Largest Health Insurance Fund Research Articles

Prognostic impact of cardiac events in asymptomatic mitral regurgitation

Abstract Background Mitral regurgitation (MR) is the most common valvular heart disease in adults and is associated with increased morbidity and mortality. Treatment recommendations of degenerative MR have been liberalized, however, the role of asymptomatic patients is still insufficiently defined. Purpose The purpose of this study were to evaluate the prevalence of cardiac events in a large asymptomatic MR cohort, based on health insurance data analysis, in comparison with healthy propensity score-matched general population and to define the prognostic impact of such cardiac events on ten-year survival. Methods We retrospectively analyzed health insurance claims data from Germany’s second largest health insurance fund, which maintains longitudinal data on outpatient and inpatient medical services for 8.7 million German residents. We included all patients with an outpatient diagnosis of MR (I34.0) in a minimum of two quarters during a calendar year and first recorded diagnosis between 2008 and 2011. To identify an asymptomatic MR cohort (study group), all patients with at least one complication attributable to MR / mitral valve intervention during the incidence quarter of MR were excluded. Ten-year outcomes were compared between study group vs. age- and sex-matched healthy control group. Cardiac events of interest were new congestive heart failure, new-onset atrial fibrillation, pulmonary hypertension, or cardiac decompensation. Results A total of 56.577 (62.7%) asymptomatic MR patients were identified from the whole cohort of 90.245 individuals with a newly diagnosed MR in the BARMER database. During a ten-year follow-up, 26.282 (46.5%) patients in the study group experienced at least one cardiac event vs. 11.763 (20.8%) individuals in the control group (OR: 3.31, 95%CI: 0.251-0.262, P<0.0001). The occurrence of at least one cardiac event (i.e., congestive heart failure, new-onset atrial fibrillation, pulmonary hypertension or cardiac decompensation) in the study group was associated with a significantly worse ten-year survival as compared to the control group. The risk of cardiac events was age- and sex-dependent, while female patients with an asymptomatic MR had a lower risk as compared to males in all age groups (OR: 0.38, 95%CI: -1.193- -0.754, P<0.0001). Only 1.530 (2.7%) patients underwent mitral valve (MV) intervention in the study group during ten-year follow-up. Conclusions Our study reveals high incidence of asymptomatic MR in a representative cohort of health insurance claims data in Germany. Every second patient with an asymptomatic MR experiences at least one cardiac event during a ten-year follow-up period that is associated with a significantly worse survival. The definition of asymptomatic MR cohort at risk of developing cardiac events may potentially improve early treatment strategies and lead to better outcome in the future.Abstract picture

Prognostic impact of disease-related complications in asymptomatic mitral regurgitation: a health insurance claims analysis.

The impact of mitral regurgitation (MR) in asymptomatic patients is not well defined. We aimed to determine the prevalence of MR-related complications and their association with 10-year survival in a large unselected asymptomatic MR cohort. Health insurance claims data from Germany's second largest health insurance fund, BARMER, which maintains longitudinal data on 8.7 million German residents, were retrospectively analyzed. All patients with an outpatient diagnosis of MR in a minimum of two quarters during a calendar year and first recorded diagnosis between 2008 and 2011 were included. Patients with any complication attributable to MR or mitral valve intervention at index were excluded. Outcomes were compared between study group and age- and sex-matched controls (i.e., without known cardiac disease). MR-related complications of interest were new congestive heart failure, new-onset atrial fibrillation, pulmonary hypertension, or cardiac decompensation. A total of 56,577 individuals (median age 68 years, 67% female) with asymptomatic MR were identified. At 10 years, MR-related complications were more frequent in the study group vs. control group (46.5% vs. 20.8%, OR 3.31, P < 0.0001). Furthermore, MR-related complications were more common in male vs. female patients with an asymptomatic MR (OR 2.65, P < 0.0001). The occurrence of at least one MR-related complication was associated with a reduced 10-year survival (OR 1.80, P < 0.0001). Almost half of patients with asymptomatic MR experience complications during a 10 year follow-up which result in impaired survival. These results imply the necessity of long-term disease management program. Furthermore, decision-making process and timing for mitral valve intervention in asymptomatic patients should be reevaluated.

