Capitation Payment Research Articles

Adequacy of dental capitation payment at community health centers in the implementation of Indonesian National Health Insurance

Aim: Managed care is considered a cost-control measure to prevent skyrocketing health-care expenditure. The Indonesian government launched National Health Insurance (NHI) at the beginning of 2014, with financial management for dental services that differs based on whether a fee-for-service or capitation scheme is used. This difference in financial schemes may financially affect community health centers (CHCs) that implement NHI. The aim was to compare the adequacy of funds for CHCs based on fee-for-service and capitation revenue in the implementation of Indonesian NHI for dental services. Materials and Methods: This is an observational study with a retrospective research design. Fee-for-service and capitation revenue data were obtained from NHI participants’ dental records at selected CHCs in Yogyakarta Province. The unit analysis included dental services data from January 2014 until December 2014 collected from 30 CHCs selected from rural, suburban, and urban areas. Purposive sampling was used to define the CHC included in the research. Results: The utilization rate and the number of participants affected the adequacy of financial revenue at each CHC sampled. Rural and urban areas had statistically significant differences (independent t-test, P 0.05). Conclusions: The capitation funding scheme for dental treatments in the Indonesian NHI can sufficiently provide a benefit package of eight dental treatments in rural and suburban areas, but not in urban areas.

The impact of capitated payment on preventive care utilization in community health clinics

Only half of the United States population regularly receives recommended preventive care services. Alternative payment models (e.g., a per-member-per-month capitated payment model) may encourage the delivery of preventive services when compared to a fee-for-service visitbased model; however, evaluation is lacking in the United States. This study assesses the impact of implementing Oregon's Alternative Payment Methodology (APM) on orders for preventive services within community health centers (CHCs). This retrospective cohort study uses electronic health record data from the OCHIN, Inc., 2012–2018, analyzed in 2018–2019. Twenty-seven CHCs which implemented APM in 2013–2016 were compared to six non-APM CHCs. Clinic-level quarterly rates of ordering nine preventive services in 2012–2018 were calculated. For each phase and preventive service, we used difference-in-differences analysis to assess the APM impact on ordering preventive care. We found greater increases for APM CHCs compared to non-APM CHCs for orders of mammograms (difference-in-differences estimates (DDs) across four phases:1.69–2.45). Both groups had decreases in ordering cervical cancer screenings, however, APM CHCs had smaller decreases (DDs:1.62–1.93). The APM CHCs had significantly greater decreases in influenza vaccinations (DDs:0.17–0.32). There were no consistent significant differences in pre-post changes in APM vs. non-APM CHCs for cardiometabolic risk screenings, smoking status and depression assessments. There was nonsignificant change in the proportion of nontraditional encounters in APM clinics compared to controls. Transition from fee-for-service to an APM did not negatively impact delivery of preventive care. Further studies are needed to understand how to change encounter structures to best deliver recommended preventive care.

Calibrating Medicaid payment to need for long-term services and supports.

The Massachusetts Medicaid and Children's Health Insurance Program, MassHealth, offers comprehensive Senior Care Options (SCO) plans to its Medicare-eligible members 65 years and older. Historically, MassHealth has paid a fixed per-person capitation rate for any "nursing home-certifiable" SCO member despite considerable heterogeneity of need. Our objective was to develop a model to predict long-term services and supports (LTSS) costs for community-dwelling SCO members. Concurrent predictive modeling. We studied nursing home-certifiable SCO members who were enrolled for at least 183 days during 2016-2017 and used linear models to predict annual cost of community-based LTSS from demographic, medical, social determinants of health, and functional characteristics. We evaluated model performance using predictive performance (R2) and predictive ratios (observed costs divided by predicted costs) for various vulnerable subgroups. The modeling population included 35,259 enrollees. Mean (SD) annualized LTSS cost was $14,071 ($13,174). Functional status (ie, activities of daily living [ADLs] and instrumental ADLs) accounted for most of the variability in community LTSS cost (R2 = 18.4%) explainable by available variables. The Massachusetts SCO (MA-SCO) model (R2 = 21.6%) predicts accurately for several high-cost, vulnerable subgroups. Compared with fixed per-member capitation payments for all, the MA-SCO model reduces, for example, the payment to one plan by 28% and increases that to another by 35%. Predictive models using administrative data and functional status information can appropriately allocate payments for subgroups of members with LTSS needs that differ substantially from average. Calibrating payment to need mitigates incentives for population skimming and promotes the sustainability of mission-oriented organizations.

