General Health Insurance Research Articles

Optimal ex post risk adjustment in markets with adverse selection

This paper studies general health insurance markets and proposes a scheme of transfers among a regulator and insurers that discourages risk selection and promotes efficient competition. The proposed scheme conditions transfers on the ex post profits of insurers and requires the regulator to hold minimal information to implement it. Equilibrium exists and each equilibrium allocation is efficient in any environment with a finite number of types and states even if single-crossing is not satisfied. I argue that the proposed scheme features the characteristics of ex post risk adjustment.

The Cost of Prenatal Care Services in the City of Aydın: A Cross-Sectional Study.

To determine the cost of prenatal care services provided to pregnant women in the city of Aydın, Turkey. This cross-sectional study was conducted over the period of February-December 2016 at the Aydın Maternity and Children's Hospital. The convenience sampling method was used to recruit 403 women who were in weeks 36-42 of pregnancy into the study. Data for the study were collected with the Descriptive Information Form and the Prenatal Care Service Usage Form. Descriptive statistics, Mann-Whitney U and Kruskal-Wallis tests were used to analyse data. It was determined that the pregnant women were followed up an average total number of 10.94±4.30 times and 97.0% received care at the state hospital. It was found that for each pregnant woman, the mean total cost of prenatal care was $138.77±$93.44, the sum paid by general health insurance was $96.12±$46.38, individual contributions stood at $25.05±$10.43 and payments made to the private institutions was $110.32±$142.31. It was observed that the total prenatal care cost was not influenced by some of the characteristics of the pregnant women. It was revealed in the study that most pregnant women received prenatal care at the state hospitals and at family health centers and that they had approximately 11 prenatal care follow-ups amounting to a total mean cost of about $139. A contribution can be made to making prenatal care more cost-effective by organizing the number and scope of prenatal care sites on the basis of the individual characteristics of risk factors pregnant women.

P4.14: Financial burden of critically-ill patients receiving parenteral nutrition (PN) in a reference intensive care unit (ICU) in Istanbul: An additional cost from Syrian refugees

Introduction: The number of critically-ill patients has increased over the years due to progress in intensive care medicine and parenteral nutrition (PN) techniques. Long-term survival is possible and does not depend only primarily on the disease etiology (head trauma and pulmonary complications etc.) but on accompanying morbidities and complications such as central venous catheter infections. Prolonged ICU admissions are costly as well. Therefore, covering the cost of these critical patients (primary disease treatment including interventional and surgical issues, all consultations and treatment protocols) is an important issue, and having health insurance coverage for their treatment and all of the needed follow-up care (including almost 4 millions Syrian refugees, as well) is critical. Methods: A computer-based analysis was done retrospectively to search the covering health insurance programmes of our patients treated in our adult ICUs during January to December 2018. Syrian refuees were also included in the study, as state insurance coverage was supplied to all. Other then known government-issued general health insurance, private health insurance options and the payments done by the patients’ own resources were also interrogated. Results: A total of 186 patients were included in the study. Mean age was 51 years (range, 18–91). The average period of ICU stay was 45 days (range, 1–204), including longer hospitalization time due to surgical complications or existing comorbidities. The postoperative stay in intensive care unit (ICU) was also included in this period. In our data, the only health insurance coverage was seen to be supplied by the state (n=186, 100 %). There was no private insurance coverage. No patients used their own financial resources for treatment, as well (including Syrian refugees). Conclusion: It is well-known that state insurance in Turkey covers all policlinic applications and postdischarge home care (including all refugees), and patients pay only a small amount of fee as employee contribution for the medications at pharmacies. The new information in the present study is the governmental coverage of all Syrian refugees in ICUs, as well. Taking the great amount of bill that an ICU patient should encounter, the importance of state insurance is obvious for the comfort of patient and the ease of financial portion of their treatment.

Legal perspectives on black box recording devices in the operating environment.

