Health Insurance Fund Research Articles

Cost-effectiveness of ambroxol in the treatment of Gaucher disease type 2.

Our aim was to compare the costs and efficacy of ambroxol in combination with imiglucerase with the costs and efficacy of imiglucerase only in the treatment of Gaucher disease type 2 (GD2) in the socio-economic settings of the Republic of Serbia, an upper-middle-income European economy. The perspective of the Serbian Republic Health Insurance Fund was chosen for this study, and the time horizon was 6 years. The main outcomes of the study were quality-adjusted life years gained with ambroxol + imiglucerase and comparator, and direct costs of treatment. The study was conducted through the generation and simulation of the Markov chain model. The model results were obtained after Monte Carlo microsimulation of a sample with 1,000 virtual patients. Treatment with ambroxol in combination with imiglucerase was cost-effective when compared with imiglucerase only and was associated with positive values of net monetary benefit regardless of the onset of the disease. Such beneficial result for ambroxol and imiglucerase combination is primarily driven by the low cost of ambroxol and its considerable clinical effectiveness in slowing the progression of neural complications of GD2. If ambroxol and imiglucerase are used in combination for the treatment of GD2, it is more cost-effective than using imiglucerase alone.

The Fiscal Space for Health in Vietnam: Challenges from Population Aging

Vietnam's population is aging, leading to a higher proportion of elderly individuals. Despite significant health financing reforms, But changes in epidemiology, demographics, and growing demand for health care will continue to put pressure on health spending. This paper examines the fiscal space for health in Vietnam amidst population aging by analyzing data from 2009 to 2020. Findings reveal that healthcare resources have not kept pace with the escalating demands due to the aging of Vietnam's population faster than forecast. Total health expenditure as a percentage of GDP shows this clear increase. Private healthcare spending, particularly out-of-pocket expenses, is on the rise. Spending from the health insurance fund also increases every year,, placing future burdens on young workers. In addition, the State budget allocations for healthcare have also grown, but economic growth will compensate for this shortfall.

Telephone Health Coaching and Remote Exercise Monitoring (TeGeCoach) in Peripheral Arterial Occlusive Disease.

Supervised exercise programs are used to treat intermittent claudication (IC). Home-based exercise programs have been developed to lower barriers to participation. We studied the effects of one such exercise program (TeGeCoach) on self-reported walking ability in patients with IC. In a pragmatic multicenter randomized controlled trial (registration number NCT03496948), 1982 patients with symp - tomatic IC insured by one of three German statutory health insurance funds received either telephone health coaching with remote exercise monitoring (TeGeCoach; n = 994) or routine care (n = 988). The primary outcome was the change in Walking Impairment Questionnaire (WIQ) scores after 12 and 24 months in the intention-to-treat population. The secondary outcomes were healthrelated quality of life, symptoms of depression or anxiety, health competence, patient activation, alcohol use, and nicotine depen - dence. There was a significant group difference in WIQ score in favor of TeGeCoach (p < 0.0001), amounting to 6.30 points at 12 months (Bonferroni-corrected 95% CI [4.02; 8.59], Cohen's d = 0.26) and 4.55 points at 24 months ([2.20; 6.91], d = 0.19). Some of the secondary outcomes also showed positive results in favor of TeGeCoach at 12 months with small effect sizes (d ≥ 0.20), including physical health-related quality of life and patient activation. The average daily step count was not higher in the TeGeCoach group. Significant improvements regarding symptom burden demonstrate the benefit of a home-based exercise program and thus expand the opportunities for guideline-oriented treatment of IC. Future studies should additionally address the effect of home-based exercise programs on clinical variables by means of, for example, the 6-minute walk test.