Custom-made health-care: an experimental investigation

BackgroundPhysicians’ financial interests might conflict with the best service to patients. It is essential to gain a thorough understanding of the effect of remuneration systems on physician behaviour.MethodsWe conducted a controlled laboratory experiment using a within-subject design to investigate physician behaviour underpayment heterogeneity. Each physician provided medical care to patients whose treatments were paid for under fee-for-service (FFS) or capitation (CAP).ResultsWe observed that physicians customized their care in response to the payment system. FFS patients received considerably more medical care than did CAP patients with the same illness and treatment preference. Physicians over-served FFS patients and under-served CAP patients. After a CAP payment reduction, we observed neither a quantity reduction under CAP nor a spillover in FFS patients’ treatment.ConclusionsThe results suggest that, in our experimental model, fee regulation can be used to some extent to control physician spending since we did not identify a behavioural response to the CAP payment cut. Physicians did not recoup lost income by altering treatment behaviour toward CAP and/or FFS patients. Experimental economics is an excellent tool for ensuring the welfare of all those involved in the health system. Further research should investigate payment incentives as a means of developing health care teams that are more efficient.

National Health Insurance Deficit in Indonesia: Identification of Causes and Solutions for Resolution

INTRODUCTION: Since it was implemented in 2014, National Health Insurance Program (JKN) in Indonesia experienced a financial deficit. JKN recorded a deficit of 9.7 trillion, 9.75 trillion and 10.98 trillion rupiah from 2016-2018, respectively. The deficit is estimated to still continue in the upcoming years. Systemic solutions are needed to bring JKN improvement in the future. 
 
 METHODS: Data was collected from June to December 2019 by in-depth interviews with selected informants and literature review, which later was analyzed by content and with data triangulation. 
 
 RESULT: The results of in-depth interviews and a review of some of the literature shows that there are four main factors that causes JKN deficit, which are capitation payment system to provider, the alleged fraud, lag of backed-referral system, and catastrophic disease. 
 
 CONCLUSION: This study provides a solution to the handling of JKN deficits in the short and long term in accordance with problems in terms of funding and JKN expenditure. The solution can be an alternative policy that can be implemented by the Government of Indonesia to deal with the JKN deficit.

Medicaid Behavioral Health Homes: Lessons Learned and Early Findings From Maine.

Individuals with serious mental illnesses represent a high-need, high-cost population. To address this population's needs under the State Innovation Models Initiative, Maine assisted Medicaid-participating behavioral health providers in changing to behavioral health homes (BHHs). The authors explored BHHs' experiences in transforming care from 2014 to 2017 and investigated changes in utilization, care coordination, and Medicaid expenditures before and after Medicaid-covered individuals enrolled in a BHH. The authors interviewed stakeholders, conducted focus groups with BHH consumers and providers, and used pre-post analyses of Medicaid fee-for-service claims. Program features such as capitated payments, connection to the state's health information exchange, and one-on-one technical assistance altered delivery of behavioral health care. Interviewees reported some challenges, such as understanding team roles, sharing clinical data, and integrating care with primary care providers. Analyses of data for 7,560 BHH enrollees with serious and persistent mental illness (adults) or serious emotional disturbance (children) indicated no changes in inpatient admissions, 30-day inpatient readmissions, emergency department visits, behavioral health-related expenditures, and professional expenditures after the switch to the BHH model. Total Medicaid expenditures increased by $170 per beneficiary per month. The BHH model did not change several measures of utilization and expenditures, but it was well received by behavioral health providers. Medicaid programs experimenting with new care delivery models for individuals with complex conditions may look to the Maine experience for guidance in program design.

Medicare Advantage Chart Reviews Are Associated With Billions in Additional Payments for Some Plans.

In the Medicare Advantage (MA) program, private plans receive capitated payments that are adjusted based on their enrollees' number and type of clinical conditions. Plans have the ability to review charts to identify additional conditions that are not present in claims data, thereby increasing risk-adjusted payments. Recently the Government Accountability Office released a report raising concerns about the use of these chart reviews as a potential tool for upcoding. To measure the extent to which plans receive additional payments for chart reviews, and the variation in chart reviews across plans. In this cross-sectional study we use 2015 MA Encounter data to calculate how many additional diagnoses codes were added for each enrollee using chart reviews. We then calculate how these additional diagnosis codes translate to additional reimbursements across plans. A total of 14,021,692 beneficiaries enrolled in 510 MA contracts in 2015. Individual and contract level hierarchical condition category codes, total plan reimbursement. Chart reviews were associated with a $2.3 billion increase in payments to plans, a 3.7% increase in Medicare spending to MA plans. Just 10% of plans accounted for 42% of the $2.3 billion in additional spending attributed to chart review. Among these plans, the relative increase in risk score from chart review was 17.2%. For-profit plans engaged in chart reviews substantially more frequently than nonprofit plans. Given the substantial and highly variable increase in payments attributable to chart review, further investigation of the validity of this practice and its implications for Medicare spending is needed.