BackgroundA video and medical data recorder in the operating theatre is possible, but concerns over privacy, data use and litigation have limited widespread implementation. The literature on legal considerations and challenges to overcome, and guidelines related to use of data recording in the surgical environment, are presented in this narrative review.MethodsA review of PubMed and Embase databases and Cochrane Library was undertaken. International jurisprudence on the topic was searched. Practice recommendations and legal perspectives were acquired based on experience with implementation and use of a video and medical data recorder in the operating theatre.ResultsAfter removing duplicates, 116 citations were retrieved and abstracts screened; 31 articles were assessed for eligibility and 20 papers were finally included. According to the European General Data Protection Regulation and US Health Insurance Portability and Accountability Act, researchers are required to make sure that personal data collected from patients and healthcare professionals are used fairly and lawfully, for limited and specifically stated purposes, in an adequate and relevant manner, kept safe and secure, and stored for no longer than is absolutely necessary. Data collected for the sole purpose of healthcare quality improvement are not required to be added to the patient's medical record.ConclusionTransparency on the use and purpose of recorded data should be ensured to both staff and patients. The recorded video data do not need to be used as evidence in court if patient medical records are well maintained. Clear legislation on data responsibility is needed to use the medical recorder optimally for quality improvement initiatives.

Prevalence of prescribed benzodiazepine long-term use in the French general population according to sociodemographic and clinical factors: findings from the CONSTANCES cohort

BackgroundData are lacking regarding the prevalence of benzodiazepine long-term use in the general population. Our aim was to examine the prevalence of prescribed benzodiazepine long-term use (BLTU) according to sociodemographic and clinical factors in the French general population.MethodsData came from 4686 men and 4849 women included in 2015 in the French population-based CONSTANCES cohort. BLTU was examined using drug reimbursement administrative registries from 2009 to 2015. Analyses were weighted to provide results representative of the French general population covered by the general health insurance scheme. Weighted prevalence of BTLU and weighted Odds Ratios (OR) of having BTLU were computed with their 95% Confidence Interval (95% CI) according to age, education level, occupational status, occupational grade, household income, marital status, alcohol use disorder risk and depressive symptoms. All the analyses were stratified for gender.ResultsWeighted prevalence of BLTU were 2.8%(95% CI:2.3–3.4) and 3.8%(95% CI: 3.3–4.5) in men and women, respectively. Compared to men, women had an increased risk of having benzodiazepine long-term use with OR = 1.34(95% CI = 1.02–1.76). Aging, low education, not being at-work, low occupational grade, low income, being alone and depressive state were associated with increased risks of having BTLU.ConclusionsBLTU is widespread in the French general population, however this issue may particularly concern vulnerable subgroups. These findings may help in raising attention on this public health burden as well as targeting specific at-risk subgroups in preventive intervention.

Trends in Eye Care Use and Eyeglasses Affordability

Understanding eye care use over time is essential to estimate continued unmet health care needs and help guide future public health priorities. To update trends in using eye care and affording eyeglasses in the United States. This analysis of data from the US National Health Interview Survey included adults 18 years and older from 9 annual cross-sectional population-based samples ranging in size from 21 781 to 36 697 participants from 2008 to 2016. Data were analyzed from August 2017 to February 2018. Visual impairment, defined as self-reported difficulty seeing despite wearing eyeglasses. Outcome measures included visits to an eye care professional and inability to afford eyeglasses when needed in the past year. Survey logistic regression, adjusted for age, sex, race/ethnicity, visual impairment status, education, employment, general health, poverty-income ratio, and vision insurance, was used to examine associations between survey year and eye care outcomes. Analyses included 9 annual cross-sectional population-based samples pooled from 2008 to 2016, ranging in size from 21 781 to 36 697 participants aged 18 years or older. Compared with 2008, greater proportions of the US population were 65 years or older, Hispanic, or Asian in 2016. There was a significant trend for eye care use and difficulty affording eyeglasses from 2008 to 2016. In fully adjusted models, Americans were less likely to use eye care in 2014 compared with 2008 (odds ratio [OR], 0.90; 99.9% CI, 0.82-0.98; P < .001). Compared with 2008, Americans were also less likely to report difficulty affording eyeglasses from 2014 onwards (2014: OR, 0.82; 99.9% CI, 0.69-0.97; P < .001; 2015: OR, 0.81; 99.9% CI, 0.69-0.96; P < .001; 2016: OR, 0.70; 99.9% CI, 0.59-0.82; P < .001). After adjusting for all covariates, including survey year, those with visual impairment compared with those without were more likely to use eye care (OR, 1.54; 99.9% CI, 1.45-1.65; P < .001) but had greater difficulty affording eyeglasses (OR, 3.86; 99.9% CI, 0.58-0.72; P < .001). Women were also more likely to use eye care (OR, 1.42; 99.9% CI, 1.37-1.48; P < .001) and report difficulty affording eyeglasses (OR, 1.68; 99.9% CI, 1.56-1.81; P < .001) compared with men. Compared with non-Hispanic white individuals, black, Asian, and Hispanic individuals were less likely to use eye care, and Asian and black individuals were less likely to have difficulty affording eyeglasses. These data indicate decreased difficulty affording eyeglasses among Americans from 2014 to 2016, possibly related to economic recovery and health care reform. However, the findings suggest women and racial/ethnic minorities are more likely to have lower use of eye care or inability to afford eyeglasses.

