Health Care Voucher Research Articles

Elderly Health Care Voucher Scheme in Hong Kong: needs assessment and an evaluation of outcomes

ABSTRACT Elderly Health Care Voucher Scheme represents a form of demand-side subsidy given to the elders to choose a spectrum of medical services in the private medical sector. The current paper aims at (a) conducting a needs assessment of the scheme with an analytical framework of the Four A 's approach (i.e., availability, awareness, accessibility, and acceptance regarding a social program) and (b) evaluating whether the outcome measures of the scheme (i.e., the use of private healthcare services, the use of primary care and the empowerment of the elders in the choice of services) were achieved. The needs assessment concludes that the utilization rate of the elders, awareness and satisfaction rate are high. The positive sides concluded from the needs assessment, however, failed to turn into the fulfillment of outcome measures due to the structural barriers. Recommendations at short-term, medium-term and long-term are made.

Service quality attributes on customers’ perceived value and behavioral intention of district health centres: a moderating effect of health-care subsidy

PurposeThis study aims to explore the influence of health-care service quality on customers’ perceived value, satisfaction, effectiveness and behavioural intention concerning district health centres (DHCs) in Hong Kong. This research also intends to assess customers’ perception of the subsidy scheme and its influence on the relationships amongst the aforementioned constructs.Design/methodology/approachThe convenience and snowball sampling approaches were adopted, and the self-administered questionnaire was sent to 309 customers of DHCs.FindingsService quality attributes in terms of staffing and procedures positively increased customers’ perceived value and staffing, procedures and operations. Physical facilities positively promoted customers’ satisfaction, consequently improving DHCs’ effectiveness and behavioural intention. However, core treatments and services of DHCs did not impact customers’ perceived value and satisfaction. Furthermore, customers receiving subsidies exhibited a more positive perception than those without subsidies.Practical implicationsHealth-care organisations are advised to strategically allocate resources (staffing, facilities and procedures and operations management) to optimise overall performance outcomes. DHC operators could reinforce the core services of DHCs and health-care voucher subsidies to local citizens so as to enhance the effectiveness of DHCs and behavioural intention of customers.Originality/valueThis study integrates the input–process–output approach in measuring the effectiveness of and customers’ behavioural intention towards newly established DHCs.

Healthcare for individuals without health insurance in Germany – a mixed methods approach to assess the situation and current challenges

BackgroundHealth insurance is mandatory in Germany; nevertheless, many individuals there have no health insurance and depend on a parallel healthcare structure. Voluntary associations, such as MediNetz and healthcare vouchers (“Anonymer Krankenschein” - AKS), support uninsured citizens. This study aimed to provide insights into associations, such as MediNetz and AKS that provide healthcare for individuals without health insurance in North Rhine-Westphalia, the largest federal state in Germany.MethodsA mixed methods approach was chosen. A qualitative study using interviews with experts was performed to gain their knowledge and explore the various challenges that AKS and MediNetz associations faced and the possible improvements that could be made. A quantitative survey was conducted to analyse the demographic data of the patients who required AKS or MediNetz’s assistance and the characteristics of each association through a separate questionnaire. Data was received from the association in Aachen, Bielefeld, Bonn, Düsseldorf, and Essen.ResultsMore women than men sought medical care; most were between 25 and 49 years old. The proportion of individuals without residency status accounted for the largest share (53.6%). Common reasons for patients to make contact were acute illnesses (40.2%) and pregnancies (22.3%). Most patients were sent to gynaecologists and general practitioners. Asking the experts, it became apparent that the existing system could not reach the standard of the regular healthcare in Germany. Financial and human resources were insufficient. Therefore, prevention was limited, especially chronically ill patients or patients with a severe illness requiring hospitalisation could not be treated. AKS had advantages compared to MediNetz, as the care came closer to the expected German medical standards.ConclusionsThe results showed a demand for associations providing healthcare for individuals without health insurance. However, the healthcare provided by MediNetz and AKS did not reach the standard of healthcare in Germany and mainly depended on the organisations’ resources. Funded projects such as an AKS combined with clearing centres significantly improved healthcare. Until structural measures are implemented, they can be a transitional solution by spreading nationwide.

