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PubMed2001

Reforming the Israeli health system: findings of a 3-year evaluation.

Israel, like many other European countries, has recently reformed its health care system. The regulated market created by the National Health Insurance (NHI) law embodies many of the principles of managed competition. The purpose of this paper is to present initial findings from an evaluation of the first 3 years of the reform (1995-1997) regarding the implementation of the reform and the extent to which it has achieved its main goals. The evaluation was conducted using multiple quantitative and qualitative research tools: interviews with key informants; analysis of documents and sick fund financial statements; analysis of trends in sick fund membership; and population surveys conducted in 1995 and 1997 to assess the impact of the reform on outcome measures related to level of services to the public. Data from the evaluation show that the NHI law achieved a considerable number of its goals: to provide insurance coverage for the entire population, to ensure freedom of movement among sick funds, and to standardize the way resources are allocated to sick funds. The incentives that are embodied in the law have encouraged the sick funds to improve the level of services provided to the average insuree, and to develop services in the periphery and for some of the weaker populations. From the financial perspective, concerns that NHI would lead to a rise in the national health expenditure were not realized as of 1997. In the wake of NHI, there has been a decline in the age adjusted per capita expenditure in three sick funds, with no reports by insurees, at least through 1997, on a decline in satisfaction or level of service. However, the Israeli experience shows that regulating competition does not necessarily lead to economic stability and equality. Regulating the competition also did not solve some of the major policy issues in the Israeli health system including level of resources allocated to health, organizational structure of the hospital system, manpower planning and the extent of government involvement in system. Additional policy changes may be needed to resolve these issues. Up-to-date information is essential in helping policymakers track the process of reform implementation and results, and identify problems which need to be addressed in the future.

Consumer Behavior↗
PubMed2002

Why is less money spent on health care for the elderly than for the rest of the population? Health care rationing in German hospitals.

The consequences of population ageing for the public health care system and health care costs may be less severe than is commonly assumed. Hospital discharge data from Germany's largest health insurer (AOK) show that the cost of caring for patients during their last year of life makes up a large part of total health expenditures. And this last year of life is less costly if patients die at an advanced age. As a multivariate analysis reveals, oldest old patients as a rule receive less costly treatment than younger patients for the same illness. Moreover, this pattern is more pronounced for elderly women than for elderly men. These findings suggest that health care is informally rationed according to the age and sex of the patient. The data also indicate that there may be more age-related rationing going on in Germany than in the United States. Future research should investigate the national, institutional, and individual factors behind health care rationing. In this paper, I discuss the physician's professional decision as one plausible determinant.

Adult↗
PubMed1993

Effect of value-added utilities on prescription refill compliance and Medicaid health care expenditures--a study of patients with non-insulin-dependent diabetes mellitus.

An estimated 20 million Americans suffer from diabetes. Patients with non-insulin-dependent diabetes mellitus (NIDDM) comprise approximately 90% of the diabetic population. An estimated 10-30% of patients with NIDDM withdraw from their prescribed regimen within 1 year of diagnosis, and of the remainder, nearly 20% administer insufficient medication to facilitate an adequate reduction in blood glucose. A randomized trial was undertaken to discern the effect of pharmacy-based value-added utilities on prescription-refill compliance with sulfonylurea therapy and health service utilization. The subjects were 258 Medicaid beneficiaries from the state of South Carolina, previously untreated for NIDDM, prescribed 5 mg of the second-generation sulfonylurea glyburide twice daily, and monitored with regard to prescription-refill compliance and health service utilization for 1 year. Subjects provided informed consent and were randomly assigned to one of four experimental groups: (i) the control cohort received standard pharmaceutical care with each dispensing of glyburide; (ii) the second cohort received standard pharmaceutical care and was mailed a medication-refill reminder 10 days prior to each sequential refill date; (iii) the third cohort received standard pharmaceutical care and was provided unit-of-use packaging with each prescription-refill request; (iv) the fourth cohort received standard pharmaceutical care, mailed medication-refill reminders, and unit-of-use packaging. Analysis of variance (ANOVA) procedures revealed that patients receiving mailed prescription-refill reminders, unit-of-use packaging, or a combination of both interventions achieved a significant (P < or = 0.05) increase in the Medication Possession Ratio (MPR) for sulfonylurea therapy relative to controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Diabetes Mellitus, Type 2↗
PubMed1994

Federal and nationwide intensive care units and healthcare costs: 1986-1992.