Evaluation of the Incidence of Hematologic Malignant Neoplasms Among Breast Cancer Survivors in France

Breast cancer survivors are at an increased risk of developing certain types of hematologic malignant neoplasm after diagnosis. To estimate the incidence of various types of hematologic malignant neoplasm in breast cancer survivors, both in absolute terms and in association with the general population. This nationwide cohort study conducted in France used data from the French National Health Data System, a database that contains all of French residents' health-related expenses. All French women aged 20 to 85 years with an incident breast cancer diagnosis between July 1, 2006, and December 31, 2015, were included (n = 439 704) and followed up until hematologic malignant neoplasm occurrence, death, loss of follow-up, or December 31, 2016, whichever came first. Comparisons were made with all French women in the general population who were registered in the French general health insurance program each year from January 1, 2007, and December 31, 2016. Data analysis was performed from January 23, 2018, to May 25, 2018. Main outcomes were incident hematologic malignant neoplasm cases occurring at least 6 months after breast cancer diagnosis. The various types of hematologic malignant neoplasm considered were acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), myeloproliferative neoplasms (MPNs), multiple myeloma (MM), Hodgkin lymphoma or non-Hodgkin lymphoma (HL/NHL), and acute lymphoblastic leukemia or lymphocytic lymphoma (ALL/LL). Incidence of these various types was estimated among breast cancer survivors and compared with the incidence in women in the general population. The 439 704 women in the study had a median (interquartile range [IQR]) age of 59 (50-69) years and were followed up for a median (IQR) duration of 5 (2.8-7.5) years. Overall, 3046 cases of hematologic malignant neoplasm occurred: 509 cases (16.7%) of AML (crude incidence rate [CIR] per 100 000 person-years, 24.5; 95% CI, 22.4-26.8), 832 cases (27.3%) of MDS (CIR, 40.1; 95% CI, 37.4-42.9), and 267 cases (8.8%) of MPN (CIR, 12.8; 95% CI, 11.4-14.5). Lymphoid neoplasm cases included 420 cases (13.8%) of MM (CIR, 20.3; 95% CI, 18.4-22.3), 912 cases (29.9%) of HL/NHL (CIR, 44.4; 95% CI, 41.1-50.0), and 106 cases (3.5%) of ALL/LL (CIR, 5.1; 95% CI, 4.2-6.2). Compared with the general population, breast cancer survivors had statistically significantly higher incidence of AML (standardized incidence rate ratio [SIRR], 2.8; 95% CI, 2.5-3.2) and MDS (SIRR, 5.0; 95% CI, 4.4-5.7) and, to a lesser extent, MM (SIRR, 1.5; 95% CI, 1.3-1.7]) and ALL/LL (SIRR, 2.0; 95% CI, 1.3-3.0). The finding that AML and MDS still occur among breast cancer survivors today, and that ALL/LL and MM may also be of concern, merits the continuous monitoring of hematologic malignant neoplasms and the thorough investigations into their underlying mechanisms.

Why enterprises need to adopt ‘need-to-know’ security

A host of different cyber attacks – including phishing and ransomware, advanced persistent threats conducted by nation-state actors, zero-day exploits and more – are forcing security professionals to bring their ‘A game’ to work every day. In addition to these attacks, information security professionals must manage information in compliance with data privacy regulations such as the General Data Protection Regulation (GDPR) and Health Insurance Portability and Accountability Act (HIPAA) or else face stiff fines. Massive data breaches and large penalties imposed by regulatory bodies show no signs of abating and continue to make headlines across the world. To thwart new attacks and prevent breaches, you need to develop a new mindset that challenges the status quo and nurtures new ways of thinking, especially when it comes to protecting information assets. Traditional approaches are being rendered ineffective by social engineering attacks, globalisation and the Internet of Things. In the face of these and other challenges, a multipronged approach with a ‘need-to-know’-based security model at the foundation is an effective strategy to secure enterprise information and prevent a breach, explains Aaron Rangel of iManage.