Geographic Accessibility of General Practitioners by Car and Public Transport - A Study Using the Minimum Travel Time Method in a Rural Area in the North-East of Germany

Basic medical care should be accessible to all people without restriction. However, the distribution of practices in rural areas is often limited to the centers, meaning that distances have to be covered. The Federal Joint Committee (G-BA), the highest decision-making body of the joint self-government of physicians, dentists, hospitals and health insurance funds in Germany, only states for cars that 95% of the population should be able to reach general practitioners (GPs) in less than 20 minutes on average. The aim of this study was to determine the geographic accessibility of GP practices by car and public transport. A cross-sectional study was conducted in a rural area in the north-east of Germany called Neustrelitz Central Zone and reported according to the STROBE statement. Geographic data of OpenStreetMap and the Federal Agency for Cartography and Geodesy and GP practices data of the Associations of Statutory Health Insurance Physicians Mecklenburg-Western Pomerania and Brandenburg were used. Based on the method of minimum travel time, the required travel times by car and public transport from the local centers to the three nearest physician locations were determined using various online tools. On average, inhabitants need 10.7 minutes to reach the three nearest GP practices by car, up to a maximum of 19 minutes. The average travel time by public transport for an appointment at 10 a.m. is four hours and twelve minutes. While it is possible for all municipalities (and their inhabitants) to reach the nearest GP practices in time for an appointment at 10 a.m. and to complete the return journey on the same day, this is no longer possible for 35% of municipalities (and their inhabitants) for an appointment at 3 p.m. and for 53% for an appointment at 5 p.m. In the Neustrelitz Central Zone, the accessibility of GP practices by car is ensured in accordance with the G-BA statements. On the other hand, the accessibility of GP practices by public transport can be a problem for people who do not have their own car. This could be remedied, for example, by expanding eHealth or mobile medical practices.

The usage and costs of national drug price-negotiated anticancer medicines in a first-tier city in Northeast China: a study based on health insurance data

BackgroundThe National Drug Price Negotiation (NDPN) policy has entered a normalisation stage, aiming to alleviate, to some extent, the disease-related and economic burdens experienced by cancer patients. This study analysed the use and subsequent burden of anticancer medicines among cancer patients in a first-tier city in northeast China.MethodsWe assessed the usage of 64 negotiated anticancer medicines using the data on the actual drug deployment situation, the frequency of medical insurance claims and actual medication costs. The affordability of these medicines was measured using the catastrophic health expenditure (CHE) incidence and intensity of occurrence. Finally, we used the defined daily doses (DDDs) and defined daily doses cost (DDDc) as indicators to evaluate the actual use of these medicines in the region.ResultsDuring the study period, 63 of the 64 medicines were readily available. From the perspective of drug usage, the frequency of medical insurance claims for negotiated anticancer medicines and medication costs showed an increasing trend from 2018 to 2021. Cancer patients typically sought medical treatment at tertiary hospitals and purchased medicines at community pharmacies. The overall quantity and cost of medications for patients covered by the Urban Employee Basic Medical Insurance (UEBMI) were five times higher than those covered by the Urban and Rural Resident Medical Insurance (URRMI). The frequency of medical insurance claims and medication costs were highest for lung and breast cancer patients. Furthermore, from 2018 to 2021, CHE incidence showed a decreasing trend (2.85–1.60%) under urban patients’ payment capability level, but an increasing trend (11.94%–18.42) under rural patients’ payment capability level. The average occurrence intensities for urban (0.55–1.26 times) and rural (1.27–1.74 times) patients showed an increasing trend. From the perspective of drug utilisation, the overall DDD of negotiated anticancer medicines showed an increasing trend, while the DDDc exhibited a decreasing trend.ConclusionThis study demonstrates that access to drugs for urban cancer patients has improved. However, patients’ medical behaviours are affected by some factors such as hospital level and type of medical insurance. In the future, the Chinese Department of Health Insurance Management should further improve its work in promoting the fairness of medical resource distribution and strengthen its supervision of the nation’s health insurance funds.

Midwives Responding to the Needs of Uninsured Clients: Old Order and New Immigrant Women in Midwifery Care

The funding structure of midwifery in Ontario enables midwives to provide care to women without provincial health care coverage. This article explores midwives’ experiences in providing care to two key groups of women without provincial insurance: 1) women who lack coverage as a result of their precarious immigration status, and 2) women who opt out of publicly funded health insurance for religious reasons. Data from 15 interviews with midwives who serve these communities reveal several important themes that shape their experiences. Further, as midwives adapt their practice to work with communities of uninsured women, their goal of providing culturally competent midwifery care to more diverse groups of women becomes actualized.

