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PubMed1999

Rural health prepayment schemes in China: towards a more active role for government.

A large majority of China's rural population were members of health prepayment schemes in the 1970's. Most of these schemes collapsed during the transition to a market economy. Some localities subsequently reestablished schemes. In early 1997 a new government policy identified health prepayment as a major potential source of rural health finance. This paper draws on the experience of existing schemes to explore how government can support implementation of this policy. The decision to support the establishment of health prepayment schemes is part of the government's effort to establish new sources of finance for social services. It believes that individuals are more likely to accept voluntary contributions to a prepayment scheme than tax increases. The voluntary nature of the contributions limits the possibilities for risk-sharing and redistribution between rich and poor. This underlines the need for the government to fund a substantial share of health expenditure out of general revenues, particularly in poor localities. The paper notes that many successful prepayment schemes depend on close supervision by local political leaders. It argues that the national programme will have to translate these measures into a regulatory system which defines the responsibilities of scheme management bodies and local governments. A number of prepayment schemes have collapsed because members did not feel they got value for money. Local health bureaux will have to cooperate with prepayment schemes to ensure that health facilities provide good quality services at a reasonable cost. Users' representatives can also monitor performance. The paper concludes that government needs to clarify the relationship between health prepayment schemes and other actors in rural localities in order to increase the chance that schemes will become a major source rural health finance.

China↗
PubMedDate not supplied

Can life expectancies be used to determine if health promotion works?

PURPOSE: The goal of this study was to develop a method to measure the impact and cost-effectiveness of health promotion. DESIGN: Age- and sex-specific changes in life expectancy in Canada between 1970 to 1972 and 1985 to 1987, after the introduction of national health insurance (1970) and health promotion (1975), are used to assess the impact due to biological hardiness, improvements in the health care field, and the effects of health promotion. SUBJECTS: The subjects were the total male and female population of Canada between the years 1970 to 1972 and 1985 to 1987. MEASURES: Life expectancy by years of age by sex was the measurement used. RESULTS: A method is presented that allows the calculation of the differential effects of health promotion, health care, and biological hardiness on changes in life expectancy based on sequential subtraction of life expectancies for one-year age cohorts over a 15-year period. Results were obtained for each year of age for men and women, showing gender and age differences in the relative impact of the three factors. In this illustrative example using Canadian data, health promotion was found to have less impact on longevity than health care or biological hardiness. However, of the three, health promotion was the most cost-effective. CONCLUSION: This method can be used to quantify changes in life span due to health promotion, health care, and biological hardiness for men and women at each year of age and to relate this to health expenditures for the whole population. The method is limited in that it cannot determine the relative impact of other factors that can affect life expectancy such as environmental changes or social trends.

Age Factors↗
PubMed1994

Home care: the next frontier of pediatric practice.

An overview of pediatric home care issues reveals the breadth and scope of services available to permit pediatricians to provide care at home. This care option has undergone explosive growth and represents one of the fastest-growing health expenditures. Paradoxically, direct physician involvement in the home has been limited during this expansion because of the way home care has been designed and organized with inadequate reimbursement for physician participation, and lack of awareness by, and education of, physicians concerning their roles and responsibilities. The rationale for physician involvement in home care includes the need for determination and reevaluation of the medical necessity of home care services. Future changes in health care delivery and payment will encourage even more consideration of alternative care sites. Physician participation in program and protocol design will facilitate and encourage the appropriate use of the home as a care setting. For the pediatrician to know about home care requires the development of a curriculum to be implemented in academic centers for physicians-in-training and in professional associations for continuing medical education. This curriculum should enable physicians to become primary participants in home care and should lead to research opportunities to evaluate the benefits of home care.

Child↗
PubMed1991

The consumer: silent or intimate player in the quality revolution.

