Health Care Financing System Research Articles

External Factors That Influence the Practice of Radiology: Proceedings of the International Society for Strategic Studies in Radiology Meeting.

In both the United States and Europe, efforts to reduce soaring health care costs have led to intense scrutiny of both standard and innovative uses of imaging. Given that the United States spends a larger share of its gross domestic product on health care than any other nation and also has the most varied health care financing and delivery systems in the world, it has become an especially fertile environment for developing and testing approaches to controlling health care costs and value. This report focuses on recent reforms that have had a dampening effect on imaging use in the United States and provides a glimpse of obstacles that imaging practices may soon face or are already facing in other countries. On the basis of material presented at the 2015 meeting of the International Society for Strategic Studies in Radiology, this report outlines the effects of reforms aimed at (a) controlling imaging use, (b) controlling payer expense through changes in benefit design, and (c) controlling both costs and quality through "value-based" payment schemes. Reasons are considered for radiology practices on both sides of the Atlantic about why the emphasis needs to shift from providing a large volume of imaging services to increasing the value of imaging as manifested in clinical outcomes, patient satisfaction, and overall system savings. Options for facilitating the shift from volume to value are discussed, from the use of advanced management strategies that improve workflow to the creation of programs for patient engagement, the development of new clinical decision-making support tools, and the validation of clinically relevant imaging biomarkers. Radiologists in collaboration with industry must enhance their efforts to expand the performance of comparative effectiveness research to establish the value of these initiatives, while being mindful of the importance of minimizing conflicts of interest. © RSNA, 2017.

Are nurses meeting the needs of men in primary care?

Meeting men's health needs by improving healthcare service access is a key objective of comprehensive primary health care. The aims of this qualitative study were to explore the perception of nurses in men's health services and to describe men's expectation of the nurse. The comparative component identifies the barriers and facilitators to improved access to health services. A purposive sample of 19 nurses and 20 men was recruited from metropolitan and regional settings in the state of Victoria, Australia, and each participant was interviewed individually or as part of three focus groups. The main findings were: nurses and men were unclear on the role of the nurse in men's health; and health promotion provided by nurses was predominantly opportunistic. Both participant groups indicated barriers to healthcare access related to: the culture and environment in general practice; limitation of Australia's Medicare healthcare financing system; out-of-pocket costs, waiting time and lack of extended hours; and men not wanting to be perceived as complainers. Facilitators related to: positive inter-professional relations; effective communication; personal qualities; and level of preparedness of nurse education. The findings demonstrate a need for the role to be better understood by both men and nurses in order to develop alternative approaches to meeting men's healthcare needs.

Impact of oncologist payment method on health care outcomes, costs, quality: a rapid review.

BackgroundThe incidence of cancer and the cost of its treatment continue to rise. The effect of these dual forces is a major burden on the system of health care financing. One cost containment approach involves changing the way physicians are paid. Payers are testing reimbursement methods such as capitation and prospective payment while also evaluating how the changes impact health outcomes, resource utilization, and quality of care. The purpose of this study is to identify evidence related to physician payment methods’ impacts, with a focus on cancer control.MethodsWe conducted a rapid review. This involved defining eligibility criteria, identifying a search strategy, performing study selection according to the eligibility criteria, and abstracting data from included studies. This process was accompanied by a gray literature search for special topics.ResultsThe incentives in fee-for-service payment systems generally lead to health care services being applied inconsistently because providers practice independently with few systems in place for developing treatment protocols and practice reviews. This inconsistency is pronounced in cancer care because much of the total per patient spending occurs in the last month of life. Some insurers are predicting that this variation can be reduced through the use of prospective or bundled payments combined with decision support systems. Workload, recruitment, and retention are all affected by changes to physician payment models; effects seem to be magnified in the specialist context as their several extra years of training lower their overall supply.ConclusionsExperimentation with physician payment methods has tended to neglect cancer care providers. Policymakers designing cancer-focused physician reimbursement pilot programs should incorporate quality measurement since very ill patients may receive too little treatment when payment models do not cover oncologists’ total costs, e.g., fee-for-service systems whose prices do not account for the possible presence of other diseases.Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0341-2) contains supplementary material, which is available to authorized users.

Economic Evaluations of First-Line Chemotherapy Regimens for Pancreatic Cancer: A Critical Review.

