Payment Policy Research Articles

Risks and profitability of business models of insurance companies

Ukrainian insurance companies are steadily moving towards the European development framework, facilitated by the adoption of a series of radical regulatory documents by the National Bank of Ukraine (NBU) concerning the super­vision of their activities based on a risk-oriented approach. This, in turn, requires insurance compa­nies to make fundamental changes to their risk management processes and substantiate their choice of a viable business model capable of ensu­ring their long-term. The aim of the article is to determine the level of risks and the related profitability of business models of insurance companies of Ukraine, as well as to develop recommendations for their transfor­mation based on proactive risk management. The research is based on the use of a set of such methods as analysis, comparison, grouping, correlation. Various methodical approaches to distinguishing the business models of insurers are revealed and their brief description is given. An analysis of risks for business models of life and non-life insurance was carried out based on the system of selected indicators. An analysis of the correlation relationship between the ratio of insurance payments to insurance premiums (dependent variable) and independent variables was carried out. Proposals aimed at imple­menting innovative business models based on proactive risk management have been deve­loped. Formulated and empirically tested hypo­theses regarding the reduction of the scale of the insurance business under the influence of the unfavorable economic situation, the war in Ukraine and the strengthening of regulatory requirements for insurers; different levels of risks are inherent in the business models of non-life and life insurers; the introduction of innova­tive business models for insurers should be based on the conceptual principles of proactive risk management

Interfacility Competition and its Impact on Cost of Carpal Tunnel Release.

Carpal tunnel release (CTR) is the most common hand surgery procedure, but little is known about how healthcare market characteristics influence cost. The objective of this study was to understand the association of healthcare market competition and facility availability on out-of-pocket and total insurer payments for patients undergoing CTR. This retrospective cross-sectional study used a national sample of private insurance claims from 2015-2020. Adults who had CTR were included, while acute or inpatient CTRs, or lacking geographical information were excluded. Linear regression was applied to investigate the impact of the healthcare market competition and facility availability (ambulatory surgery center (ASC), hospital outpatient departments (HOPD), outpatient clinics) on the out-of-pocket expenses and total insurer payment. Market competition was measured using the Herfindahl-Hirschman Index. Of 119,828 patients, 76% underwent open CTR. The most competitive hospital markets were HOPDs and ASCs, respectively. As HOPD competition decreased, out-of-pocket expenses and total insurer payment decreased significantly. As ASC competition decreased, only total insurer payments decreased significantly. CTRs performed in outpatient clinics increased slightly over time. However, HOPDs remained the most common location until 2020 when their popularity was similar to ASCs. Finally, out-of-pocket expenses increased significantly whereas total insurer payments did not change significantly throughout the study period. This study found decreased healthcare market competition was not associated with increased CTR costs, suggesting that costs are complex and multifactorial. To reduce healthcare costs, this study supports the movement of CTRs to clinic and ASCs.

Prolonged Boarding and Racial Discrimination and Dissatisfaction Among Emergency Department Patients

