Two-tiered Health Care System Research Articles

Rehabilitation after musculoskeletal injury: Israeli and South African perspectives.

Rehabilitation for patients sustaining isolated and multiple musculoskeletal injuries due to trauma remains a mainstay of recovery. There are a wide variety of systems in place to manage the rehabilitation process. This article describes the post-traumatic rehabilitation procedures from 2 member countries of the International Orthopaedic Trauma Association, Israel and South Africa. The systems are reflective of the clear differences between these 2 countries with vastly different economic strata and health care systems. In Israel, the rehabilitation programs and resources are most likely the result of the mature social support systems and the trauma experience. In South Africa, the programs are reflective of a two-tier health care system, with patients exposed to varying levels of rehabilitation resources.

The Push to Integrate Mid-Level Providers into Dentistry

The Push to Integrate Mid-Level Providers into Dentistry

Sleepwalking into a two-tiered healthcare system.

Sleepwalking into a two-tiered healthcare system.

Medicare policies in a two-Tier healthcare system with overtreatment

To alleviate the problem in two-tier healthcare systems in which city hospitals are overutilized while community hospitals are underutilized, some countries (e.g., China) exploit the induction effect of medicare policy and adopt a differentiated medicare policy (DMP) instead of an undifferentiated medicare policy (UDMP). The difference between the two policies lies in the fact that DMP provides no or low reimbursement for patients who directly seek care from city hospitals, while UDMP reimburses all patients at the same rate. However, some countries (e.g., Austria and Japan) have different attitudes toward this approach. To explore the causes of this variation, we examine the impact of medicare policies on service operations in a two-tier healthcare system in which a city hospital can provide services for all kinds of patients but will likely overtreat mildly ill patients, while a community hospital focuses on treating mild illness and refers severely ill patients to a city hospital. Our results indicate that DMP does not always benefit the community hospital and can benefit the city hospital in some cases, which goes against public expectations. Furthermore, DMP may have a counterproductive effect in reducing patient waiting times, but it can outperform UDMP in terms of patient utility and social welfare, even though DMP may cause some patients to suffer financial losses. Interestingly, we find Pareto zones that can yield multi-win outcomes when UDMP is adopted, but these Pareto zones narrow as the reimbursement rate increases.

Characterising differences in red blood cell usage patterns between healthcare sectors in South Africa: 2014-2019.

South Africa aims to transition from a two-tiered healthcare system (public and private) to universal health coverage. Data on red blood cell (RBC) product usage reveal disparities between the sectors. Blood transfusion services further need to understand differing disease profiles and transfusion prescribing practices between the sectors to ensure blood security should the transition to a two-tiered health system come to fruition. Operational data for public and private healthcare RBC requests between 1 January 2014 and 31 March 2019, obtained from the South African National Blood Service (SANBS), were retrospectively analysed. Sector-specific demographic and utilisation trends were compared for the dominant clinical disciplines. Pre-transfusion haemoglobin (Hb) patterns were also delineated for 2018. Between 2014 and 2019, 2,356,411 public and private sector RBC transfusion events resulted in the issue of 4,020,094 RBC units (1,553,159 transfusion events and 2,495,054 units within the public sector versus 803,282 transfusion events and 1,525,040 units in private). The dominant clinical disciplines within the public sector were Medical (32.9%), Gynaecology/Obstetrics (27.3%), General Surgery (13.6%), and Paediatrics (including Paediatric Surgery) (6.5%), compared to Intensive Care Units (33.2%), Medical (28.3%), General Surgery (10.4%), and Haematology/Oncology (8.3%) in the private sector. Median pre-transfusion Hb values for 2018 were lower in the public than in the private sector: 6.9 g/dL public sector versus 8 g/dL private sector. Clinical drivers of RBC usage within the public and private healthcare sectors in South Africa differ significantly. Disparate pre-transfusion Hb between the sectors are likely due to differing disease profiles and severity, as well as differences in practice in prescribing transfusions. Implementation of a nationally co-ordinated Patient Blood Management programme may help to address these disparities and help ensure a sustainable blood transfusion system.

Mind the gap: Patterns of red blood cell product usage in South Africa, 2014 - 2019.