Effect sizes of efficacy of first-line treatments for (metastatic) pancreas cancer are constrained, underscoring the need for evaluations of the efficacy-to-cost relationship. We critically review economic evaluations of first-line chemotherapy regimens for pancreatic cancer since the 1997 introduction of gemcitabine. We searched PubMed/MEDLINE and EMBASE (1997-2015), and the websites of health technology assessment agencies. Two authors independently reviewed economic studies for eligibility in this review; evaluated peer-reviewed, journal-published studies in terms of the Drummond Checklist; and critiqued the technical and scientific merit of all studies. Sixteen pharmacoeconomic evaluations were included: ten published in nine peer-reviewed journals and six on three websites. Six were on single-agent therapies and ten on combination therapies. Analyses conducted included cost-effectiveness (three studies), cost-utility (one study), or combined cost-effectiveness and cost-utility (12 studies). Studies diverged in results, mainly because of different assumptions, methods, inputs, and country-specific guidelines. The two most recent regimens, nanoparticle albumin-bound paclitaxel plus gemcitabine (NAB-P+GEM) and the combination of fluorouracil, oxaliplatin, leucovorin, and irinotecan (FOLFIRINOX), were evaluated in an indirect comparison, yielding a statistically similar benefit in overall survival but superior progression-free survival for FOLFIRINOX. NAB-P+GEM showed greater economic benefit over FOLFIRINOX. In conclusion, the divergence in results observed across studies is attributable to economic drivers that are specific to countries and their healthcare (financing) systems. No recommendations regarding the relative economic benefit of treatment regimens, general or country-specific, are made as the purpose of pharmacoeconomic analysis is to inform policy decision-making and clinical practice, not set policy or define clinical practice.

Neuropsychology in Finland – over 30 years of systematically trained clinical practice

Objective: The aim of this invited paper for a special issue of international practice in The Clinical Neuropsychologist is to provide information on training models, clinical practice, and professional issues within neuropsychology in Finland. Method: Relevant information was gathered via literature searches, a survey by the Neuropsychology Working Group of the Finnish Psychological Association, archives of the Finnish Neuropsychological Society, and personal communication with professionals in Finland. Results: The roots of Finnish neuropsychology are linked to the early German tradition of experimental psychology. Since the 1970s, it has been strongly influenced by both the psychometric approach in the U.S. and the qualitative approach by Luria. Systematic specialization training program began in Finland in 1983. It was first organized by the Finnish Neuropsychological Society and since 1997 by Finnish universities. At present, around 260 neuropsychologists have completed this training. According to the survey by the Finnish Psychological Association in 2014, 67% of Finnish neuropsychologists work in the public sector, 36% in the private sector, and 28% reported that they had private practice. Work includes assessments for 90% of the respondents, rehabilitation for 74%, and many are involved in teaching and research. Of the respondents, 20% worked both with adults and children, 44% with adults only and 36% with children only. Within test development, pediatric neuropsychology is an especially prominent field. Conclusions: A unique blend of approaches and a solid systematic training tradition has led to a strong position of neuropsychologists as distinguished experts in the Finnish health care system.

Transition to Retirement and Use of Private Health Care.

Associations between retirement and changes in health care use have not been shown in a longitudinal setting. In the Finnish universal health care system, transition into retirement from employment entails loss of access to occupational health care that provides easily accessible primary health care services, which may cause changes in utilization of other health care sectors. The aim of this study was to find out whether transition into old-age retirement is associated with change in utilization of private health care. The panel data consist of a 30% random sample of the Finnish population aged 62-75 in 2006-2011. Register data on National Health Insurance compensation were linked to socio-demographic covariates. Fixed-effects logistic and Poisson regression models were used. Adjusted for changes in covariates, retirement from employment was associated especially with private general practitioner visits but also with specialist visits among both women and men. Interaction analyses showed that retirement was associated with an increase in private care use only among those with higher-than-median income. The results may indicate preferences for quick access to care, mistrust toward the universal system, and problems of the public system in delivering needed services.

Social Responsibility and Healthcare in Finland.

This article examines current trends and prospects in Finnish healthcare literature and discussion. The Finnish healthcare system was long considered to manifest an equal, universal, and solidaristic welfare scheme. However, recent data reveals structural inequalities in access to healthcare that result in health differences among socioeconomic groups. The political will aims at tackling these inequalities, but the ideological trend toward responsibilization of the individual taking place across political spheres elsewhere in Europe creates potential challenges to this goal. The applications of this trend have a theoretical background in the responsibility-sensitive egalitarian-or luck egalitarian-tradition. The theory, which is unfit for real-life policy applications, has explicit appeal in considerations aiming at the responsibilization of the individual within the healthcare sector. It remains to be seen in which direction the Finnish welfare schemes will continue to develop.

