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PubMed1995

Mandated managed care for Medicaid recipients.

The need to control governmental health expenditures has led to experiments with mandated managed care for Medicaid recipients. Loss of freedom to choose care providers was considered a worthy sacrifice. The authors examine the historical and legislative background, including research and demonstration projects. Although they view some form of rationing as inevitable, they argue that Medicaid recipients should not be singled out to bear the main part of the burden.

Community Participation↗
PubMed1985

Hospital system management in France and Canada: national pluralism and provincial centralism.

Since the mid-1960s, France and Canada have developed different ways of managing their hospital systems. In Canada, each provincial government has gradually imposed technocratic control with the aim of planning the allocation of health-care resources. In spite of attempts to do the same in France, the hospital system has grown with few restrictions other than those set by the medical profession itself. Consequently, health expenditures have risen at one of the fastest paces in Europe. The provincial monopoly over hospital care in Canada contrasts with the juxtaposition of local 'cartels' throughout France resulting, for the latter, in a much more uncoordinated system. After a description of each country's hospital system and its historical origins, the advantages and disadvantages of each system are assessed so as to understand current public debate in each country.

Canada↗
PubMed2006

Lack of autodisable syringe use and health care indicators are associated with high HIV prevalence: an international ecologic analysis.

PURPOSE: A growing body of evidence strongly suggests that unsafe health care is an important factor driving the human immunodeficiency virus (HIV) epidemic in sub-Saharan Africa. We investigate whether nonuse of autodisable syringes and other health care indicators predict national HIV prevalence. METHODS: These ecologic analyses use countries as study units in descriptive analyses and regression analyses. Two sets of observations are used: (i) all low- and lower-middle-income countries, and (ii) all sub-Saharan African countries with available data. RESULTS: In the descriptive analysis, health care indicators (health expenditures, vaccination coverage, and use of autodisable syringes) have a U-shaped relationship with HIV prevalence in the larger sample. Greater density of physicians is associated with lower HIV prevalence. In sub-Saharan Africa, antenatal care coverage is associated with increasing HIV prevalence. In regression analyses, nonuse of autodisable syringes is associated robustly with greater HIV prevalence in all models. For the larger sample, greater HIV prevalence also is associated with higher Gini Index, less female economic activity, less urbanization, and less percentage of Muslims. In sub-Saharan Africa, tetanus vaccination coverage has a U-shaped association with HIV prevalence. Low physician density and percentage of Muslims are associated with HIV prevalence. Other economic and health care indicators and epidemic age are not significant correlates of HIV prevalence. CONCLUSIONS: This analysis adds to the other sources of evidence for health care transmission of HIV (in sub-Saharan Africa and regions with similar epidemiologic characteristics) by showing that health care indicators (failure to use autodisable syringes and greater tetanus coverage) are associated robustly with greater HIV prevalence. We recommend that resources be reallocated to address health care transmission of HIV/acquired immunodeficiency syndrome.

Africa South of the Sahara↗
PubMed1998

Services utilization before and after the prospective payment system by patients with somatization disorder.

This study analyzed services utilization before and after the implementation of Medicare's Prospective Payment System (PPS) in psychiatric patients with somatization disorder in two samples: one recruited before the PPS and the other after the PPS. Individuals with this psychiatric disorder present with multiple unexplained medical complaints and consume a great number of health resources. The results from this study indicated that Medicare PPS was associated with fewer hospital admissions and fewer hospital days, with a greater number of physician visits (for Medicare patients) and emergency room visits (for non-Medicare patients) and with lower overall health expenditures. However, there were no significant changes in the average length of stay after PPS. In contrast to previous studies, Medicare PPS was significantly associated with changes in service utilization by non-Medicare patients as well, a possible "spillover effect." This study confirms the results from other research indicating that higher levels of efficiency may be achieved for certain psychiatric disorders through prospective payment mechanisms.

Adult↗
PubMed2004

The impact of physician payment methods on raising the efficiency of the healthcare system: an international comparison.