OBJECTIVES: To establish Department of Veterans Affairs' intensive care unit (ICU) costs from a database and to use this information to validate the Russell equation, the most commonly used method of calculating ICU costs. To compare and trend Department of Veterans Affairs' and nationwide (USA) ICU and healthcare costs. DESIGN: Comparison study. SETTING: Database analysis of Department of Veterans Affairs' and nationwide ICUs over a 6-yr period (1986-1992), with biennial evaluations. MAIN MEASURES: Costs and bed occupancies of Department of Veterans Affairs' and nationwide hospitals and ICUs, as well as United States national health expenditures and gross domestic product. RESULTS: Fifty percent to Department of Veterans Affairs' ICU funds were used for nurse and physician salaries. Department of Veterans Affairs' ICU direct and indirect cost ratios have remained constant (2:1). The Russell equation is valid, providing that the "inpatient only" cost variable is used. ICU costs were consistently lower in the Department of Veterans Affairs' than nationwide, as compared by the Russell equation. A smaller fraction of the hospital budget was allocated to the ICU in the Department of Veterans Affairs than in nationwide institutions. Despite an increasing nationwide ICU patient workload, the percentage of ICU fund allocations has not increased. Health care in the United States increases at a rate greater than the increase in gross domestic product. Healthcare delivery costs are increasing at a greater rate nationwide than in the Department of Veterans Affairs. The percentage increase in ICU cost per day, both in the Department of Veterans Affairs and nationwide, was less than the increase in healthcare costs. The percent of the gross domestic product, national health expenditure, and hospital cost used by the ICU has increased minimally during the course of this study. CONCLUSIONS: The Department of Veterans Affairs has the only national ICU line item cost database available. For the Russell equation calculation to be accurate, inpatient only costs should be used. Until customized Health Care Financing Administration analyses become available, nationwide ICU costs are best determined by the Russell equation. Department of Veterans Affairs' ICUs have a consistent cost advantage over nationwide ICUs. Increases in United States healthcare delivery costs continue to exceed the increase in gross domestic product. Cost containment is already occurring in critical care.

Bed Occupancy↗
PubMed1997

Primary care and health reform in New Zealand.

AIMS: (1) To describe New Zealand's primary care system (2) to compare New Zealand to other Anglo-American members of the OECD with respect to the adequacy of primary care, and (3) to assess the cost-efficiency and effectiveness of New Zealand's system by comparing health spending and health indicators relevant to primary care. METHOD: A cross-national comparison of primary care, health spending and health indicators in New Zealand, Australia, Canada, the United Kingdom and the United States of America. Main outcome measures were health spending measured in purchasing power parties. Health indicators: mean life expectancy in years, years of potential life lost and infant mortality rates. RESULTS: New Zealand's primary care system ranked below the UK, above the USA and similar to Canada and Australia. Favourable characteristics of New Zealand's primary care system were the use of generalists as the predominant type of practitioner and the low proportion of active physicians who were specialists. Compared to the other countries, New Zealand scored poorly for financial that are necessary for the practise of good primary care. New Zealand and the UK had the lowest spending per capita on health care. New Zealand and the USA scored lowest for all three of the health care indicators. CONCLUSIONS: The quality of primary care in New Zealand is limited by barriers to access to care and the intermediate level of practise characteristics essential to primary care. Compared to other AngloAmerican OECD nations, New Zealand has relatively low levels of national health expenditure. In order to improve the quality of primary care, future reform should aim to facilitate access to care, increase the gatekeeping role of primary care physicians, and promote the practise characteristics essential to primary care.

Australia↗
PubMedDate not supplied

Economic consequences of comorbid depression, anxiety, and allergic rhinitis.

The present study extends prior work on the association between allergic rhinitis (AR) and common mental disorders by testing three related hypotheses: 1) that AR is associated with increased rates of depression and anxiety disorders in a large insured population, 2) comorbid AR, depression, and anxiety are associated with increased health and mental health expenditures, and 3) allergy treatment moderates the association between increased expenditures and comorbid AR, depression, and anxiety. Data are from MARKETSCAN, a large health care claims database of over 600,000 privately insured persons. Results indicate that AR is associated with higher rates of depression and anxiety disorder. Outpatient health care expenditures were increased by an average annual amount of $207 when AR and anxiety disorder were comorbid and $363 when AR and depression were comorbid. Finally, prescription treatment of AR moderated the increased expenditures associated with comorbidity.

