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PubMed1991

Smoking-attributable mortality, years of potential life lost, and direct health care costs for Puerto Rico, 1983.

The authors report the impact of smoking upon health in Puerto Rico for the year 1983. Using a microcomputer spread-sheet program that calculates smoking-attributable disease impact, they estimated that 2,468 deaths were attributable to smoking. This represented 11.5% of all deaths on the island in 1983 and resulted in approximately 19,445 years of potential life lost (YPLL). It appears that cigarette smoking caused US+55.9 million in direct health care expenditures for Puerto Rico in 1983, an amount equal to 10% of the island's yearly expenditures on health. Calculations such as these demonstrate the enormous disease impact of smoking and may assist policy-makers in planning prevention and intervention activities, both in Puerto Rico and elsewhere in Latin America.

Adolescent↗
PubMed2005

Informal payment for health care: evidence from Hungary.

While there is a growing body of evidence that informal payments for health care are widespread and enduring in the former communist countries of Central and Eastern Europe and Central Asia, evidence on the scale of the phenomenon is not only limited, but what is available is often conflicting. Hungary exemplifies this controversy, as the available literature provides conflicting figures, differing by an order of magnitude among various surveys, with a similarly large difference between survey findings and expert estimates. This study advances understanding of the methodological issues involved in researching informal payments by providing a systematic analysis of the methodology of available empirical research and official statistics on the scale of informal payments in Hungary. The paper explores the potential sources of differences, to assess the scope to reduce the differences between various estimates and to define the upper and lower boundaries within which the true magnitude of informal payments can be expected to lie. Our analysis suggests that in 2001 the overall magnitude of informal payments lay between 16.2 and 50.9 billion HUF (euro 64.8- euro 203.6 million, US dollars 77.1-242.4 million), which amounted to 1.5-4.6% of total health expenditures in Hungary. Looked at this way, informal payments do not seem to be an important source of health care financing. However, as informal payments are unequally distributed among health workers, with the bulk of the money going to physicians, with some not taking any informal payments, family doctors and some specialists may have earned between 60 and 236% of their net official income from this source in 2001. This suggests that it is not the overall amount of informal payment that makes it a policy concern, but the consequences of its unequal distribution among health workers. What is remarkable about informal payments in Hungary is that a relatively small amount of money can keep the system running, which gives rise to the hypothesis that, in certain cases, it is the hope of substantial informal payments in the future that motivates physicians to remain in the system. This is a difficult challenge for policy-makers as it would require a much larger amount of money to achieve equilibrium under any formal alternative.

Delivery of Health Care↗
PubMed1999

Managing external resources in Mozambique: building new aid relationships on shifting sands?

The Mozambican health sector is recovering from war and general disruption. This massive endeavour is supported by several donor agencies, which contribute a substantial proportion of national health expenditure. The final years of the war and the transition period have seen an extreme fragmentation of the health sector. To correct it, serious efforts to coordinate the plethora of aid agencies and related external inputs have taken place. This paper reviews the actors present on the Mozambican health scene and their interactions. The existing aid management mechanisms are described and their effectiveness appraised. The factors affecting both the process and its outcomes are analyzed. Given the prevailing complexity, this research presents a number of tentative conclusions. First, the evidence suggests that coordination efforts have paid off. However, progress has required intense and sustained work. Incremental approaches, where donor demands are progressively raised as the system is strengthened, have been crucial. The initiative has come mainly from donors, with the Ministry of Health receptive and reactive. When the recipient administration has been able to take advantage of donor initiatives, success has ensued. Individual people have been crucial in shaping the process. Critical factors contributing to positive developments on both sides of the donor-recipient relationship have been frankness, risk-taking and a long-term perspective.

Budgets↗
PubMed2003

Healthy life expectancy: comparison of OECD countries in 2001.

OBJECTIVES: To compare average levels of population health for Australia and other OECD countries in 2001. METHODS: Healthy life expectancies (HALE) for OECD countries for 2001 are based on analysis of mortality data for OECD countries, country-specific estimates of health state prevalences for 135 causes from the Global Burden of Disease 2000 study, and an analysis of 34 health surveys in 28 OECD countries, using novel methods to improve the comparability of self-report data. RESULTS: HALE at birth ranges from a low of 59.8 years for Turkey to a high of 73.6 years in Japan in 2001. Australia ranks fourth among OECD countries at 71.6 years with a 95% uncertainty interval of 70.9 to 72.8 years, ahead of New Zealand in 13th place at 70.3 years. The equivalent 'lost' healthy years at birth range from around 10 years in OECD countries with lowest life expectancies to around eight years in those with high life expectancies at birth. There is a statistically significant association between higher levels of health expenditure and higher healthy life expectancy across OECD countries, although causal inferences require more sophisticated analyses of the health system and non-health system determinants of levels of health. CONCLUSIONS: The new methods used in the WHO Multi-Country Household Survey Study have increased the comparability of self-report data across OECD countries, a major step forward in the use of self-reported data on health. Building on this experience, WHO is developing improved health status measurement techniques for a World Health Survey to be carried out in 2002/03.