This article reviews policies on physician payment methods that Organisation for Economic Cooperation and Development (OECD) countries have implemented to promote an efficient deployment of physicians. Countries' experiences show that payment by fee-for-service, capitation and salary influences physician activity levels and productivity. However, the impact of these simple payment methods is complex and may be diluted by clinical, demographic, ethical and organisational factors. Policies that have attempted to curb health expenditure by controlling fee levels have sometimes been eroded by physicians increasing the volume of service supply, or providing services that attract higher fees. Flexible blended payment methods based on the combination of a fixed component, through either capitation or salary, and a variable component, through fee-for-service, may produce a desirable mix of incentives. Integrating such blended payment methods with mechanisms to monitor physician activity may offer potential success.

Capitation Fee↗
PubMed1998

Peripheral arterial obliterative disease. Cost of illness in France.

The main purpose of this study, carried out in 1995, was to determine, using available sources, the cost of peripheral arterial obliterative disease (PAOD) in France over a 1-year period. This cost-of-illness study was based on a retrospective analysis of the available literature and databases. It involved a description of epidemiological data and a cost estimate of the different medical resources consumed over 1 year. For this latter purpose, a payer perspective was chosen. Data were extracted from national representative surveys and databases with respect to morbidity and mortality [from the National Institute of Health and Medical Research (Institut National de la Santé et de la Recherche Médicale; INSERM) and the National Sickness Insurance Fund for Salaried People (Caisse Nationale d'Assurance Maladie des Travailleurs Salariés; CNAMTS)], consultations, examination tests and drug prescriptions [from the French Medical Audit conducted by Intercontinental Medical Statistics (IMS)], hospitalisations [from the Statistical Unit of the Department of Health-Service des Statistiques, des Etudes et des Systemes d'Information (SESI) and the National Public Research Centre in Health Economics (Centre de Recherche d'Etude et de Documentation en Economie de la Santé; CREDES)] and related health expenditure from CNAMTS. In France, the prevalence of stage II PAOD (Leriche and Fontaine classification) in 1992 was estimated to be 675,000; 53% of these patients had undergone vascular or bypass surgery. The total annual cost of healthcare (including consultations, drugs, laboratory tests, hospitalisation and hydrotherapy) for the management of patients with PAOD ranged from 3.9 billion French francs (F) to F4.6 billion (1995 values), depending on the type of hospital considered. 50% of this cost was related to hospitalisations and 75% was covered by the CNAMTS. Although this study was only a partial evaluation and did not take into account indirect costs or nonmedical direct costs, such as transport and care by healthcare assistants and paramedics, these results may help to establish public health priorities and modify clinical practice to favour an earlier diagnosis of PAOD.

Arterial Occlusive Diseases↗
PubMed1994

Factors complicating cost containment in the treatment of suicidal patients.

OBJECTIVE: The treatment of suicidal patients contributes to escalating mental health expenditures. Fiscal realities necessitate that cost-containment measures be implemented wherever possible. The authors reviewed the literature to delineate factors that impede cost containment for the treatment of suicidal patients and to outline strategies for controlling costs while improving the quality of care. METHODS: Psychological Abstracts and MEDLINE databases were reviewed. Retrieval and analysis focused on literature published between 1982 and 1992. RESULTS AND CONCLUSIONS: Five factors unique to the treatment of suicidal patients that impede cost containment were identified: the lack of a specific and cost-effective screening method to determine true risk of suicide, the high number of parasuicidal and malingering patients, revolving-door admissions of involuntary patients who become noncompliant with treatment after discharge, the adverse clinical consequences of further increases in existing discriminatory mental health benefits, and the medicolegal liability incurred in treating suicidal patients. The low frequency of completed suicides in relation to attempts and reported ideation indicates that most inpatients labeled suicidal are hospitalized unnecessarily. Thus inpatient treatment should be reserved for patients who make attempts of high lethality and patients with suicidal ideation who are at high risk because of other factors. Ideally, suicidal patients should be committed not to an inpatient facility but to a treatment network in which they can move appropriately between inpatient, day hospital, and outpatient care.

Cost Control↗
PubMed1995

The rise and fall of democratic universalism: health care reform in Italy, 1978-1994.