Nurses are an agency's frontline representative; their centrality to the development of realistic and positive perceptions of care received must be acknowledged by the agency's management staff. Nurses must be recognized, not just as employees, but as entrepreneurs selling a product; the product of nursing care is a satisfied client with positive outcomes. The satisfied client is a major "marketer" for the health care facility and nursing services. It has been reported that satisfied customers will relate their satisfaction to four or five other people; dissatisfied customers will elaborate their dissatisfaction to 9 or 10 other people. As public policy on health care resource allocation is drafted, clients and third-party payors must collaborate with providers. Because public consumption will provide the principal advantage in the competitive health care industry, decisions regarding quality, cost, and access must be based on a national database of information (in universally understandable language), including an analysis of nursing and medical interventions, health outcomes, and health expenditures. The new paradigm shift toward total quality management recognizes that quality is no longer simply an attribute of a product or service; it also measures a relationship. A balanced relationship, reflecting trust between nurses, employers, underwriters, physicians, and the client, allows every player to define quality dimensions, make judgments, and contribute to the quality of care delivered and received. The consumer must be an intimate player in this scenario, or the health care system will continue to falter.

Consumer Behavior↗
PubMed2002

[What explains the growth of national insurance expenditure for primary health care?].

BACKGROUND: Fee-for-item payments are the main source of remuneration for primary care physicians in Norway. Physicians receive a major part of these payments from the National Insurance Administration. The present study describes the development in the National Insurance Administration expenditure for primary physician services in Norway from 1990 to 2000. MATERIAL AND METHODS: The analyses were performed on accounting data from the National Insurance Administration and data on the number of physician per 10,000 population from Statistics Norway. RESULTS: From 1990 to 2000, expenditure increased by 84%, from NOK 863.8 million to NOK 1.58 billion. Our main finding is that a substantial part of this increase can be explained by increases in the number of primary care physicians, population size, and the level of fees. INTERPRETATION: One interpretation of our findings is that National Insurance Administration expenditure on primary physician services to some extent can be controlled by regulating the number of physicians practicing with reimbursement from the National Insurance Administration and the level of fees.

Fee-for-Service Plans↗
PubMed2006

Methodological issues for the information model of a knowledge-based telehealthcare system for nephrology (Nefrotel).

Several studies point out the paradox that classic telemedicine by which doctor interacts remotely with patients in real-time is disappearing despite it has not been widely adopted yet. Many cues indicate that health information technologies will be finally adopted because of the growth in health expenditure and the emerging healthcare challenges. Notwithstanding, a detailed analysis of the referred concern has led us to propose a shift in the paradigm of telemedicine systems. This paper presents the major methodological issues of the information model of a novel telehealthcare system for nephrology (Nefrotel) which supports the cited shift in the paradigm. With this objective, we first revise the technological requirements of the database of Nefrotel, and second analyze the current scenario of health information model standards. Our study has shown that it is possible to ensure the compliance and evolution of Nefrotel with information model standards, maximizing its interoperability.

Computer Communication Networks↗
PubMed2000

A note on risk adjustment and fair compensation.

This note comments on the application of results from the theory of fair compensation to risk adjustment. It argues that the main flaw of such application lies in the consideration of health plans merely as administrative social agents, through which money flows from a central fund to providers of medical care, ignoring their economic behaviour. However, it is that behaviour which raises the issue of risk selection to begin with. With linear health expenditure function, the fair compensation axiomatic solution is shown to be equivalent to the solution of a simple optimal regulation problem. That equivalence permits the analysis of several further issues related to risk adjustment and to the application of the theory of fair compensation to it.

Cost Control↗
PubMed1991

Medicare: the Canadian experience.

In the 1940s Canada and the United States had similar lack of structure and reimbursement for diagnostic, hospital, and physician services. In Canada over the next 40 years there evolved a complex system mandated and partially funded by the federal government, but administered and delivered through 10 provincial and 2 territorial jurisdictions. Each must negotiate with federal government on cost sharing and deal with hospital budgets and physician compensation at the provincial or territorial level. The Medical Care Act of 1966 enshrined in law the five principles of public administration, universality, comprehensiveness, portability, and accessibility, converting all medical services in Canada from a privilege to a right. Any patient participation in hospital or physician charges came under increasing political attack. In 1984 the Canada Health Act specified financial penalties in federal transfer payments to provinces that permitted any direct patient charges. While Canada has "contained" health expenditures at 8.7% of gross national product, universal access to quality care is increasingly subject to rationing. The relationship between the profession and governments hard pressed to fund escalating costs in a deteriorating economy has been one of increasingly bitter confrontations. There have been four acrimonious doctors' strikes. More optimistically, there is now an emerging recognition of society's need to have physicians actively participating with other providers and governments to create a balance between access to quality health services and both public and private funding.

