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PubMed1997

[What should medical decision be based on?].

Medical decision making is basically related to three criteria: 1) estimated effectiveness in terms of objective and subjective results: 2) equity related to the concept of justice in the societal context; 3) legitimacy according to the willingness to pay of the society, its resource availability and the fraction of its income that is allowed to be spent for health care. A worsening dilemma is unescapable between a utilitarian medical project, and the traditional hippocratic rule of rescue no matter what the cost may be. Every care taker should be involved to give a clear account of medical decision in order to generate and adopt some acceptable view for a reliable implementation with respect to equity and justice.

Decision Making↗
PubMed1988

Generational equity and social insurance.

In recent years, critics have argued that, when inter-generational transfer programs such as Medicare are judged by the standard of "generational equity", these programs are seen to be unfair. It is argued that, under a pay-as-you-go system, future generations are committed to burdens without their consent; that claims are not contractually guaranteed; that early entrants reap windfalls gains; that successive cohorts are tempted to provide insupportably high benefit levels; and, finally, that fluctuations leave future generations at unacceptable risk. Attempts have been made to defend social insurance programs by means of a "lifespan prudential model" of age-group resource allocation, but this defense does not adequately take account of uncertainties and inequities faced by historical birth cohorts. A deeper defense must acknowledge an element of risk-sharing and solidarity while trying to limit inequities within reasonable bounds.

Aged↗
PubMedDate not supplied

The economics of for-profit and not-for-profit hospitals.

This paper examines the economics of for-profit and not-for-profit hospitals through the prism of capital acquisitions. The exercise suggests that of two hospitals that are equally efficient in producing health care, the for-profit hospital would have to charge higher prices than the not-for-profit hospital would, to break even on capital acquisitions. The reasons for this divergence are (1) the typically higher cost of equity capital that for-profit hospitals face; and (2) the income taxes they must pay. The paper recommends holding tax-exempt hospitals more formally accountable for the social obligation they shoulder, in return for their tax preference.

Capital Expenditures↗
PubMed2005

[Changes in distributive equity of health insurance contribution burden].

OBJECTIVES: We analyzed the changes from 1996 to 2002 in distributive equity of the contribution burden in the Korean National Health Insurance. METHODS: The study subjects were a total of 8923 employee households and a total of 7296 self-employed households over the period from 1996 to 2002. Those were the households meeting the two criteria as completing each annual survey and having no change in the job of head of the household during that period from the raw data of the Household Income and Expenditure Survey annually conducted by the Korean National Statistical Office. The unit of analysis was a household, and this was the standard for assessing the contribution that is now applied on a monthly basis. Deciles Distribution Ratio, Contribution Concentration Curve and Contribution Concentration Index were estimated as the index of inequality. Multiple regression analysis was conducted to compare the annual ability-to-pay elasticity of the contribution to the reference year of 1996 for three groups (all households, the employee households, and the self-employed households). RESULTS: For the index of inequality, the distributive equity of contribution was improved in all three groups. In particular, the employee group experienced a substantial improvement. Using multiple regression analysis, the ability-to-pay elasticity of the contribution in the employee group significantly increased (beta = 0.232, p < 0.0001) in the year 2002 as compared to the reference year of 1996. The elasticity in the self-employed group also significantly increased (beta = 0.186, p < 0.05), although its change was smaller than that in the employee group. CONCLUSIONS: The employee group had a greater improvement for the distributive equity of the contribution burden than the self-employed group. Within the observation period, there were two important integration reforms: one was the integration of 227 self-employed societies in 1998 and the other was the integration of 139 employee societies in 2000. We expected that the equity of the contribution burden would be improved for the self-employed group since the integration reform of 1998. However, it was not improved for the self-employed group until the year 2000. This result suggests that capturing exactly the beneficiaries' ability-to-pay such as income is the precedent for distributive equity of the contribution burden, although a more sophisticated imposition standard of contribution is needed.

Adult↗
PubMed2002

The citizen's preferences for financing public health care: a Danish survey.

The Danish public's willingness to forego private consumption in order to obtain improved health care services was investigated using conjoint analysis. The survey was undertaken in the year 1999. 1865 respondents participated in face-to-face interviews and were presented with pair wise choices of different future health care systems. Openness towards the introduction of user charges to a smaller degree demonstrated willingness to compromise relative equity in access to health care in order to avoid a tax increase. Willingness-to-pay for quality attributes lie in the range 780-2350 DKK ($89-$267) if paid by increasing maximum user charges, and in the 0-1220 DKK ($0-$139) bracket, when financed by increased income taxes.

Adult↗
PubMed2004

Shifting the burden of health care finance: a case study of public-private partnership in Singapore.