Feasibility of a telephone-delivered educational intervention for knowledge transfer of COVID-19-related information to older adults in Hong Kong: a pre–post-pilot study

BackgroundDuring the COVID-19 pandemic, educational interventions have become necessary to prevent the spread of health-related misinformation among Hong Kong older adults. The primary objective of this study was to assess the feasibility of a student-led, telephone-delivered intervention to improve COVID-19-related health knowledge among Hong Kong older adults. The secondary objective was to evaluate the impact of the intervention on the student volunteers.MethodsTwenty-five participants aged 65 or above who were able to communicate in Cantonese and had no hearing or cognitive impairments were recruited for this longitudinal pre–post-study from a community center in Hong Kong. The pilot telephone-delivered intervention consisted of five telephone call sessions conducted by 25 student volunteers. Each participant was paired with the same volunteer throughout the intervention. The first four sessions included pre-tests that assessed the participants’ understanding of three COVID-19-related themes: medication safety, healthcare voucher scheme, and COVID-19 myth-busting. Standardized explanations of the pre-test questions were offered to participants during the phone calls. In the last session, a post-test on all the themes was conducted. The intervention’s feasibility was assessed based on (a) percentage changes in the participants’ test scores, (b) attrition rate, and (c) the acceptability of the intervention by the participants. The impact of the intervention on the student volunteers was evaluated based on a student feedback survey. There was no control group.ResultsSignificant improvements in the participants’ test scores (out of 100%) for all themes were observed after the intervention: from 76 to 95.2% for medication safety, from 64.0 to 88.8% for the healthcare voucher scheme, and from 78.0 to 93.2% for COVID-19 myth-busting. The average improvement in test scores of the three themes was 18.4% (95% CI 12.2 to 24.6%). Most participants were satisfied with the program. The student feedback survey suggested that the intervention enhanced students’ communication skills and understanding of Hong Kong older adults.ConclusionThis pilot study offers initial evidence of the potential and feasibility of student-led, telephone-delivered educational interventions for the transfer of COVID-19-related knowledge to older adults and their benefits for the student volunteers. Future studies should include larger samples and a control group.

Unseen Threats of Chronic Diseases among the Middle-Aged: Examining the Feasibility of Well-Defined Healthcare Vouchers in Encouraging Uptake of General Checkups.

Background: The ageing population and the emergence of chronic diseases continue to pose immense challenges to the healthcare system. This study aims to explore how likely middle-aged citizens could be encouraged to attend health checkups by well-defined healthcare vouchers, and to explore potential factors associated with the uptake of health checkups. Methods: A cross-sectional survey with self-administered structured questionnaires was conducted among Hong Kong residents aged 45–59. The questionnaire consisted of 25 items, including attitudes toward healthcare vouchers and checkups, utilisation patterns of healthcare services, and socio-demographics. Results: We received 278 responses between June and September 2021. Among the study participants, 62.6% (174) attended regular checkups currently, and a total of 252 (90.6%) indicated that it was likely for them to undertake health checkups with well-defined vouchers. This proportion showed an increase of 44.8% after introducing vouchers (78 of 174) when compared with the proportion currently attending regular health checkups. Multiple logistic regression analysis revealed that the perceived barrier of health checkup uptake included financial cost (AOR 0.367, 95% CI 0.162–0.832, p = 0.016), whilst the government’s recommendation (AOR 1.685, 95% CI 1.052–2.698, p = 0.030) and full support by the employer-purchased insurance (AOR 2.395, 95% CI 1.036–5.523, p = 0.041) were positively associated with uptakes. Conclusions: Financial cost is a significant barrier to health promotion and disease prevention. Well-defined vouchers, as a demand-side financial tool, were widely accepted by our participants as incentives to undergo health checkups. Our findings indicate that the voucher scheme could be extended to individuals aged 45–59 for health checkups by easing the financial barrier, and show the importance of involving government recommendations and employer-purchased insurance.

