National Public Health Insurance Research Articles

PP18 Unlocking The Potential Of Medical Device Reimbursement In India For Better Health Outcomes

IntroductionThe Indian healthcare landscape has witnessed several promising changes including the introduction of a comprehensive medical technology inclusion process, Diagnosis-related group (DRG)-pilot and value-based incentives for hospital services under the national public health insurance scheme. Realizing the need for a more patient-centric stance towards improving healthcare outcomes as the way forward, we propose incremental changes including greater participation of public and private care-providers in topic prioritization and the appraisal committee. We also propose a unique evidence-driven approach using reimbursement as a lever for rewarding quality and innovation in medical technologies.MethodsWe developed two discussion guides to capture the ideas around deeper involvement of care-providers and patient societies, and introduction of value-based reimbursement for incentivizing high-quality implantable medical devices in India. The guides were prepared using secondary research and key informant interviews. Over 25 key stakeholders representing payers, regulatory agencies, government authorities, clinical experts, and industry players selected through quota sampling participated in a roundtable meeting. Based on the meeting outcomes, key recommendations for leveraging medical device reimbursement for better health outcomes were developed.ResultsThis qualitative research was carried out with participation of key stakeholders across the medical device reimbursement process. The group proposed recommendations for bringing care-providers closer to the process through a structured and inclusive nomination approach involving therapy users and patient groups at various stages of evaluation. Complementing the existing value-based incentives framework for hospital services, we proposed a similar two-step pathway for incentivizing quality of implantable medical devices. The proposal includes the introduction of certification-based and outcome-based incentives built on a scientific and holistic evaluation criterion.ConclusionsThrough this process, we created a pragmatic and concrete call for a stronger voice from care-providers and patient groups in the evaluation process. Consecutively, the proposed innovative framework introducing value-based incentives for implantable medical devices will be instrumental in enabling access to quality health care to poor patients. These strategies follow the principles of value-based care and will go a long way in achieving better health outcomes for the population. The scientific initiative has been made possible with the support of St. Jude Medical India Pvt Ltd. (now Abbott).

PP64 Cost-Effectiveness Of Fractional Flow Reserve As Diagnostic Tool In Coronary Artery Disease Versus Angiogram Alone In Indian context

IntroductionFractional Flow Reserve (FFR) is a diagnostic tool that aids decision-making in the treatment of coronary artery disease (CAD). FFR provides an objective measurement and is used as an adjunct to an angiogram. The clinical and cost-benefit of using FFR have been well established across published literature. This research was aimed at evaluating the economic impact of using FFR as an adjunct to angiogram versus an angiogram alone, in the Indian healthcare context.MethodsA study from a tertiary care public hospital in India estimated the impact of using FFR as an adjunct to angiogram in management of CAD. This study was used to create a mathematical simulation model to estimate cost-effectiveness and economic impact of using FFR over seven years’ time horizon, from the Indian health systems perspective. A targeted literature review was performed to collect the clinical inputs for the model, and the national public health insurance program data was referenced to obtain the cost inputs.ResultsA hypothetical cohort of 100,000 patients in the model reported 30 percent reduction in unnecessary stenting. Moreover, 14,025 deaths were averted with the adoption of FFR. In addition, there was a cost-saving of INR46,986 (574USD) per death averted and INR5,169 (63USD) per patient treated over a seven-year time horizon. The analysis demonstrated that FFR inclusion in the current clinical practice saves INR2,651 (32USD) per patient in overall upfront cost and INR2,518 (31USD) per patient in overall follow-up cost over a seven year follow-up period owing to improved diagnosis and prognosis.ConclusionsIn conclusion, FFR prevents unnecessary stenting, reduces overall mortality, and proves to be a cost-saving intervention in the long-term when used as a decision-making criterion in CAD patients in the Indian context.