Genetic Variant Reinterpretation: Economic and Population Health Management Challenges.

Genetic Variant Reinterpretation: Economic and Population Health Management Challenges.

Quality of Diabetes Care in Blended Fee-for-Service and Blended Capitation Payment Systems

ObjectivesIn the middle to late 2000s, many family physicians switched from a Family Health Group (FHG; a blended fee-for-service model) to a Family Health Organization (FHO; a blended capitation model) in Ontario, Canada. The evidence on the link between physician remuneration schemes and quality of diabetes care is mixed in the literature. We examined whether physicians who switched from the FHG to FHO model provided better care for individuals living with diabetes relative to those who remained in the FHG model. MethodsUsing longitudinal health administrative data from 2006 to 2016, we investigated the impact of physicians switching from FHG to FHO on 8 quality indicators related to diabetes care. Because FHO physicians are likely to be systematically different from FHGs, we employed propensity-score-based inverse probability-weighted fixed-effects regression models. All analyses were conducted at the physician level. ResultsWe found that FHO physicians were more likely to provide glycated hemoglobin testing by 2.75% (95% confidence interval [CI], 1.89% to 3.60%), lipid assessment by 2.76% (CI, 1.95% to 3.57%), nephropathy screening by 1.08% (95% CI, 0.51% to 1.66%) and statin prescription by 1.08% (95% CI, 0.51% to 1.66%). Patients under FHOs had a lower estimated risk of mortality by 0.0124% (95% CI, 0.0123% to 0.0126%) per physician per year. However, FHG and FHO physicians were similar for annual eye examination, prescription of angiotensin-converting enzyme inhibitors (or angiotensin II receptor blockers) and patients’ risk of avoidable diabetes-related hospitalizations. ConclusionsCompared with blended fee-for-service, blended capitation payment is associated with a small, but statistically significant, improvement in some aspects of diabetes care.

Stirring the pot: Switching from blended fee‐for‐service to blended capitation models of physician remuneration

In Canada's most populous province, Ontario, family physicians may choose between the blended fee-for-service (Family Health Group [FHG]) and blended capitation (Family Health Organization [FHO] payment models). Both models incentivize physicians to provide after-hours (AH) and comprehensive care, but FHO physicians receive a capitation payment per enrolled patient adjusted for age and sex, plus a reduced fee-for-service while FHG physicians are paid by fee-for-service. We develop a theoretical model of physician labor supply with multitasking to predict their behavior under FHG and FHO, and estimable equations are derived to test the predictions empirically. Using health administrative data from 2006 to 2014 and a two-stage estimation strategy, we study the impact of switching from FHG to FHO on the production of a capitated basket of services, after-hours services and nonincentivized services. Our results reveal that switching from the FHG to FHO reduces the production of capitated services to enrolled patients and services to nonenrolled patients by 15% and 5% per annum and increases the production of after-hours and nonincentivized services by 8% and 15% per annum.

Technology, Telehealth, and Nephrology: The Time Is Now.

The global health emergency of coronavirus disease 2019 (COVID-19) has brought telemedicine to the forefront of the US health system and transformed the way health care is delivered. Although the need for telehealth to improve social distancing, and protect both patients and providers, was first and foremost in this transition, it has provided a great opportunity to rethink the future of health care with telehealth fully integrated as an option for patients. Some of the known benefits of telehealth include improved access to care, decreased travel time, and cost savings (1), and as we have clearly understood with COVID-19, provision of care during an infectious disease epidemic/pandemic. Patients with CKD and ESKD have a high disease burden, limited resources, and require care in different settings from multiple health care providers, thus contributing to their burden of disease; this may be an ideal patient population to benefit from telemedicine. Technology-based strategies to improve care such as remote patient monitoring, synchronous telehealth visits for both CKD patients and dialysis rounds, and asynchronous dialysis education platforms can be applied to nephrology care to great effect (2,3). Here, we discuss some such strategies that have been used successfully to improve nephrology care and have come to the forefront during this current pandemic. Remote monitoring of treatment adherence has been shown to achieve better BP readings in hypertensives and glycemic control in diabetics, both leading causes of CKD (4). A smartphone-based system to enhance self-care was successfully promoted in advanced CKD patients; prebuilt algorithms provided real-time feedback to patients and alerts to providers when treatment thresholds were exceeded or critical changes occurred (5). Telemedicine, with remote synchronous video visits, has demonstrated equivalent outcomes and reductions in cancelled or “no show” visits in two separate studies conducted at Veteran Affairs health systems (3). The …