Changes in utilisation of optometry services with a non-targeted publicly-funded health care voucher system

ABSTRACT Clinical relevance Understanding the impact of a health care voucher scheme and service access barriers could facilitate optometry service promotion to the older population. Background A voucher is one strategy to improve the utilisation of the different health care services available in the private sector. This study aims to explore how a health care voucher system for older people impacts utilisation of optometry services from the perspective of service users and service providers. Methods People aged 65 years or above were recruited to fill in a structured questionnaire studying the usage characteristics and access barriers of optometry services and the health care voucher. Views from the optometrists about the voucher scheme were collected by questionnaire. Results A total of 1156 valid questionnaires from eligible voucher users was collected. Results showed that 53.7% (621/1156) of participants had used optometry services within the past 2 years. Lack of familiarity with services provided, professional fees, and prices of spectacles were the main barriers to using optometry services. Of those participants who had used the voucher for optometry services previously, 80.4% (284/353) had an eye examination in the past 2 years. Among 389 optometrists who participated in the study, over 80% agreed that the voucher scheme improved awareness of major eye conditions and access to prescription spectacles when necessary. Conclusion The health care voucher for older people improved access to optometry services. Access could be further improved by increasing price transparency of professional services and prescription spectacles. Responses from optometry service providers supported the view that the voucher scheme improved access to, and utilisation of, preventive care services.

Inequalities in access to healthcare by local policy model among newly arrived refugees: evidence from population-based studies in two German states

BackgroundAccess to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers’ access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV).MethodsWe used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates.ResultsCompared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) while ASR under the EHC model did not differ from ASR with regular access in any of the outcomes. The comparison between EHC and HV model showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). GP and emergency department utilization, unmet needs and avoidable hospitalization did not show significant differences in any of the fully adjusted models.ConclusionASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Potential patterns of differences in GP utilization, unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies.

Healthcare Voucher Scheme for Screening of Cardiovascular Risk Factors: A Population-Based Study.

The present study aimed to evaluate the factors associated with unwillingness to join a healthcare voucher scheme for screening of cardiovascular risk factors in a Chinese population. We conducted a telephone survey by random selection of 1200 subjects who were aged 45 years or above in Hong Kong. We collected data on their attitude, perception, and perceived feasibility of a healthcare voucher scheme. The overall rates of having received at least one type, two types, and all three types of screening tests are 81.1%, 80.7%, and 79.3%, respectively. Younger individuals (aOR = 0.338, p = 0.004), those of a higher educational level (aOR = 1.825, p = 0.006), being employed (aOR = 3.030, p = 0.037), and lower perception of screening as beneficial (aOR = 0.495, p < 0.001) were significantly associated with no regular screening for at least one medical condition. The overall rate of willingness to join the voucher scheme (among those aged ≥ 45) is 83.7%. Male sex (aOR = 2.049, p = 0.010) and absence of family history of cardiovascular disease (aOR = 0.362, p = 0.002) are independent predictors of unwillingness to join. Our findings highlighted the significance of sex and family history on screening of cardiovascular factors. These constructs and independent predictors identified provide evidence-based formulation and implementation targeted screening strategies that enhance the screening rate of the three cardiovascular risk factors.

Oral Health Care of Older Adults in Hong Kong.

The older adult population is increasing both in number and in proportion worldwide. In Hong Kong, the number of people aged 65 or above is expected to reach 2.5 million in 2039, thus becoming one-third of the population. With this growing population, the need for dental care among older adults is expected to surge. Oral health care is one of the government’s core policy agendas and the Department of Health has emphasised its importance. It has implemented a number of policies, such as increasing the number of dental training places, setting up an expert group for oral health care policy planning, and conducting regular oral health surveys of the population. It is subsidizing several programmes, including the Elderly Health Care Voucher Scheme, Community Care Fund Elderly Dental Assistance Programme, Outreach Dental Care Programme, and Comprehensive Social Security Assistance Programme, in order to promote oral health care in older adults. These programmes have received support and positive feedback from both the public and dental service providers. The purpose of this review is to provide an overview of the oral health care of older adults in Hong Kong and recommendations to enhance their effectiveness.