Choroidal melanoma tumor profile and treatment pattern for newly diagnosed patients at a reference public hospital in Sao Paulo, Brazil

BackgroundChoroid, ciliary body, and iris melanomas are often grouped as uveal melanoma, the most common intraocular primary malignancy. The purpose of the current study was to analyze the tumor profile of newly diagnosed cases of choroidal melanoma at a reference center in Sao Paulo, Brazil, and to investigate the frequency of eyes treated by enucleation that could have been treated with brachytherapy if available in the service.MethodsMedical records of patients referred to our service with initial diagnostic hypothesis of choroidal melanoma from July 2014 to June 2020 were analysed on demographics, diagnosis confirmation, tumor measurement by ultrasonography and established treatment. Data were evaluated on clinical and demographic characteristics as age, sex, affected eye, ultrasound parameters, and treatment management of patients with clinically diagnosed choroidal melanoma. Among the patients submitted to enucleation, we investigated how many could have been selected to receive brachytherapy.ResultsFrom the 102 patients referred with the choroidal melanoma diagnosis hypothesis, 70 (68.62%) were confirmed. Mean measurements from the tumors in millimetres were: 9.19 ± 3.69 at height and 12.97 ± 3.09 by 13.30 ± 3.30 at basal. A total of 48 cases (68.57%) were enucleated, 8 (11.43%) were treated by brachytherapy in a different service, and 14 patients (20.00%) returned for enucleation at their original referral center. Out of the 48 patients enucleated, 26 (54.17%) could have been selected to brachytherapy treatment.ConclusionsThe results indicate a late diagnosis of choroidal melanoma cases referred to our service. Most enucleated cases could have been treated with brachytherapy if it was broadly available at the national public health insurance. Further public health political efforts should focus on early diagnosis and better quality of life post-treatment for oncologic patients.

Understanding linkage to biopsy and treatment for breast cancer after a high-risk telemammography result in Peru: a mixed-methods study

ObjectivesThis mixed-method study aimed to understand the effectiveness of linkage to biopsy and treatment in women with a high-risk mammography result (Breast Imaging Reporting and Data System, BI-RADS 4 and...

Overview of recent cases before the Court of Justice of the European Union (September 2021-December 2021)

The concept of ‘working time’ for a period of stand-by time according to a stand-by system applicable to firefighters was interpreted by the Court in MG (C-214/20). In the Y case (C-636/19), the Court interpreted the concept of ‘insured person’ for the purpose of reimbursement of healthcare costs under Directive 2011/24. In the TS case (C-538/19), the Court dealt with another cross-border healthcare case. This time the question was whether a Member State can require an authorisation for cross-border healthcare to be subject to the submission of a medical report drawn up by a doctor from its national public health insurance system in light of Article 20 of Regulation 883/2004 and Article 56 TFEU. In ASGI and APN (C-462/20), the exclusion of third-country nationals from the eligibility to the Italian family card was under scrutiny. In SC (C-866/19), the Court clarified that the principle of aggregation applies to the calculation of the theoretical amount of benefit but not to the calculation of the actual amount of benefit under Article 52(1)(b) of Regulation 883/2004. In K (C-285/20), the Court held that being on sick leave and receiving sickness benefits can be considered as equivalent to the pursuit of an economic activity for the purpose of applying the rules on unemployment benefits for wholly unemployed frontier workers under Article 65(2) and (5) of Regulation 883/2004.

Care pathways in invasive meningococcal disease: a retrospective analysis of the French national public health insurance database

ABSTRACT Invasive meningococcal disease (IMD) carries a high burden in terms of mortality, long-term complications, and cost, which can be significantly reduced by vaccination. The objectives of this case–control study were to document the care pathways of patients with IMD before, during, and after hospitalization and to assess in-hospital complications and long-term sequelae. Cases consisted of all people hospitalized for IMD in France between 2012 and 2017. Controls were matched by age, gender, and district of residence. Data were extracted from the French national public health insurance database on demographics, hospitalizations, mortality and potential sequelae of IMD. Overall, 3,532 cases and 10,590 controls were assessed and followed up for 2.8 years (median). During hospitalization, 1,577 cases (44.6%) stayed in an intensive care unit, 1,238 (35.1%) required mechanical ventilation, and 43 (1.2%) underwent amputation; 293 cases (8.3%) died in hospital and a further 163 (4.6%) died following discharge; 823 cases (25.4% of survivors) presented ≥1 sequela and 298 (9.2%) presented multiple sequelae. The most frequently documented sequelae were epilepsy (N = 205; 5.8%), anxiety (N = 196; 5.5%), and severe neurological disorders (N = 193; 5.5%). All individual sequelae were significantly more frequent (p < .0001) in cases than controls. Hearing/visual impairment and communication problems were conditions that presented the highest risk for cases compared to controls (risk ratios >20 in all cases). In conclusion, this study highlights the importance of providing optimal medical care for patients with IMD, of minimizing the delay before hospitalization, and of effective prevention through comprehensive vaccination programs.