Understanding excess mortality during COVID in Belgium: the influence of health and social factors

Abstract Background This study aims to investigate how pre-existing health status and social background contribute to excess mortality during the COVID-19 crisis in Belgium. Methods The study population consists of 1.4 million adult members of Solidaris, the second largest health insurance fund in Belgium. Pre-existing health status was identified using health care reimbursement data, including medication use. Social characteristics included financial support, migrant background, and household composition. Excess mortality during the COVID-19 crisis was measured as the relative difference between all-cause mortality in 2020 or 2021 versus the pooled yearly estimates in 2015-2019. Yearly age- and sex-adjusted mortality rate ratios (MRR) were estimated using Poisson regression to study potential differences by health status and social factors. Results Compared with healthy persons, all investigated health problems were associated with increased mortality, with most notably an MRR of 8.4 (CI 8.0-8.9) for persons with cancer in 2021. Compared with 2015-2019, MRRs for persons with mental disorders (anxiety, depression) and diabetes were significantly higher than expected in 2020. Interestingly, mortality for persons with mental disorders was significantly lower than expected in 2021. Significant mortality deficits were also observed for persons with cancer and chronic respiratory conditions (COPD, asthma) in 2020 and 2021. After controlling for social characteristics, only the mortality deficits for persons with cancer and chronic respiratory conditions remained significant (p &amp;lt; 0.005), with respectively, 17% and 11% lower mortality in 2020, and 12% and 6% lower mortality in 2021. Conclusions Large mortality differences were observed by pre-existing health problem and social background during the COVID-19 crisis. A significant mortality deficit was observed for persons with cancer and chronic respiratory conditions in 2020 and in 2021. Key messages • Information on pre-existing health problems and social background are key to understanding excess mortality patterns. • The already large health and social inequalities in mortality did not widen further during the COVID-19 crisis in Belgium.

The effect of influenza and pneumococcal vaccination in the elderly on health service utilisation and costs: a claims data-based cohort study

BackgroundTo date, cost-effectiveness of influenza and pneumococcal vaccinations was assumed in several health economic modelling studies, but confirmation by real-world data is sparse. The aim of this study is to assess the effects on health care utilisation and costs in the elderly using real-world data on both, outpatient and inpatient care.MethodsRetrospective community-based cohort study with 138,877 individuals aged ≥ 60 years, insured in a large health insurance fund in Thuringia (Germany). We assessed health care utilisation and costs due to influenza- or pneumococcal-associated diseases, respiratory infections, and sepsis in 2015 and 2016. Individuals were classified into four groups according to their vaccination status from 2008 to 2016 (none, both, or either only influenza or pneumococcal vaccination). Inverse probability weighting based on 236 pre-treatment covariates was used to adjust for potential indication and healthy vaccinee bias.ResultsInfluenza vaccination appeared as cost-saving in 2016, with lower disease-related health care costs of − €178.87 [95% CI − €240.03;− €117.17] per individual (2015: − €50.02 [95% CI − €115.48;€15.44]). Cost-savings mainly resulted from hospital inpatient care, whereas higher costs occurred for outpatient care. Overall cost savings of pneumococcal vaccination were not statistically significant in both years, but disease-related outpatient care costs were lower in pneumococci-vaccinated individuals in 2015 [− €9.43; 95% CI − €17.56;− €1.30] and 2016 [− €12.93; 95% CI − €25.37;− €0.48]. Although we used complex adjustment, residual bias cannot be completely ruled out.ConclusionInfluenza and pneumococcal vaccination in the elderly can be cost-saving in selective seasons and health care divisions. As cost effects vary, interpretation of findings is partly challenging.