Emergency department (ED) boarding times have increased rapidly, but their health equity outcomes are unknown. To investigate whether prolonged ED boarding is associated with increased perceived racial discrimination and dissatisfaction and whether associations vary between patients from marginalized racial and ethnic groups vs non-Hispanic White patients. This is a cross-sectional study of hospitalized adults who boarded in the ED during internal medicine admissions at a large, urban hospital in Boston, Massachusetts, from June 2023 to January 2024. Equal proportions of non-Hispanic White patients and patients from marginalized racial and ethnic groups (American Indian or Alaska Native, Hispanic, non-Hispanic Black and/or African American, and multiracial) were selected randomly. The duration of ED boarding was categorized as less than 4 hours (reference), 4 to less than 24 hours, and 24 or more hours. Primary outcomes were odds of reporting (1) discrimination via the Discrimination in Medical Settings scale, and (2) dissatisfaction via the adapted Picker Patient Experience-15 questionnaire. Marginalized race and ethnicity was tested as an effect modifier. Multivariable logistic regression models adjusted for patient age, sex, language, and insurance payer. Of 598 patients approached, 527 were enrolled, and 525 completed the surveys (response rate, 87.8%). The mean age (SD) was 60.6 (18.7) years, 300 patients (57.1%) were female, 246 patients (47.3%) identified as non-Hispanic White, and 274 (52.7%) were from a marginalized racial or ethnic group. In total, 135 (25.7%) boarded less than 4 hours (reference), 202 (38.5%) boarded 4 to less than 24 hours, and 188 (35.8%) boarded 24 hours or longer. Compared with less than 4 hours, boarding 24 hours or longer was associated with increased perceived discrimination (odds ratio [OR], 1.84; 95% CI, 1.14-2.99; P = .01). An increased association was observed in the subgroup of patients from racial and ethnic marginalized groups (OR, 2.36; 95% CI, 1.20-4.65; P = .01); effect modification was not significant (P for interaction, .10). For all patients, boarding 24 hours or longer was associated with increased dissatisfaction with care (OR, 1.77; 95% CI, 1.03-3.06; P = .04); effect modification was not significant (P for interaction, .80). In this cross-sectional study, hospitalized patients who boarded in the ED 24 hours or longer reported more discrimination and dissatisfaction with care, which may disproportionately affect patients from marginalized racial and ethnic groups. As ED boarding times increase nationally, it is critical to recognize their potential to exacerbate health inequities and to respond with equity-focused solutions.

Правовий статус страховика як учасника договірних страхових відносин

Despite the regulation of insurance relations by Ukrainian legislation, due attention from both scientists and legislators requires the issue of improving the legal status of participants in insurance relations, determining their place in such relations in order to effectively protect their rights and interests. The purpose of the article is to study the legal status of the insurer as a participant in insurance contractual relations, analyze existing approaches to its determination, establish the features of the insurer's legal personality and provide proposals for further improvement of legislation in this area. A characteristic feature of an insurance contract as an independent type of civil legal obligations within the group of contracts for the provision of services is that the conclusion of insurance contracts is directly the subject of activity of specially authorized participants in civil relations – insurance organizations (insurers). It has been established that the insurer, as a participant in insurance contractual relations, is a legal entity that, being specially created to provide insurance services and having received a license for this in the prescribed manner, undertakes the obligation, in accordance with the terms of the contract or an indication of the law, to provide insurance to the insured for a certain fee, to carry out an insurance payment (insurance compensation) to the insured or beneficiary as a result of the occurrence of a certain event (insured event). In insurance contractual relations, the insurer can only have a legal entity on its side, which is empowered to carry out insurance activities only after receiving a special permit (license), which indicates that legal entities - insurers have special legal personality. An insurance organization is endowed with the general legal capacity of a legal entity with a special scope of legal capacity as a financial institution. Attention is drawn to the fact that a significant factor in the modernization of the civil legislation of Ukraine today is the global trend towards unification and harmonization of private law regulation, the formation of optimal legal norms for many areas of private law relations, including insurance. In this regard, the need is justified to determine at the legislative level the requirements for the insurer when it carries out certain types of compulsory insurance, which have their own specifics and provide for the creation of increased guarantees of protection for those persons who, due to objective circumstances, are exposed to increased risk and the extension of insurance protection to cases possible violation of public interests by the method of guaranteeing receipt of insurance payment (insurance compensation). It is concluded that the recodification of the civil legislation of Ukraine opens up prospects for a qualitative update of the legal regulation of insurance contractual relations and will contribute to the development of the provision of insurance services, strengthening of legal institutions in the field of insurance, raising the standards of providing insurance services and ensuring adequate protection of the rights of participants in insurance relations

Research on the Effects of Corporate Social Insurance on Total Factor Productivity