Impact of Government Funded Health Insurance Scheme on OOP and Quality of Health Care: A Study of Maternal Health Care in Rajasthan

There has been a gradual shift of India’s health policies in favour of government-funded health insurance schemes rather than investment in public health facilities. The impact of this shift on quality of health care, especially for the poor and vulnerable population, is yet to be fully understood. The current study has been undertaken to study the effectiveness of one such state government-funded health insurance scheme, known as Bhamashah Swasthya Bima Yojana (BSBY), on out-of-pocket (OOP) expenditure and quality of health care services for the child delivery cases in a low-income community in the capital city of Jaipur in Rajasthan, India. While this study contributes to knowledge on the impact of access to health insurance on OOP expenditure, it covers a critical gap in the literature regarding its effect on quality of health care. The empirical analysis, conducted using log-linear and logit models, indicates that BSBY has a positive impact on reduction of OOP and improvement in quality of treatment in the study area.

The impact of the SARS-CoV2 pandemic on the prescription of thyroid medication in Austria – A nationwide population-based registry analysis

BackgroundCase reports indicate a clinical connection between SARS-CoV-2 and thyroid dysfunctions. However, evidence from large population-based registry analyses is sparse, especially in Europe, where iodine deficiency is common. This study aimed to analyze the impact of the COVID-19 pandemic on healthcare provision for thyroid diseases in Austria. MethodsWe performed a retrospective, population-based registry analysis of the Austrian health insurance fund database, covering more than 9 million inhabitants. Data from all patients with prescriptions of thyroid-specific drugs and/or inpatient thyroid-related diagnoses from 2017 to 2019 (pre-pandemic years) were compared to 2020 and 2021 (pandemic years; characterized by high numbers of SARS-CoV2 infections and population-wide vaccination strategy). The incidence rates of thyroid medication prescriptions for hypothyroidism and hyperthyroidism were calculated for every year to evaluate the impact of the pandemic. ResultsThe incidence rate for total thyroid medication prescription was 539.07/100,000 individuals (534.23–543.93 95%CI) in 2018 and declined during the pandemic (2020: 387.19/100,000 (383.12–391.29 95%CI); 2021: 336.90/100,000 (333.11–340.73 95%CI)). Similarly, the incidence rate for levothyroxine prescription was higher pre-pandemic (2018: 465.46/100,000 (460.97–469.98 95%CI) and declined during the pandemic (2020: 348.14/100,000 (344.28–352.03 95%CI); 2021: 300.30/100,000 (296.7–303.91 95%CI). The incidence rates of thiamazole prescriptions (2018: 10.24/100,000 (9.58–10.93 95%CI); 2020: 8.62/100,000 (8.03–9.26 95%CI); 2021: 11.17/100,000 (10.49–11.89 95%CI) were stable. ConclusionsThese findings suggest no clinically significant impact of SARS-CoV2 and/or vaccination on thyroid function at a population level.

RETROSPECTIVE, OBSERVATIONAL, LONGITUDINAL STUDY OF DRUG UTILIZATION FOR THE TREATMENT OF UNCOMPLICATED ESSENTIAL HYPERTENSION IN BULGARIA

Objective: To evaluate drug utilization and assess rational drug use in the treatment of patients with uncomplicated essential hypertension in Bulgaria, using quantitative and qualitative measures at national level. Design and method: Retrospective, observational, longitudinal study of data from the public registers of the National Health Insurance Fund for the period 2017-2021 using the WHO ATS/DDD methodology and descriptive statistical methods. Results: The analyzed population included 129 312 patients with uncomplicated essential hypertension /I10/ - 11.09% of all hypertensive patients in Bulgaria. The average cost per year was 8 229 567.10 BGN (1 Euro=1.95583 BGN) - respectively the cost per patient per year was 63.64 BGN, the monthly cost was 5.30 BGN and the cost per day was 0.17 BGN. The amount of 8 229 567.10 BGN was divided into two groups - costs for mono-products (67.73%) and costs for combined products (32.27%). The analysis of the actual therapeutic practice in Bulgaria showed that the most prescribed products for this indication were beta-blockers Nebivolol and Bisoprolol, calcium channel blocker Lercanidipine and centrally acting anti-adrenergic agents Moxonidine and Rilmenidine. Sartans were represent predominantly by Telmisartan. In all cross-sectional analyses, the significant use of Lercanidipine was very prominent. Regarding the fixed-dose combinations, medicinal products, containing AT1-blocker and thiazide diuretic were preferred choice for treatment - the most prescribed combination was Valsartan with Hydrochlorothiazide (15.93% of the reimbursement costs for fixed-dose combinations). Conclusions: Despite of the clear recommendation in the guidelines, monotherapy was still preferred treatment for uncomplicated essential hypertension /I10/ in Bulgaria, during the studied period /2017-2021/. We must persist with the continuous education of the GPs, in order to improve the therapy and control of the arterial hypertension in Bulgaria.