PDB56 ECONOMIC IMPACT OF TYPE 2 DIABETES AND DIABETES-ASSOCIATED COMPLICATIONS: A LARGE CLAIMS-BASED STUDY

The chronic nature and complications of type 2 diabetes (T2DM) impose a large economic burden on society. Our aim was to provide reliable estimates of direct costs associated with the management of T2DM and its complications in the Czech Republic. A retrospective prevalence-based cost-of-illness study analysed health insurance claims for years 2013-2017 provided by the second largest health insurance fund in the Czech Republic (1,307,000 insured, i.e. 12.5 % of the Czech population). The selection of diabetic patients was defined by ICD-10 diagnose E11 recorded at least twice and at least one prescription of antidiabetics (ATC A10). The overall sample size consisted of 62,895 patients with T2DM. Out of the total patient population, 52% had no complications, 22% only microvascular, 13% only macrovascular and 14% both micro- and macrovascular complications. From a health-care payer perspective, there was a steady increase in the mean total costs per diabetic patient per year (pppy), from €878 in 2013 to €1,264 in 2017 (+44%). In 2013, medicines were the major contributor to direct costs (56%). However, this proportion gradually declined until it reached 49% in 2017. Other main drivers of costs were hospital care (14%), medical devices (8%) and outpatient care (7%). The mean total direct costs pppy were 1) €656 (without complications; denoted as baseline), 2) €1,058 (microvascular complications; +61% relative to baseline costs without complications), 3) €1,281 (macrovascular complications; +95%) 4) €2,025 (micro- and macrovascular complications; +209%). Results suggest that the costs of T2DM are substantial and are growing both over time and with associated complications. To our knowledge, this is the first Czech study providing contemporary real-world evidence on the average diabetic patient costs and associated complications. Our estimates may support health care stakeholders in evaluating the optimal resource allocation across different prevention and intervention programs.

PCV68 ECONOMIC BURDEN OF ATHEROTROMBOTIC DISEASE IN THE CZECH REPUBLIC

Atherothrombotic diseases impose a large burden on Czech society, mainly because of the increased prevalence of high-risk patients with several comorbidities. Thus, the aim was to evaluate the direct and indirect costs associated with coronary (CAD) and peripheral artery diseases (PAD) in the Czech Republic. The prevalence of CAD combined with PAD was based on health insurance claims for years 2015-2017 provided by the fifth largest health insurance fund (700,000 insured, i.e. 7 % of the population) and expert opinion. A global Markov model was adopted to predict the number of subsequent cardiovascular events in this population treated with aspirin in secondary prevention. Healthcare costs were based on corresponding reimbursement tariffs. Indirect costs of atherothrombotic disease were calculated based on claims from Czech Social Security Administration (CSSA) database. A total number of 49,215 patients suffering from both CAD and PAD was estimated. In lifetime horizon, these patients will develop 18,766 myocardial infarctions, 7,439 strokes, 6,639 cases of extracranial and 1,525 intracranial haemorrhage, 5,311 cases of acute limb ischaemia, 4,648 amputations, 3,098 cases of venous thromboembolism and 22,292 cardiovascular deaths. From a healthcare payer perspective, all these events will be associated with a total cost of €360.7 million. According to CSSA database, CAD or PAD induce 1,946 cases of invalidity per year, corresponding to €7.4 million of invalidity pensions annually and €24.7 million loss of productivity/year. Moreover, CAD or PAD lead to 4,802 sick-leaves each year, corresponding to annual productivity loss of €55.5 million. In sum, these indirect costs equal to €87.6 million per year. The costs associated with atherothrombotic diseases are substantial. To our knowledge, this is the first Czech study evaluating the burden of atherothrombotic diseases from societal perspective. Our estimates may support future health policy decisions concerning various prevention and intervention programs.

The effect of gender-specific invitation letters on utilization ofcolorectal cancer screening.

Colorectal cancer (CRC) screening can effectively reduce cancer-associated mortality. In Germany, individuals over the age of 50 or 55 have access to CRC screening services. However, utilization rates are persistently low, particular in the male population. This observational study investigates the effect of standard versus gender-specific invitation letters on utilization of CRC screening services. We analyzed utilization rates of individuals who were insured by a large health insurance fund in Bavaria, Germany. Persons who became eligible for CRC screening received a standard (2013-2014) or a gender-specific invitation letter (2015-2016). We compared utilization rates within 6 months after receipt of the invitation letter using billing codes of the health insurance fund. Invitation letters were sent to 49 535 individuals, of which 48.8 % were gender-specific. The overall utilization rate did not differ between recipients of the standard versus gender-specific invitation letter (11.6 % vs 11.1 %; RR: 0.97 [0.92-1.02], p = 0.19). However, uptake of screening colonoscopy was significantly higher among recipients of gender-specific invitations (2.9 % vs 3.5 %; RR: 1.21 [1.04-1.39], p = 0.01), whereas utilization of fecal occult blood tests declined (10.4 % vs 9.7 %; RR: 0.93 [0.88-0.99], p = 0.016). Gender-specific design of invitation letters can modify the patients' preference for specific CRC screening services and increase the acceptance of screening colonoscopy.

