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PubMedDate not supplied

Regulating private health insurance to serve the public interest: policy issues for developing countries.

Private health insurance plays a large and increasing role around the world. This paper reviews international experiences and shows that private health insurance is significant in countries with widely different income levels and health system structures. It contrasts trends in private health insurance expansion across regions and highlights countries with particularly important experiences of private coverage. It then discusses the regulatory approaches and policies that can structure private health insurance markets in ways that mobilize resources for health care, promote financial risk protection, protect consumers and reduce inequities. The paper argues that policy makers need to confront the role that private health insurance will play in their health systems and regulate the sector appropriately so that it serves public goals of universal coverage and equity.

Developing Countries↗
PubMed1995

Comparison of obstetric outcome of a primary-care access clinic staffed by certified nurse-midwives and a private practice group of obstetricians in the same community.

OBJECTIVE: The purpose of this study was to compare the obstetric outcome of a primary-care access clinic staffed by certified nurse-midwives, supervised by a private practice group of four obstetricians, with the obstetric outcome of that group's private practice patients. STUDY DESIGN: A retrospective cohort study was performed. Obstetric outcome of 496 clinic patients was compared with that of 611 private patients in the same community from Aug. 1, 1991, to March 31, 1994. RESULTS: Obstetric outcomes as measured by (1) perinatal morbidity and mortality, (2) Apgar score, (3) birth weights, and (4) prematurity rates were comparable between the two groups. Significant was the cesarean section rate of 13.1% (10.5% primary) for the clinic patients and 26.4% (18.5% primary) for the private patients and the high percentage (81.8%) of private patients who elected to have repeat cesarean sections. CONCLUSIONS: (1) Low-income, uninsured, and underinsured women who have access to excellent prenatal care with supervised certified nurse-midwives can have obstetric outcomes similar to women having prenatal care with private obstetricians. (2) Prenatal care with supervised certified nurse-midwives can reduce the cesarean section rate without compromising infant outcome. (3) Utilization of certified nurse-midwives supervised by obstetricians may provide the optimum model for perinatal care, particularly for those women who are at high risk because of social and economic factors and who are currently underserved.

Adult↗
PubMed1988

A study of the movement of nurses and nursing skills between the NHS and the private sector in England and Wales.

An investigation of 2165 qualified nurses joining eight NHS District Health Authorities (DHAs) and 72 private sector institutions was undertaken in order to measure the skills which move between these sectors and to estimate the likely impact on NHS nursing services of any future growth in the private sector. It was found that 42% (95% confidence interval: 36%, 48%) of the nurses joining private acute hospitals and 28% (95% CI: 21%, 37%) of those joining long-stay private nursing homes came directly from the NHS workforce. Fewer qualified nurses move from the private sector to the NHS. Private acute hospitals appear to attract recruits from a specific section of the NHS workforce: nurses under 30 years of age with specialist skills such as theatre nursing, renal nursing, intensive care and oncology.

Adult↗
PubMed1984

Survey of the previous investigation and treatment by private practitioners of patients with pulmonary tuberculosis attending government chest clinics in Hong Kong. Hong Kong Chest Service/British Medical Research Council.

A questionnaire was applied to 159 consecutive patients with smear-positive and 187 with smear-negative pulmonary tuberculosis attending the 8 full-time Government chest clinics in Hong Kong for the first time for their current illness, who had already attended a private practitioner at a private general practice, a private clinic, or an independent hospital, outside the Government or Government-subsidised Service. The aim was to obtain details of management by private practitioners, and in particular of the antituberculosis chemotherapy prescribed. The great majority (86%) of the patients had originally attended a private practitioner because of symptoms. Only 18% had had their sputum examined, although 76% had had a chest radiograph; 65% of the smear-positive and 71% of the smear-negative patients had been told that they had, or might have, tuberculosis. For 40% there was an interval of more than a month between their first attendance at a private practitioner and at a Government chest clinic. Only 11% of the patients were referred without delay to a Government chest clinic, and another 21% once tuberculosis had been diagnosed or suspected. The patients were asked to name the drugs they had been prescribed, to produce samples, or to identify them from a perspex board containing samples of all 49 antituberculosis tablets and capsules known to be available in Hong Kong at the time. In the event, only 11% of the patients could name some or all of their medicaments and only 7% could produce samples, although a further 76% were able to describe them with or without the aid of the perspex board. In all, 19% of the patients were definitely or probably prescribed an antituberculosis regimen, although this was not always an adequate regimen. The findings suggest that there is considerable scope for active case-finding aimed at encouraging patients who are likely to have tuberculosis to attend a Government chest clinic.