Effect of electronic commerce on output and total factor productivity in Kenya

Abstract. Kenya seeks to transform into a middle-income country by 2030 with target annual growth rates of 10 percent. However, this has not been realized since growth rates are under 10 percent while 36 percent of the population lives below the poverty line. Various studies interpret this as an underperformance. However, this study held the view that the economic growth witnessed in the years 2007 to 2018pointed to a resilient economy characterized by average steady growth rates of 5.4 percent despite the deterioration of the global economic outlook. This resilience coincided with the adoption of e-commerce, increased output in absolute values and emphasis of Information and Communication Technology as a key industry under the economic pillar of the Kenya Vision 2030. The period also saw the emergence of mobile payment gateways, which is a key enabler for E-commerce among others. E-commerce activities increase efficiency and ease of doing business by reducing costs and barriers of operation, which are important for achieving economic growth in transition countries such as Kenya. The main objective of the study was to investigate the effect of e-commerce on output and total factor productivity. The study developed a framework following the neoclassical and endogenous growth theories. The study used quarterly time-series data from the period 2007 to 2018 and applied Ordinary Least Squares regression models. The results showed that e-commerce had a positive effect on output. The effect of e-commerce on Total Factor Productivity was positive when considering the value of mobile payments while that of card payments was negative. The results suggest that continued investments towards e-commerce in terms of capital and mobile payments technology will be important for Kenya to sustain output growth and productivity increase. Keywords. E-commerce, ICT, Output, Mobile payments, Total factor productivity. JEL. 011, 033, 041, 047, P24.

Health insurance literacy: discussion and reaction of Facebook users' towards the National Health Insurance in Indonesia.

Universal Health Coverage always persevered as a pro poor policy in many countries, characterized by a major impact on higher out-of-pocket healthcare costs, with low-cost alternative prescription drugs and capitation payments made to physicians, in order to reduce inequity. These concerns have been discussed widely on social media, including Facebook, but social media are consistently neglected as a source of scientific information. The purpose of this study, therefore, is to analyze the thought process or feelings of individuals about the policies, also focusing on the possible reactions. Hence, a systematic review in the form of discussion forums on the Facebook page of the National Health Insurance Agency, Indonesia was conducted from 2015 to 2016, with regards to the implementation of National Health Insurance, within a year and half after the policy was launched. In addition, the contents of 148 discussions were deductively analyzed, and the findings showed the pragmatic disposition of most Facebook users towards health care utilization, the costs of Insurance, and the possible benefits of payment. Furthermore, the debate conducted in social media related with the policy and its practice issues ought to be countered through appropriate modification.Significance for public healthSocial media has been incorporated for the communication of health strategies in Indonesia, through the discussions related to National Health Insurance policies. Social media can provide opportunities to better understand the concept of health insurance literacy and facilitate growth in social norms and skills, as participants of online forums. Until now, there is a deficiency in studies related to the use of social media as source of news where people pay attention to specific issues. This study analyzes the thought process and feelings of individuals, as well as the reaction towards the National Health Policies implemented.

Preferences of healthcare providers for capitation payment in Kenya: a discrete choice experiment.