Data Privacy Compliant Validation of Health Insurance Claims Data: the IDOMENEO Approach.

Recently, health insurance claims have regained the attention of the scientific community as a source of real-world evidence in health care research and quality improvement. To date, very few studies are available which investigate the validity of health insurance claims; these may be affected by bias from several sources, such as possible upcoding of co-morbidities and complications for reimbursement advantages. The IDOMENEO study investigates the inpatient treatment of peripheral arterial disease (PAD) comprehensively using various data sources with a consortium involving experts from health care research and data privacy, a large health insurance fund, biostatisticians, jurists, and computer scientists. Prospective registry data were collected from 30–40 vascular centres in Germany using the GermanVasc registry. In addition, health insurance claims data were prospectively collected from BARMER, the second largest health insurance fund in Germany. The consortium is currently developing a data privacy compliant method of health insurance claims data validation, the methodological foundations of which are described here.

Nurse-work instability and incidence of sick leave \u2013 results of a prospective study of nurses aged over 40

BackgroundThe Nurse Work Instability Scale (Nurse-WIS) is an occupation-specific instrument that ascertains “work instability,” the interval before restricted work ability or prolonged sick leave occurs. The objective of the study was to assess if nurses with a high risk baseline-score in the Nurse-WIS take longer periods of sick leave due to musculoskeletal diseases and/or psychological impairments than other nurses.MethodsA total of 4500 nurses randomly selected from one of the largest health insurance funds in Germany (DAK-Gesundheit) were invited by letter to participate in the study. The participants answered a questionnaire at baseline and gave consent to a transfer of data concerning sick leave during the twelve months following completion of the questionnaire from the health insurance to the study centre. Sensitivity, specificity and positive and negative predictive values (PPV and NPV) for long-term sick leave were calculated. In order to analyze the association between the Nurse-WIS and sick leave during follow-up, a multiple ordinal logistic model (proportional odds model) was applied.ResultsA total of 1592 nurses took part in the study (response 35.6%). No loss of follow-up occurred. The number of nurses with a high score (20–28 points) in the Nurse-WIS was 628 (39.4%), and 639 (40.1%) had taken sick leave due to musculoskeletal diseases or psychological impairment during the follow-up period. The odds ratio for sick leave in nurses with a high Nurse-WIS score was 3.42 (95%CI 2.54–4.60). Sensitivity for long-term sick leave (< 42 days) was 64.1%, specificity 63.4%, PPV 17.0% and NPP 93.8%.ConclusionThe German version of the Nurse-WIS predicts long-term sick leave, but the PPV is rather low. Combining questionnaire data with secondary data from a health insurer was feasible. Therefore further studies employing this combination of data are advisable.

The Choice of Transcatheter Aortic Valve Implementation (TAVI): Do Patient Co-morbidity and Hospital Ownership Type Matter?

Innovative technologies challenge healthcare systems, as evidence on costs and benefits frequently usually are slow to reflect new technology. We investigated these dynamics for Germany, using the emergence of transcatheter aortic valve implementation (TAVI) as an alternative to conventional aortic valve replacements (CAVR). We focused on the role of patient co-morbidity-which would be a medical explanation for adopting TAVI-and hospital ownership status, hypothesizing that for-profit facilities are more likely to capitalize on the favorable reimbursement conditions of TAVI. The analysis uses claims data from the Techniker Krankenkasse, the largest health insurance fund in Germany, for the years 2009-2015, covering 2892 patients with TAVI and 9523 with CAVR. The decision on TAVI versus CAVR was estimated for patient-level data, that is, socioeconomic data as well as co-morbidity. At the hospital level, we included the ownership type. We also controlled for effects of the respective owner (rather than the type of ownership), including a random intercept. While the co-morbidity score of TAVI patients was much higher in the early years, over time, the score almost converged with that of CAVR patients. This is in agreement with emerging evidence that suggests the use of TAVI also leads to better patient outcomes. Our results indicate that the type of ownership does not drive the switch to TAVI. We found little, if any, effect from the respective owner, regardless of ownership type. Overall, the effects of co-morbidity suggest that providers acted responsibly when adopting TAVI while evidence was still emerging.