Adolescent↗
PubMed1995

Choosing between public and private health-care: a case study of malaria treatment in Brazil.

Individuals infected with malaria may be treated either in the public sector in in a private clinic. Private treatment is better, but expensive. Using micro-level data from a colonization project in Brazil, we estimate the factors that determine an individual's choice between the two sectors. Private treatment is (strongly) price sensitive and (weakly) wealth sensitive. Rural individuals are more likely to choose private treatment, but long distances to the treatment source deter private treatment. Individuals belonging to small, literate households are more likely to choose private treatment. Gender, age, and number of previous infections are unimportant. Policy implications are discussed.

Ambulatory Care Facilities↗
PubMed2005

Private insurance and the utilization of chemical dependency treatment.

This study examines how different types of health coverage influence the likelihood of entering treatment for an alcohol problem, and the extent that people in treatment are able to use their insurance to help cover the costs of care. Survey data are analyzed from a sample of problem drinkers drawn from the general population and chemical dependency treatment programs in the same community. We find that, in comparison to being on Medicaid and being uninsured, having private coverage does not significantly alter the odds of treatment entry. Being in a private managed care plan, as compared to traditional indemnity coverage, also does not appear to impact the chances of treatment entry. However, having private coverage, as compared to being on Medicare, doubles the odds of treatment entry. For problem drinkers who obtain treatment, those with private coverage are as or more likely than other insured groups to report that insurance helped to pay treatment expenses. Even so, 10% of those privately insured report having paid for all of their treatment costs out of pocket. We conclude that, while prior studies have rarely found that having insurance significantly impacts alcohol treatment entry, the type of coverage one possesses may matter in some cases. Our results concerning Medicare coverage may point to potential problems with making treatment affordable to some problem drinkers outside the private insurance system.

Adult↗
PubMed2006

Public-private partnerships for equity of access to care for tuberculosis and HIV/AIDS: lessons from Pune, India.

The private medical sector is an important and rapidly growing source of health care in India. Private medical providers (PMP) are a diverse group, known to be poorly regulated by government policies and variable in the quality of services provided. Studies of their practices have documented inappropriate prescribing as well as violation of ethical guidelines on patient care. However, despite the critique that inequitable services characterise the private medical sector, PMPs remain important and preferred providers of primary care. This paper argues that their greater involvement in the public health framework is imperative to addressing the goal of health equity. Through a review of two research studies conducted in Pune, India, to examine the role of PMPs in tuberculosis (TB) and HIV/AIDS care, the themes of equity and access arising in private sector delivery of care for TB and HIV/AIDS are explored and the future policy directions for involving PMPs in public health programmes are highlighted. The paper concludes that public-private partnerships can enhance continuity of care for patients with TB and HIV/AIDS and argues that interventions to involve PMPs must be supported by appropriate research, along with political commitment and leadership from both public and private sectors.

Delivery of Health Care↗
PubMed1998

Motivation and reward factors that affect private physician involvement in an obstetrics and gynecology clerkship.

OBJECTIVE: The Department of Obstetrics, Gynecology and Reproductive Biology in the College of Human Medicine at Michigan State University has 163 private-practice obstetricians and gynecologists teaching clerkship students, on a volunteer basis, in six Michigan cities. The department wanted to learn what motivates their involvement in the department's required clerkship, to determine their attitudes toward private office teaching, and to determine what incentives are important to them in their role as educators. METHODS: The department developed a questionnaire that was mailed to the obstetricians and gynecologists involved in its required obstetrics and gynecology clerkship. The response rate was 68% (111 of 163). RESULTS: Respondents indicated personal and professional motivations transcend financial considerations. Almost 60% of respondents reported at least a moderate interest in teaching in their private offices in spite of perceived negative consequences, such as adverse impact on patient flow. The incentives in which private practitioners were primarily interested included seminars or meetings that would enhance their teaching skills or educational contribution; discounts on computers, athletic and cultural events, and books; and university support in producing educational materials. CONCLUSION: Departments using private practitioners in medical education need to nurture the relationship continually with their volunteer faculty. Faculty development aimed at assisting private practitioners with their teaching role in the ambulatory care setting might be extremely worthwhile. Financial remuneration may not be key to attracting and retaining volunteer faculty. The implications of pay arrangements for volunteer faculty should be considered carefully before implementation.