Provider payment mechanisms (PPMs) are important to the universal health coverage (UHC) agenda as they can influence healthcare provider behaviour and create incentives for health service delivery, quality and efficiency. Therefore, when designing PPMs, it is important to consider providers’ preferences for PPM characteristics. We set out to uncover senior health facility managers’ preferences for the attributes of a capitation payment mechanism in Kenya. We use a discrete choice experiment and focus on four capitation attributes, namely, payment schedule, timeliness of payments, capitation rate per individual per year and services to be paid by the capitation rate. Using a Bayesian efficient experimental design, choice data were collected from 233 senior health facility managers across 98 health facilities in seven Kenyan counties. Panel mixed multinomial logit and latent class models were used in the analysis. We found that capitation arrangements with frequent payment schedules, timelier disbursements, higher payment rates per individual per year and those that paid for a limited set of health services were preferred. The capitation rate per individual per year was the most important attribute. Respondents were willing to accept an increase in the capitation rate to compensate for bundling a broader set of health services under the capitation payment. In addition, we found preference heterogeneity across respondents and latent classes. In conclusion, these attributes can be used as potential targets for interventions aimed at configuring capitation to achieve UHC.

Pediatric outpatient utilization by differing Medicaid payment models in the United States

BackgroundIn the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients’ healthcare utilization. Adults in capitated plans utilize primary care providers (PCP) more than emergency departments (ED), compared to fee-for-service (FFS). Pediatric data are lacking. We aim to determine the association between US capitated and FFS Medicaid payment models and children’s outpatient utilization.MethodsThis retrospective cohort compared outpatient utilization between two payment models of US Medicaid enrollees aged 1–18 years using Truven’s 2014 Marketscan Medicaid database. Children enrolled > 11 months were included, and were excluded for eligibility due to disability/complex chronic condition, lack of outpatient utilization, or provider capitation penetration rate < 5% or > 95%. Negative binomial and logistic regression assessed relationships between payment model and number of visits or odds of utilization, respectively.ResultsOf 711,008 children, 66,980(9.4%) had FFS and 644,028(90.6%) had capitated plans. Children in capitated plans had greater odds of visits to urgent care, PCP-acute, and PCP-well-child care (aOR 1.21[95%CI 1.15–1.26]; aOR 2.07[95%CI 2.03–2.13]; aOR 1.86 [95%CI 1.82–1.91], respectively), and had lower odds of visits to EDs and specialty care (aOR 0.82 [95%CI 0.8–0.83]; aOR 0.61 [95%CI 0.59–0.62], respectively), compared to FFS.ConclusionsThe majority of children in this US Medicaid population had capitated plans associated with higher utilization of acute care, but increased proportion of lower-cost sites, such as PCP-acute visits and UC. Health insurance programs that encourage capitated payment models and care through the PCP may improve access to timely acute care in lower-cost settings for children with non-complex chronic conditions.

Measuring Patient Activation as Part of Kidney Disease Policy: Are We There Yet?

Optimal care occurs when patients possess the skills, knowledge, and confidence needed to effectively manage their health. Promoting such patient activation in kidney disease care is increasingly being prioritized, and patient activation has recently emerged as central to kidney disease legislative policy in the United States. Two options of the Centers for Medicare and Medicaid Services Kidney Care Choices model-the Kidney Care First option and the Comprehensive Kidney Care Contracting option-now include patient activation as a quality metric; both models specifically name the patient activation measure (PAM) as the patient-reported outcome to use when assessing activation in kidney disease. Because nephrology practices participating in these models will receive capitated payments according to changes in patients' PAM scores, it is time to more critically evaluate this measure as it applies to patients with kidney disease. In this review, we raise important issues related to the PAM's applicability to kidney health, review and summarize existing literature that applies this measure to patients with kidney disease, and outline key elements to consider when implementing the PAM into practice and policy. Our aim is to spur further dialogue regarding how to assess and address patient activation in kidney disease to facilitate best practices for supporting patients in the successful management of their kidney health.

PCN221 OCM TO OCF: IMPLICATIONS FOR TOTAL COST OF CARE

To map the limitations of the Oncology Care Model (OCM) to the proposed features of the 2021 Oncology Care First (OCF) model in order to evaluate whether the OCF is more likely to successfully reduce total cost of care. The study employed a pragmatic literature review to identify key shortcomings of the current OCM model with respect to lowering total cost of care. Interviews with thought leaders in the field of value-based payment models helped to then shed light on whether the OCF would address these gaps. These findings were mapped to specific features (e.g., two-sided risk, tumor-specific adjustments) proposed for the OCF. Several elements within the OCM have led to participants achieving subpar improvements on total cost and quality of care. These include insufficient consideration of tumor-specific care differences, challenges with accurate patient attribution, diminishing returns from self-benchmarked price targets, and insufficient timely feedback on performance metrics. The OCF attempts to address the first two issues by including new tumor-specific calculation methods and providing prospective payments to any oncology patient managed by a participating practice. However, the partially capitated prospective payment, the requirement for electronic Patient Reported Outcomes (ePRO), and the faster trajectory towards two-sided risk will likely drive a bias in OCF participation towards innovative practices. These practices will continue to suffer from diminishing benefits of further improvement, and with an updated novel therapies adjustment, they may experience an increase in drug-related total cost of care. While the OCF model builds upon the OCM, there are still several components that have been critiqued under OCM and remain unaddressed. Given past OCM experiences, the OCF may ultimately follow a similar trajectory and have limited impact on the total cost of care unless solutions to these issues are included in the final program design.