Nursing home prices and quality of care - Evidence from administrative data

There is widespread concern about the quality of care in nursing homes. On the basis of administrative data of a large health insurance fund, we investigate whether nursing home prices are associated with relevant quality of care indicators at the resident level. Our results indicate negative associations between price and both inappropriate and psychotropic medication. In contrast, we do not find any relationship between the price and impairments of physical health.

Variations over time in the effects of age and sex on hospitalization rates before and after admission to a nursing home: A German cohort study

ObjectivesWe examined hospitalization rates for nursing home residents before and after their entry to the home, stratified by sex and age. Study designA cohort study was conducted using data from a large health insurance fund on 127,227 residents aged 65 years and over newly admitted to a nursing home between January 1, 2010, and December 31, 2014. Main outcome measurementsWe assessed hospitalization rates and proportions being hospitalized in 6-month intervals one year before nursing home placement and up to 5 years thereafter. Multiple Poisson regression models were fitted to calculate relative risks (RR). ResultsMean age was 84.0 years and 74.6% of the cohort were females. Hospitalization rates were 194.4 per 100 person-years (PY) in the 12 months before entry to the nursing home and 120.0 per 100 PY thereafter. Rates were highest immediately before entry in both sexes. The influence of age was most pronounced in the 12–7 months before entry (RR: 2.37 for 65–74 vs. 95+ years) and declined thereafter (1.29–1.38 up to month 24 after entry). In contrast, the influence of sex was greater after entry (RR: 1.13 for males vs. females in the 12–7 months before and 1.23–1.31 up to month 24 after entry). ConclusionsHospitalization rates of nursing home residents are much higher in Germany than in other Western countries. We have provided some insight into the influence of age and sex on hospitalization rates, which varied over the period (time before and after entry to the nursing home) analyzed. We urgently recommend that future studies on the hospitalization of residents stratify their analyses by sex, age and period.

Nursing Home Prices and Quality of Care - Evidence from Administrative Data

There is widespread concern about the quality of care in nursing homes. Based on administrative data of a large health insurance fund, we investigate whether nursing home prices affect relevant quality of care indicators at the resident level. Our results indicate a significantly negative price effect on inappropriate and psychotropic medication. In contrast, we find no evidence for fewer painful physical sufferings for residents of nursing homes with higher prices.

Like mother, like daughter? Mother's history of cervical cancer screening and daughter's Human Papillomavirus vaccine uptake in Flanders (Belgium)

We investigated whether and to what extent the uptake of the Human Papillomavirus (HPV) vaccine by girls aged 12-18 was related to the cervical cancer screening history of age-appropriate older female household members (assumed to be their mothers) in Flanders (Belgium). We studied administrative records on 127,854 female members of the National Alliance of Christian Mutualities, which is the largest health insurance fund in Flanders. Reimbursement data for HPV vaccination of girls for the period 2007-2009 were linked with reimbursement data for cervical cancer screening of their mothers in the three preceding years. A multilevel logit model was used to study associations between both preventive behaviors. In the model we controlled for both the girl's and the mother's age, the province of residence and the socio-economic background of the family. A clear association between a mother's history of participation in cervical cancer screening and her daughter's HPV vaccination initiation was found. The conditional odds of HPV vaccination initiation were more than 4 times higher for girls whose mother had one Pap test than for girls whose mother had none (odds ratio [OR]=4.5; 95% confidence interval [CI]=3.5-5.9). For girls whose mother had three or more Pap tests, the conditional odds were 16 times higher than for girls whose mother did not have any pap tests ([OR]=16.0; 95% [CI]=12.1-21.2). The effect of screening (having received 1 pap smear as compared to none) was larger for girls living in neighborhoods with the lowest median income ([OR]=6.0, 95% [CI]=3.6-10.1). In a situation where both cervical cancer screening and HPV vaccination are opportunistic, we found evidence that these preventive behaviors cluster within families.