Canada↗
PubMed2003

Determinants of child mortality in LDCs: empirical findings from demographic and health surveys.

Empirical studies on child mortality at the disaggregated level-by social-economic group or geographic location-are more informative for designing health polices. Using Demographic and Health Survey data from over 60 low-income countries, this study (1) presents global patterns of the level and inequality in child mortality and (2) investigates the determinants of child mortality, both at the national level and separately for urban and rural areas. The global patterns of health outcomes reveal two interesting observations. First, as child mortality declines, the gap in mortality between the poor and the better-off widens. Second, while child mortality in rural areas is substantially higher than in urban areas, the reduction in child mortality is much slower in rural areas where the poor are concentrated. This suggests that health interventions implemented in the past decade may not have been as effective as intended in reaching the poor. The analysis on mortality determination shows that at the national level access to electricity, incomes, vaccination in the first year of birth, and public health expenditure significantly reduce child mortality. The electricity effect is large and independent of the income effect. While in urban areas, access to electricity is the only significant mortality determinant, in rural areas, vaccination in the first year of birth is the only significant factor.

Child, Preschool↗
PubMed2003

A randomised controlled trial to assess the impact of a package comprising a patient-orientated, evidence-based self-help guidebook and patient-centred consultations on disease management and satisfaction in inflammatory bowel disease.

OBJECTIVES: To determine if a whole systems approach to self-management improves clinical outcomes and leads to cost-effective use of NHS services. DESIGN: Nineteen hospitals were randomised to 10 control sites and nine intervention sites. Consultants from intervention sites received training in patient-centred care before recruitment and introduced the intervention to eligible patients. Patients at the control sites were recruited and went on to have an ordinary consultation. Qualitative interviews were undertaken to obtain an in-depth understanding of patients' and consultants' experience of the intervention. SETTING: Follow-up outpatient clinics at 19 hospitals in the north-west of England. PARTICIPANTS: Seven hundred patients (297 at intervention sites and 403 at control sites) with established ulcerative colitis or Crohn's disease, aged 16 years and over, and able to write in English. INTERVENTIONS: Consultants were trained to provide a patient-centred approach to care. Guidebooks on ulcerative colitis and Crohn's disease were developed with patients prior to the study. Patients prepared a written self-management plan and self-referred to services based on a self-evaluation of their need for advice. MAIN OUTCOME MEASURES: Rates of hospital outpatient consultation, quality of life (QoL) and acceptability to patients. Health service resource use and assessed cost effectiveness using the EQ-5D. RESULTS: After 1 year, the intervention resulted in fewer hospital visits, without change in the number of primary care visits. Patients felt more able to cope with their condition. The intervention produced no reduction in QoL and did not raise anxiety. The intervention group reported fewer symptom relapses; 74% of patients in the intervention group indicated a preference to continue the system. Qualitative results showed the guidebook was effective but organisational limitations constrained patient-centred aspects of the intervention for some. Cost-effectiveness analyses favoured self-management over standard care. CONCLUSIONS: Further use of this method in chronic disease management seems likely to improve overall patient satisfaction and reduce health expenditure without evidence of adverse effect on disease control. Further attention needs to be given to self-referral and access arrangements and a re-distribution of control to patients through increased adherence to patient-centred norms on the part of consultants. Future research is recommended to evaluate the operating systems within secondary and primary care that would allow self-managers to self-refer and to keep them informed of new treatments, also to explore models for training health professionals in self-care methods, to study long-term effects of self-management in chronic disease and to transfer this approach to other chronic conditions.

Adolescent↗
PubMed1985

Medical demography in Denmark. I. From a deficit to a surplus of doctors.

In the 1970s and beginning of the 1980s Denmark like other western countries has experienced a substantial growth in the number of medical doctors. Throughout the country, the doctor population ratio has improved considerably, a number of new specialised methods of examination and treatment have been started, and the need for doctors to work overtime has largely been abolished. At the same time, however, the growth in the number of doctors has also given rise to problems of postgraduate education, unemployment, the emigration. Furthermore, there has been political anxiety about the impact of an ever growing supply of new doctors on the continuous growth in health expenditure. This article briefly describes the development in the number of doctors through the last decades and the status of the current employment of doctors. Problems created by the growth in the number of doctors, and various initiatives to solve the problems and limit the growth in the supply of doctors are examined. A subsequent article will discuss and elucidate the future development in supply and demand on the employment market for doctors. The article begins with a short outline of the Danish health care system.