Persistence to statin treatment: A cohort study in Lithuania.

Cardiovascular diseases are the main causes of death, and statins can reduce the risk of major vascular events. Lithuania is among the European countries with the highest cardiovascular mortality despite a rapidly increasing use of statins. Previous reviews have shown the problem of poor patient adherence, but there are limited studies from Eastern European countries. The aim of this study was to evaluate treatment persistence in new users of statins in Lithuania and to investigate factors associated with persistence. Dispensed prescriptions from patients aged >18 years old initiated on statins in 2018-2019 were included, and data were obtained from a national health insurance fund. Persistence was assessed by the proportion of patients who still had statins dispensed 1year after the first dispensing. Factors associated with persistence were assessed using logistic regression. A total of 104 726 patients (41.3% men) were initiated on statin treatment. Only 41% of them continued statin use 1year after initiation. Factors associated with higher persistence rate were older age, higher dose of statin, use of other medicines and use of statins as secondary prevention. Low persistence to statin therapy needs to be recognized by healthcare workers, pharmacists and policy makers to address this problem.

Health insurance fraud detection based on multi-channel heterogeneous graph structure learning

Health insurance fraud is becoming more common and impacting the fairness and sustainability of the health insurance system. Traditional health insurance fraud detection primarily relies on recognizing established data patterns. However, with the ever-expanding and complex nature of health insurance data, it is difficult for these traditional methods to effectively capture evolving fraudulent activity and tactics and keep pace with the constant improvements and innovations of fraudsters. As a result, there is an urgent need for more accurate and flexible analytics to detect potential fraud. To address this, the Multi-channel Heterogeneous Graph Structured Learning-based health insurance fraud detection method (MHGSL) was proposed. MHGSL constructs a graph of health insurance data from various entities, such as patients, departments, and medicines, and employs graph structure learning to extract topological structure, features, and semantic information to construct multiple graphs that reflect the diversity and complexity of the data. We utilize deep learning methods such as heterogeneous graph neural networks and graph convolutional neural networks to combine multi-channel information transfer and feature fusion to detect anomalies in health insurance data. The results of extensive experiments on real health insurance data demonstrate that MHGSL achieves a high level of accuracy in detecting potential fraud, which is better than existing methods, and is able to quickly and accurately identify patients with fraudulent behaviors to avoid loss of health insurance funds. Experiments have shown that multi-channel heterogeneous graph structure learning in MHGSL can be very helpful for health insurance fraud detection. It provides a promising solution for detecting health insurance fraud and improving the fairness and sustainability of the health insurance system. Subsequent research on fraud detection methods can consider semantic information between patients and different types of entities.

Practical training concept for perfusionists at the heart and diabetes center Nordrhein-Westfalen.

Increasing regulations and requirements of advisory bodies, in particular the Joint Federal Committee and the Medical Service of the health insurance funds, make it necessary to employ only demonstrably well-trained perfusionists. The minimum requirement for this staff is EBCP certification. Currently there is limited availability of such specialists on the German market. Therefore, the qualification of young people in this area is of central importance. The aim of this paper is to strengthen the training of perfusionists at our centre, to standardise the process and to provide the respective student with a "roadmap" to their internship. The structure is based on a rough division of the 24 weeks of internship. This is described in detail in the following and is backed up with the learning objectives for the respective time periods. At our centre, practical training has been standardized and clear responsibilities have been defined. Furthermore, as a centre of maximum care in the field of cardiac surgery, we can offer students the necessary number of perfusions in just six months to meet the requirements of the ECBP for practical training. According to this concept, 20 perfusionists have been successfully trained in the last 8 years. All of them have passed the exams and have been certified according to EBCP. The aim of the practical semester is for the student to be in a position at the end of the semester to independently supervise simple cardiac surgery procedures with the aid of the Extra- Corporal Circulation (ECC) and to carry this out in accordance with the currently valid guidelines and directives (1-8) and the departmental procedural instructions based on them. Great emphasis is placed to the students becoming aware of their competence to act, knowing their limits and being able to assess when these limits have been reached and the involvement of experienced colleagues is necessary to ensure patient safety.