Long-term effectiveness of elderly health care voucher scheme strategies: a system dynamics simulation analysis

BackgroundThe elderly healthcare voucher (EHCV) scheme is expected to lead to an increase in the number of elderly people selecting private primary healthcare services and reduce reliance on the public sector in Hong Kong. However, studies thus far have reported that this scheme has not received satisfactory responses. In this study, we examined changes in the ratio of visits between public and private doctors in primary care (to measure reliance on the public sector) for different strategic scenarios in the EHCV scheme.MethodsBased on comments from an expert panel, a system dynamics model was formulated to simulate the impact of various enhanced strategies in the scheme: increasing voucher amounts, lowering the age eligibility, and designating vouchers for chronic conditions follow-up. Data and statistics for the model calibration were collected from various sources.ResultsThe simulation results show that the current EHCV scheme is unable to reduce the utilization of public healthcare services, as well as the ratio of visits between public and private primary care among the local aging population. When comparing three different tested scenarios, even if the increase in the annual voucher amount could be maintained at the current pace or the age eligibility can be lowered to include those aged 60 years, the impact on shifts from public-to-private utilization were insignificant. The public-to-private ratio could only be marginally reduced from 0.74 to 0.64 in the first several years. Nevertheless, introducing a chronic disease-oriented voucher could result in a significant drop of 0.50 in the public-to-private ratio during the early implementation phase. However, the effect could not be maintained for an extended period.ConclusionsOur findings will assist officials in improving the design of the EHCV scheme, within the wider context of promoting primary care among the elderly. We suggest that an additional chronic disease-oriented voucher can serve as an alternative strategy. The scheme must be redesigned to address more specific objectives or provide a separate voucher that promotes under-utilized healthcare services (e.g., preventive care), instead of services designed for unspecified reasons, which may lead to concerns regarding exploitation.

Addressing the Mental and Emotional Health Impacts of COVID-19 on Children and Adolescents: Lessons From HIV/AIDS.

The COVID-19 pandemic has led to lasting mental health and psychosocial consequences just as were experienced with the HIV epidemic. A rapid review of published systematic reviews on HIV/AIDS and mental health outcomes and responses among children and adolescents was used to identify lessons for the COVID-19 pandemic response. The review found that HIV/AIDS responses to promote mental health, prevent ill-health and treat mental health conditions included diverse interventions at the structural or national, community, household and individual levels. Some of these responses can be easily replicated, others require substantial adaptation, and some can inform development of new innovative offline and online responses to mitigate impact of COVID-19 on mental health of children and adolescents. Programs that mitigate economic impacts including child grants, income generating activities for caregivers, food distribution, health care vouchers, and other economic empowerment interventions can be replicated with minor adjustments. Helplines for vulnerable or abused children and shelters for victims of gender-based violence can be scaled up to respond to the COVID pandemic, with minimal adaptation to adhere to prevention of contagion. Mass media campaigns to combat stigma and discrimination were successfully employed in the HIV response, and similar interventions could be developed and applied in the COVID context. Some programs will need more substantial adjustments. In health facilities, mainstreaming child-sensitive mental health training of frontline workers and task sharing/shifting to community volunteers and social workers as was done for HIV with community health workers, could advance mental illness detection, particularly among abuse victims, but requires adaptation of protocols. At the community and household levels, expansion of parenting programs can help caregivers navigate negative mental health effects on children, however, these are not often operating at scale, nor well-linked to services. Programs requiring innovation include converting adolescent and youth safe physical spaces into virtual spaces particularly for at-risk girls and young women; organizing virtual community support groups, conversations, and developing online resources. Re-opening of schools and introduction of health and hygiene policies, provides another opportunity for innovation - to provide mental health and psychosocial support to all children as a standard package of care and practice.

Barriers to preventive care utilization among Hong Kong community-dwelling older people and their views on using financial incentives to improve preventive care utilization.