Social insurance is an insurance arrangement that the country or the government collects from some specific groups, such as enterprises, through compulsory means and then sets up social security funds to guarantee the basic living standards of specific groups of society, including the old, weak, sick, disabled, pregnant and temporarily unemployed. It is a legal responsibility and obligation that enterprises or employers must undertake and in the financial aspect, it is a rigid labor cost besides the wages. In China, enterprise is the main object that should afford the payment of social insurance and its contribution rate is higher than the international level, followed by some negative effects. This article prefers to study the correlation between corporate social insurance and TFP and find a reasonable range of the contribution rate based on the other researchers’ data and viewpoints. It may also provide some possible suggestions to the governments to decrease the burden of firms and ensure the development of a welfare security system.

The state of the property insurance market of Ukraine in the conditions of war

Introduction. The paper highlights the theoretical and methodological foundations of the functioning of the property insurance market in Ukraine. It was determined that property insurance is of crucial importance for raising the standard of living of the population and creating a strong system of protection of state finances, ensuring the stability of the country's economy. The purpose of the paper is to determine the essence of insured property and research the state of the property insurance market of Ukraine during the period of martial law. Results. The current trends in the development of property insurance in Ukraine are considered. The paper examines and analyzes the current state of the property insurance market of Ukraine and the main indicators of insurance activity for 2021-2023. It was determined that property insurance is the largest branch of the insurance market of Ukraine, and despite all the problems related to the war, the Ukrainian insurance market continued active recovery in 2023. The main problems of the property insurance market, which restrain its development, are identified, directions for its improvement and further development are proposed. In order to develop the insurance property of Ukraine after the war, it was proposed to soften the regulatory requirements for calculating contributions, reduce the tax burden on insurance activity, strengthen the control of insurance payments, and ensure the possibility of preferential lending. Conclusions. Analysis of the development of property insurance in Ukraine in recent years allows us to come to the disappointing conclusion that the war significantly affected the development of property insurance, there was a significant decrease in insurance premiums and insurance payments in 2020. But in 2023, the property insurance market of Ukraine began to grow, which indicates its readiness for adaptation and recovery in the post-war years.

The Literature that Commercial Insurance Payers Use to Substantiate Knee Osteochondral Allograft Policies Are of a Low Level of Evidence.

The purpose of this study is to analyze how the largest insurance companies support their medical necessity policies regarding osteochondral allograft transplantation (OCA) and to determine whether the literature they cite in their policies is of a high level of evidence (LOE). The 10 largest national health insurance companies were identified. Each payer was contacted via phone or email to obtain their coverage policy regarding OCA. For each policy, the medical necessity criteria were recorded, and all cited references were screened. For all references applicable to OCA, the LOE was recorded, and each reference was screened to determine whether they mentioned the specific criteria reported in the policies. The medical policies for 6 of the 10 national health insurance companies were identified. These 6 policies cited a collective total of 102 applicable references. Most of these studies were an LOE of IV (n = 58, 56.9%) and an LOE of V (n = 18, 17.6%). There were similarities amongst the medical necessity criteria between different commercial payers; however, most criteria were poorly supported by the cited literature. Our results demonstrate that commercial insurance companies utilize studies that are of a low LOE when justifying their medical necessity criteria. Moreover, these cited studies infrequently support or mention the commercial payers' criteria. Future studies should continue to explore how well-supported insurance policies are with the goal of potentially increasing access and authorization for well-supported treatment modalities.