A Fresh Fruit and Vegetable Prescription Program for Prenatal Patients in Flint, Michigan: Baseline Food Security and Dietary Intake.

Although adequate nutritional status during pregnancy is necessary to support optimal fetal development, many low-income women have poor access to fresh, high-nutrient foods. To address these challenges, a pediatric fruit and vegetable (FV) prescription program was expanded to include pregnant women, providing one prescription for fresh FVs worth 15 US dollars during each prenatal office visit for redemption at farmers'/mobile markets. This analysis describes baseline sociodemographic characteristics, food security, and dietary intake among 253 pregnant women in Flint, Michigan in 2022-23. Dietary recall data were collected and analyzed using the Automated Self-Administered 24-h Tool developed by the US National Cancer Institute, with nutrition output reported in relation to adherence to US Dietary Guidelines. Most participants (mean ± SD age 26.51 ± 4.90 years) identified as African American (53%) and were receiving publicly funded health insurance (66%). Most (75%) reported no food insecurity, yet the majority failed to meet dietary recommendations for whole grains (99.3%), vegetables (93.1%), dairy (93.1%), and fruits (69.4%). Moreover, most did not meet micronutrient recommendations through food sources, including vitamin D (100%), iron (98.6%), folic acid (98.6%), vitamin A (82.6%), calcium (68.8%), and vitamin C (62.5%). Results raise deep concerns regarding diet and nutrition among pregnant women in this US city.

End-of-life care in Germany between 2016 and 2020 - A repeated cross-sectional analysis of statutory health insurance data.

The Hospice and Palliative Care Act of 2015 aimed at developing and regulating the provision of palliative care (PC) services in Germany. As a result of the legal changes, people with incurable diseases should be enabled to experience their final stage of life including death according to their own wishes. However, it remains unknown whether the act has impacted end-of-life care (EoLC) in Germany. The present study examined trends in EoLC indicators for patients who died between 2016 and 2020, in the context of Lower Saxony, Germany. Repeated cross-sectional analysis was conducted on data from the statutory health insurance fund AOK Lower Saxony (AOK-LS), referring to the years 2016-2020. EoLC indicators were: (1) the number of patients receiving any form of outpatient PC, (2) the number of patients receiving generalist outpatient PC and (3) specialist outpatient PC in the last year of life, (4) the onset of generalist outpatient PC and (5) the onset of specialist outpatient PC before death, (6) the number of hospitalisations in the 6 months prior to death and (7) the number of days spent in hospital in the 6 months prior to death. Data for each year were analysed descriptively and a comparison between 2016 and 2020 was carried out using t-tests and chi-square tests. Data from 160,927 deceased AOK-LS members were analysed. The number of patients receiving outpatient PC remained almost consistent over time (2016 vs. 2020 p = .077). The number of patients receiving generalist outpatient PC decreased from 28.4% (2016) to 24.5% (2020; p < .001), whereas the number of patients receiving specialist outpatient PC increased from 8.5% (2016) to 11.2% (2020; p < .001). The onset of generalist outpatient PC moved from 106 (2016) to 93 days (2020; p < .001) before death, on average. The onset of specialist outpatient PC showed the reverse pattern (2016: 55 days before death; 2020: 59 days before death; p = .041). Despite growing needs for PC at the end of life, the number of patients receiving outpatient PC did not increase between 2016 and 2020. Furthermore, specialist outpatient PC is being increasingly prescribed over generalist outpatient PC. Although the early initiation of outpatient PC has been proven valuable for the majority of people at the end of life, generalist outpatient PC was not initiated earlier in the disease trajectory over the study period, as was found to be true for specialist outpatient PC. Future studies should seek to determine how existing PC needs can be optimally met within the outpatient sector and identify factors that can support the earlier initiation of especially generalist outpatient PC. The study "Optimal Care at the End of Life" was registered in the German Clinical Trials Register (DRKS00015108; 22 January 2019).