A key component of any successful healthcare system is the availability of sufficient, safe blood products delivered in an equitable manner. South Africa (SA) has a two-tiered healthcare system with public and privately funded sectors. Blood utilisation data for both sectors are lacking. Evaluation of blood utilisation patterns in each healthcare sector will enable implementation of systems to bring about more equality. To conduct a critical evaluation of red blood cell (RBC) product utilisation patterns at the South African National Blood Service (SANBS). Operationally collected data from RBC requests submitted to SANBS blood banks for the period 1 January 2014 - 31 March 2019 were used to determine temporal RBC product utilisation patterns by healthcare sector. Demographic patterns were determined, and per capita RBC utilisation trends calculated. Of the 2356441 transfusion events, 65.9% occurred in the public and 34.1% in the private sector. Public sector patients were younger (median (interquartile range (IQR)) 33 (22 - 49) years) than in the private sector (median (IQR) 54 (37 - 68) years), and mainly female in both sectors (66.2% in the public sector and 53.4% in the private sector). Between 2014 and 2018, per capita RBC utilisation decreased from 11.9 to 11.0/1 000 population in the public sector, but increased from 34.8 to 38.2/1 000 population in the private sector. We confirmed distinctly different RBC utilisation patterns between the healthcare sectors in SA. Possible drivers for these differences may be healthcare access, differing patient populations and prescriber habits. Better understanding of these drivers may help inform equitable public health policy.

PET/CT in malignant melanoma: a two-tiered healthcare system? Updated healthcare situation regarding initial staging of malignant melanoma with PET/CT.

Patients with stageIIC malignant melanoma are recommended to undergo cross-sectional imaging for initial staging. PET/CT is superior to other methods regarding its diagnostic accuracy of the tumor spread in stageIII. So far there is no meaningful data on the nationwide availability, usage and cost recovery of this imaging technique. Questionnaires on the healthcare situation in 2018 were sent to all German dermatology clinics and PET/CT centers in March and April 2019. 61.2% of the dermatology clinics (71/115) and 48.2% of the PET/CT centers (77/160) took part in the survey. A total of 22,645 patients with malignant melanoma were seen in these clinics in 2018. 16.8% of the patients with stageIIC melanoma received a PET/CT for primary staging. The costs of this examination were covered for all statutory and privately insured patients in 40% and 68% of dermatology clinics (20/50 and 34/50), respectively. 68.0% (34/50) of all dermatology clinics reported relevant changes of treatment according to PET/CT findings. Long examination periods by the health insurance companies and the time required to submit the application were the most common reasons for dermatology clinics to reject a request for PET/CT. Relevant incidental findings were reported in 90.2% (47/51) of all PET/CT centers. There are clear differences in the nationwide availability and cost coverage of PET/CT in primary staging for stageIIC melanoma. For these reasons, a two-tiered healthcare system may be assumed.

Challenges and Changes of Pharmacy Practice During the COVID-19 Crisis in Malaysia: Instability as an Opportunity.

Pharmacy practice is the discipline concerning the roles of pharmacists in the healthcare setting. Healthcare in Malaysia encompasses numerous sectors, such as academics, community, enforcement, hospital, industrial, jurisprudence, military, regulatory and research and development. In addressing the crisis brought on by the coronavirus disease 2019 (COVID-19) pandemic, pharmacists and technicians have been highly involved in the delivery of healthcare services. Malaysia has a distinct two-tier healthcare system and within this context, it is essential to integrate services during a crisis to maximise the available but limited medical resources. Often, the focus is on realistic and logical public–private partnerships. However, integrating different ministries offering healthcare facilities is also important and inter-agency pharmacy practice coordination must be optimised. The Malaysian Armed Forces Health Services can be primed to enhance the nation’s healthcare capacity and capability. As the COVID-19 pandemic continues to grip the nation and cause an unprecedented number of Malaysians to become very ill, pharmacists must be resilient in leading, adapting and integrating well-rounded strategies in their respective fields to ensure good pharmacy practice.

Emergency Medicine's Role in the Crossroads of Social Revolution and the COVID-19 Pandemic.

Emergency Medicine's Role in the Crossroads of Social Revolution and the COVID-19 Pandemic.