BackgroundFinancial incentive is increasingly used as a mean to promote preventive care utilization (PCU), but the current Elderly Health Care Voucher Scheme (EHCVS) in Hong Kong is ineffective for encouraging PCU.ObjectiveTo explore the older people's barriers to PCU and their views on financial incentive, including EHCVS, for improving private PCU.Design and settingFocus‐group discussions were conducted in community elderly centres located in five districts of Hong Kong.ParticipantsCommunity‐dwelling older people aged 60 years or above.ResultsLack of understanding about preventive care and low awareness of the need for preventive care were key factors for the low motivation for PCU. Uncertainty over the level of service fee charged and concerns over service quality hindered the choice of using the private service providers under the current EHCVS. Financial incentives specific for preventive care services were thought to be cues to actions and guides for service promotion. However, some flexibility in service coverage and a set time limit of the financial incentives were preferred to accommodate individual needs.ConclusionsApart from promoting knowledge of preventive care, official monitoring for service fee and quality is important for empowering older people to choose private service providers for preventive care. Financial incentives for preventive care services should be more specific to cue service promotion and uptake of preventive care while maintaining flexibility to accommodate individual needs.Patient or public contributionParticipants were recruited using purposive sampling with the coordination of community elderly centres. Data were analysed using thematic coding.

Dental Care Services for Older Adults in Hong Kong-A Shared Funding, Administration, and Provision Mode.

Hong Kong has a large and growing population of older adults but their oral health conditions and utilization of dental services are far from optimal. To reduce the financial barriers and to improve the accessibility of dental care services to the older adults, a number of programmes adopting an innovative shared funding, administration, and provision mode have recently been implemented. In this review, an online search on the Hong Kong government websites and the electronic medical literature databases was conducted using keywords such as “dental care,” “dental service,” and “Hong Kong.” Dental care services for older adults in Hong Kong were identified. These programmes include government-funded outreach dental care service provided by non-governmental organizations (NGOs), provision of dentures and related treatments by private and NGO dentists supported by the Community Care Fund, and government healthcare vouchers for private healthcare, including dental, services. This paper presents the details of the operation of these programmes and the initial findings. There is indirect evidence that these public-funded dental care service programmes have gained acceptance and support from the government, the service recipients, and the providers. The experience gained is of great value for the development of appropriate dental care services for the older adults in Hong Kong and worldwide.

Can voucher scheme enhance primary care provision for older adults: cross-sectional study in Hong Kong

BackgroundThe Hong Kong government has launched the Elderly Health Care Voucher (EHCV) scheme to facilitate primary care in the private sector for older adults. This study aimed to examine whether voucher use was associated with a shift of healthcare burden from the public to the private sector, vaccine uptake and continuity of care.MethodsThis cross-sectional survey recruited older adults with ≥3 chronic diseases through convenience sampling from seven general outpatient clinics, seven geriatric day hospitals, and five specialist outpatient clinics of the public healthcare sector in Hong Kong. We used multiple logistic regression to address the study objective.ResultsA total of 1032 patients participated in the survey. We included 714 participants aged 70 or above in the analysis. EHCV use was associated with higher utilization of private primary care services, including general practitioner and family doctor (Adjusted Odds Ratio (AOR) 2.67, 95% Confidence Interval (95%CI) 1.51–4.72) and Chinese medicine clinic (AOR 3.53, 95%CI 1.47–8.49). There were no significant associations of EHCV use with public general outpatient clinic attendance, Accident & Emergency attendance, and hospitalization. Furthermore, EHCV users were more likely to receive pneumococcal vaccination (AOR 2.17, 95%CI 1.22–3.85) and were less likely to visit the same doctors for chronic disease management (AOR 0.10, 95%CI 0.01–0.73).ConclusionsWhile the EHCV may promote private primary care utilization and preventive care, older patients continue to rely on public services and the EHCV may worsen continuity of care. Policy-makers should designate voucher usage for chronic disease management and continuity of care.

Healthcare vouchers for better elderly services? Input from private healthcare service providers in Hong Kong.