Examining inequalities in spatial access to national health insurance fund contracted facilities in Kenya.

Kenya aims to achieve universal health coverage (UHC) by 2030 and has selected the National Health Insurance Fund (NHIF) as the 'vehicle' to drive the UHC agenda. While there is some progress in moving the country towards UHC, the availability and accessibility to NHIF-contracted facilities may be a barrier to equitable access to care. We estimated the spatial access to NHIF-contracted facilities in Kenya to provide information to advance the UHC agenda in Kenya. We merged NHIF-contracted facility data to the geocoded inventory of health facilities in Kenya to assign facility geospatial locations. We combined this database with covariates data including road network, elevation, land use, and travel barriers. We estimated the proportion of the population living within 60- and 120-minute travel time to an NHIF-contracted facility at a 1-x1-kilometer spatial resolution nationally and at county levels using the WHO AccessMod tool. We included a total of 3,858 NHIF-contracted facilities. Nationally, 81.4% and 89.6% of the population lived within 60- and 120-minute travel time to an NHIF-contracted facility respectively. At the county level, the proportion of the population living within 1-hour of travel time to an NHIF-contracted facility ranged from as low as 28.1% in Wajir county to 100% in Nyamira and Kisii counties. Overall, only four counties (Kiambu, Kisii, Nairobi and Nyamira) had met the target of having 100% of their population living within 1-hour (60min) travel time to an NHIF-contracted facility. On average, it takes 209, 210 and 216min to travel to an NHIF-contracted facility, outpatient and inpatient facilities respectively. At the county level, travel time to an NHIF-contracted facility ranged from 10min in Vihiga County to 333min in Garissa. Our study offers evidence of the spatial access estimates to NHIF-contracted facilities in Kenya that can inform contracting decisions by the social health insurer, especially focussing on marginalised counties where more facilities need to be contracted. Besides, this evidence will be crucial as the country gears towards accelerating progress towards achieving UHC using social health insurance as the strategy to drive the UHC agenda in Kenya.

Hepatitis C screening in Lithuania: first-year results and scenarios for achieving WHO elimination targets.

The World Health Organization (WHO) has outlined a set of targets to achieve eliminating hepatitis C by 2030. In May 2022, Lithuanian health authorities initiated a hepatitis C virus (HCV) screening program to start working towards elimination. In the program, bonus was given to general practitioners (GPs) to promote and conduct anti-HCV tests for two situations: (1) one time testing for individuals born in 1945-1994 and (2) annual HCV testing for persons who inject drugs or are living with human immunodeficiency virus (HIV) regardless of age. This study aimed to model the current viral hepatitis C epidemiological status in Lithuania and to outline the requirements for WHO elimination targets using the first-year HCV screening results. Individuals were invited to participate in the anti-HCV screening by GPs during routine visits. Patients who tested positive were then referred to a gastroenterologist or infectious disease doctor for further confirmatory testing. If a patient received a positive RNA test and a fibrosis staging result of ≥ F2, the doctor prescribed direct-acting antivirals. Information on the patients screened, diagnosed, and treated was obtained from the National Health Insurance Fund. The Markov disease progression model, developed by the CDA Foundation, was used to evaluate the screening program results and HCV elimination progress in Lithuania. Between May 2022 and April 2023, 790,070 individuals underwent anti-HCV testing, with 11,943 individuals (1.5%) receiving positive results. Anti-HCV seroprevalence was found to be higher among males than females, 1.9% and 1.2%, respectively. Within the risk population tested, 2087 (31.1%) seropositive individuals were identified. When comparing the screening program results to WHO elimination targets through modelling, 2180 patients still need to be treated annually until 2030, along with expanding fibrosis restrictions. If an elimination approach was implemented, 1000 new infections would be prevented, while saving 150 lives and averting 90 decompensated cirrhosis cases and 110 hepatocellular carcinoma cases. During the first year of the Lithuanian screening program, GPs were able to screen 44% of the target population. However, the country will not meet elimination targets as it currently stands without increasing treatment levels and lifting fibrosis restrictions.