The Effect of Company Risk and Company Complexity on Audit Fees with Moderation of Dividend Payment Policy

This study aims to determine: (1) The effect of company risk on audit fee, (2) The effect of company complexity on audit fee, (3) The effect of company risk on audit fees moderated by dividend payment policy, (4) The effect of company complexity on audit fees moderated by dividend payment policy. Population in this research ar e nonfinancial companies listed in Indonesia Stock Exchange (IDX) in 2020 – 2022. The sample is determined based on Stratified Random Sampling method with a total sample of 10 companiees. The data used in this research is secondary data. The technique of collecting data by the method of documentation at www.idx.com and the official website of each company. The analytical method used is multiple regression analysis. The result showed that: (1) Company risk influence a significant positive on audit fee, (2) Company complexity no significant effect on on audit fee, (3) Company risk no significant effect on audit fees moderated by dividend payment policy (3), and (4) Company complexity no significant effect on audit fees moderated by dividend payment policy.

Factors Determining the Risks of an Insurance Contract

The process of public production is interrupted or disrupted as a result of the destructive action of natural forces or as a result of various negative situations. The creation of such undesirable situations is a regular process and is connected with the contradictory nature of public production. The risk indicators should also be discussed. In order to overcome the existing negative situations, as well as to provide unconditional compensation for the caused damage, insurance certainly plays a crucial role. Insurance expresses what kind of economic relations act as economic categories. The essence of the insurance is that the damage will be distributed among many insurers, and their contribution will be relatively small for each of them. Moreover, Insurance is a set of economic relations between its participants, caused by the formation of a target insurance fund and its use in order to cover losses and pay insurance sums. Insurance risk lies in the basis of insurance. Keywords: Economic relationship, insurance amount, insurance payment, insurance rate.

Incidence and related risk factors for postoperative delirium following revision total knee arthroplasty: a retrospective nationwide inpatient sample database study.

Postoperative delirium (POD) is a common surgical complication. However, the incidence and risk factors associated with postoperative delirium after revision total knee arthroplasty (rTKA) have not been comprehensively explored through extensive national databases. Utilizing the National Inpatient Sample (NIS), the largest comprehensive U.S. hospital healthcare database, we undertook a retrospective investigation involving 127,400 patients who underwent rTKA between 2010 and 2019. We assessed various aspects, including patient demographics, hospital characteristics, pre-existing medical conditions, and perioperative complications. The overall incidence of postoperative delirium (POD) in patients undergoing rTKA between 2010 and 2019 was 0.97%. The highest incidence rate of 1.31% was recorded in 2013. Notably, this patient cohort demonstrated advanced age, increased burden of co-morbidities, prolonged hospital stays, increased hospitalization costs, and elevated in-hospital mortality rates (P < 0.001). Moreover, non-elective admissions, non-private insurance payments, and a preference for teaching hospitals were commonly observed among these patients. During their hospitalization, individuals who developed delirium subsequent to rTKA were more prone to experiencing certain perioperative complications. These complications encompassed medical issues like acute myocardial infarction, continuous invasive mechanical ventilation, postoperative shock, sepsis, stroke and other medical problems. Additionally, surgical complications including hemorrhage / seroma / hematoma, irrigation and debridement, prosthetic joint infection, periprosthetic fracture, and wound dehiscence / nonunion were noted. Several risk factors were found to be linked with the development of POD. These included advanced age (≥ 75years), alcohol abuse, coagulation disorders, congestive heart failure, depression, fluid and electrolyte imbalances, and more. Conversely, female sex, having private insurance, and undergoing elective hospitalization emerged as protective factors against POD. Our findings suggest that the general prevalence of POD in rTKA is relatively low according to NIS. There was a significant connection between the POD of rTKA and advanced age, prolonged length of stay (LOS), more in-patients' costs, higher in-hospital mortality rate, increased comorbidities, postoperative medical complications and postoperative surgical complications. This study helps to understand the risk factors associated with POD to improve poor outcomes.