Aged↗
PubMed2003

Medical costs of fourteen occupational illnesses in the United States in 1999.

OBJECTIVES: This study estimated the annual medical costs associated with 14 occupational illnesses in the United States in 1999. METHODS: National data sets collected by the National Center for Health Statistics, the Health Care Financing Administration, and the Agency for Healthcare Research and Quality were aggregated and analyzed. The cost assessment began with estimates of national health expenditures. These included categories for hospital care, professional services, nursing homes, and medical products, including drugs, administration, public health activities, research and construction. The total disease burden was assessed from estimates of hospital days and number of outpatient visits. The occupational disease burden was assessed by multiplying the total disease burden by a given percentage of the proportionate attributable risk for the disease in question. The occupational burden was then combined with costs for each disease. Adjustments were made for unique inpatient and outpatient costs. RESULTS: In the preferred model, the 14 diseases generated USD 14.5 billion in medical costs in 1999. Roughly USD 10.7 billion was attributed to men and USD 3.8 billion to women. The diseases generating the most costs were as follows: circulatory diseases in the age group 24-64 years (USD 4.7 billion), cancer (USD 4.3 billion), chronic obstructive pulmonary disease (USD 2.2 billion), and asthma (USD 1.5 billion). A sensitivity analysis generated alternative estimates. An upper age limit of 74 years increased the circulatory disease estimate by USD 3.7 billion. The range of the sensitivity analysis was USD 9.6-19.7 billion. CONCLUSION: This study significantly improves over the methodology of previous literature. Our methods were transparent. Occupational illnesses were a major contributor to the total cost of medical care.

Adult↗
PubMed2002

[The French and English health systems: compared evolution after the mid-1990s].

In the recent past, the British and French health care systems have both undergone significant reforms, enveloped in a state of Urgency, resulting primarily in France from the increasing rate of growth in health expenditure and in England from malfunctioning procedures such as waiting lists. After describing current features of the National Health Service (NHS), this study extracts and considers the points of convergence and divergence in the respective policies of the two countries: similarities in the choice of priorities, decentralisation of decision-making, negotiation between actors at the local level, development of the quality concept, and the differences in formulating objectives and involving the system's users. The considerations provided here should allow for a better understanding of the developments of these respective health policies and their future evolution.

Delivery of Health Care↗
PubMed1987

Fiscal conditions and state government policy choices.

Decentralization of public program administration and financing to subnational units of government is examined in the context of hospital and nursing home assistance programs in the United States. Do subnational governments (i.e., states) adapt service utilization controls and tighter program eligibility during periods of fiscal austerity? Are these actions affected by expenditure levels, state budget balances, tax revenues, and the state's proportion of low income persons? Published data covering the period 1978-1982 from each of the 50 U.S. states were analyzed using multiple regression. States with a low proportion of low-income persons and a high per capita tax base were likely to increase minimum income eligibility standards to keep pace with inflation. All other states, regardless of fiscal condition, tended toward more restrictive income standards. States were equally likely to adopt utilization controls for health and long-term care services regardless of state revenue or health expenditures.

Health Policy↗
PubMed2000

Medical progress and rationing of cardiological services.

Due to the financial restrictions imposed on all national health services, the problem of allocating medical resources has gained new economical and political dimensions. Although each patient expects optimal treatment, the rationing of medical services make it increasingly difficult to provide the most adequate therapy. Health politicians and medical doctors have all advocated that health expenditures can be reduced by effective prevention of coronary heart disease, one of the main cost factors for all health services. Due to the introduction of statins, primary and secondary prevention of coronary heart disease can now be accomplished effectively. However, such treatment does not induce cost reduction, but rather an increase in costs. This applies predominantly to primary prevention. Treatment of all who would benefit from lipid lowering by statins would be prohibitively expensive for all national health care systems.