Australia’s Two-Tier Health Care System United Against COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has had and continues to have an unprecedented impact on health care systems worldwide. The Australian system has yet to be truly tested by the pandemic, as rapid implementation of public health measures has curbed infection rates. Australia’s 2-tier health care has allowed sufficient staffing, equipment, and beds to continue providing acute health care in the face of an exceptional and extreme demand. No health system is perfect and, although Australia’s has some wonderful attributes that make it the envy of many other countries, it faces a number of important challenges. This paper describes how Australia’s health care structure has adapted to respond to the COVID-19 crisis, examines the challenges involved and the lessons learned, and explores how this environmental pressure could lead to systemic adaptations.

On two-tier healthcare system under capacity constraint

In the healthcare industry, to reduce the waiting time for patients, policy makers may allow private hospitals (or called the toll system) to enter the market. However, when the total healthcare capacity in the market is limited (e.g. the number of medical staff or equipment is limited), the entrance of the toll system may offer higher salaries to attract medical staff from public hospitals (or called the free system) and reduce its capacity. Then whether or not introducing toll system in the system can reduce the waiting time becomes an issue. In this paper, we investigate the impact of capacity constraint on a two-tier healthcare system. The results show that when the total capacity is tight enough, the two-tier healthcare system often yields less social welfare than the one-tier free system; and when the total capacity is sufficient (the demand does not exceed the total capacity), the two-tier healthcare system improves the social welfare. Specially, we find under certain conditions the capacity constraint can improve social welfare. In addition, if the capacity constraint has a negative effect on the two-tier system’s performance, the government can set an appropriate upper limit for the toll system’s capacity to remove the negative effect.

Hospital Referral and Capacity Strategies in a Two-Tier Healthcare System

Healthcare referral has been widely advocated and adopted through the implementation of a two-tier healthcare system whereby patients are transferred from a comprehensive hospital provider (CHP) to a primary hospital provider (PHP). However, operationally, exactly how to implement the healthcare referral program remains a challenging research question, especially when considering the possibility of patient revisits and the coordination needed between the CHP and PHP. To address such a challenge, this paper considers a two-tier healthcare system consisting of a CHP and a PHP. By establishing a three-stage Stackelberg game within a queuing framework among the CHP, the PHP and their patients, we first investigate the equilibrium strategy in terms of the CHP’s referral rate and the PHP’s capacity level, and then examine the impact of revisit rates and referral payments (RP) on the healthcare system and the equilibrium outcomes (e.g., expected utility, social welfare, and waiting times). Two major findings of our study are: (1) Both the equilibrium referral rate and the equilibrium capacity first increase and then decrease according to the revisit rate; in addition, the patient referral process always improves the PHP's performance but is likely to sacrifice the social welfare of the CHP. (2) There exists an RP threshold value such that if the RP is below the threshold, then all the permitted patients should be referred and the system performance will be enhanced, in which case a win-win-win situation in terms of expected utilities can be attained that benefits all the stakeholders, i.e., the CHP, the PHP, and the patients. Otherwise, only a portion of the permitted patients can be referred, and an increase in RP always reduces the efficiency of the healthcare delivery system, i.e., a higher RP mitigates the operational performance of the healthcare system. Our analysis sheds light on how to implement a healthcare referral scheme.

The Comparison of Effectiveness between Static Clinic and Mobile Health Clinic in Remote Areas in Sabah

Background: The population of Malaysia is estimated in 2018 to be around 32.04 million and 23.5% of the population resides in rural areas. The Ministry of Health has provided healthcare services to the rural areas with the access of modern healthcare facilities based on the two-tier healthcare system. In remote areas, mobile health clinic is the extension of healthcare service by the nearest static health clinic. However, most of the remote areas only covered by a community clinic or Klinik Desa which is limited for mother and child healthcare. There is demand from the people in remote areas for static health clinic or Klinik Kesihatan. Objectives: This study is to evaluate and compare the effectiveness between two health services in remote areas applied in Sabah. This study also determines which type of health services that able to worth the service to people in remote areas. Methods: This is a descriptive study. Data was taken from HMIS report (Per PL 206) under Sabah State Health Department. The data analysed by using Microsoft Excel. Results: This study was conducted based from the data obtained in 2015 till 2017 for the number of patients attended to static health clinics and mobile health clinics on selected remote areas. For example, Jambongan Health Clinic only have an average of 10 – 15 patients per day while the Mobile Health Clinic team under Beluran Health District which covers the adjacent remote areas of Jambongan Island have more than 20 patients per day on a single visit. Another example is from Terian Health Clinic in Penampang, which only have an averageof 5 – 10 patients per day. However, on the mobile health team on a single visit to the village next to Terian which is Kg. Buayan, the average patients attended for the service is mo re than 20 patients. Conclusion: From the study, it was noted that people in remote areas prefer the mobile health service to visit their villages. This can be due to financial issue and limitation of transportation service to the nearest static clinic. The density of population and the development of the rural areas play important roles for the healthcare service to be effective in remote areas.
 Keywords: mobile health clinic, static clinic, effectiveness of healthcare, primary healthcare