Adolescent↗
PubMed2005

A national profile of health care utilization and expenditures for children with special health care needs.

OBJECTIVES: To provide the first nationally representative data on total health care expenses, out-of-pocket health care expenses, and information on the extent to which out-of-pocket expenses are financially burdensome for families of children with special health care needs (CSHCN). To also compare utilization and expenditure patterns for children with and without special health care needs. DESIGN: We used data from the 2000 Medical Expenditure Panel Survey (MEPS). We present univariate, bivariate, and multivariate statistics on utilization and expenditures adjusted for the complex sample design. PARTICIPANTS: The 2000 MEPS data set contains 6965 children younger than 18 years. Using the CSHCN definition adopted by the federal Maternal and Child Health Bureau and operationalized using the CSHCN Screener, 949 children (15.6%) were identified as children with special health care needs. MAIN OUTCOME MEASURES: Compared with other children, CSHCN had 3 times higher health care expenditures (2099 dollars vs 628 dollars; P<.01). The 15.6% of CSHCN accounted for 42.1% of total medical care costs (excluding dental costs) and 33.6% of total health care costs (including dental costs) attributed to children in 2000. Families of CSHCN were best protected against inpatient hospital care expenses and most exposed to dental care expenses. Families of CSHCN experiencing high out-of-pocket expenses (exceeding 5% of family income) were approximately 11 times more likely to be from households with incomes below 200% of the federal poverty level (odds ratio, 10.9; 95% confidence interval, 3.55-33.76) than to be from families with incomes at or above 400% of the federal poverty level. CONCLUSIONS: Families with CSHCN experience much higher expenditures, including out-of-pocket expenditures, than other children. Insurance plays an important protective role for families of CSHCN, but it still provides incomplete protection. Health policy changes that would extend the breadth and depth of insurance coverage are needed to ensure that all families of CSHCN are protected against burdensome expenses.

Adolescent↗
PubMed1993

Implications of a global budget for facility-based health spending.

This paper compares the five-year forecast growth in hospital, nursing facility, and home health expenditures to the growth that would result if three alternative global budget targets were met. Implementing a global budget offers the potential for substantial savings, but achieving this potential would be difficult. Except in the hospital inpatient sector, it would be nearly impossible to meet a target based on growth in gross domestic product without finding a way to curtail the current trend of volume increases. We believe it also would be necessary to reduce the gap between economywide inflation and inflation in the prices of goods and services that health facilities buy.

Budgets↗
PubMed1988

Current policy issues in the Irish Health Services.

The article provides a general outline of current policy issues in the Irish health services. Referring to a demographic and epidemiological background and taking into account the recent trends in health expenditure, the author deals with six main issues: selection and clarification of objectives, funding, resource allocation, organisation, managing for change, the public/private mix. Comparing Ireland to other European countries, the author concludes that, because of limited resources, Ireland must be clearer and cleverer. The meeting of the expectations of the population will continue to provide a stirring challenge.

Demography↗
PubMed2003

The impact of Medicare home health policy changes on Medicare beneficiaries.

This brief presents results from an analysis of how a new payment system -- the Interim Payment System (IPS) - mandated by the 1997 Balanced Budget Act (BBA) affected Medicare home health service use and beneficiary outcomes. The study found that the IPS had a considerable impact on home health utilization, causing reductions in the overall proportion of Medicare beneficiaries who received the service; the number of home health visits per home health user; the average length of a home health episode of care; and overall Medicare home health expenditures. The study also examined the impact of these reductions on outcomes experienced by Medicare beneficiaries. Evidence presented in this brief shows that, overall, the impact of the IPS on beneficiary outcomes was minimal. Moreover, it appears that service reductions did not cause significant increases in the use of other types of post-acute care.

Budgets↗
PubMed1989

Adjusting employer group capitation premiums by Community Rating by class factors.

Community rating of employer group health maintenance organization (HMO) capitation premiums results in low premiums for some groups and high premiums for other groups, as compared with the marginal costs of providing services. In effect, low health risk groups are cross subsidizing high health-risk groups in an HMO. This has caused several inefficiencies in the health plan marketplace, which have directly benefited higher-risk groups. For this reason, certain low-risk groups are searching for new strategies to improve market efficiency. One strategy is Community Rating by Class (CRC), a system which adjusts community rated capitation premiums by broad-based risk factors. This article examines CRC as a strategy to help reduce the inefficiencies caused by current federal regulations. In regressions predicting future year total family health expenditures, the CRC Model achieved an R2 value of 0.211. This value was over half the R2 value of an experience rated approach, based on prior year utilization and expenditure variables. Family size accounted for 80% of the variance explained by the CRC Model. The results indicate that the CRC rating approach may be a good mechanism to correct for cross subsidization of employer group capitation premiums.