Anticholesteremic Agents↗
PubMed1993

Health care financing for the elderly in Japan.

This paper examines the financing of elderly health care in Japan for medical institutions, nursing homes, and at home. The analysis demonstrates that the conventional figures for elderly health expenditures in Japan systematically underestimate the real costs by excluding the costs of uninsured services, nursing homes, and home health care. The paper estimates these costs and shows that they add about 10% to the conventional figure for elderly health care costs in Japan. This inquiry also shows how government policy for health care financing shaped distinctive Japanese patterns of elderly care provision. The financing system provided a hidden subsidy--through national health insurance coverage of long-term hospitalization--that encouraged high institutionalization rates of elderly in medical facilities. Public financing for long-term elderly hospitalization, however, has not been matched by government attention to quality of care, resulting in serious quality problems and reflecting a social trade-off between cost and quality. Also, until recently the financing system rarely reimbursed home health care, thereby creating strong disincentives to the development of formal home health care services. This analysis has important implications for reforms now being considered by the Japanese government in the financing and provision of health care for the elderly, especially the limitations of relying on reimbursement price policy. The reforms could have unintended negative consequences for equity, efficiency, and quality of care.

Aged↗
PubMed1998

Homelessness: health service use and related costs.

OBJECTIVES: This study examines health service use and costs for homeless and domiciled veterans hospitalized in psychiatric and substance abuse units at Department of Veterans Affairs (VA) medical centers, nationwide. METHODS: A national survey of residential status at the time of admission was conducted on all VA inpatients hospitalized in acute mental health care units on September 30, 1995. Survey data were merged with computerized workload data bases to assess service use and cost during the 6 months before and after the date of discharge from the index hospitalization. RESULTS: Of 9,108 veterans with complete survey data, 1,797 (20%) had been literally homeless at the time of admission, and 1,380 (15%) were doubled up temporarily, for a total homelessness rate of 35%. Combining patients from general psychiatry and substance abuse programs, the average annual cost of care for homeless veterans, after adjusting for other factors, was $27,206; $3,196 (13.3%) higher than the cost of care for domiciled veterans (P < 0.0001). Approximately 26% of annual inpatient VA mental health expenditures ($404 million) are spent on the care of homeless persons. CONCLUSIONS: Homelessness adds substantially to the cost of health care services for persons with mental illness in VA, and most likely, in other "safety net" systems that serve the poor. These high costs, along with the prospect of declining public funding for health and social welfare programs, and an anticipated increase in the numbers of homeless mentally ill persons, portend a difficult time ahead for both homeless patients and the organizations that care for them.

Adult↗
PubMed2005

[Computerization and the importance of information in health system, as in health care resources registry].

The possibilities of creating a health care resources registry and its operating in Croatia as well as the importance of information in health system are described. At the Croatian Institute of Public Health, monitoring of human resources is performed through the national Health Workers Registry. It also covers basic data on all health units, bed capacities of health facilities included. The initiated health care computerization has urged the idea of forming one more database on physical resources, i.e. on registered medical devices and equipment, more complete. Linking these databases on health resources would produce a single Health Care Resources Registry. The concept views Health Care Resources Registry as part of the overall health information system with centralized information on the health system. The planned development of segments of a single health information system is based on the implementation of the accepted international standards and common network services. Network services that are based on verified Internet technologies are used within a safe, reliable and closed health computer network, which makes up the health intranet (WAN--Wide Area Network). The resource registry is a software solution based on the relational database that monitors history, thus permitting the data collected over a longer period to be analyzed. Such a solution assumes the existence of a directory service, which would replace the current independent software for the Health Workers Registry. In the Health Care Resources Registry, the basic data set encompasses data objects and attributes from the directory service. The directory service is compatible with the LDAP protocol (Lightweight Directory Access Protocol), providing services uniformly to the current records on human and physical resources. Through the storage of attributes defined according to the HL7 (Health Level Seven) standard, directory service is accessible to all applications of the health information system. Directory service does not follow the history of attribute changes, and is optimized for a large number of authorizing inquiries. With it, one follows the following objects and attributes: persons, groups of people (patients, physicians, other personnel), roles (right of access and administrator permissions), organizational units, unit locations, devices and services (according to the list of services and procedures). One can add to the Health Care Resource Registry such attributes as are nonessential for inclusion in the directory service, but are of public health value. Authentication, authorization and digital signature are done by means of Smart Cards, which are used as protective elements against access to system functions, and simultaneously as a physical medium for the storage of the official certificate with which documents are signed digitally. As FINA (state financial control agency) has completed a system for certificate issuance and verification, the option of official digital signature is also available as a computer network service. Any changes taking place in the directory service are transferred by XML messages to a separate part of the Registry that reads them and automatically modifies records in the relational database. Because data input and data changes are made in health units, this makes the data updated and directly connected with health working operations. This avoids all one-time data collection campaigns using form filling about the devices and equipment in the future. As it is very difficult to monitor from a central standpoint how accurate and update the information is, it is necessary to delegate the permissions and duties associated with making changes to the directory service. By this organizational setup, the time needed to ensure data quality control is reduced. In the case described, the Health Care Resource Registry becomes an indicator of change, acquiring certain characteristics of an analytical system. An analysis of topical data renders possible proactive action and makes more effective the planning and utilization of available resources. Providing answers on the current data quickly could also be important to solution-seeking in emergencies. The present proposal to establish the Registry is intended to facilitate the future process of planning and striking a balance between investments in human and physical resources. For health expenditure control, having reliable information related to the use and purchase of new medical technology is particularly important. World Health Organization and European Union have also emphasized the need to develop new indicators in this area.