Denmark↗
PubMed2003

Children and adolescents with attention deficit-hyperactivity disorder: 1. Prevalence and cost of care.

The objective of this study was to use population-based data to estimate the prevalence and cost of treatment for attention-deficit hyperactivity disorder (ADHD). The North Dakota Department of Health Claims Database was used to estimate the administrative prevalence, annual cost of care per case, and total annual cost of care for subjects with ADHD compared with controls. The case population was 7745, and the mean prevalence rate was 3.9%, with a peak prevalence at 10 years of age. For children with ADHD, the annual cost of care was 649 dollars compared with that of controls at 495 dollars. Cost of care attributable to ADHD was 649 dollars - 495 dollars = 54 dollars (31%). Utilization by children with ADHD with publicly funded payers was increased 25 to 175% over that of children with privately funded coverage. In North Dakota, the annual cost of care for children with ADHD was 5.1 million dollars, 5.6% of all health care costs for children. The annual attributable cost of care was 1.79 million dollars. Thus, 1.9% of total health expenditures for children was attributable to ADHD. In the United States, the cost of care attributable to children with ADHD would be 2.15 billion dollars annually.

Adolescent↗
PubMed1994

Obesity and insurance risk: the insurance industry's viewpoint.

Obesity is regarded by insurance companies as a substantial risk for both life and disability policies. This risk increases proportionally with the degree of obesity. Mortality statistics for life insurance were the earliest indicator that the cost of obesity to the individual was a decreased life span and increased illness, particularly that affecting the cardiovascular and musculoskeletal systems. The prevalence of coronary heart disease rises with increases in the body mass index in both men and women. Cigarette smoking greatly augments these risks in both sexes. Hypertension and diabetes are very common in obese persons and add further to the risks of vascular disease. Abdominal obesity (when the abdominal girth measured round the umbilicus exceeds the maximum measurement round the hips) is correlated with the risk of cardiac disease and stroke, independently of bodyweight. Insurance companies consider abdominal obesity as unfavourable and rate it accordingly. Obesity (even that of moderate degree) greatly increases the chances of disability due to cardiovascular disease or musculoskeletal illness. In one study of 51 522 adult Finns, 25% of disability pensions in women were found to result directly from obesity. Obesity causes increased health expenditure, decreased life span and productivity, and premature retirement. Insurance companies are compelled to build these risks into their policies. However, because the excess mortality occurs late in mild to moderate obesity, some companies may minimise this risk for life policies that mature early.

Cardiovascular Diseases↗
PubMed2002

Foul weather friends: big business and health care reform in the 1990s in historical perspective.

Existing accounts of the Clinton health reform efforts of the early 1990s neglect to examine how the change in big business reform interests during the short period between the late 1980s and 1994 might have altered the trajectory of compulsory health insurance legislation in Congress. This article explores evidence that big employers lost their early interest in reform because they believed their private remedies for bringing down health cost inflation were finally beginning to work. This had a discouraging effect on reform efforts. Historical analysis shows how hard times during the Great Depression also aligned big business interests with those of reformers seeking compulsory social insurance. Unlike the present case, however, the economic climate did not quickly improve, and the social insurance reform of the New Deal succeeded. The article speculates, therefore, that had employer health expenditures not flattened out, continuing and even growing big business support might have neutralized small business and other opposition that contributed heavily to the failure of reform. Thus in light of the Clinton administration's demonstrated willingness to compromise with business on details of its plan, some kind of major reform might have succeeded.

Commerce↗
PubMed1998

Hospitalisation of the elderly during the last year of life: an application of record linkage in Western Australia 1985-1994.

