ron Pressman Future Financial Frameworks Future financial frameworks – Essentials for risk-based capital management, by Nikolaus von Bomhard and Clemens Frey Stochastic Modelling—Boon or Bane for Insurance Industry Capital Regulation?, by Oliver Bäte, Philipp von Plato, Günther Thallinger Natural and Large Catastropes Risk and Value: Changing Perceptions and Cultural Challenges for the Property & Casualty Industry, by Brian O’Hara Natural and Large Catastrophes: Changing Risk Characteristics and Challenges for the Insurance Industry, by John R. Coomber ALSO Group Aspects of Regulatory Reform in the Insurance Sector, by Patrick Darlap and Bernhard Mayr Business Opportunities and Market Realities in Financial Conglomerates, by Sotiris K. Staikouras Economic criteria for compulsory insurance, by Prof. Dr. Michael G. Faure The Challenge of Solvency Reform for European Insurers, by Philippe Trainar

Vol. 31, No. 2 / April 2006 SPECIAL ISSUE ON LAW AND ECONOMICS AND INTERNATIONAL LIABILITY REGIMES Law and Economics (Guest editor: Reimund Schwarze) Editorial, by Reimund Schwarze Fairness and Equality in Insurance Classification, Yves Thiery and Caroline Van Schoubroeck Age as a Variable in Insurance Pricing and Risk Classification, Mary Kelly and Norma Nielson Unisex-Tariffs in Health Insurance, Oliver Riedel Risk Classification and Social Welfare, Michael Hoy International Liability Regimes Mainstreams in the Development of European Tort Law: A Front-Line Snapshot, Bernhard A. Koch Tort Law and Liability Insurance, Gerhard Wagner International Forum Shopping and Transnational Lawsuits, Harald Koch Factors Likely to Influence Tort Litigation in the European Union, Joan Schmit Forum Shopping – A Practitioner’s Perspective, Anthony Fitzsimmons How Important are Insurers in Compensating Claims for Personal Injury in the UK?, Richard Lewis The Social Construction of Bodily Injury, Phil Bell The American Class Action Fairness Act and Forum-Shopping American-Style, Linda S. Mullenix

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The Geneva Risk and Insurance Review (formerly The Geneva Papers on Risk and Insurance Theory) Vol.30, No.2 / December 2005

Uncertainty and the Cost of Reversal, by Giovanni IMMORDINO A Study of Mutual Insurance for Bank Deposits, by Carole BERNARD, Olivier Le COURTOIS and François QUITTARD-PINON Wealth Effects on Self-Insurance and Self-Protection against Monetary and Nonmonetary Losses, by Kangoh LEE Optimal Insurance Design Under a Value-at-Risk Framework, by Ching-Ping WANG, David SHYU and Hung-Hsi HUANG

Recent Working Papers Series “Etudes et Dossiers”

No. 300 / August 2005 THE GENEVA ASSOCIATION’S HEALTH AND AGEING RESEARCH PROGRAMME CONTACTS AND LINKS, Special Issue

No. 301 / October 2005 THE CROs’ SPRING WORKSHOP 2005 OF THE GENEVA ASSOCIATION, ORGANIZED WITH HANNOVER RE, Hannover, 11 –12 May 2005

No. 302 / November 2005 WORLD RISK AND INSURANCE ECONOMICS CONGRESS INAUGURAL CONFERENCE, Salt Lake City, USA, 7 – 11 August 2005

No. 303 / December 2005 ANNUAL LIABILITY REGIMES CONFERENCE ON HOW TO BETTER REACT TO DEVELOPMENTS IN LIABILITY AND INSURANCE, Munich, 26 – 28 October 2005

No. 304 / December 2005 2nd INTERNATIONAL INSURANCE AND FINANCE SEMINAR OF THE GENEVA ASSOCIATION, London, 10 – 11 November 2005

No. 305 / December 2005 3rd HEALTH AND AGEING CONFERENCE ON LONGEVITY – a MEDICAL AND ACTURIAL CHALLENGE, Munich, 24 November 2005

No. 306 / December 2005 3rd ART OF CROs, ANNUAL ROUND TABLE OF CHIEF RISK OFFICERS, Brussels, 3 – 4 October 2005

No. 307 / December 2005 3rd CHIEF COMMUNICATION OFFICERS MEETING, Paris, 8 – 9 December 2005

No. 308 / January 2006 4th ANNUAL MONTEPASCHI VITA FORUM, Rome, 14 October 2005

No. 309 / January 2006 PARIS INTERNATIONAL CONFERENCE ON RISK AND INSURANCE ECONOMICS, Paris, 13 December 2005

No. 310 / March 2006 SOLVENCY II: STRATEGIC STAKES FOR THE INSURANCE INDUSTRY, Brussels, 14 November 2005 & SOLVENCY II: CHALLENGING ISSUES FOR INSURANCE INDUSTRY, Milan, 23 November 2005

No. 311 / March 2006 1st CRO ASSEMBLY 2005 ON CREATING A RISK CULTURE, Rüschlikon, 16 – 17 November 2005

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X. CONFERENCES ORGANISED AND/OR SPONSORED BY THE GENEVA ASSOCIATION

2006 April Chicago Second International Longevity risk and Capital Market Solutions 24 Symposium co-sponsored by The Geneva Association

May 8-9 Bordeaux CRO’s Spring Workshop 2006 17-20 Munich 33rd General Assembly of The Geneva Association (members only) hosted by the German members

August 24 Geneva The Geneva Association Session on The Financing of Longevity Risk at the 4th Congress of the European Union Geriatric Medicine Society

September 18-20 Barcelona 33rd Seminar of the European Group of Risk and Insurance Economists

October 13 Rome Montepaschi Vita Annual Forum, organized by Montepaschi Vita and The Geneva Association 17-18 Zurich 4th ART of CROs. A joint initiative of The Geneva Association and Swiss Re. 26-27 Zurich 3rd Liability Regimes Conference, a joint initiative by Munich Re, RSA, SCOR, Swiss Re, Zurich Financial Services and The Geneva Association

November London 3rd International Insurance and Finance Seminar of The Geneva Association 6-7 Vienna 4th Health & Ageing Conference, hosted by Uniqa 16-17 Madrid 20th MORE (Management of Risks in the Economy) Conference 21-22 Munich 2nd Chief Risk Officer Assembly. A joint initiative of The Geneva Association and Munich Re. 28 Milan European Insurance Forum on “The Insurance Industry and Risk Governance”, co-organized with Macros Risk Management, ANIA and The Geneva Association

December 12 Paris 5th Paris International Insurance Conference, co-organized with the FFSA 14-15 Amsterdam 4th Meeting of the Global Insurance Communications Network, hosted by ING

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