Hong Kong's health system comprises parallel and segmented public and private financed and provided sectors, in which access to the limited public primary healthcare has been an issue. This gave the government the impetus to implement the Elderly Healthcare Voucher Scheme since 2009, providing Hong Kong resident aged 65 and above an annual entitlement of HK$2,000 to purchase private primary healthcare. This was to reduce the demand for public healthcare and encourage the use of private preventive care and chronic disease management. To evaluate the effectiveness and impact of the voucher scheme, in-depth understanding from the providers' perspectives on implementation barriers and facilitators was studied. The perspectives of 33 service providerswere sought through five focus group discussions and seven telephone interviews between 2016 and 2017. Mixed sampling strategies were used, and the discussion covered three main areas: (a) factors that affect the impact of voucher scheme in bridging the private and public primary healthcare sector; (b) perceived barriers to participation in the voucher scheme and (c) potential enhancement of the voucher scheme. Participants agreed that the voucher scheme encouraged uptake of private primary care for acute episodes, but not for chronic disease management and rehabilitation due to inadequate financial entitlements and the elderly persons' lack of knowledge on the services covered. Low financial incentives, tedious administrative work and inadequate communications were identified as barriers for enrolment. The voucher scheme has resulted in increased utilisation of private primary healthcare but has not reduced the demand for public primary healthcare. Fundamental questions remain about the scheme's potential role in improving universal health coverage and financial sustainability which are related to the program design and to whether this is the better mechanism, or a complementary mechanism to address some of the more complex health system priorities including better chronic disease management.

An overview of health policies for asylum-seekers in Germany

Health policies for asylum-seekers are a subject of debate across European countries. However, information on current strategies to respond to these populations’ health needs is scarce. To facilitate comparative research, this paper renders a detailed overview of Germany’s asylum-seeker health policies.Following a description of the historic development and administrative structure of asylum-seeker health care in Germany, we provide a detailed account of asylum-seekers’ scope of health entitlements, as it is defined by federal law. We explain the main mechanisms that are used to implement the law on local levels and regulate health care access; namely, the electronic health insurance card and the health care voucher. Financing and billing structures are described, and main points of critique of Germany’s asylum-seeker health policies are summarized.Our description highlights fragmentation and internal variations as central features of Germany’s asylum-seeker health policies. It explicates how these features are rooted in decentralization, and in the regulation of restricted health benefits through a parallel system, separate from statutory health insurance. As a case-study, Germany’s asylum-seeker health policies illustrate the administrative, economic and ethical burdens implied in granting health benefits through a parallel system, and in absence of central health governance. The (re)integration of asylum-seeker health care in statutory health insurance could reduce these burdens and contribute to equitable health care access.

Differences in health care utilization by access policy among newly arrived refugees in Germany

Abstract Introduction In the first few months after refugees arrive in Germany, access to healthcare in most states is granted via health care vouchers (HcVs) that are issued by local authorities. After 15 to 18 months or formal recognition of refugee status, access is granted via electronic health cards (eHC) issued by statutory health insurance funds. We analyze whether these access policies (HcV vs. eHC) are associated with differences in needs-based utilization. Methods We use data from a cross-sectional survey among newly arrived refugees and asylum seekers (n = 560; response rate 41.7%) in Germany's 3rd largest federal state to analyze differences in reported utilization of GP and specialist services in the last 4 weeks. We use logistic regression to calculate odds ratios (OR), adjusting for socio-demographic characteristics, health status, duration of stay and proximity of service providers. Results Fewer refugees with HcVs reported using GP or specialist services in the last four weeks compared to those using regular eHCs (GP: 52.76% vs. 61.48%; SP: 38.97 vs. 45.09%). For specialist use, this difference persisted after adjustment, with eHC users having significantly higher odds of needs-based utilization (OR: 2.00; 95%-CI: 1.01-3.95). After adjustment, odds for GP use are also higher among persons with eHC, but less significant (OR: 1.37; 95%-CI: 0.67-2.82). Furthermore, the lack of a HcV was the second most reported reason among HcV users to refrain from utilization (17.09% for specialist and 15.51% for GP use). Conclusions The access model is associated with differences in needs-based utilization for specialist (and partly for GP) use after controlling for important confounders. The lack of (timely) HcV provision constitutes a relevant access barrier. The results provide evidence that with equal needs, refugees with HcVs have more difficulties accessing services. Key messages Access policies are associated with differences in healthcare utilization among newly arrived refugees in Germany. Early access to health cards and the statutory health insurance is likely to facilitate need-based utilization of health services for newly arrived refugees.