In 1978, a sweeping reform created the first national health service of continental Europe: Italy's Servizio Sanitario Nazionale. This new scheme was based on the principle of "full democratic universalism": The state would provide free and equal benefits to every citizen and the organization of public health would subject to popular control, essentially through political parties. However, the severe problems encountered in implementing the reform design and rapidly increasing health expenditures soon eroded any consensus on this principle. Thus the 1980s and early 1990s witnessed a gradual shift to "conditional and well managed universalism." These latter principles stress the need to differentiate access to care according to some criterion to regulate demand and the need for efficient use of scarce resources through adequate valorization of managerial skills and the use of "market-type" incentives. An elaborated system of user copayments was introduced gradually, and in 1992 a "reform of the reform" profoundly changed the organizational framework of the Servizio Sanitario Nazionale. The new government elected in the spring of 1994 announced ambitious plans to partially dismantle public universal insurance. Although these plans may prove difficult, the potential to form an anti-universalistic coalition seems strong in the contemporary Italian health care arena.

Cost Control↗
PubMed1998

From research to practice: use of short course zidovudine to prevent mother-to-child HIV transmission in the context of routine health care in Northern Thailand.

Thailand has made remarkable progress in battling the HIVepidemic, as the decreases in HIV prevalence and changes in sexual behavior attest. Yet, in Phayao, a northern province severely affected by HIV, approximately 280 HIV-infected women, or 5% of all pregnant women, gave birth to an estimated 70 infected children in 1997. As many of these infants die within their first year of life, the infant mortality rate is on the rise after years of decline. The province, however, responded quickly to this crisis. Since July 1997, the Ministry of Public Health (MOPH) offers through Phayao's seven public hospitals a short regimen of zidovudine to all consenting HIV-infected women to prevent mother-to-child transmission of the virus. The overall prophylactic coverage for the province reached 68% of all HIV-infected pregnant women in the fourth quarter of 1997, either through the MOPH program or through the North Thailand Perinatal HIV Prevention Trial, the parallel clinical trial conducted by the MOPH and the Ministry of University Affairs. Analysis of the data collected showed that compliance to the intervention was excellent, around 90%. This was achieved at an additional cost of US$ 0.13 per capita per year, affordable even in the context of the economic crisis, and represents less than 1% of public health expenditures in Thailand. The cost per Disability Adjusted Life Years saved is approximately US$35, making it highly cost-effective. In less than a year, the MOPH implemented this program on a large scale in this relatively poor province, with limited external support. Women receive pretest counseling at their first prenatal visit, are offered HIV testing and, if they accept, return for posttest counseling two weeks later. In the case of a positive test result, a confirmation test is performed at the provincial hospital. HIV-infected women are offered zidovudine the 34th week of pregnancy or as soon as possible thereafter. Before starting treatment, the women's hemoglobin, CBC and platelets are measured. Infants begin taking oral zidovudine shortly after birth and continue until they are one week old. Subsequently, health centers regularly follow the infants, and volunteers provide case management of childhood illness, nutrition problem solving, childhood immunizations and home visits. Mothers feed the infants breastmilk substitutes, and women with insufficient income receive the substitutes free of charge. The northern Thailand experience provides important insights into the feasibility of large scale interventions to prevent perinatal HIV, such as the need for the reorganization of the delivery of health care and quality counseling. On the basis of this experience, a simplified schedule of three intervention phases (Screen, Treat and Care), which can be incorporated into routine mother and child health care, is proposed. Follow-up of the child, however, will require more frequent and intensive contact with health care services than usual. At a time when many countries are reevaluating their health care systems, these insights should be considered, so as to additional better the needs of HIV-infected women during pregnancy and beyond.

Anti-HIV Agents↗
PubMed2004

Prevalence and direct medical costs of end-stage renal disease in patients with type 2 diabetes mellitus in Switzerland for 2001.