Flint Goodridge Hospital and Black Health Care in Twentieth-Century New Orleans

Flint Goodridge Hospital and Black Health Care in Twentieth-Century New Orleans

The current state of prostate cancer treatment in Trinidad and Tobago.

Prostate cancer mortality in the Caribbean region is among the highest in the world and prostate cancer is the most common cancer in Trinidad and Tobago. There is a two-tiered healthcare system in Trinidad and Tobago, and prostate cancer related issues account for a significant percentage of urologists’ workload. Delivery of care is sometimes constrained by limited financial resources. Prostate-specific antigen testing is widely available but there is no national guideline. Treatment options available include active surveillance, radical prostatectomy, external beam radiotherapy and brachytherapy. Patients have access to androgen deprivation, chemotherapy and palliative care for the management of advanced disease. Generally, the infrastructure for treatment in Trinidad and Tobago is satisfactory but would benefit from further investments in technology and human resources.

Should glaucoma be public funded in Nigeria? Background, justification, and the study overview

Many Nigeria's individuals with glaucoma are losing vision because they cannot afford glaucoma treatment. A work, “Should glaucoma be public funded in Nigeria?,” was conducted and written into articles. The objective of this article was to present the work's background, glaucoma overview, research question, rationale, and overview of the work. The work is an ethical (normative) study advocating public-funded glaucoma treatment. Relevant literatures were reviewed and cited. The rationale for the study includes inability of individuals with glaucoma to afford treatment, poor treatment compliance due to poverty, absent universal healthcare insurance, and negative impact of glaucoma on quality life. The work overview includes strong rebuttal of oppositions to public-funded glaucoma treatment; adverse effect of glaucoma on visual function domains, quality of life, daily activities, health, education, economy, and work; three-level budgetary glaucoma funding – macro, meso, and micro-allocations vis–a-vis a justice-based glaucoma funding through a two-tiered healthcare system, namely, tier-one providing basic universal health care for glaucoma at no cost at the point of delivery and tier-two covering all imaginable glaucoma care but at the client's expense are suggested.

A Critical Discussion of Arguments Against the Introduction of a Two-Tier Healthcare System in Japan

In medical ethics, an appropriate national healthcare system that meets the requirements of justice in healthcare resource allocation is a major concern. Japan is no exception to this trend, and the pros and cons of introducing a two-tier healthcare system (mixed billing system), which permits insured medical care services to be provided along with services not covered by social health insurance, have been the subject of debate for many years. The Supreme Court ruled in 2011 that it was valid for the government to ban mixing medical treatments and both the Ministry of Health, Labour and Welfare and Japanese Medical Association oppose the introduction of such a system. In this paper, we examine the main arguments against the introduction of a two-tier healthcare system and ideas that form their basis, which can be broadly divided into opinions based on the importance of equality and those derived from the logical conclusion that the outcomes would be detrimental. We point out issues and shortcomings of each standpoint and argue that the introduction of the system would not necessarily threaten equality and social solidarity in Japanese society, and that abuses of a self-pay tier would be controllable to a certain extent. Then, the authors—who do not actively promote the introduction of a two-tier healthcare system—conclude that the allegation that is completely devoted to one side (i.e., the importance of equality) and the theory that social healthcare is collapsing, which makes the public excessively nervous, cannot be accepted.