Healthcare Resource Consumption and Cost of Invasive Meningococcal Disease in France: A Study of the National Health Insurance Database.

IntroductionInvasive meningococcal disease (IMD) is an uncommon but serious infectious disease. Its economic burden is known to be high but is poorly characterised. The objective of this study was to determine costs, as captured in the healthcare claims database, incurred by all patients hospitalised for IMD in France over a 6-year period.MethodsThis case–control study was performed using the French national public health insurance database (SNDS). Cases comprised all individuals hospitalised with acute IMD in France between 2012 and 2017 inclusive. For each case, three controls were identified, matched for age, gender and region of residence. All healthcare resource consumption by cases and controls during the follow-up period was documented. Costs were analysed for the index hospitalisation in cases, 1 year following the index date and then for 5 years following the index date. Costs were assigned from national tariffs. The analysis was performed from a societal perspective. IMD sequelae were identified from hospital discharge summaries.ResultsA total of 3532 cases and 10,590 controls were evaluated. The mean per capita cost of the index IMD hospitalisation was €11,256, and increased with age and with the presence of sequelae. In the year following the index date, mean per capita direct medical costs were €6564 in cases and €2890 in controls. Annual costs were €4254 in cases without sequelae, €10,799 in cases with one sequela and €20,096 in cases with more than one sequela. In the fifth year of follow-up, mean per capita costs were €2646 in cases and €1478 in controls. The excess cost in cases was principally due to the management of sequelae. Amputation, skin scarring and mental retardation generated per capita costs in excess of €20,000 in the first year and in excess of €10,000 for subsequent years.ConclusionThe economic burden of IMD in France is high and, over the long-term, is driven by sequelae management.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-021-00468-w.

Risk factors for invasive meningococcal disease: a retrospective analysis of the French national public health insurance database

ABSTRACT Vaccination of at-risk populations against Neisseria meningitidis is an important strategy to prevent invasive meningococcal disease (IMD). The objective of this study was to characterize preexisting risk factors in patients with IMD and to compare their relative importance. This case-control analysis was performed in the French national public health insurance database (SNDS). Cases consisted of all people hospitalized for IMD in France over a six-year period (2012–2017). Controls were matched by age, gender, and district of residence. Medical risk factors were identified from ICD-10 codes in the SNDS. Socioeconomic risk factors studied were low household income and social deprivation of the municipality of residence. Associations of these risk factors with hospitalization for IMD were quantified as odds ratios (ORs) between cases and controls with their 95% confidence intervals (95%CI). The medical risk factors showing the most robust associations were congenital immunodeficiency (OR: 39.1 [95%CI: 5.1–299], acquired immunodeficiency (10.3 [4.5–24.0]) and asplenia/hyposplenia (6.7 [3.7–14.7]). In addition, certain chronic medical conditions, such as autoimmune disorders (5.4 [2.5–11.8]), hemophilia (4.7 [1.8–12.2]) and severe chronic respiratory disorders (4.3 [3.1–6.2]) were also strongly associated, as was low household income (1.68 [1.49–1.80]). In conclusion, this study has documented potential risk factors associated with hospitalization for IMD in a large and comprehensive sample of individuals with IMD in France. Several of the risk factors identified may help identify groups who could benefit from targeted prevention measures (such as vaccination) in order to reduce the burden of IMD.

Public health insurance and the labor market: Evidence from China's Urban Resident Basic Medical Insurance.