Adult↗
PubMed2000

The demand for private health care in the UK.

Policy change has eroded the entitlement of UK residents to free state-provided health care, with a resulting rise in the use of the private sector. This paper examines the choice between public and private health care. It models the use of private health care as a function of its costs and benefits relative to state care and no care. The results indicate a difference between users of private care and other care, and the importance of past use as a predictor of current use. But they also show considerable movement between the public and private sectors, indicating a complex relationship in public and private sector use.

Choice Behavior↗
PubMed2003

Assessment of public vs private MSW management: a case study.

Public-private partnerships in urban environmental services have witnessed increased interest in recent years primarily to reform the weak performance of the public sector, reduce cost, improve efficiency, and ensure environmental protection. In this context, successful public-private partnerships require a thorough analysis of opportunities, a deliberate attention to process details, and a continuous examination of services to determine whether they are more effectively performed by the private sector. A comparative assessment of municipal solid waste collection services in the two largest cities in Lebanon where until recently municipal solid waste collection is private in one and public in the other is conducted. While quality of municipal solid waste collection improved, due to private sector participation, the corresponding cost did not, due to monopoly and an inadequate organizational plan defining a proper division of responsibilities between the private and the public sector.

Cities↗
PubMed2002

Facets of private practice nursing: a conceptual model.

AIM: This paper critically examines the literature relating to private practice nursing. Particular attention is given to the reasons nurses choose private practice and the major issues involved. A conceptual model has been developed based on this information. BACKGROUND: Nurses' roles are expanding into different work domains. Private practice nursing is one of the advanced practice options available. It also requires the nurse to develop business knowledge and skills. METHODS: A literature search was conducted of Pub-Med, Cinahl, Medline and InfoTrac databases using the terms 'private practice', 'nurse entrepreneur', 'nurses in business', Inurse practitioners', 'self-employed nurse', 'advanced practice' and 'clinical nurse specialist'. Further relevant articles were identified from the reference lists of papers detected by this literature search. In addition, conference proceedings were examined for any other material on this topic. FINDINGS: A thorough search of the existing literature revealed one unpublished theoretically based study which examined limited aspects of private practice nursing in Victoria. A reasonable number of articles and publications that provided anecdotal and personal accounts of being a nurse in business were identified. This review highlights the need for further theoretically based research in this area of nursing, so as to expand nursing knowledge. Suggestions are given for further research in this topical area. CONCLUSIONS/IMPLICATIONS: Existing research into private practice nursing is limited and not sufficient to inform changes to policy and nurse education. More research is needed.

Australia↗
PubMed2004

A comparison of hepatitis C treatment and outcomes at academic, private and Veterans' Affairs treatment centres.

BACKGROUND: Currently, there is a lack of published data examining hepatitis C treatment practices in different care settings. AIM: To provide data describing treatment practices for patients with hepatitis C virus infection in actual clinical practice, and to examine clinical outcomes in patients treated with interferon alpha-2b/ribavirin combination therapy in academically affiliated centres, private treatment centres and Veterans' Affairs treatment centres. METHODS: This multi-centre, retrospective, cohort study of 231 patients examined hepatitis C virus treatment practices in patients receiving interferon alpha-2b from January 1997 to May 2001 and explored outcomes in academically affiliated, private and Veterans' Affairs centres. RESULTS: Differences in treatment practice and use of diagnostic procedures were found. Genotype testing was under-utilized in non-academic sites (academic centres, 79.2%; private centres, 33.7%; Veterans' Affairs centres, 35.9%; P<0.001). Liver biopsies were performed less often in private sites (academic centres, 95.8%; private centres, 80.0%; Veterans' Affairs centres, 92.2%; P<0.01). End-of-treatment viral response (academic centres, 40.0%; private centres, 31.3%; Veterans' Affairs centres, 17.2%; P<0.05) was lower than that found in published trial data. Multivariate analysis revealed genotype 1 as the single significant predictor of treatment failure (P<0.01). CONCLUSIONS: Outside of the academic setting, there is significantly less diagnostic work-up performed prior to the initiation of hepatitis C virus therapy. This suggests a need for a standardization of care across treatment settings.