Toward sustainable environmental management: Insights from Chinese first-tier cities' consumers' response to green electricity payment policies

China's renewable energy industry is facing the challenge of overcapacity. The environmental management literature suggests that consumers' participation in the green electricity market holds immense potential in addressing renewable energy consumption concerns. However, the question of how payment policies influence China's consumers' willingness to pay for green electricity remains unresolved. Based on 2854 valid questionnaires from a survey conducted in China's four first-tier cities in 2023, our research findings reveal: (1) While 97.9% of consumers express a willingness to use green electricity, only 63.1% are willing to pay a higher cost, indicating the existence of a “value-action” gap between environmental awareness and actual willingness to pay. (2) China's consumers' willingness to pay for green electricity is approximately 38.4 RMB per month. This figure has decreased by 5.7 RMB compared to our survey in 2019. (3) Consumers' willingness to pay will be influenced by the attitudes of those around them. (4) The voluntary payment policy positively impacts consumers' willingness to pay for green electricity. (5) Male, younger, lower education level, higher income, and larger household size consumers exhibit a higher willingness to pay. (6) Electricity price sensitivity weakens the impact of payment policies on willingness to pay.

Is Insurance Payor Associated With Hospital Admission of Emergency Department Adult Patients With Odontogenic Infections?

Patients who present to the emergency department (ED) with severe odontogenic infections are often hospitalized for surgical drainage and medical management. However, inpatient management of these patients can be financially burdensome. While medical indications for hospital admission are well established, it remains unclear if patient insurance status is associated with admission. The purpose of this study was to determine the nationally representative estimates of the incidence of hospital admission for patients with odontogenic infections and the association with insurance payor. This retrospective cohort study used the 2018 Nationwide Emergency Department Sample. Patients with odontogenic infections (based on International Classification of Diseases, 10th Revision codes) were included. Patients aged <18years or who had missing data were excluded. The primary predictor variable was primary payor (private insurance, Medicare, Medicaid, self-pay, and other). The primary outcome variable was hospital admission (yes/no). Covariates included sociodemographic, medical, infection, and hospital variables. Descriptive, bivariate, and multivariable logistic regression analyses were used to determine national estimates and predictors of admission. Odds ratios and 99% confidence intervals were computed. Discharge weights were accounted for in all analyses to provide nationally representative estimates. This study included 31,221 weighted ED encounters, of which 10,451 (33.5%) were admitted. In the study cohort, 7,687 (24.6%) had private insurance, 5,046 (16.2%) had Medicare, 10,070 (32.3%) had Medicaid, 7,436 (23.8%) were self-pay, and 982 (3.1%) had other. Bivariate analysis suggested that payor status was significantly associated with hospital admission (P<.01). The multivariable analysis showed that self-pay patients had significantly lower odds of hospital admission compared to those with private insurance (odds ratio, 0.54; 99% confidence interval, 0.42-0.70). Other independent predictors of hospital admission included infection in more than 1 location based on International Classification of Diseases, 10th Revision code, higher Charlson comorbidity index, and alcohol/substance use disorders. Approximately one-third of patients presenting to the ED with odontogenic infections were admitted. Patients with no insurance were less likely to be admitted compared to those with private insurance. This finding may reflect multiple possibilities, including hospital financial incentives.

Impact of insurance payer type (medicare vs. private) on the patient reported outcomes after shoulder arthroplasty

BackgroundThis study’s purpose is to determine if there is a difference in patient reported outcome measures (PROMs) following shoulder arthroplasty (SA) based upon payer insurance type with a secondary outcome of determining if any appreciable difference surpasses the minimal clinically important difference (MCID). MethodsSubjects undergoing anatomic and reverse total shoulder arthroplasty (aTSA and rTSA) were prospectively enrolled between March 2019 – March 2021. Subjects completed PROMIS Upper Extremity (P-UE), the American Shoulder and Elbow Score (ASES), and the Simple Shoulder Test (SST) preoperatively and at 2-weeks, 6-weeks, 3-months, 6-months, and 12-months postoperatively. Descriptive statistics of baseline patient characteristics and preoperative PROMs (ASES, SST, P-UE) were compared between insurance types. Results143 patients were identified who met the inclusion criteria for this study. There were 98 patients within the Medicare cohort and 45 patients with private insurance. Patients in the Medicare cohort were older (mean age 70.5 vs 61.3 years), with high proportion of smokers, diabetics, and rTSA compared to the private payor cohort. There were no significant differences between the two cohorts with respect to outcomes scores except for significantly better SST in the private insurance cohort (69.3 versus 79.4, p=0.02). No significant differences were noted for the achievement of MCID between cohorts [P-UE (p=1.0), ASES (p=0.25), SST (0.52)] and pre- to postoperative improvements for P-UE (p=0.62), ASES (p=0.4), or SST (0.66). ConclusionOur study demonstrates that, at a tertiary level academic institution in a metropolitan city, payor type does not have significant impact on achieving MCID or pre-to-postoperative improvements in PROMs after SA.