Knowledge and perceptions about dental health insurance among dental practitioners of Jaipur City

Background: The general health insurance plans merely cover the hospitalization and medicinal costs. Dental insurance is meant to insure people against the dental disease and their expense of treatment. Aim: The aim of the study is to assess the knowledge and perceptions regarding dental health insurance among private dental practitioners of Jaipur city. Material and Methods: A cross-sectional study was conducted among private dental practitioners aged 25–59 years in Jaipur city, a 20-item self-designed questionnaire was used to assess the knowledge and perceptions regarding dental health insurance. Data were analyzed using MedCalc software version 14.2.1.0. Chi-square test was applied for analyzing the categorical data. The confidence interval and level of significance were set at 95% and P ≤ 0.05, respectively. Results: The dental practitioners were aware of dental insurance, and the Internet was found to be the major source of knowledge (57.00%) regarding dental health insurance, and there was statistically significant (P = 0.026) difference between male and female dental practitioners (39 males and 18 females). Overall, 80% of the dental practitioners felt that individuals with numerous or ongoing oral health problems are more likely to purchase dental insurance. Cashless treatment facility was found to be the biggest (62.00%) influencing factor affecting the health insurance subscriptions; also, there was a statistically significant difference (P = 0.001) between male and female dental practitioners about the same. Conclusion: In the present study, dental insurance has been found to be associated with higher rates of visiting for a checkup and regular dental visiting and was correlated with patient acceptance of prescribed dental treatment, which suggests that insured individuals may face fewer financial barriers to comprehensive dental care.

Optimal Ex Post Risk Adjustment in Markets with Adverse Selection

This paper studies general health insurance markets. It proposes an ex post risk adjustment scheme that discourages risk selection and promotes efficient competition. Under the proposed risk adjustment scheme, the regulator engages in transfers that are conditional on the ex post profits of insurers. The risk adjustment scheme is entirely budget balanced, as it does not call for government subsidies, and requires the regulator to hold minimal information to implement it. Equilibrium is shown to exist and be efficient in any environment with a finite number of types and states even if single-crossing is not satisfied.

Association between insurance status, anticoagulation quality, and clinical outcomes in patients with acute venous thromboembolism

IntroductionA higher level of health insurance coverage may be related to better quality of care and outcomes. Whether insurance status is associated with anticoagulation quality and clinical outcomes in patients with venous thromboembolism (VTE) is unknown. MethodsWe studied 819 elderly patients treated with vitamin K antagonists for VTE in a Swiss prospective multicenter cohort (09/2009–12/2013). The study outcomes were the anticoagulation quality, defined as the time spent in the therapeutic INR range, and clinical events, i.e. the time to a first VTE recurrence, major bleeding, and mortality. We assessed the association between insurance status (private vs. general), anticoagulation quality, and clinical outcomes using regression models, adjusting for potential confounders. ResultsAlthough the unadjusted mean percentage of time spent in the therapeutic INR range (2.0–3.0) was slightly higher in patients with private vs. general insurance (65% vs. 61%; p = 0.030), the adjusted difference was not statistically significant (1.53%, 95% CI −1.97 to 5.04). Patients with private insurance had a lower 36-month cumulative incidence of major bleeding (9.7% vs. 15.7%; p = 0.018). After adjustment, privately insured patients had a lower risk of major bleeding compared to patients with general insurance (sub-hazard ratio 0.57, 95% CI 0.32 to 0.98). Insurance status was not associated with recurrent VTE or mortality. ConclusionPrivately insured patients spent somewhat more time in therapeutic INR range and had a lower rate of major bleeding than generally insured patients. Basic (general) health insurance may be a marker of lower anticoagulation quality and higher risk of major bleeding.