This study provides empirical evidence on the labor market effects of public health insurance using evidence from China. In 2007, China launched a national public health insurance program, Urban Resident Basic Medical Insurance (URBMI), targeting residents in urban areas who were not insured by employment-based health insurance. Using panel data from the China Health and Nutrition Survey, I identify the impacts of the program based on its staggered implementation across cities. I find that URBMI did not have a significant average causal effect on labor force participation. However, it did increase employment mobility, as evidenced by the decrease in long-term employment and expansion of fixed-term contract jobs and self-employment. After the program was implemented, job lock declined and job flexibility increased, especially among women, the less educated, and individuals with good health status. The results also suggest increased employment for unhealthy workers, indicating a direct health improvement effect.

Challenges facing Australian counselling psychologists: A qualitative analysis

ObjectiveIn the last decade, Australian counselling psychologists have seen a decline in the profession as academic programs close and their professional identity diminishes. In 2006, the Federal Government introduced the Better Access mental health initiative, which provides Medicare (Australia's national public health insurance scheme) funding for the community to access psychological services. While the Better Access initiative has been successful for consumers, it has created significant tensions within the psychology profession, offering higher rebates for services offered by a clinical psychologist. The literature highlights that the Better Access system has placed counselling psychology in a vulnerable position. Is this the only threat to the profession? This study sought to establish what Australian counselling psychologists perceive as the challenges facing the profession.MethodA web‐based survey was distributed to Australian counselling psychologists seeking information on a range of demographic and professional characteristics. The survey collected information on various aspects of professional identity and practice. Respondents were asked to identify what they see as the challenges facing counselling psychology.ResultsThe main challenges highlighted were related to inequalities in rebate schemes between clinical and counselling psychologists, ingrained biases towards clinical psychology resulting in power imbalances, divides, and in‐fighting within the profession, difficulties demarcating the unique identity of counselling psychologists (both from within and outside), and changes threatening the existence of counselling psychology as a viable training pathway in Australia.ConclusionThis paper explores the current challenges to the profession, recommendations for change at the individual and system levels, and directions for the future of the profession.

Public Health Insurance and the Labor Market: Evidence from China's Urban Resident Basic Medical Insurance

This paper provides empirical evidence on the labor market effects of public health insurance using evidence from China. In 2007, China launched a national public health insurance program, Urban Resident Basic Medical Insurance (URBMI), targeting residents in urban areas who were not insured by employment-based health insurance. Using panel data from the China Health and Nutrition Survey, I identify the impacts of the program based on its staggered implementation across cities. I find that URBMI did not have a significant average causal effect on labor force participation. However, it did increase employment mobility, as evidenced by the decrease in long-term employment and expansion of fixed-term contract jobs and self-employment. After the program was implemented, job lock declined and job flexibility increased, especially among women, the less educated, and individuals with good health status. The results also suggest increased employment for unhealthy workers, indicating a direct health improvement effect.

Description épidémiologique de la corticothérapie orale prolongée : résultats issus de la base de données de l’assurance maladie

BackgroundThere is very little epidemiologic data available in the literature concerning long-term corticosteroid prescriptions in France. MethodsThe information was collected from a national public health-insurance database in our geographic area of Provence-Alpes-Côte-d’Azur and Corsica. We included in the analysis, patients using a daily glucocorticoid above 7,5 milligrams for a period exceeding 90 days. ResultsAmong the patients, 4,1 million were included in the analysis. The prevalence of glucocorticoids was around 0.8% and the incidence was 2.3/1000 inhabitants/year. The mean age of the patients was 57.6±18.8 years old. The median prednisone-equivalent dose was 11.9mg/day (Interquartile range: 8.6–20.0). The average treatment duration was 206 days (CI 95% 202–210). Most prescriptions (72,0%) were started by general practitioners. ConclusionLong-term corticosteroid therapy is frequent in France. Its description is close to what is already known in Europe.

Implementing a Childhood Cancer Outcomes Surveillance System Within a Population-Based Cancer Registry.