Inwieweit bilden definierte Tagesdosen (DDD) die tatsächlich verordneten Tagesdosen ab? Eine Analyse ambulanter Verordnungsdaten

Defined daily doses (DDD) are used to analyse drug utilisation. For frequently prescribed drug groups, we studied to what extent the DDD correspond to the average prescribed daily doses (PDD). We analysed all drugs prescribed for more than three months to insured of a large health insurance fund in Mecklenburg-Vorpommern, one federal state in Germany. PDD for plain ACE inhibitors, selective beta-antagonists and some antidiabetics (sulfonylurea compounds) were calculated and compared with their DDD. During the study period, about 38 500 patients received continuous prescriptions of each ACE inhibitors or selective beta-antagonists, and about 9 000 of sulfonylurea compounds. PDD differed from DDD in varying degrees. For ACE inhibitors, PDD ranged between 1.5 DDD (for captopril) and 3.5 (for ramipril). The PDD for beta antagonists were on average 0.9 DDD, similar for bisoprolol (0.8 DDD) and metoprolol (0.9 DDD). As for oral antidiabetics, doctors prescribed 1.0 DDD glibenclamid per day and patient and 2.0 DDD glimepirid. Depending on differences between DDD and PDD, real daily costs for drug therapy differed from the theoretical costs per DDD, for example in the case of ramipril they were 0.24 euros compared to 0.07 euros. The PDD were much higher than the DDD for several frequently prescribed drugs. Consequently, the daily drug costs exceeded the drug costs based on DDD. Evaluations of drug costs on the basis for DDD require careful interpretation. Moreover, the number of DDD alone is not a valid measurement for the appropriateness of drug therapy and can only give a rough estimate of the number of patients treated, at least for the drug groups in this study.

Gesundheitsökonomische Analyse der Wirkungen des Angebots komplementärmedizinischer Leistungen der Krankenkassen

A randomized experiment was set up in which 7,500 policyholders of Switzerland’s largest health insurance fund, Helvetia, were offered free supplementary insurance for complementary medicine for 3 years. This was meant to simulate a situation in which the experimental group had access to the full range of complementary medical treatments under their health insurance policies. The remaining policyholders in the scheme (670,000 people) formed the control group. A third group of policyholders who had taken out additional insurance for complementary medical services at their own expense is mentioned only in passing. The health insurer’s cost and benefit data were analyzed to evaluate the effect of the offered free supplementary insurance for complementary medicine. In addition, a survey was carried out among random samples of subjects from the experimental group and from the control group using the 36-Item Short-Form Health Survey (SF-36) to examine the effects of including complementary medicine on people’s subjective state of health. The analysis of the cost data showed that subjects in the experimental group used complementary medicine in addition to mainstream medical services. It became also clear that alternative medical treatments were given in combination with orthodox medicine; less than 1% of the experimental group used exclusively alternative medical services. However, as only a very small percentage of the experimental subjects (6.6%) took advantage of complementary medicine, no significant impact on overall health cost could be inferred. On the other hand, multiple regressions showed that the use of complementary medicine had a greater effect on the treatment costs than sex, age or language region. Neither at the beginning nor the end of the experiment were any significant differences noted in the scales of the SF-36 between the experimental and the control group; nor did multiple regressions reveal any effects on subjects’ state of health due to the inclusion of complementary medicine in the basic insurance cover. This study was presented in the media and at a public hearing of the Swiss National Science Foundation. It triggered numerous valuable discussions. The study design and the conclusions were not left uncontested.