Since becoming independent in 1965, Singapore has attained high standards in health care provision while successfully transferring a substantial portion of the health care burden to the private sector. The government's share of total health care expenditure contracted from 50% in 1965 to 25% in 2000. At first glance, the efficiency-driven health care financing reforms which emphasize individual over state responsibility appear to have been implemented at the expense of equity. On closer examination, however, Singaporeans themselves seem unconcerned about any perceived inequity of the system. Indeed, they appear content to pay part of their medical expenses, plus additional monies if they demand a higher level of services. In fact, access to needed care for the poor is explicitly guaranteed. Mechanisms also exist to protect against financial impoverishment resulting from catastrophic illness. Singapore's experience provides an interesting case study in public-private partnership, illustrating how a hard-headed approach to health policy can achieve national health goals while balancing efficiency and equity concerns.

Attitude to Health↗
PubMed2005

The Irish health system: developments in strategy, structure, funding and delivery since 1980.

As the Irish health system embarks upon its first major structural reorganisation in over 30 years, developments within this system over the past two decades are assessed. Real cuts in health expenditure achieved in the 1980s contrast sharply with the unprecedented increase in resources devoted to the health system in the 1990s. While successive statements of health strategy have prioritised the objectives of equity, efficiency and quality of care, questions arise regarding the return achieved with the increased investment. With higher levels of economic growth, more people have been buying private health insurance such that almost half the population are now privately insured. At the same time, the numbers with eligibility for health services without charge have decreased while those from lower socio-economic groups continue to have higher levels of utilisation. Equity issues arise, however, with regard to access to public hospitals as the rate of growth in admissions for private patients outstrips that for public patients. The establishment of a National Treatment Purchase Fund to purchase treatment in private facilities for public patients on waiting lists raises efficiency and equity questions as the treatment of private patients in public hospitals is heavily subsidised while the State pays full cost for the treatment of public patients in private facilities.

Financial Management↗
PubMed2006

Beliefs about informal payments in Albania.

Informal payments for health care are a growing concern in Albania and other transitional economy countries. Recent international studies have shown that informal payments can have negative effects on health care access, equity and health status by causing people to forgo or delay seeking care, or sell assets to pay for care. Many countries are putting in place reforms meant to reduce informal payments. In order to be successful, such policies need to consider people's attitudes and beliefs about the practice. This study collected data from 222 citizens in Albania regarding intentions, past behaviours, attitudes and beliefs about informal payments. Comparing people who intend to make informal payments with people who do not intend to make payments, the study found differences in attitudes as well as beliefs about the consequences of making informal payments, in perceptions about what others think and in control beliefs, but no difference in moral beliefs or demographic characteristics. People who intend to make informal payments the next time they seek care are more likely to believe they will get faster and better quality care than non-intenders, but also think they must pay to receive any care at all. People who do not intend to make informal payments are more likely to report that they have connections with medical personnel, which may be substituting for informal payments. The study has implications for educational campaigns accompanying policy reforms. Campaigns which focus on anti-corruption messages are unlikely to be effective, as moral beliefs do not appear to influence intention.

Adult↗
PubMed1983

Medicare program; assistants at surgery--Health Care Financing Administration. Final rule.

These regulations amend the interim final Medicare rules published on October 1, 1982, that implement section 113 of the Tax Equity and Fiscal Responsibility Act of 1982 (Pub. L. 97-248). Those regulations provide that Medicare will pay on a reasonable charge basis for the services of a physician who actively assists the physician in charge of a case in performing a surgical procedure (i.e., an assistant at surgery) in teaching hospitals only under certain specific conditions. These regulations add as a result of public comments a new condition under which assistants at surgery may be reimbursed. They also clarify the rules for determining the amount of payment for services furnished by assistants at surgery in all settings.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1993

Improving the implementation of cost recovery for health: lessons from Zimbabwe.

In the current debate over health financing policy in developing countries, governments are increasingly focusing on cost recovery--having patients pay part or all of their health care costs--as a way to mobilize more resources for health, improve equity by selectively charging the wealthy, and increase efficiency by encouraging reinvestment of fee revenues into cost-effective primary care. Zimbabwe offers an important example of a country with a tradition of levying fees in government health facilities, but where enforcement became lax in the 1980s. In 1991, policymakers resolved to resuscitate and strengthen cost recovery, as part of a broader economic reform program. This paper discusses the strengths and weaknesses of Zimbabwe's cost recovery system, its potential for improvement, and the obstacles to change in revising the fee structure and billing and collection procedures. It argues that cost recovery can help to achieve Zimbabwe's health objectives, but only in conjunction with other measures to redirect public spending to essential public health and clinic care and improve the efficiency of government services. The paper finds that during the 1980s, the fee schedule became badly misaligned with actual medical care costs and created distortions in patient referral patterns. Billing and collection were also weak, because of deficiencies in personnel and information systems and lack of incentives for revenue generation. The paper concludes that if key steps were taken to raise the collections-to-billings ratio, recover fees from privately-insured patients, and adjust fees in line with medical cost inflation, recoveries could increase fourfold, from 5% to 20% of government spending for clinical care. At the same time, access to government health services for the poor could be maintained by improving exemption procedures.