Financial Burden and Outcomes of Firearm Injuries in U.S. Hospitals, 2003–2020

Firearm-related injuries (FRIs) are serious but a preventable public health issue. The objective of this study was to describe FRI inpatient costs by (1) patient insurance payer type, and (2) hospital safety-net mix. FRIs were identified using International Classification of Disease diagnosis codes in the National Inpatient Sample. All admissions between 2003 and 2020 were included. The primary outcome was consumer-price index adjusted inpatient stay costs. Mixed effects generalized linear regressions, with a random intercept at the hospital level, were used to describe costs. Analyses were sample weighted and performed between 2023 and 2024. Among 538,795 FRIs, the median age was 27 years (interquartile range: 21 - 37 years). Injuries by payer type were highest among self-pay (280,161; 39%), followed by Medicaid (182,716; 34%), private (113,650; 21%), and Medicare (30,110; 6%). Inflation-adjusted costs of FRI stays totaled $15.2 billion, with $6.2 billion from Medicaid and $5 billion from the self-pay group. After 2014, FRI incidence declined among self-pay/no-charge patients and increased among Medicaid-covered patients - representing a 127% total increase in Medicaid costs from $169 million in 2003 to $753 million in 2020. Among moderate-high and high safety-net mix hospitals, costs increased from $257 million in 2003 to $567 million in 2020. The incidence and costs of FRIs among Medicaid-insured has substantially increased since 2003. Importantly, these increased costs are disproportionately placed on disadvantaged patients and safety-net hospitals.

Trend analysis and regulatory strategies for traditional Chinese medicine formula granules

With the advent of the &quot;post-pilot era&quot; of traditional Chinese medicine formula granules, there are still a series of policy, technical, and industrial issues that need to be addressed in their production, regulation, and application practices. This article systematically reviews the development history and relevant policy evolution of traditional Chinese medicine formula granules, and summarizes the current industrial status in terms of quality standards, medical insurance payments, and market landscape. Based on a comparative analysis and positioning discussion between traditional Chinese medicine formula granules and traditional herbal decoctions, it is believed that the following practical issues still exist in this field:(1)A reasonable competitive evolution mechanism has not yet been formed, making it difficult to &quot;improve quality and efficiency&quot; of products;(2)The number of national standards is limited, and local standards operate independently;(3)Production processes are relatively constrained;(4)There is a contradiction between fixed equivalents and fluctuations in raw materials;(5)Market positioning needs to be clarified, and medication scenarios are limited. Furthermore, based on the perspective of shaping a healthy ecosystem for the traditional Chinese medicine industry and promoting rational clinical use of traditional Chinese medicine, the following suggestions are put forward:(1)Guide the formation of a product-based competitive landscape for traditional Chinese medicine formula granules;(2)Promote the establishment of a comprehensive regulatory system for the entire production process of traditional Chinese medicine formula granules;(3)Conduct systematic research on the relationship between the equivalents and intake of formula granules;(4)Break through existing application scenarios and reasonably expand the application forms of formula granules.