STUDY OBJECTIVE: To measure the trend, pattern, and cost of time spent in hospital during the last year of life in Western Australia and to identify trends in the place of death. The results were compared with those reported from the Oxford Record Linkage Study. DESIGN: Mortality records for those aged 65 years and over were linked to inpatient hospital morbidity records with a date of separation within one year before death. Comparative inpatient resource utilisation was estimated using ANDRG 3.0 cost weights for Australian public hospitals. SETTING: Western Australia. PARTICIPANTS: All 68,875 persons aged 65 years and over who died between 1 January 1985 and 31 December 1994. MAIN RESULTS: Increasing proportions of all age groups (65-74, 75-84, and 85+ years) were admitted to hospital at least once in the year before death during 1985-94, but the chance of admission decreased with age. There was a trend towards a greater number of shorter admissions per person. Total bed days per person showed no significant increase, except at ages 65-74 years. Total inpatient resource utilisation during the last year of life was lowest and remained constant in those aged 85 years and over, while increasing gradually (3.7% per annum) in the younger elderly. The Western Australian population spent more time in hospital in the last year of life at ages 65-74 years, but the advanced elderly spent less time in hospital, when compared with the Oxford Region. CONCLUSIONS: Recent gains in life expectancy and higher per capita health expenditure have not been accompanied by more time spent in hospital during the last year of life at ages 75+ years. International differences between Western Australia and Oxford can be explained by differences in aged care provision.

Aged↗
PubMed1999

Depressive symptoms and health costs in older medical patients.

OBJECTIVE: The authors assessed the association between depressive symptoms and health costs for a national Veterans Administration (VA) sample. METHOD: The Rand Depression Index was administered to 1,316 medical or surgical inpatients over the age of 60 at nine VA hospitals. Scores were merged with utilization, demographic, and hospital data from national VA inpatient and outpatient files. RESULTS: Medical costs for respondents with the highest quartile of symptoms were approximately $3,200-or 50%-greater than medical costs for those in the least symptomatic quartile. Depressive symptoms were not associated with any statistically significant mental health expenditures. CONCLUSIONS: The study extends previous reports of the high medical costs associated with depressive disorders to an older, public sector population. The mechanisms underlying increased medical costs associated with depressive symptoms, while the subject of much speculation in the literature, still remain largely unknown.

Age Factors↗
PubMed2002

Risk factors for presentation to hospital with severe anaemia in Tanzanian children: a case-control study.

In malaria endemic areas anaemia is a usually silent condition that nevertheless places a considerable burden on health services. Cases of severe anaemia often require hospitalization and blood transfusions. The objective of this study was to assess risk factors for admission with anaemia to facilitate the design of anaemia control programmes. We conducted a prospective case-control study of children aged 2-59 months admitted to a district hospital in southern Tanzania. There were 216 cases of severe anaemia [packed cell volume (PCV) < 25%] and 234 age-matched controls (PCV > or = 25%). Most cases [55.6% (n = 120)] were < 1 year of age. Anaemia was significantly associated with the educational level of parents, type of accommodation, health-seeking behaviour, the child's nutritional status and recent and current medical history. Of these, the single most important factor was Plasmodium falciparum parasitaemia [OR 4.3, 95% confidence interval (CI) 2.9-6.5, P < 0.001]. Multivariate analysis showed that increased recent health expenditure [OR 2.2 (95% CI 1.3-3.9), P = 0.005], malnutrition [OR 2.4 (95%CI 1.3-4.3), P < 0.001], living > 10 km from the hospital [OR 3.0 (95% CI 1.9-4.9), P < 0.001], a history of previous blood transfusion [OR 3.8 (95% CI 1.7-9.1), P < 0.001] and P. falciparum parasitaemia [OR 9.5 (95% CI 4.3-21.3), P < 0.001] were independently related to risk of being admitted with anaemia. These findings are considered in terms of the pathophysiological pathway leading to anaemia. The concentration of anaemia in infants and problems of access to health services and adequate case management underline the need for targeted preventive strategies for anaemia control.

Adult↗
PubMed1999

Asthma outcome measures.

Annually, asthma accounts for 10.4 million physician visits, 468,000 hospitalizations, 1.8 million emergency room visits, and 10 million missed school days. According to the Centers for Disease Control and Prevention, the number of asthma deaths has increased progressively since 1978 form 1,800 to 5,400 per year. It is an expensive disease, accounting for about 1% of all health expenditure in the United States in 1990. Asthma has a significant impact on the patient and the community at large and the assessment of the clinical, physiologic, humanistic and economic outcomes will be measured.

Acute Disease↗