Adolescent↗
PubMed1997

[Screening for prostatic carcinoma in dysuric patients: diagnostic protocols and cost-benefit analysis].

This work deals with our experience of a programme of early diagnosis of prostate cancer carried out on patients suffering from dysuria through rectal-digital examination (EDR), hematic dosage of PSA (IRMA COAT-A-COUNT DPC) and transrectal echtomography. We have also quantified the costs and verified which methods, either single or combined with other methods, are most advantageous as regards costs/benefits. From Jan 1991 to Jan 1995 306 of 1185 patients (25.8%) underwent prostate biopsy by means of transperineal echograph with gauge 18 needles as in Hodge's technique. Histologic examination revealed prostate adenocarcinoma in 81 (26.5%) cases, benign prostate hypertrophy in 196 (64%), acute and/or chronic phlogosis in 26 (8.5%) and granulomatosic prostatitis in 3 (1%). The diagnostic sensitivity, preciseness and accuracy were, respectively, 92.5%, 78.3%, 79.3% for the EDR, 80.2%, 93.3% and 90% for PSA with cut-off 10 ng/ml, 91% 78.3%, and 90% for the PSA with cut-off 4 ng/ml, 100%, 30.3% and 48.6% for the echograph, 98.8%, 60% and 77% for EDR+PSA (cut-off 4 ng/ml), 98.8%, 65.8 and 79.9% for EDR+PSA (cut-off 10 ng/ml), 100%, 22% and 64.2% for EDR+echograph, 100%, 20% and 62.9% for echograph+PSA (cut-off 4 ng/ml), 100%, 26.6% and 64.9% for echograph+PSA (cut-off 10 ng/ml). We calculated that a programme of early diagnosis using the three methods, if completely at the patient's expense, would cost 207.000-437.000 lire (average 322.000) per patient for a total of 245,295,000-517,845,000 (average 381,570,000). An eco-guided prostate biopsy with a histologic examination would cost 250.000-500.000 lire (average 375.000) per patient with a total cost for 306 patients of 76,500,000-153,000,000 (average 114,750,000). We also quantified, in the light of the results reported here, the number of biopsied which would have been necessary if we had used only two methods in the screening and we also estimated the costs. The results reveal that the echograph is not to be considered as a first approach method as it gives a high number of false positive results; in fact if we had excluded it from the screening we would not have ignored any diagnosis of prostate neoplasia and we would have avoided about 141 (46.2%) biopsied with a reduction in health expenditure of 62.1%. On the contrary the EDR and the PSA have a better cost/benefit result: setting the cut-off of the PSA at 4 ng/ml or at 10 ng/ml without varying the diagnostic accuracy, the sensitivity and/or specificity of the method increase respectively. To conclude, we consider the EDR and the serum dosage of PSA necessary and adequate methods in the programme of early diagnosis and screening of prostate neoplasy. The prostate echography should be reserved for cases of doubt (hematic PSA between 4-10 ng/ml etc.) and for the exclusion of needle biopsy. These measures also result in an optimization of health expenditure.

Adult↗
PubMed2002

The prospects for reform of the Japanese healthcare system.

It is widely recognised that the Japanese healthcare system has been ranked as one of the best in the world because of its excellent efficiency and equity. The longevity and low infant mortality of the Japanese population have been achieved with a relatively low ratio of health expenditure to gross domestic product. All Japanese are covered by universal medical care insurance and all are provided with completely free access to the same medical care. Nevertheless, it should be pointed out that the medical care service is not as good as it looks. Owing to lack of competition between both hospitals and powerless insurers - the outcome of too many regulations - there is only a small incentive to improve the efficiency and quality of medical service. Furthermore, because of Japan's rapidly aging society and low birth rate, together with the long depression the economy has experienced, it is very difficult to maintain the 'pay-as-you-go' health system. For health system reform, our proposals are as follows: deregulating health markets, including pharmaceutical markets; strengthening the role of insurers; introducing information technology; and restructuring the healthcare of the elderly. We are expecting the new cabinet, which enjoys much popularity, to have the courage to initiate health reform along these lines, in spite of opposition from powerful interest groups, bureaucrats, and even members of ruling parties.