The deposit insurer’s capacity assessment in the context of impact on the financial system stability

The paper is devoted to the development of a scientific and methodological approach to determining the indicators of the deposit insurer's ability to influence the financial system stability. The scale and complexity of the tasks of ensuring the immediate and gradual reconstruction of Ukraine, high dynamics and proper quality of economic growth, the functioning of the economy in the conditions of war and a constant external threat actualize the issue of increasing domestic investment potential and intensifying the transformation of household savings into investments. It creates challenges for the deposit insurance system. In the research structural and logical analysis, induction, comparison, and relative values were used. The capacity of a deposit insurer in the context of its impact on financial stability should be considered in the context of operational, resource and payment capacity, each of which can be assessed by an appropriate indicator. The operational capacity reflects the ability of the deposit insurer to influence the situation in the deposit market and perform the function of deposit guaranteeing. The normative value of the operational capacity indicator in Ukraine is proposed to be set at the level which, in the conditions of the dynamic banking sector of Ukraine and the deposit market as its component, will allow considering the slightest deviations of the indicator (μ+2σ). The resource capacity reflects the coverage level of guaranteed deposits by the insurer's financial resources. The normative value of the resource capacity indicator in Ukraine is proposed to be set at the level of 0.8%, which meets the requirements of Directive 2014/49/EU of the European Parliament and of the Council. The payment capacity reflects the sufficiency of the deposit insurer's financial resources to pay compensation to depositors in the future. The normative value of the payment capacity indicator in Ukraine, by analogy with the indicator of the ratio between insurance technical reserves and the average value of insurance payments, is proposed to be set at least 1 in annual terms and not less than 12 in monthly terms.

TO THE CONCEPT OF INSURANCE INDEMNITY UNDER MOTOR TPL CONTRACTS

The present study is devoted to the issue of defining the concept of insurance compensation under contracts of compulsory motor third party liability insurance (hereinafter - CMTPL) in the system of related concepts of CMTPL using the formal-legal method of research. The article considers various approaches of insurance organisations to the concept of insurance indemnity in the context of legal relations in the field of CMTPL insurance, as well as examines the practical problems faced by both professional participants of the insurance services market - insurers, and persons who apply to them, whose property, in particular vehicles, has suffered as a result of damage caused to them by the perpetrators of road accidents. The paper analyses both regulatory legal acts in the field of CMTPL insurance and the practice of insurance organisations in carrying out their obligations under CMTPL insurance contracts in terms of insurance indemnities and related concepts: ‘insurance payments', “organisation of vehicle repair”, “insurance amounts”, etc. The paper concludes that it is necessary to establish legally the definition of the concept of insurance indemnity, to include in the content of this concept the organisation or payment for repairs within the insurance sum, and to justify the need to increase the terms of insurance indemnity in the form of repairs under CMTPL insurance contracts from thirty to forty-five days.

Evaluating the effect of health insurance reform on health equity and financial protection for elderly in low- and middle-income countries: evidences from China

BackgroundTo achieve Universal Health Coverage (UHC), China have implemented health system reform to expend health coverage and improve health equity. Scholars have explored the implementing effect of this health reform, but gaps remained in health care received by elderly. This study aims to assess the effect of implementing health insurance payment reform on health care received by elderly, as well as to evaluate its effect on cost sharing to identify whether improve financial protection of elderly under this reform.MethodsWe identified hospitalization of 46,714 elderly with cerebral infarction from 2013 to 2023. To examine the determinant role played by DRGs payment reform in healthcare for elderly and their financial protection, this study employs the OLS linear regression model for analysis. In the robustness checks, we validated the baseline results through several methods, including excluding the data from the initial implementation of the reform (2021), reducing the impact of the pandemic, and exploring the group effects of different demographic characteristics.ResultsThe findings proposed that implementing DRGs payment reduces drug expenses but increases treatment expense of chronic disease for elderly in China. This exacerbates healthcare costs for elderly patients and seems to be contrary to the original purpose of health care reform. Additionally, the implementation of DRGs payment reduced the spending of medical insurance fund, while increased the out-of-pocket of patients, revealing a shift in health care expenses from health insurance fund to out-of-pocket.ConclusionsThis study shares the lessons from China’s health reform and provides enlightenment on how to effective implement health reform to improve health equity and achieve UHC in such low- and middle-income countries facing challenges in health financing.