PurposeApproximately 80% of cases of childhood cancer occur in low- and middle-income countries and are associated with high mortality rates. Assessing outcomes is essential for designing effective strategies to improve outcomes equally worldwide. We implemented a real-time surveillance system, VIGICANCER, embedded in a population-based cancer registry (PBCR) to assess childhood cancer outcomes.MethodsVIGICANCER was established in 2009 as an integral part of Cali’s PBCR to collect real-time data on outcomes of patients (age < 19 years) with a new diagnosis of cancer treated in pediatric oncology units in Cali, Colombia. Baseline and follow-up data (death, relapse, treatment abandonment, second neoplasms) were collected from medical records, hospital discharge logs, pathology reports, death certificates, and the National Public Health Insurance database. A quality assurance process was implemented for the system.ResultsFrom 2009 to 2013, data from 1,242 patients were included in VIGICANCER: 32% of patients were younger than 5 years, 55% were male, and 15% were Afro-descendants. International Classification of Childhood Cancer group I diagnoses predominated in all age groups except children younger than 1 year old, in whom CNS tumors predominated. Five-year overall survival for all cancers was 51.7% (95% CI, 47.9% to 55.4%) for children (< 15 years), and 39.4% (95% CI, 29.8% to 50.5%) for adolescents (15 to 18.9 years). Five-year overall survival for acute lymphoblastic leukemia was 55.6% (95% CI, 48.5% to 62.2%).ConclusionOur study demonstrates the feasibility of implementing a real-time childhood cancer outcomes surveillance system embedded in a PBCR that can guide interventions to improve clinical outcomes in low- and middle-income countries.

Overuse of preoperative laboratory coagulation testing and ABO blood typing: a French national study

BackgroundFollowing publication of guidelines on routine preoperative tests, the French Society of Anaesthesiology and Intensive Care (SFAR), in association with French national public health insurance, conducted a survey to evaluate adherence to guidelines and the economic consequences. MethodsUsing the French Hospital Discharge Database and National Health Insurance Information system, tests performed during the 30 days before surgery were analysed for two situations: (1) standard laboratory coagulation tests and ABO blood typing in children able to walk and scheduled for tonsillectomy/adenoidectomy; and (2) ABO blood typing in adults before laparoscopic cholecystectomy, thyroidectomy, lumbar discectomy or breast surgery. Guidelines do not recommend any preoperative tests in these settings. ResultsBetween 2013 and 2015, a coagulation test was performed in 49% of the 241 017 children who underwent tonsillectomy and 39% of the 133 790 children who underwent adenoidectomy. A similar pattern was observed for ABO blood typing although re-operation rates for bleeding on the first postoperative day were very low (0.12–0.31% for tonsillectomy and 0.01–0.02% for adenoidectomy). Between 2012 and 2015, ABO blood typing was performed in 32–45% of the 1 114 082 patients who underwent one of the four selected procedures. The transfusion rate was very low (0.02–0.31%). The mean cost for the four procedures over the 4 yr period was €5 310 000 (sd €325 000). ConclusionsStandard laboratory coagulation tests and ABO blood typing are still routinely prescribed before surgery and anaesthesia despite current guidelines. This over-prescription represents a high and unnecessary cost, and should therefore be addressed.

Determinants of self-perceived health for Canadians aged 40 and older and policy implications

BackgroundPerceived health status indicates people’s overall perception of their health, including both physical and psychological dimensions. The aim of this study was to examine the determinants of self-perceived health for Canadians aged 40 and older using data from the Canadian Community Health Survey (2010).MethodsMultiple logistic regression models were employed to identify factors associated with self-perceived health in two age groups: Adults aged 65+ and Adults aged 40–64.ResultsWe found that higher income was significantly associated with better health status while chronic conditions and stress were associated with worse health status. In the 40–64 and 65+ age groups, individuals in the highest income bracket were 4.65 and 1.94 times, respectively, more likely to report better health than individuals in the lowest income bracket. The difference in the level of income associated health inequities between the two age groups point to the need for understanding the reasons behind lower inequities among seniors and how much the social protections provided by the Canadian government to seniors contribute to lowering inequities.ConclusionsThough Canada has a national public health insurance system providing coverage to all Canadians, health inequities associated with income persist providing further evidence of the importance of the social determinants of health. Examining the extent of these inequities and what factors influence them helps direct policy attention. In addition to documenting inequities, this paper discusses policy options for reducing the identified inequities.