Aged↗
PubMed1999

Future directions for the national health accounts.

Over the past 15 years, the Health Care Financing Administration (HCFA) has engaged in ongoing efforts to improve the methodology and data collection processes used to develop the national health accounts (NHA) estimates of national health expenditures (NHE). In March 1998, HCFA initiated a third conference to explore possible improvements or useful extensions to the current NHA projects. This article summarizes the issues discussed at the conference, provides an overview of three commissioned papers on future directions for the NHA that were presented, and summarizes suggestions made by participants regarding future directions for the accounts.

Accounting↗
PubMedDate not supplied

The financial burden of malaria in Tanzania: implications for future government policy.

Malaria is the cause of more mortality and morbidity in Tanzania than any other disease, in large part due to growing resistance to anti-malarial drugs. This study estimates that over 1% of GDP is devoted to the disease, representing US$2.2 per capita, and 39% of total health expenditure nationally. Government facilities devote almost one-third of their resources to the disease. Private expenditure, primarily on drugs, coils, sprays and bed-nets, represents 71% of total expenditures. Given the dominance of malaria treatment outside Government facilities, strategies to control behaviour in the private sector are critical. Together with regulations on private providers, and other interventions such as promoting the use of bed-nets in rural areas, greater research into and use of information strategies is required. Public policies should be designed to influence behaviour, to encourage households to seek adequate diagnosis of fever and to complete appropriate treatment with the right drugs.

Cost of Illness↗
PubMed1998

Is public health between East and West? Analysis of wealth, health and mortality in Austria, Central and Eastern European Countries and Croatia relative to the European Union.

AIM: To provide a conceptual framework for health planning activities in the "middle income" transition countries. METHOD: Economic, demographic, and disease-related data in Central and Eastern European (CEE) countries, including Croatia and Austria, were compared to the Europen Union (EU) average. Data were selected from the databases provided by the World Health Organization, Organization for Economic Cooperation and Development, World Bank, United Nations, and the European Bank of Reconstruction and Development. Life expectancy and mortality were extrapolated until the year 2000 by using an exponential growth model for the WHO time series data, starting in 1994. Death rates due to ischemic heart diseases (18%) and cerebrovascular diseases (13%) were selected to show frequent causes of death. RESULTS: Relative to the EU average, the gross domestic product (GDP) share of health expenditures in transition countries was disproportionate to wealth and premature death. The population in CEE-countries was younger and the share of people aged >65 was predicted to remain about 15% below the EU average and Austria. For Croatia, the share of people aged 65 would be on the increase, similar to the share predicted for Austria (slightly above the EU average). Mortality of selected non-communicable, chronic diseases is predicted to increase and remain relatively high. Mortality rates due to infectious diseases have been declining but remained comparatively on a high level. CONCLUSIONS: Coexistence of demographic and epidemiological transition along with high mortality rates due to infectious diseases creates a "double burden". Economic transition has the potential to comprise both the increase in wealth, and life and health expectancy.

Aged↗
PubMed2004

Reducing health care costs by rationalizing staffing in primary care settings.

Jordan spends around 9% of its GDP on health care services, a high figure compared with similar developing countries. This study assessed staffing patterns in relation to Ministry of Health expenditures in a nationally representative sample of 97 primary care facilities. The economic costs of primary care facilities amounted to Jordanian dinar (JD) 42.3 million. Personnel costs consumed 53.8% of recurrent costs and in monetary terms the amount of down time (time not being used effectively) amounted to JD 9.7 million (about US$ 13.7 million). The Ministry should consider changing the functioning of its primary care facilities to obtain a more cost-effective use of staff time.

Cost Control↗
PubMed2002

Social risk management options for medical care in Indonesia.

This paper investigates the extent to which price subsidies for medical care are a suitable instrument to reduce household's exposure to catastrophic financial risks associated with ill-health in Indonesia. Using the 1995 SUSENAS household survey, the observed distribution of user fees and health expenditures is used to derive a distribution of 'needed' medical expenditures. The trade-off between the tax burden and effectiveness in reducing the exposure to catastrophic risk is analyzed for two existing price regimes along with a number of hypothetical regimes. We find that the existing regimes significantly reduce the exposure to catastrophic shocks but do not eliminate them. Simulations suggest that further reductions could be achieved if a larger proportion of government subsidies were directed to inpatient care. Subsidizing outpatient treatment is a cost effective policy to reduce exposure to catastrophic risks only for the very poor.

Adult↗