Can Big Data Cure Risk Selection in Healthcare Capitation Programs?

Problem definition: This paper analyzes a market design problem in Medicare Advantage (MA), the largest risk-adjusted capitation payment program in the U.S. healthcare market. Evidence exists that the current MA capitation payment program unintentionally incentivizes health plans to cherry pick profitable patient types, which is referred to as selection. However, the root causes of the risk selection are not comprehensively understood, which we study in this paper. Academic / Practical Relevance: The existing literature primarily attributes the observed risk selection in MA market to data limitations and low explanatory power (e.g. low R^2) of the current risk adjustment design. As a result, the current understanding and expectation are that risk selection would gradually disappear over time with increased availability of big data. However, if informationally imperfect risk adjustment is not the only cause of risk selection, big data would provide false assurance to key stakeholders, which we investigate in this paper. Given that risk-adjusted capitation payment models have been increasingly adopted by payers in the U.S., our study would be of primary interest to payers, providers and policy makers in the healthcare market. Results: This paper shows that big data alone cannot cure risk selection in the MA capitation program. In particular, we show that even if the current MA risk adjustment design became informationally perfect (e.g. R^2=1), health plans would still have incentives to conduct risk selection, as imperfect risk adjustment is not the only cause of risk selection in the MA market. More specifically, we show that incentives would continue to persist for risk selection in the age of big data through strategically subsidizing some subgroups of patients using capitation payments collected from other subgroups, which we call selection induced by cross subsidization''. We further propose a simple mechanism to address this risk selection problem induced by cross subsidization in MA. Methodology: We construct a game-theoretical model to derive the MA capitation rates under informationally perfect risk adjustment, and show that these capitation rates cannot eliminate risk selection in MA. Managerial Implications: To eliminate risk selection, payers should modify their current capitation mechanisms to take into account the cross subsidization incentives, as proposed in this paper.

Unblocking Barriers of Access to Hepatitis C Treatment in China: Lessons Learned from Tianjin.

Background:The high price is a critical barrier of access to new direct-anting-antiviral (DAA) therapies for hepatitis C for both the patients and the society. Many countries continue to face the challenge of financing such expensive medicines. Such examples include both high-income and middle-income countries. Existing evidence about the efforts of China to address this challenge is limited. To our knowledge, this is the first detailed description of a novel financing model and comprehensive analysis of its impact on patient financial burden of hepatitis C treatment in China.Objective:To examine the evolution of approaches to navigating patients’ barriers of access to DAA-based treatment of hepatitis C in Tianjin City, China.Methods:Review of publicly available literature, including published and grey literature. Conduct on-site data extraction and key informant interview. The patient financial burden of hepatitis C treatment was analyzed. The financial burden of hepatitis C patients with different treatment models and health insurance financing models was measured by calculating the number of annual income to cover patient out-of-pocket (OOP) expenditure for the standard treatment course accordingly.Findings:Tianjin is the first area to pilot a capitated provider payment program for the treatment of hepatitis C. Through which, the retirees and employees spend 0.7 and 1.0 months of their salary, and residents spend 5.6-6.8 months of their salary for the treatment, the financial burden of patients were much relieved. By the end of March 2019, the first-year pilot program had 876 hepatitis C patients registered the new insurance coverage and treated in Tianjin.Conclusions:The study showed that the financial barriers of access to new hepatitis C treatment for patients could be unblocked with government commitment and novel financing models. International experiences demonstrated that centralized bulk procurement is a good leverage for price negotiation, primarily when using innovative payment approaches. To replicate the initial success of Tianjin, continued efforts are needed for stronger strategic price negotiation, preferably at central level. The case of Tianjin brings implications to the other areas of China and even other developing countries that government commitment, novel financing model and pooled procurement are critical elements of stronger purchasing power and a better secure of treatment.

The Ethics of Universal Health Insurance

The Ethics of Universal Health Insurance