BACKGROUND: The prevalence of end-stage renal disease (ESRD) in patients with type 2 diabetes mellitus (type 2 DM) has increased in recent decades throughout the world. In most industrialised countries, diabetic nephropathy in type 2 diabetics is the most frequent cause of ESRD. AIMS: The prevalence and direct medical costs for the insurance funds in Switzerland were determined for ESRD in patients with type 2 DM. METHODS: Prevalence was determined on the basis of a written retrospective cross-sectional analysis covering all centres for dialysis and transplantation in Switzerland. Costs were calculated separately for the three different therapeutic options for ESRD - haemodialysis, peritoneal dialysis and renal transplantation. Costs were calculated on the basis of the percentage of the patients in this cross-sectional study who received each of these treatments. Cost data from the Swiss Union for the Social Duties of the Insurance Funds (SVK) were used for all three treatments. SVK data were not available for some phases of transplantation, and for these phases the consumption of health resources was determined by interviewing experts on the telephone, using a questionnaire. RESULTS: The cross-sectional study in the dialysis and transplantation centres was based on full collection of data. In Switzerland in the year 2001, the prevalence of ESRD in patients with type 2 DM came to 73.0 per million inhabitants. The direct medical costs of this complication came to a total of CHF 46,065,788 (0.1% of the total health expenditure). This corresponds to CHF 1570 per 100,000 inhabitants per day. 81.6% of these costs are for haemodialysis, 7.1% for peritoneal dialysis and 11.4% for renal transplantation. ESRD costs are CHF 215 per patient per day. CONCLUSIONS: The prevalence of ESRD in patients with type 2 DM in Switzerland was 73.0 per million inhabitants in 2001. The costs of this avoidable late complication are considerable.

Cross-Sectional Studies↗
PubMed2003

The hospital cost of vertebral fractures in the EU: estimates using national datasets.

The purpose of this study was to estimate the hospital cost of vertebral fractures in the EU using national datasets to explore some of the methodologic limitations associated with such an approach. Hospital costs for vertebral fractures across the EU were compared with the hospital costs associated with hip fractures. Additionally, these costs were placed into the health care context by making comparisons with national health care expenditure. All EU Ministries of Health were contacted to identify national datasets to estimate the average length of stay, cost per diem and the number of patients discharged with vertebral fractures. Where national information was not available expert opinion and data from the relevant literature were used instead. Countries show a marked difference in the length of stay between men and women, with differences ranging from 0.32 days in Austria to 20.2 days in Spain. The average hospitalization rate was found to be 8% across the EU, with higher rates found for men than for women. Interestingly a positive correlation between health expenditure per capita and hospitalization rates was found. The total cost of vertebral fractures in the EU was estimated at euro 377 million per year. Across the EU the hospital cost of a vertebral fracture was on average 63% that of a hip fracture. National datasets allow us to estimate the cost of vertebral fractures in the EU but show limitations. In the absence of large scale prospective studies, national datasets need to be further refined to ensure more accurate estimations of the cost of vertebral fractures in the EU.

Cost of Illness↗
PubMed1996

Harmonization of clinical practice guidelines for the prevention and treatment of osteoporosis and osteopenia in Europe: a difficult challenge.

Europe is a patchwork of various medical cultures and financial resources. Variations abound with respect to financing, accessibility to public health systems, health expenditures, drug registration and reimbursement, the prescription of drugs, and clinical applications, as well as the perception of osteoporosis itself. However, there are possibilities for the harmonization of medical services among the various countries within Europe. The European Agency for the Evaluation of Medicinal Products (EAEMP) is attending to the centralized or decentralized procedures for the registration of drugs. The Group for the Respect of Ethics and Excellence in Science (GREES) is investigating guidelines for drug registration as well as gathering and making available medical references. The European Foundation for Osteoporosis and Bone Diseases (EFFO) is increasing awareness of the prevalence of the disease and the need for prevention and treatment. Finally, the International Federation of Societies on Skeletal Diseases (IFSSD) is coordinating epidemiologic, clinical, and social research. There is a need for increased awareness of osteoporosis throughout Europe. Health authorities are in need of cost/benefit reports leading to the registration and reimbursement of agents. Primary care physicians need information about osteoporosis and need to become involved in the diagnosis and science of the disease. Awareness needs to be generated among specialists; they need to be educated in the latest techniques for diagnosis and treatment. Finally, the general population needs to become aware of osteoporosis and to be encouraged to participate in the prevention and treatment of this disease. Current screening and detection in Europe is being done by densitometry. However, other techniques on the horizon include ultrasound and biochemical markers. Primary prevention, i.e., maximizing peak bone mass, includes examining the genetics of osteoporosis to determine the high-risk population and promoting reasonable physical exercise and dietary/life-style habits (e.g., increased calcium and avoidance of tobacco). Secondary prevention includes the identification of high-risk groups through risk factors, biochemical markers, and densitometry and adherence to the World Health Organization definition of osteopenia-osteoporosis (adapted to financial concerns by GREES guidelines). Other therapies include hormone replacement agents (although there are risks for cancer and concerns about durability), calcium and other inhibitors of bone resorption, physical activity, and vitamin D prophylaxis in the elderly. Treatment of established or severe osteoporosis includes drugs upon availability (inhibitors of bone resorption and stimulators of bone formation), surgery, and experimental approaches.