Academic Medical Centers↗
PubMed2000

Abdominal pain and appendicitis: is there a difference in referrals between HMO pediatricians and private pediatricians?

BACKGROUND: In the last few years, there have been many reports of the rising incidence of late appendicitis and perforated appendicitis. The rise of managed care medicine has been blamed for this, because the health maintenance organizations (HMO) and gatekeepers allegedly want to keep the child away from the surgeon and hospital to save costs. METHODS: The authors were in a unique position a number of years ago because they had only a single HMO in their area of practice (New Brunswick, NJ) employing 14 pediatricians, and 86 pediatricians were in private practice or on the medical school staff. The HMO had a yearly contract with the pediatric surgeons, and all visits and surgeries were covered by a yearly agreement (capitated agreement). The authors compared the number of children with appendicitis, perforated appendicitis, or just abdominal pain (not requiring surgery), between both groups over a 5-year period (1991 to 1996). RESULTS: A total of 492 patients were referred with abdominal pain over a 5-year period. Two hundred eight (42%) had appendicitis, and 284 (58%) had just abdominal pain and eventually were sent home. The HMO pediatricians diagnosed appendicitis accurately in 46% of their patients (55 of 118), and 54% were abdominal pain that was not appendicitis (63 of 118). For the private pediatricians, the percentages were: 40% of their patients had appendicitis (153 of 374), and 60% had abdominal pain without appendicitis (221 of 374). The incidence of perforated appendicitis was similar (28% HMO v 30% private), and the incidence of negative explorations were similar (8% HMO v 9% private). CONCLUSIONS: The results are very similar in both groups, with a similar percentage of abdominal pain not being appendicitis (60% v 54%). HMO patients did not pay for consultations, and the HMO was not charged for any consultations. However, it does not appear that they overused the consultations for abdominal pain that were not appendicitis. Their accuracy for correct diagnosis of appendicitis was similar to the private group (46% v 40%), and the incidence of perforated appendicitis for both groups was 28% to 30%. The authors cannot draw any conclusions from their experience that HMOs in general do refer patients to surgeons in a timely fashion, and do not delay the referrals to avoid the cost of consultation, because the authors had a capitated agreement with their HMO, and consultations were free. Both groups of pediatricians, the HMO and the private pediatricians, did not realize financial gain or loss by sending children to the pediatric surgeon and were not penalized by sending patients with abdominal pain to the surgeon. On the contrary, their referral habits and judgments were similar and did not appear to change by being part of an HMO.

Abdominal Pain↗
PubMed1986

Relation of private or clinic care to the cesarean birth rate.

The rising rate of cesarean births in the United States has been the focus of academic attention as well as attention from the media during the past decade. Although there is a consensus about the indications for cesarean delivery that have led to the increased rate (dystocia, malpresentation, fetal distress, and previous cesarean delivery), the influence of other key factors, such as whether the patient received care from a private physician or through a hospital clinic, has not been established. In a review of 65,647 deliveries in four Brooklyn hospitals between 1977 and 1982, we found that private physicians performed significantly more cesarean sections than house officers and attending physicians. Private patients giving birth to their first child were significantly more likely than clinic patients to undergo cesarean delivery if dystocia, malpresentation, or fetal distress was diagnosed, and private patients with one or more previous deliveries were significantly more likely to undergo cesarean delivery if dystocia or malpresentation was diagnosed. Private patients had fewer perinatal deaths, which were concentrated among infants with birth weights under 2000 g, but the infants of private patients had a significantly higher rate of low Apgar scores and birth injuries than the infants of clinic patients.

Adult↗
PubMed1999

A reappraisal of private employers' role in providing health insurance.