Continued restrictions on nurse practitioners: A qualitative study of the early implementation of full practice authority in Massachusetts

BackgroundIn January 2021, the Commonwealth of Massachusetts granted nurse practitioners (NPs) full practice authority (FPA). Little is known about how care delivery changed after FPA legislation. PurposeTo understand the NP perception of early implementation of FPA in Massachusetts. MethodsQualitative descriptive design using inductive thematic analysis of open-ended responses to a web-based survey of NPs in Massachusetts from October to December 2021. FindingsSurvey response rate was 50.3% (N = 144). Inductive thematic analysis of open-ended responses identified four themes, including: (a) internal and external barriers obstructed FPA implementation, (b) employer communication about scope-of-practice changes was minimal, (c) NPs led initiatives to implement FPA, and (d) some efforts effectively implemented FPA. DiscussionAlmost 1 year after FPA was passed, external policies persisted that financially incentivized employers to not change NP scope-of-practice. Concerted efforts are needed to ensure that federal and payer policies, such as incident-to billing, are aligned with state law to encourage the implementation of FPA.

Clinical Outcomes of a Novel Multidisciplinary Care Program in Advanced Kidney Disease (PEAK)

IntroductionMulti-disciplinary care (MDC) for late-stage chronic kidney disease (CKD) has been associated with improved patient outcomes compared with traditional nephrology care, but the optimal MDC model is unknown. In 2015, we implemented a novel MDC model for patients with late-stage CKD informed by the Chronic Care Model conceptual framework, including an expanded MDC team, care plan meetings, clinical risk prediction, and a patient dashboard. MethodsWe conducted a single-center, retrospective cohort study of adults with late-stage CKD (estimated glomerular filtration rate [eGFR] < 30 mL/min per 1.73m2) enrolled from May 2015 to February 2020 in the Program for Education in Advanced Kidney disease (PEAK). Our primary composite outcome was an optimal transition to end-stage kidney disease (ESKD) defined as starting in-center hemodialysis (ICHD) as an outpatient with an arteriovenous fistula (AVF) or graft (AVG), or receiving home dialysis, or a pre-emptive kidney transplant. Secondary outcomes included home dialysis initiation, pre-emptive transplantation, vascular access at dialysis initiation, and location of ICHD initiation. We used logistic regression to examine trends in outcomes. Results were stratified by race, ethnicity, and insurance payor and compared with national and regional averages from the United States Renal Data System (USRDS) averaged from 2015 to 2019. ResultsAmong 489 patients in the PEAK program, 37 (8%) died prior to ESKD and 151 (31%) never progressed to ESKD. Of the 301 (62%) patients who progressed to ESKD, 175 (58%) achieved an optimal transition to ESKD, including 54 (18%) peritoneal dialysis, 16 (5%) home hemodialysis, and 36 (12%) preemptive transplant. Of the 195 (65%) patients starting ICHD, 51% started with an AVF or AVG and 52% started as an outpatient. The likelihood of starting home dialysis increased by 1.34 times per year from 2015 to 2020 (95% CI 1.05 – 1.71, p = 0.018) in multivariable adjusted results. Optimal transitions to ESKD and home dialysis rates were higher than national USRDS data (58% vs. 30%; 23% vs. 11%) across patient race, ethnicity, and payor. ConclusionsPatients enrolled in a novel comprehensive MDC model coupled with risk prediction and health information technology were nearly twice as likely to achieve an optimal transition to ESKD and start dialysis at home, compared with national averages.