Cost/effectiveness of elivaldogene autotemcel vs. hematopoietic stem cells transplantation in patients with cerebral adrenoleukodystrophy (CALD)

Cerebral adrenoleukodystrophy (CALD) is a severe, rare neurological disease with a progressive course and poor prognosis. Allogeneic hematopoietic stem cell transplantation (HSCT) is still considered the standard of care for CALD. Elivaldogene autotemcel is a novel gene therapy for the treatment of childhood-onset CALD. Since many novel gene therapies are associated with high costs, our aim was to compare costs and effectiveness of elivaldogene autotemcel with the costs and effectiveness of allogeneic HSCT treatment of childhood-onset CALD. The analysis used an 80-year horizon and the perspective of the Serbian Republic Health Insurance Fund. Quality-adjusted life years (QALYs) gained with elivaldogene autotemcel and HSCT, as well as direct treatment costs, were our major outcomes. For the purposes of the economic analysis, we constructed and simulated a discrete-event simulation model to calculate the outcomes. We obtained the results of the model using a Monte Carlo simulation, which we conducted on 1000 virtual CALD patients. The analysis indicated that elivaldogene autotemcel was not cost-effective when compared to HSCT, and the net monetary benefit was negative. The base case incremental cost/effectiveness ratio was 259,848,512 RSD/QALY. Elivaldogene autotemcel is not more cost-effective than HSCT for the treatment of CALD from the perspective of the Serbian Republic Health Insurance Fund, according to classic pharmacoeconomic analysis and criteria. To ensure that the treatment is affordable for all patients for whom it is prescribed, a differentiated pricing strategy with lower drug prices in developing nations seems to be required.

Совершенствование риск-ориентированного подхода, как критерий экономической безопасности ФФОМС

The article examines some negative elements of the mechanism of functioning of the compulsory health insurance fund, which pose a threat to the economic security of the Russian budget system. It is concluded that it is necessary to consider certain trends in improving the risk-based approach, further automation and digitalization of the CHI system, as well as to establish recommended thresholds and take into account the system of indicators for evaluating the effectiveness of the use of budgetary funds by their recipients (medical organizations within the CHI system), the use of which will increase the level of effectiveness of control over expenditure and targeted use budget funds.

Medical expenditures and the measurement of poverty in the United States

Using data from the Medical Expenditure Panel Survey (MEPS) we estimate the fraction of the US population that is health poor. A person is health poor if their income prior to paying health insurance premiums and out-of-pocket healthcare costs is above the poverty line, but their income net-of-premiums and out-of-pocket healthcare costs is below the poverty line. Because resources used to finance health insurance premiums and out-of-pocket costs are (A) lexicographically preferred and (B) cannot be used to maintain an individual’s standard of living, they should be excluded from official poverty estimates. Approximately 1% to 2% of the US population is health poor. Elderly individuals, individuals in ill health, and low-income individuals are more likely to be health poor than other groups. We use our estimates of the health poor to evaluate alternative healthcare reform policies. The Affordable Care Act reduced the proportion of individuals near-poverty that are health poor from 23% to 18% and reduced the proportion of all individuals that are health poor from 1.5% to 1.1%. In contrast, counterfactual simulations of a Medicare for All plan similar to Saez and Zucman’s (2019b) suggest that Medicare for All would all but eliminate health poverty.

Profits over care? An analysis of the relationship between corporate capitalism in the healthcare industry and cancer mortality in the United States

The characteristic features of 21st-century corporate capitalism – monopoly and financialization – are increasingly being recognized by public health scholars as undermining the foundations of human health. While the “vectors” through which this is occurring are well known – poverty, inequality, climate change among others – locating the root cause of this process in the nature and institutions of contemporary capitalism is relatively new. Researchers have been somewhat slow to study the relationship between contemporary capitalism and human health. In this paper, we focus on one of the leading causes of death in the United States; cancer, and empirically estimate the relationship between various measures of financialization and monopoly in the US healthcare system and cancer mortality. The measures we focus on are for the hospital industry, the health insurance industry, and the pharmaceutical industry. Using a fixed effects model with different specifications and control variables, our analysis is at the state level for the years 2012–2019. These variables include data on population demographic controls, social and economic factors, and health behavior and clinical care. We compare Medicaid expansion states with non-Medicaid expansion states to investigate variations in state-level funded health insurance coverage. The results show a statistically significant positive correlation between the HHI index in the individual healthcare market and cancer mortality and the opioid dispensing rate and cancer mortality.