Female↗
PubMed1996

Redefining rate regulation in a competitive environment.

Neither rate regulation nor market competition alone is likely to contain health care spending in the long run. We need an approach to cost containment that can simultaneously address the major causes of rising health expenditures: higher prices, greater intensity, and new technologies. Whereas rate regulation and market competition have been viewed as alternative strategies, an innovative approach would include a rate-regulatory system that is compatible with an evolving competitive market. We discuss the Maryland hospital rate-setting system as an illustration of the compatibility of a regulatory approach within a competitive market. In addition, we consider the feasibility of expanding a hospital rate-setting system nationwide and to the nonhospital sectors.

Capitation Fee↗
PubMed2004

Preventing injury and injury-related disability in children and adolescents.

Injury is the leading cause of death and a prevalent source of disability and excess health expenditures in children and adolescents. There are predictable patterns to injury that provide clues to prevention. Epidemiologically-based theoretical frameworks are available to guide development of injury prevention strategies, to add structure to our observations, and focus to our prevention activities. While all-cause injury mortality rates have decreased in children and adolescents over the last 20 years, large ethnic disparities persist, indicating the need for intensified efforts in high-risk communities. Strong leadership from pediatric surgeons and pediatricians operating hospital-based community injury prevention programs has produced successful reductions in child and adolescent injury rates in resource-limited and minority neighborhoods. Among the program features considered essential are: (1) an ongoing injury surveillance system; (2) well-focused, multifaceted prevention activities, including both passive and active prevention approaches; (3) education; (4) enlistment of other health professionals, local government officials, community leaders, and the public; and (5) evaluation and refinement of prevention activities.

Adolescent↗
PubMed2000

Overview: epilepsy surgery in developing countries.

Epilepsy surgery (ES) is addressed in relation to economic classifications of national resources and welfare in developing countries. A decade ago, ten developing countries conducted ES; now 26 such countries have reported results of ES. A number of international authorities define indicators of national economic welfare. Adopting the economic classification of the International Monetary Fund. we find that ES is nonexistent in 98% of African countries, 76% of Asian countries, 58% of European countries, 82% of Middle East countries, and in 86% of countries of the Western Hemisphere. The 1980-1990 global ES survey conducted by the International League Against Epilepsy identified ten developing countries reporting ES (DCRES): Brazil, China, Czechoslovakia, Hungary, Mexico, Poland, Taiwan, the U.S.S.R., Yugoslavia, and Viet Nam. The present survey based on the proceedings of the 19th-23rd International Epilepsy Congresses and Medline reports from 1991 to November 1999 revealed at least 26 (18.3%) DCRES of 142 developing countries: Argentina, Brazil, Chile, China, Colombia, Czech Republic, Egypt, Estonia, Hungary, India, Iran, Israel, Korea, Lithuania, Mexico, P.R.China, the U.S.S.R., Singapore, Slovenia, South Africa, South Korea, Taiwan, Turkey, Ukraine, Uruguay, and former Yugoslavia. National vital statistics expose the hardships of developing countries. The population ratio of developed countries to developing countries is approximately 1:5. The reverse per capita Gross Domestic Product ratio is 20:1. Great disparities exist in vital statistics, all to the disadvantage of the DCRES. The World Health Organization defines health-related sectors geographically, then divides developing countries into several subgroups. Disability caused by length of disease and years lived with disability can be quantified monetarily for epilepsy, and the total health expenditures of developed and developing countries can be compared. The DCRES are short of technology, and their ES teams must choose from an excess of surgical candidates, investigating with computed tomography, magnetic resonance imaging, noninvasive video-electroencephalography, and neuropsychology. The surgical outcomes achieved are similar to those in the developed world, but at a fractional cost. To internationalize ES, outcome, cost, and savings from care, evolution of assessment methodology is needed. Also needed is general support from the developed world.

Adolescent↗