Effectiveness of a Wellness Program for Individuals With Spina Bifida and Spinal Cord Injury Within an Integrated Delivery System

ObjectiveTo determine whether an evidence-based wellness program for individuals with spina bifida and spinal cord injury would improve health outcomes and patient experience of care, result in a positive return on investment (ROI), and provide evidence for scalability. DesignNonrandomized, noncontrolled cohort study; 2 years of enrollment. SettingAcademic hospital-based outpatient physiatry clinic partnered with an insurance division within an integrated health care delivery and financing system. ParticipantsIndividuals (N=69) with spina bifida and spinal cord injury were consented; 4 were excluded (5.7%), and the remaining 65 (94.2%) participated in the intervention. InterventionsEvidence-based wellness program consisting of care coordination from a mobile nurse, patient education, and patient incentives. Main Outcome MeasuresValidated measures of function, mood, quality of life, and perception of care delivery; knowledge of preventable conditions; self-rating of health; and utilization and cost. ResultsImprovements in all main outcome measures were seen after 2 years of enrollment. Although cost in year 1 of enrollment increased because of hospitalizations and the overall ROI was negative, a small positive ROI was seen in year 2 of enrollment. ConclusionsParticipation in an evidence-based wellness program was associated with improved health and experience of care. Scaling the program to larger numbers may result in an overall positive ROI.

The development of voluntary private health insurance in the Nordic countries

The Nordic countries represent an institutional setting with tax-based health care financing and universal access to health care services. Very few health care services are excluded from what are offered within the publically financed health care system. User fees are often non-existing or low and capped. Nevertheless, the markets for voluntary private health insurance (VPHI) have been rapidly expanding. In this paper we describe the development of the market for VPHI in the Nordic countries. We outline similarities and differences and provide discussion of the rationale for the existence of different types of VPHI. Data is collected on the population covered by VPHI, type and scope of coverage, suppliers of VPHI and their relations with health providers. It seems that the main roles of VPHI are to cover out-of-pocket payments for services that are only partly financed by the public health care system (complementary), and to provide preferential access to treatments that are also available free of charge within the public health care system, but often with some waiting time (duplicate).Published: April 2016.

Care Utilization with China’s New Rural Cooperative Medical Scheme: Updated Evidence from the China Health and Retirement Longitudinal Study 2011–2012

China's New Rural Cooperative Medical Scheme (NRCMS), a healthcare financing system for rural residents in China, underwent significant enhancement since 2008. Studies based on pre-2008 NRCMS data showed an increase in inpatient care utilization after NRCMS coverage. However evidence was mixed for the relationship between outpatient care use and NRCMS coverage. We assessed whether enrollment in the enhanced NRCMS was associated with less delaying or foregoing medical care, as a reduction in foregoing needed care signals about removing liquidity constraint among the enrollees. Using a national sample of rural residents (N = 12,740) from the 2011-2012 wave of China Health and Retirement Longitudinal Study, we examined the association between NRCMS coverage and the likelihood of delaying or foregoing medical care (outpatient and inpatient) by survey-weighted regression models controlling for demographics, education, geographic regions, household expenditures, pre-existing chronic diseases, and access to local healthcare facilities. Zero-inflated negative binomial model was used to estimate the association between NRCMS coverage and number of medical visits. NRCMS coverage was significantly associated with lower odds of delaying or foregoing inpatient care (OR: 0.42, 95% CI: 0.22-0.81). A negative but insignificant association was found between NRCMS coverage and delaying/foregoing outpatient care when ill. Among those who needed health care, the expected number of outpatient visits for NRCMS enrollees was 1.35 (95% CI: 1.03-1.77) times of those uninsured, and the expected number of inpatient visits for NRCMS enrollees was 1.83 (95% CI: 1.16-2.88) times of those uninsured. This study shows that the enhanced NRCMS coverage was associated with less delaying or foregoing inpatient care deemed as necessary by health professionals, which is likely to result from improved financial reimbursement of the NRCMS.