BACKGROUND: In 1996, according to official figures, 61 percent of Americans received health insurance through employers. However, this estimate includes persons who relied primarily on government insurance such as Medicare, workers whose employers arranged their insurance but contributed nothing toward the premiums, and government employees whose private coverage was paid for by taxpayers. METHODS: To estimate the number of persons whose principal health insurance was paid for in whole or in part by employers in the private sector and the number receiving government-funded insurance, we analyzed data from the March 1997 Current Population Survey. Approximately 130,000 persons representative of the noninstitutionalized U.S. population were sampled. We considered people to be covered principally by health insurance paid for by private-sector employers if they had no public insurance coverage and were covered by insurance from a non-governmental employer who paid all or part of their premiums. Those who were covered by Medicaid, Medicare, insurance resulting from former or current military service, or the Indian Health Service were considered to be receiving government insurance. RESULTS: In 1996, 43.1 percent of the population (90 percent confidence interval, 42.7 to 43.5 percent) depended principally on health insurance paid for by private-sector employers, 34.2 percent (90 percent confidence interval, 33.8 to 34.6 percent) had publicly funded insurance, 7.1 percent (90 percent confidence interval, 6.8 to 7.6 percent) purchased their own coverage, and 15.6 percent (90 percent confidence interval, 15.3 to 15.9 percent) were uninsured. In only six states was more than half the population covered principally by health insurance paid for by private-sector employers. CONCLUSIONS: Current definitions of health insurance overemphasize the role of private employers and underestimate the extent to which government pays for health insurance.

Adolescent↗
PubMed1999

Episiotomy in NSW hospitals 1993-1996: towards understanding variations between public and private hospitals.

Episiotomy rates for women experiencing childbirth in New South Wales (NSW) hospitals are another indicator that private insurance may be a risk factor for obstetric intervention. A recent comparison of episiotomy rates in NSW public and private hospitals between 1993 and 1996 revealed that episiotomy rates were 12 to 15 percentage points higher in NSW private hospitals than in public hospitals studied. Rates also appear to be declining in NSW public hospitals, yet this trend is not evident in the NSW private hospitals studied. Although private hospital patients were almost twice as likely to experience forceps or vacuum delivery (often associated with episiotomy), this leaves a 6 to 8 percentage point difference unexplained. Given the potential health-related quality of life issues associated with perineal trauma during childbirth, further analysis of the clinical make-up of privately insured women may help determine the extent to which clinical explanations exist to support the differences in this childbirth intervention.

Adult↗
PubMed2002

Utilization of dental health services by Danish adolescents attending private or public dental health care systems.

The objectives of the study were: 1) to describe the choice of dental care system among 16-year-olds, 2) to describe the utilization of dental services among 16-17-year-olds enrolled in either public or private dental care systems, and to compare the dental services provided by the alternative systems. The study comprised 1,245 adolescents from 3 municipalities; the historical cohort study design was applied; and data were collected from dental records (public dental service) and dental claims (private practice). At age 16, 12% preferred being enrolled in the private practice system, while 88% remained in the public dental care system. During the 2-year study period the attendance rate was 99% for the public system, while 90% attended the private practice system (P< 0.001). Preventive dental services were provided more frequently by the public than the private system (P< 0.001). Despite the fact that the economic barrier was eliminated a lower attendance rate was observed for patients transferred to the private practice system.

Adolescent↗
PubMed2002

Injuries in public and private playgrounds: the relative contribution of structural, equipment and human factors.

UNLABELLED: The aim of this case-control study was to identify and quantify risk factors of injuries in playgrounds, where children spend an increasing amount of time in developed countries. The study took place in Greater Athens during 1999. A continuous Emergency Departments Injury Surveillance System (EDISS) of hospitals that cover about 30% of the children's time at risk in Greater Athens identified 777 injuries in public and private playgrounds out of a total of 17 497 injuries. Public playgrounds differ from private ones, because the former generally have more equipment, usually of greater height, with less resilient surfaces, and supervision relies mainly on parents or guardians. Patterns of type of playground use were assessed in a sample of 294 children from the same study base who served as a control group in a hierarchical case-control design. The annual incidence of playground injuries in Greater Athens was about 7 in 1000 among boys and 4 in 1000 among girls, with a 2.2 times higher risk for an injury in public than in private playgrounds (95% confidence interval 1.61-3.07). Children in public vs private playgrounds had a statistically significant eight times higher odds for concussion and six times higher for open wounds, whereas the odds for long bone fractures were four and for other fractures two; swings, slides and seesaws were the types of equipment most frequently associated with injuries. It was further shown that supervision of children was suboptimal (< 60%) in both public and private playgrounds, and children in private playgrounds sustained an unduly high frequency of sprain/ dislocation injuries (odds ratio 1.75) because they were encouraged to play bare-footed. CONCLUSION: Close to 50% of playground injuries could be prevented by structural and equipment changes, while further reduction could be accomplished through simple measures including closer supervision and encouraging children to wear proper shoes and use protective equipment whenever necessary.

Accident Prevention↗