Osteoporosis prevention among chronic glucocorticoid users: results from a public health insurance database

IntroductionLong-term glucocorticoid therapy is the leading cause of secondary osteoporosis. The management of glucocorticoid-induced osteoporosis (GIOP) seems to be inadequate in many European countries.ObjectiveTo evaluate the rate of screening and...

Health Insurance for Cancer Care in Asia: Thailand

Thailand has a universal multi-payer system with two main types of health insurance: National Health Security Office or public health insurance and private insurance. National health insurance is designed for people who are not eligible to be members of any employment-based health insurance program. Although private health insurance is also available, all Thai citizens are required to be enrolled in either national health insurance or employees’ health insurance. There are many differences between the public health insurance and private insurance. Public health insurance, therefore, initiates programs that offer many sets of benefit packages for high-cost care. For cancer care, cover screening, curative treatment such as surgery, chemotherapy, radiation together with supportive and palliative care.

P0762 : Non-RNA testing among hepatitis C virus antibody-positive patients in a national public health insurance care system: Prevalence, characteristics and predictive factors

P0762 : Non-RNA testing among hepatitis C virus antibody-positive patients in a national public health insurance care system: Prevalence, characteristics and predictive factors

Descriptive Epidemiology in Mexican children with cancer under an open national public health insurance program.

BackgroundAll the children registered at the National Council for the Prevention and Treatment of Childhood Cancer were analyzed. The rationale for this Federal Government Council is to financially support the treatment of all children registered into this system. All patients are within a network of 55 public certified hospitals nationwide.MethodsIn the current study, data from 2007 to 2012 are presented for all patients (0–18 years) with a pathological diagnosis of leukemia, lymphoma and solid tumors. The parameters analyzed were prevalence, incidence, mortality, and abandonment rate.ResultsA diagnosis of cancer was documented in 14,178 children. The incidence was of 156.9/million/year (2012). The median age was 4.9. The most common childhood cancer is leukemia, which occurs in 49.8% of patients (2007–2012); and has an incidence rate of 78.1/million/year (2012). The national mortality rate was 5.3/100,000 in 2012, however in the group between 15 to 18 years it reaches a level of 8.6.ConclusionsThe study demonstrates that there is a high incidence of childhood cancer in Mexico. In particular, the results reveal an elevated incidence and prevalence of leukemia especially from 0 to 4 years. Only 4.7% of these patients abandoned treatment. The clinical outcome for all of the children studied improved since the establishment of this national program.

The impact of cardiovascular profile on persistence associated with antihypertensive medications

Antihypertensive drug treatment (AHT) is effective in reducing the risks of cardiovascular events, but long-term persistence is required to achieve these benefits. The aim of the present study was to evaluate persistence with antihypertensive treatment in France. A total of 6924 patients, first prescribed for hypertension in 2008, were retrospectively studied from the principal French National Public Health Insurance Scheme database. Persistence was defined as remaining on therapy at the end of the 12 months postindex date. Cox proportional hazards regression models controlled for demographics and cardiovascular profile. Over 1year, 65% of patients were persistent and 16% maintained the initial therapy. When correcting for significant factors determining persistence, a 13% risk reduction of discontinuation is observed with angiotensin II antagonists (AIIAs) and 11% with angiotensin-converting enzymes inhibitors (ACE) compared with thiazide diuretics. Persistence therapy depended significantly on the cardiovascular profile. In the secondary prevention subgroup (18% of the study population), no statistically significant differences were observed between thiazide diuretics and the four major classes. In contrast, a 19% risk reduction of discontinuation is observed with AIIA and with ACE compared with thiazide diuretics for primary prevention patients without diabetes or hyperlipidaemia. When choosing AHT agents for patients with essential hypertension, practitioners are primarily driven by the cardiovascular profile of patients. The study suggests that the therapeutic decision must encompass the individual 'persistence risk', the latter not being independent from the cardiovascular risk.