Croatia↗
PubMed1993

The health status of women in the world-system.

The health status of women is examined within the context of a global political economy. The authors present a beginning attempt to model some key macrolevel processes linked to the health of women. In particular, a structural modeling technique known as LVPLS (or "soft modeling") is used to empirically test one recent formulation of world-system theory. The findings give added emphasis to the importance of the larger economic forces that affect women's health.

Economics↗
PubMed1987

Methods for developing relative need criteria to accompany a health care capital expenditure limit.

In recent years capital spending in the health care industry has escalated tremendously, and most forecasters agree that needs will increase at an even faster rate throughout the 1990s. As a result of this trend, there is a dire need to develop effective and equitable controls on capital spending in health care. One of the capital payment options under consideration is the establishment of a lid on capital expenditures and the concomitant allocation of capital to health care providers whose applications are the most meritorious. The purpose of this article is to present some ideas and methods for the development of a relative need system to accompany a capital expenditure limit and to supplement and expand the absolute need determinations of the typical CON process.

Capital Expenditures↗
PubMedDate not supplied

Health care costs and financing in world perspective.

Expenditures for health services, as a percentage of national wealth (gross national product, or GNP), have been rising throughout the world. Data to quantify this trend are available for many industrialized countries. The share of health spending derived from governmental sources has also been increasing. Mandatory or social insurance has developed to support health services in 70 nations. While widely used for paying doctors on a fee basis or by capitation, in Latin America doctors are organized in polyclinics and paid by salaries. General revenues are used to support Ministry of Health programs. Among health expenditures, the largest share goes to hospitalization. Cost sharing by patients is widely used to control rising costs. World trends have promoted equity in health care delivery.

Cost Control↗
PubMed1996

From universalism to selectivity: is 'appropriateness' the answer?

As health expenditures continue to consume increasingly large proportions of national budgets, ways must be found to assure that money spent on health is used for effective services. Only a small proportion of medical decisions are based on scientific evidence about their outcomes, thus it is not surprising that wide variations exist in clinical practice. In recent years, questions have been raised about how medical decisions are made and the proportion of medical procedures and services that are performed for appropriate reasons. One method that has been developed to quantify the amount of inappropriate use is the so-called 'RAND appropriateness method,' which is based on a structured review of the scientific literature and the collective judgement of an expert panel. Measured by this method, a number of procedures have been shown to have high rates of inappropriate or uncertain use. The challenge is to find ways to eliminate ineffective services and procedures to free resources for those that have been proven effective. Further research is needed to improve the method and to find acceptable ways its findings can be used to promote effective care.

Adult↗
PubMed1995

No insurance, public insurance, and private insurance: do these options contribute to differences in general health?

This paper examines the validity of two of the basic assumptions made about health care insurance and health, namely that having any insurance is associated with better health and, in particular, that having public, welfare-based insurance has better health consequences for the poor than does having no insurance. These questions were addressed using data from the National Medical Expenditure Survey, a national household-based survey in 1987 of more than 36,000 people who were asked to report in detail about their medical care use and expenditures, health insurance coverage, and health and functional status. The results of the analysis indicate that being without insurance is associated with having poorer general health compared to persons with private insurance, and that the health of persons who qualify for public insurance is the poorest of any group--poorer even than those without insurance.

Adolescent↗