The influence of budget-holding on cost containment and work procedures in primary care clinics

In 1990, Kupat Holim Clalit (KHC), Israel's largest health insurance fund, initiated a demonstration program for transforming primary care clinics in the Negev district of southern Israel into autonomous budget-holding units. Four program components were implemented in nine clinics: allocation of a fixed budget; expansion of day-to-day decision-making authority; establishment of a computerized information system for producing monthly reports on expenditure; and provision of incentives for budgetary responsibility (returning part of a clinic's savings for use at its discretion). The demonstration program had three objectives: budgetary control and cost containment; improvement of services and increased client satisfaction; and improvement in the motivation, initiative, responsibility, and satisfaction of clinic staff. This report presents interim findings from an evaluation study of the budget-holding program conducted in 1991–1992. The report considers three questions: How was the demonstration program implemented? Did work procedures in the clinics change following implementation of the program? How did budget-holding influence levels of expenditure in the clinics? The program components were implemented gradually in the nine clinics during 1991–1992. Not all, however, were fully implemented. The staff survey conducted after implementation of the program identified a number of changes in the work procedures of the clinics: heightened cost consciousness, discussion of the monthly expenditure reports, emphasis on the need to economize, and attempts to economize. Data on expenditure in the budget-holding clinics were analyzed and compared to data on expenditure in primary care clinics in the Negev district as a whole. It was found that while the average quarterly per capita expenses in the district increased in real terms from 1991–1992, expenses in the budget-holding clinics remained stable or, in some cases, actually decreased. While we cannot conclude categorically from the existing data that the budget-holding program is responsible for the unique patterns of expenditure in the nine clinics, we can confidently state that work procedures in the nine clinics changed following implementation of the program and that the clinics achieved cost containment relative to the district as a whole. Findings from the various research tools support one another, and reinforce the conclusion that budget-holding can potentially promote cost containment.

Clinic Decentralization: An Israeli Model and Evaluation Strategy

Presents a model for clinic decentralization, implemented by Israel′s largest health insurance fund, Kupat Holim Clalit (KHC). The main elements of the model are: allocation of a fixed budget; delegation of authority for budget utilization and service delivery; provision of incentives for fiscal responsibility; and establishment of an internal information system. Explores expected outcomes of decentralization on the basis of an extensive literature review. Emphasizes the importance of evaluating such an organizational change, and outlines an evaluation strategy. A major concern in this strategy is to control for the effects of changes taking place at the same time‐as decentralization, and the effects of background variables such as demographic characteristics, health status, etc. For this purpose, a quasi‐experimental design was developed, based on the comparison of an experimental and control clinic, both before and after decentralization.

THE DEMAND FOR PRIVATE PSYCHIATRIC SERVICES IN A HEALTH INSURED POPULATION

SummaryThis paper reports a study of the pattern of utilization of private psychiatric services by health insured persons who are members of a single large fund. The data show an increase in the average number of services per person consulting a psychiatrist with little change in the number of persons. There is a strong relation between private psychiatric contact rates and the socio‐economic index of the LGA of patient residence. Contributor units containing a medical practitioner are examined as an example of the utilization pattern of a socially elite group. The financial and administrative significance of the findings is discussed.Very little information is available in Australia concerning the relationship between the demand for health services and the socioeconomic characteristics of the clients or potential clients of the health services. Since Australian governments have shown a substantial reliance on voluntary health insurance as a mechanism for financing health care, this lack of information is surprising. Studies in the United States of America and England suggest that the upper socio‐economic classes receive more medical services than the lower, although these conclusions are not clear cut. It becomes a useful a priori hypothesis that a relationship between socio‐economic status and the demand for medical services exists in Australia, even within a health insured population.In this paper we examine the utilization of private psychiatric services by persons who were members of a single large health insurance fund in New South Wales. Claim history and membership demographic data were obtained from the health fund computer record system for the years 1977, 1978 and the period January to June, 1979. Since this fund covers about onethird of all persons with private health insurance in that state, we believe that the study may rellect the relationships for health insured populations in Australia generally. Private psychiatric services have been examined, not only because the itemization of psychiatric services is simple and data analysis is easy, but also because there is ample anecdotal evidence that the demand for psychiatric services is determined partly by client status and education. This should help establish the existence or otherwise of some socioeconomic gradient with respect to the demand for services.