PCV66 - COSTS OF EARLY REHABILITATION AFTER STROKE IN CZECH CEREBROVASCULAR CENTERS

In 2010, a network of cerebrovascular centers was established in the Czech Republic. Their integral parts are inpatient early rehabilitation units. This rehabilitation is much more intense than in general rehabilitation wards, which makes it more expensive. The goal of the study was to calculate the costs of the early rehabilitation units after stroke, and initiate the change of (DRG based) reimbursement of this type of care. The sample consisted of 94 patients with stroke diagnosed after 01 April 2017 recruited in three hospitals (Prague-30, Ostrava-30, Ústí nad Labem-34). There were 55 men and 39 women, the age ranged from 31 to 95 years. The costs were calculated by microcosting for each patient in the sample separately. Quantitative data (amounts, times) were recorded continuously into patient sheets. The collected data were processed by statistical modules of MS Excel and R Commander. It was proved that the costs of rehabilitation treatment depend on the degree of disability of the patients. The patients were categorized into 4 disability groups in agreement with the Czech Reimbursement Decree (Decree No. 134/1998 Coll. as amended). Then the costs ranged from CZK68,825 to CZK167,530 for the whole time of hospitalization, or from CZK4,283 to CZK6,164 as a one-day average. The main differences were in material costs and nursing costs. Cost and functional differences in early rehabilitation within a single diagnosis (stroke) were proved. The project showed that the costs of treatment grow with the severity of the damage, while this relation is more obvious in the motor domain and less expressed (although also present) in the cognitive domain. The results were presented to the General Health Insurance Company to be used in the reimbursement revision.

Patterns and profiles of methylphenidate use both in children and adults.

The aim of the present study was to characterize patterns of use of methylphenidate (MPH), a prescription stimulant medication recommended in the treatment of attention deficit hyperactivity disorder (ADHD) and of narcolepsy, in France, both in children and adults, over a 3-year period. Using the French General Health Insurance database, limited to two areas covering approximately 4 million individuals, we made up a cohort of incident MPH users between July 2010 and June 2013. Splitting them into distinct age groups (18-24, 25-49 and ≥50years of age for adults and <6, 6-11 and 12-17 years of age for children), we established the characteristics of these populations at MPH initiation and during follow-up according to the duration of treatment, quantities dispensed and coprescription with central nervous system (CNS) drugs. We included a cohort of 3534 incident users, involving 30 238 dispensings of MPH, leading to an annual rate of 29 incident users per 100 000 in 2013. Children (66% of new users) were characterized by long-term use of MPH with few comedications. The group of 25-49-year-old patients were dispensed MPH more frequently than other groups, had the highest mean dose and were more often coprescribed other CNS drugs. The ≥50year-old group was more often coprescribed antidepressants and antiparkinsonian drugs. Our pharmacoepidemiological study involving incident MPH users with a large number of characteristics showed different patterns of MPH use among children and adults. The results from the 25-49-year-old group suggested that MPH might be being used for medical conditions other than ADHD or narcolepsy in adults, and that it might be subject to misuse and/or abuse.

Use of analgesics in France, following dextropropoxyphene withdrawal

BackgroundIn 2009, the European Medicines Agency recommended withdrawal of dextropropoxyphene (DXP); in March 2011 it was withdrawn from the market in France. Up until that time the combination dextropropoxyphene-paracetamol (DXP/PC) was widely used for analgesia. At withdrawal, French regulators recommended that DXP/PC be replaced by other step 2 analgesics, i.e. tramadol, codeine, or opium-containing drugs, or by PC for a weak level of pain. To investigate prescribing behaviours after DXP/PC withdrawal, dispensations of analgesics before and after withdrawal were analysed.MethodsAggregated dispensation data of analgesics prescribed between January 2009 and December 2012 in the Rhône-Alpes region were obtained from the general health insurance claims data; changes in analgesic dispensation over time were analysed with the ATC/DDD methodology. Pre (Jan-June 2009) and post-withdrawal (Jan-June 2012) changes of DDDs where computed for each analgesic step.ResultsThe dispensations of DXP/PC experienced a two-step decrease until 2011. Over the withdrawal period 2009-2012, there was a 14% decrease in the overall use of analgesic (from 109 to 94 DDDs), while the use of step 2 analgesics declined by 46% (− 22 DDDs, from 47 to 25 DDDs). This latter decline included a cessation of use of DXP/PC (29 DDDs in 2009) that were only in part (+ 7 DDDs, from 18 to 25 DDDs) compensated by increased use of codeine, tramadol and opium, in monotherapy or combined with PC. For step 1 analgesics, use increased with 9%, mostly PC (+ 8 DDDs, from 31 to 39 DDDs). Step 3 analgesics dispensations remained largely unchanged over this period (around 3 DDDs).ConclusionsIn the Rhône-Alpes region, DXP/PC withdrawal was accompanied in part by an increased use of same level analgesics, and in part by an increased use of PC in monotherapy. The extent of DXP/PC use before withdrawal, and the increased use of PC after DXP withdrawal, underline the complexity of pain management.