1427P - Biopsychosocial factors underlying older patients treated for an incurable cancer in a two-tiered health care system in Brazil

Background: Patients with advanced cancer experience symptoms that include pain, fatigue, and depression. We sought to describe prevalence and identify factors associated with biopsychosocial distress in older patients (65+) diagnosed with cancer stage IV. Methods: Participants were recruited from two different types of health care facilities, public [PUB] and private [PRI] institutions, in Brazil. A cross-sectional analysis of common biopsychosocial symptoms (anxiety, depression, pain, and fatigue), and quality of life reported by older patients undergoing chemotherapy treatment was performed. Results: Older patients (n = 167) were enrolled (Mean age=73; SD = 5.6); 59.3% from PUB. Majority were female (56.3%; 38.9% PUB), white (68.9%; 35.7% PRI, p<.01), married (59.3%; 32.1% PUB, p<.01); and diagnosed with GI (29.9%; 15.8% PUB), GU (16.2%; 4.9% PUB), and hematologic (13.8%; 7.5% PRI) cancers. Almost 16% of patients reported depression symptoms (9.6% PUB) and 12% of anxiety (8.4% PUB). PUB patients also reported associated lower QOL, which is at 50th percentile of the US norm (PRI is at 75th percentile). PUB patients reported significantly more biopsychosocial problems including distress (21.6% vs 7.2%), pain (28.1% vs 12.0%), fatigue (34.7% vs 16.8%), sleep (22.8% vs 15%), neuropathy (22.8% vs 8.4%), and financial toxicity (16.2% vs 5.4%), compared to patients treated at PRI (all p < 0.05). Mostly pain (B = 1.8; B=-6.6), fatigue (B = 0.8; B=-6.5) and sleep (B = 1.2; B=-8.3) were associated with moderate to severe distress and worst QOL (all p<.01). Conclusions: Older patients with late-stage cancer in Brazil suffer substantial unrecognized morbidity which impacts their distress and QOL. Biopsychosocial screening for older patients should be included in quality cancer care. Moreover, patients treated within PUB show worse outcomes than PRI counterparts, and they are at higher risk for multiple physical, psychological, and financial morbidity. Earlier initiation of biopsychosocial screening with appropriate supportive care may improve their QOL. Legal entity responsible for the study: Cristiane Decat Bergerot Funding: None Disclosure: All authors have declared no conflicts of interest.

Assessing ostomates' quality of life in the Republic of Ireland

The Republic of Ireland's two-tier health-care system is different to that of the UK, and this includes provision for people with a stoma. In 2015, the Irish Health Service Executive (HSE) increased the number of stoma products available to patients for the first time in 7 years. To find out how this would affect the quality of life (QoL) of Irish ostomates, a working party of HSE and commercially sponsored stoma care nurses undertook a survey to obtain data on the QoL of Irish ostomates before and after the introduction of new products. Data was collected 2 weeks after the baseline reading, after the patient had been using the innovative products and experiencing increased interaction with a stoma nurse. The results are discussed in light of other similar studies undertaken across Europe. This data is used to discuss examples of stoma care practice elsewhere in Europe and the world and how they could be applied to the Irish health system to improve the QoL of Irish ostomates.

Inequities in cancer outcomes between different healthcare systems in Brazil.

31 Background: Studies have shown a clear difference among minority and economically disadvantaged patients. Less is known about marginalized populations in Brazil, a country that possesses a two-tiered healthcare system, based on socioeconomic status. We sought to explore differences in quality of life (QOL) and distress among patients receiving care within these systems. Methods: 270 patients were assessed for distress (DT), anxiety/depression (HADS) and QOL (FACT-G). Half of them was recruited at a private institution (PRI) and the other at a public institution (PUB) (each group: n=135; 68.9% breast and 31.1% gynecological cancers). We calculated descriptive statistics and examined QOL and distress using T-test and ANOVA. Results: We found ethnic differences between PUB (50.4% white, 32.6% mulato and 14.1% black) and PRI patients (82.9% white), and income disparities (PUB patients report almost a third less monthly income than PRI patients). PUB patients were mostly late-stage diagnosed 70.4% compared to PRI counterpart 42.2% (p&lt;.001). In general PUB patients reported higher rates of distress and anxiety/depression (p&lt;.03); and poorer QoL outcomes (p&lt;.01). Conclusions: This preliminary study is one of the first to investigate inequities in cancer outcomes among patients in Brazilian healthcare settings. Analyses revealed notable differences between groups across demographic characteristics, while individuals of lower socioeconomic status reported significantly poorer psychosocial outcomes. These results suggest a complex interaction between ethnicity, access to care and cancer outcomes, and warrants further research to better understand and address these inequities. Further discussion of the role of psycho-oncology research and clinical practice in reducing disparate outcomes among Brazilian cancer patients is warranted.