Russian experience and perspectives of quality assurance in healthcare through standards of care

ObjectivesThe main reform of healthcare system in Russia had begun by introduction of compulsory healthcare insurance in 1993. Since this time, Russia went through number of steps of healthcare system modernization. Most attention was paid to the resource allocation, medical equipment and drug provision, the problem of the low quality of care was repeatedly addressed. Major direction of the efforts was the creation of obligatory technical standards of care. MethodsI studied the volume of publication found in MEDLINE for period 1991–2014 and in the relevant Russian journals not covered by MEDLINE as well as legislation on health care introduced since 1991. ResultsThe review found that despite some increase in volume of funding of health care system, and provision of incentives for quality, the progress with health care quality assurance is slow. The methodology of development of evidence based guidelines is not accepted. The control over conflict of interest of participants of the development of the guiding documents is not introduced. Economic factors are not systematically addressed in decisions on provision of health care interventions. The practice of the health technology assessment does not exist. The system of financial incentives for the quality of care dominates and is developing without evidence based criteria and evidence of its efficacy. ConclusionThe documents prescribing quality healthcare are developing non-systematically in Russia. The acceptance of the modern methodology of guideline development, health technology assessment and control over conflict of interest is needed as a minimum prerequisite for the progress in the quality assurance.

Health reform in Finland: current proposals and unresolved challenges.

The Finnish health care system is widely respected for its pilot role in creating primary-care-led health systems. In the early 1990s, however, a severe economic downturn in Finland reduced public funding and weakened the Finnish system's deeply decentralized model of health care administration. Recent Bank of Finland projections forecasting several decades of slow economic growth, combined with the impact of an aging population, appear to make major reform of the existing public system inevitable. Over the last several years, political attention has focused mostly on administrative consolidation inside the public sector, particularly integration of health and social services. Current proposals call for a reformed health sector governance structure based on a new meso-level configuration of public administration. In addition, Finland's national government has proposed replacing the current multi-channel public funding structure (which includes health insurance subsidies for occupational health services) with a single-channel public funding structure. This commentary examines several key issues involved in reforming the delivery structure of the Finnish health care system. It also explores possible alternative strategies to reform current funding arrangements. The article concludes with a brief discussion of implications from this Finnish experience for the wider health reform debate.

Net Clinical Benefit of Dabigatran Over Warfarin in Patients With Atrial Fibrillation Stratified by CHA2DS2-VASc and Time in Therapeutic Range

BackgroundAlthough dabigatran is 1 of the preferred agents for stroke prevention in atrial fibrillation, warfarin remains the mainstay treatment in many publicly financed health care systems. Little is known about the net clinical benefit of switching patients who are receiving warfarin and have different risk profiles and time in therapeutic range (TTR) to dabigatran. In this study, we aimed to investigate the net clinical benefit of switching warfarin to dabigatran in relation to CHA2DS2-VASc and TTR. MethodsThis was a hospital-based observational registry. ResultsA total of 2153 patients (72.7 ± 12.2 years; CHA2DS2-VASc, 3.65 ± 1.94) were included in the analysis: 1686 patients were receiving warfarin, and 467 were receiving dabigatran. After a 4.2-year follow-up, the incidence of ischemic stroke among patients receiving warfarin and dabigatran were 4.25%/y and 1.89%/y, respectively. Among patients receiving warfarin, ischemic stroke risk was positively correlated with CHA2DS2-VASc score and negatively correlated with TTR. It was found on regression analysis that for every 10% increase in TTR, the incidence of annual ischemic stroke decreased by 0.74%/y (R2 = 0.77; P = 0.04). Patients with higher CHA2DS2-VASc scores had greater ischemic stroke risk reductions per 10% TTR increment (ie, for CHA2DS2-VASc score ≤ 2, 3-4, and ≥ 5, the reductions were −0.38%/y, −0.60%/y, and −0.84%/y, respectively). Similar trends were also observed in intracranial hemorrhage. The net clinical benefit favoured switching from warfarin to dabigatran for all patients, but the best benefit was found in those with high CHA2DS2-VASc and poor TTR. ConclusionsThe combination of CHA2DS2-VASc and TTR facilitates patient prioritization for dabigatran. The best net clinical benefit for switching from warfarin to dabigatran was found in those with both high CHA2DS2-VASc and poor TTR.

Expanding choice of primary care in Finland: much debate but little change so far

“Putting the patient in the driver's seat” is one of the top issues on the health policy agenda in Finland. One of the means believed to promote patient empowerment and patient centeredness is the introduction and further expansion of choice policies with accompanying competition between public and private service providers. However, the Finnish health care system has a highly decentralized administration with multiple funding sources and three different types of providers that people can seek primary care from (municipal health centers, occupational health care services, and private sector providers). This complicates the implementation of choice at the level of primary health care. In this paper, we describe the current policy debates and initiatives promoting the expansion of the choice of primary care provider in Finland. We examine the legislation and policies that have contributed to the current, complex service system in Finland. In light of this examination, we critically discuss the current debate on choice policies as well as the introduction of choice in the context of primary health care.