Policy Implications for Low-to-Middle Income (LMICs) Countries Considering Universal Coverage: Lessons from OECD Countries

The restructuring of health financing policy in most countries has been intensified following the World Health Assembly Resolution in 2005 by Member States to introduce or strengthen universal coverage policy. The goals of universal coverage are: to offer households financial risk protection (FRP) in order to avoid catastrophic spending and impoverishment from seeking care; to ensure equal access to health care based on relative need irrespective of ability to make health payments, social status and geographical location. This is achievable through increased prepayment of health care through general tax revenue and social health insurance, two health financing mechanism that guarantee universal coverage. Given their long experience as universal systems, OECD countries provide valuable lessons to low-to-middle income (LMICs) countries considering the introduction of universal coverage policy. The policy implications for LMICs from the OECD countries given their long experience as universal systems are fundamental in informing the policy process.

Access Is Necessary but Not Sufficient: Factors Influencing Delay and Avoidance of Health Care Services.

Background: Despite recently expanded access to health insurance, consumers still face barriers to using their coverage to obtain needed health care. Objective: To examine the characteristics of those who delay or avoid health care due to costs. Methods: Participants were recruited via Amazon MTurk and completed a survey assessing demographic characteristics, financial toxicity, health care minimizer-maximizer tendencies, health insurance knowledge, numeracy, delaying/avoiding any care, and delaying/avoiding six common health care services (three preventive and three nonpreventive services). Validated measures were used when available. Delay/avoidance behaviors were categorized into delaying/avoiding any care, preventive care, and nonpreventive care. Logistic regression models examined 1) financial toxicity, 2) minimizer-maximizer tendencies, 3) numeracy, 4) health insurance knowledge, and 5) knowledge of preventive care coverage separately on three forms of delay/avoidance behaviors, controlling for chronic conditions, insurance status, and/or income where appropriate. Results: Of 518 respondents, 470 did not fail attention-check questions and were used in analyses. Forty-five percent of respondents reported delaying/avoiding care due to cost. Multivariable analyses found that financial toxicity was related to delaying/avoiding any care (odds ratio [OR] = 0.884, P < 0.001), preventive care (OR = 0.906, P < 0.001), and nonpreventive care (OR = 0.901, P < 0.001). A tendency to minimize seeking health care (OR = 0.734, P < 0.001) and lower subjective numeracy (OR = 0.794, P = 0.023) were related to delaying/avoiding any care. General health insurance knowledge (OR = 0.989, P = 0.023) and knowledge of preventive care coverage (OR = 0.422, P < 0.001) were related to delaying/avoiding preventive care. Conclusions: Many people delay or avoid health care due to costs, even when insured. Results suggest that there may be different reasons individuals delay or avoid preventive and nonpreventive care. Findings may inform interventions to educate consumers and support discussions about health care costs to facilitate appropriate health care utilization.

Cost-Utility Analysis of Heberprot-P as an Add-on Therapy to Good Wound Care for Patients in Slovakia with Advanced Diabetic Foot Ulcer.

Objectives: To explore whether Heberprot-P (an epidermal growth factor) is a cost-effective option for the treatment of advanced diabetic foot ulcer as an add-on therapy to good wound care (GWC) in Slovakia from the perspective of health care payers.Methods: A Markov model was constructed to compare the costs and effects of Heberprot-P plus GWC to those of GWC alone from the perspective of health care payers. The 52-week clinical trial period was extended to 5- and 10-year time horizons. Transition probabilities were calculated based on a previous clinical trial of Heberprot, utility values were derived from the scientific literature, and cost vectors were collected from the General Health Insurance Fund database in Slovakia. A one-way deterministic sensitivity analysis was employed to explore the influence of uncertainty for each input parameter on the incremental cost-effectiveness ratio (ICER).Results: Based on the ICER threshold of €30,030 per quality-adjusted life year (QALY) recommended by the Slovak Ministry of Health, Heberprot-P therapy plus GWC is not a cost-effective alternative to GWC alone over a 10-year time horizon. The ICER increases if a longer time horizon is applied, as the incremental costs are similar, but the aggregated utility gain from avoided amputation is lower. Based on the sensitivity analysis, the utility multiplier for the health state “no ulcer after small amputation” had the most impact on the ICER; however, the model was robust to changes in all input parameters.Conclusions: Heberprot-P, as an add-on therapy to GWC in the treatment of advanced diabetic foot ulcer, is not a cost-effective alternative to GWC alone. However, if the unit cost of Heberprot-P were to be reduced to <€273, its ICER would be <€30,030.