Shaping access to health care for refugees at the local level in Germany

Abstract Background In Germany, the federal states and even the municipalities have considerable scope for shaping implementation of national health policies for newly arrived refugees, including in the way they organize access to health services. We analysed how gatekeepers can shape access to health care at the local level, exploring access models in six municipalities in the federal state of North Rhine-Westphalia. Methods We assessed the implementation of local access models and the consequences for access for refugees. Our study covered three municipalities with a health care voucher model and three with an electronic health card model. We combined data from official reports and from 21 semi-structured interviews with gatekeepers. Results Our research illustrates how gatekeepers at the local level can shape and facilitate access to health care for refugees, irrespective of the access model chosen. Larger municipalities are more likely to implement an electronic health card model. Gatekeepers report that costs, workload and control are the major aspects underlying the choice of model in municipalities. Access plays only a minor role, although some gatekeepers claim that the electronic health card model can improve access. Conclusions National health policies can support gatekeepers in their role as facilitators, such as through financial incentives or a minimum amount of bureaucracy. They can also allow newly arrived refugees to become members of the statutory health insurance system, which would relieve social welfare offices and general practitioners (GPs) from their role of gatekeepers.

Differences in realized access to healthcare among newly arrived refugees in Germany: results from a natural quasi-experiment

BackgroundGermany has a statutory health insurance (SHI) that covers nearly the entire population and most of the health services provided. Newly arrived refugees whose asylum claim is still being processed are initially excluded from the SHI. Instead, their entitlements are restricted and parallel access models have been implemented. We assessed differences in realized access of healthcare services between these access models.MethodsIn Germany’s largest federal state, North Rhine-Westphalia, two different access models have been implemented in the 396 municipalities: the healthcare voucher (HcV) model and the electronic health card (eHC) model. As refugees are quasi-randomly assigned to municipalities, we were able to realize a natural quasi-experiment including all newly assigned refugees from six municipalities (three for each model) in 2016 and 2017. Using claims data, we compared the standardized incidence rates (SIR) of specialist services use, emergency services use, and hospitalization due to ambulatory care sensitive conditions (ACSC) between both models. We indirectly standardized utilization patterns first for age and then for the sex.ResultsSIRs of emergency use were higher in municipalities with HcV (ranging from 1.41 to 2.63) compared to emergency rates in municipalities with eHC (ranging from 1.40 to 1.71) and differed significantly from the expected rates derived from official health reporting. SIRs of emergency and specialist use in municipalities with eHC converged with the expected rates over time. There were no significant differences in standardized hospitalization rates for ACSC.ConclusionThe results suggest that the eHC model is slightly better able to provide refugees with SHI-like access to specialist services and goes along with lower utilization of emergency services compared to the HcV model. No difference between the models was found for hospitalizations due to ACSC. Results might be slightly biased due to incompletely documented service use and due to (self-) selection on the level of municipalities with municipalities interested in facilitating access showing more interest in joining the project.

Improvement of Elderly Health Care Voucher Scheme in Hong Kong

Elderly Health Care Voucher Scheme is a financial support provided by the government to the elderly for having more choices in selecting private primary health care services. It has been launched for more than ten years (including pilot scheme). The success of the voucher depends on its effectiveness so that Hong Kong elderly can benefit from it. The aim of this article is to analyse whether the voucher scheme has achieved its goals and what improvement can be made. The scheme is successful in encouraging the elderly to use private primary care, considering that the participation rate of the scheme is high, and elderly could use private health care services to supplement public health care services. Yet, the amount of the subsidy is insufficient to support the needs of the elderly and the providers of the voucher are not enough for Hong Kong elderly. Also, it is found that private health care services give the old generation an impression of expensiveness and unreliable even with the support of the Health Care Voucher. To improve the Elderly Health Care Voucher Scheme and solve the problems, the government should increase the amount of the voucher, set standards for regular monitoring, cooperate with private health care providers and invite more providers. Ultimately, the elderly would enjoy greater flexibility in choosing medical services in meeting their needs and the scheme can effectively achieve its purpose.