Finansiranje sistema zdravstvene zaštite u Republici Srbiji (2009-2015)

Health insurance is a branch of social security, which provides insured persons the right to health protection and other rights from the mandatory health insurance. This paper presents an analysis of financing the health care system in the Republic of Serbia, which means the health care, as defined by the Law on Health Care and Health Insurance, in the period from 2009 to 2014. The aim is to identify the major tendencies in funding the health care system and to point out certain irregularities that must be corrected in the future. The health care system of the Republic of Serbia (defined as the model required health insurance and national health services, so-called. ,,National health insurance'), together with the National Health Insurance Fund (which is a state agency for the fiscal allocation of the funds collected social security contributions) there's not enough autonomy in decision-making and performing the activ­ity with large state intervention in the field of health care for the population'. Total expenditures for health care and health insurance in the Republic of Serbia, can be divided into public and private. In Serbia, the pier is a mixed system of financing the health care system, which is characterized by mostly public source of funding, because funding is mainly realized from contributions and from the budget of the Republic. The distribution of funds is done according to the system of financing capacity of health institutions. Changes in the system of health care financing are also planned in the Strategy of development of health insurance in Serbia, by the Steering Board of the Health Insurance adopted in March 2013. When it comes to health care financing, strategy, among other things, provides for the financing of primary health care by the method of capitation and stationary health institutions by the method of diagnostic related groups. All the facts obtained by analyzing the financing of the health care system indicate the need to continue reforming the health care system in the Republic of Serbia.

Making Health Care Truly Affordable after Health Care Reform.

The Affordable Care Act (ACA) is an essential first step toward making health insurance more affordable for lower and moderate income Americans. It has accomplished historic reductions in the proportion of Americans who are uninsured. The number of Americans reporting delaying medical care for financial reasons has declined by approximately one-third since 2010. Medicaid expansions, in particular, have significantly reduced financial burdens and accompanying anxieties experienced by low-income Americans in states that have embraced this opportunity. 4 Consistent with these finding, one recent analysis of credit report data finds that Medicaid expansion was associated with between a $600 and $1000 decline in collection balances among individuals who gained coverage. Notwithstanding these gains, premiums and cost-sharing are still too high for many Americans. And cost-sharing has continued to edge higher for the majority of Americans who have coverage through employer-based plans. Measures to address these challenges must build on the ACA to provide greater protection to millions of Americans and to address continued dissatisfaction with our health care financing system among middle-income Americans.

Community-Based Health Insurance and Out-of-Pocket Healthcare Spending in Africa: Evidence from Rwanda

In the absence of third party and prepayment systems such as health insurance and tax-based healthcare financing, households in many low-income countries are exposed to the financial risks of paying large medical bills from out-of-pocket. In recent years, community based health insurance schemes have become popular alternatives to fill such void in the healthcare financing systems. This paper investigates the impact of these schemes on out-of-pocket spending based on three rounds of nationally representative data from Rwanda. We estimate an Extended Two-Part Model to address endogeniety in insurance enrollment and censoring in healthcare expenditure data. We find that community based health insurance program has non-linear and mixed impacts on out-of-pocket expenditure. While the program significantly increases the probability of overall spending, it decreases the amount of per capita spending on healthcare. The program also significantly reduces spending on drug but increases outpatient spending with no detectable impact on inpatient services. Furthermore, we find notable heterogeneity in treatment effects in which households in the top income distribution realize the highest reduction in out-of-pocket spending.

Analysis of the adoption of new health technology: the case of Dupuytren's disease

Health technology assessment focuses on clinical effectiveness and cost efficiency, but achieving these goals does not guarantee the adoption of a new technology if the incentives of individual decision makers (payers, patients, providers) are not aligned. This study creates a framework for the analysis of the adoption phase. The framework is tested in the case of a new, non-invasive treatment for Dupuytren's disease. The framework is developed based on existing operations management theories. The cost-benefit analysis in the case study utilises information on the Finnish healthcare system, detailed data on the process of the surgical and treatment for Dupuytren's from seven hospital districts and expert interviews on the non-surgical treatment process. The analysis suggests that the new technology will most likely be adopted, but it also shows that there are potential hindrances. The study shows that it is important to consider the incentives of individual operators within the healthcare system.

Государственно-частное партнерство в системе финансирования здравоохранения регионов

Государственно-частное партнерство в системе финансирования здравоохранения регионов

What is an Integrated Health Care Financing and Delivery System (IDS)? and What must would-be IDS Accomplish to Become Competitive with them?

What is an Integrated Health Care Financing and Delivery System (IDS)? and What must would-be IDS Accomplish to Become Competitive with them?