Efficient Reinsurance in Health Insurance Markets

This paper studies general health insurance markets. It proposes an ex post risk adjustment scheme that discourages risk selection and promotes efficient competition. Under the proposed risk adjustment scheme, the regulator engages in transfers that are conditional on the ex post profits of insurers. The risk adjustment scheme is entirely budget balanced -- as it does not call for government subsidies -- and requires the regulator to hold minimal information to implement it. Equilibrium exists and each equilibrium allocation is efficient in any environment with a finite number of types and states even if single-crossing is not satisfied.

Onemocnění štítné žlázy v České republice: projekt EUthyroid a vyhodnocení epidemiologických dat VZP za období let 2012-2015

Institute of Endocrinology participates in the grant of European Commission EUthyroid (Towards the elimination of iodine deficiency and preventable thyroid-related diseases in Europe), together with other 28 European countries. The role of Institute of Endocrinology in EUthyroid is among other things to ensure access to national registers relating to thyroid diseases. The results presented here correspond to the years 2012-2015 and are based on data from the General Health Insurance Company Czech Republic (VZP CR), which has 6 million insured persons (ratio male : female = 1 : 1). The set is sufficiently representative to be related to the whole of the Czech Republic. According to VZP data, the prevalence of thyreopathies is constantly increasing, for example according to the code of diagnoses E00-E07 and the unique birth number, the prevalence of thyreopathies increased from 6.8 % in 2012 to 7.5 % in 2015. The increase of the prevalence is mainly concentrated to clinical manifestation of hypothyroidism (code E03, an increase from 2.8 % in 2012 to 3.2 % in 2015); the second is nontoxic struma (code E04), which had a constant prevalence of 2.5 % in the given period. On the other hand, thyroiditis (code E06), the third in the order of occurrence, increased from 1.8 % in 2012 to 2 % in 2015. The decrease in prevalence only occurred in hyperthyroidism (E05) from 0.7 % in 2012 to 0.6 % in 2015. Other thyreopathies had a prevalence of less than 1 %, and was constant between 2012 and 2015 (other thyroid disorders E07 0.8 %, thyroid disorders associated with iodine deficiency E01 0.2 %, E02 0.07 %, E00 0.01 %, thyroid carcinoma C73 0.13 %).Key words: EUthyroid - General Health Insurance Company- occurrence of thyreopathies - thyroid disease in the Czech Republic.

Human papillomavirus vaccination and risk of autoimmune diseases: A large cohort study of over 2million young girls in France.

Whether human papillomavirus (HPV) vaccination could induce or trigger autoimmune diseases (AID) has been questioned, and potentially contributes to low immunization coverage in France. This study evaluated the association between HPV vaccination and the risk of AID using routinely collected data sources. All girls aged 13-16years between 2008 and 2012, covered by the general health insurance scheme and without history of HPV vaccination or AID, were included and followed using French nationwide databases. Fourteen neurological, rheumatological, haematological, gastrointestinal or endocrine AID, were identified from ICD-10 codes allocated to hospital stays and long-term illnesses or by marker drugs. Their incidence was compared between girls exposed and non-exposed to HPV vaccination, using a Cox model adjusted for inclusion year, geographic area, socio-economic indicators, healthcare use level and other immunizations. Among 2,252,716 girls, 37% received HPV vaccine and 4,096 AID occurred during a mean follow-up time of 33months. The incidence of AID was not increased after exposure to HPV vaccination, except for Guillain-Barré syndrome (GBS) (incidence rate of 1.4 among exposed [20 cases] versus 0.4 per 100,000 PY among unexposed [23 cases]; adjusted HR: 3.78 [1.79-7.98]). This association persisted across numerous sensitivity analyses and was particularly marked in the first months following vaccination. Under the hypothesis of a causal relationship, this would result in 1-2 GBS cases attributable to HPV vaccine per 100,000 girls vaccinated. Our study provides reassuring results regarding the risk of AID after HPV vaccination, but an apparently increased risk of GBS was detected. Further studies are warranted to confirm this finding.