Cost Sharing↗
PubMed1999

Unofficial fees in Bangladesh: price, equity and institutional issues.

The widespread collection of unofficial fees at health facilities is a common form of rent-seeking behaviour in Bangladesh. Typically, unofficial fees come in the form of cash payments for the performance of required services, for direct purchase of drugs and medical-surgical requisites, and for service access. Using observational and interview methods, this study explores linkages between official and unofficial fees at three Bangladesh health facility levels; primary care Thana Health Complexes, secondary or district hospitals, and medical college hospitals. The study estimates payment levels for different income classes and different payor types at these facilities, thereby highlighting potential equity, price and institutional questions associated with unofficial fees. Not only does the practice have clear income and equity effects, there also appear to be direct effects upon patient satisfaction, perception of quality, and the ability to pay for health services. The article concludes with a discussion of 'rent capture' processes at Bangladesh facilities and the effect of unofficial fees in six areas of health sector reform: displaced official policies, reduced merit goods production, upward income redistribution, distorted human resource development, growth of facility inefficiency, and obstruction of market reforms.

Bangladesh↗
PubMed1984

Cost-shifting: the discount dilemma.

Cost-shifting, the practice by hospitals of raising their prices to make up for reimbursement shortfalls from payers that do not pay full charges, is an important and controversial issue. Concerns about cost-shifting, particularly its effects on payment equity and cost escalation, have led many insurers, business groups, and legislators to advocate rate-setting regulation for hospitals. This article seeks to clarify the definition of cost-shifting, and quantifies its magnitude in Minneapolis/St. Paul. We believe that cost-shifting is the consequential result of the failure of both public and private payers to structure payment policies that reward cost-effective hospitals, and we outline a market-oriented alternative to rate-setting to address the discount dilemma caused by cost-shifting.

Charities↗
PubMedDate not supplied

What is fair in financing fairness?

The World Health Report 2000 considers "fair financing" as one of the three goals for assessing the Health Systems Performance. Fair financing cannot be dissociated from equity that implies traditionally getting the services one's needs in return for contributing within one's ability to pay. However, the calculation in the Report considers "fairness of financial contribution" which disregards accessibility to health services. In addition to their disagreement on the concept of fairness, the authors question the validity of the statistical method used. They notice that despite the absence of financial barriers to access health services, the scoring of Lebanon came unsatisfactory. They claim that the health system in Lebanon is rather contributing in redressing the inequity of the fiscal system.

Financing, Government↗
PubMed2002

Equity, privatization and cost recovery in urban health care: the case of Lao PDR.

Along with the shift from a planned to market-oriented economy, as in many other developing countries, Lao PDR has promoted health care partnerships with the private sector, and cost recovery in public hospitals, to increase resources in the public sector, while at the same time attempting to ensure appropriate access to health care for those without means to pay. In a multi-case design, this study compares two neighbourhoods of different socioeconomic status comprising 10 households, representing urban districts in three provinces. In-depth interviews were conducted over a 1-year period with three visits to each household. Members of the households were interviewed on their perceptions and utilization of health care services. Focus group discussions of public providers and individual interviews of private providers, leaders of the villages and hospital administrators provided complementary perspectives. The study found that both socioeconomic groups utilized private health services as their first choice, including private clinics and treatment abroad for those with high socioeconomic status, while the low socioeconomic group preferred private pharmacies. The unwelcoming attitudes of health staff and procedural barriers have led both groups to meet their health care needs in the private sector. Here the health care they receive is strictly limited to what they can pay for. For the poor, in most cases, this means drugs alone, i.e. no examination, no diagnosis and only limited advice. Limited financial resources often means receiving inappropriate and insufficient medication. Equity in health care remains theoretical rather than practical and the social goals of the reform have not been achieved.

Acute Disease↗
PubMed1993

Effects of inequity on job satisfaction and self-evaluation in a national sample of African-American workers.

Data from a national survey of African-American workers were used to test predictions from equity theory regarding the "distress" that results from negative inequity (below expected level) and positive inequity (above expected level) in pay and occupational prestige. The results showed differential effects of the two types of inequity on dependent variables of job satisfaction and self-report of job-related skill. Although those faced with opposite forms of inequity fostered different strategies for inequity reduction, in each case, workers chose a strategy that was self-protective.

Adolescent↗
PubMed1997

Strategies for provider reimbursement. Should physician pay exceed that of mid-level practitioners?

It is clear that the bitter disputes over power and control in health care have been dysfunctional. The issue of reimbursement equity for nurse practitioners who provide primary care services is only one of many numerous, complex issues--each of which has many underlying and unresolved elements contributing to the dysfunctionality of the contemporary health care system. What is needed is a united effort and interdisciplinary collaboration to: a) address the maldistribution and excessive costs of health care, b) reevaluate all aspects of healthcare including who carries out what functions at what level of educational preparation and reimbursement, and c) redesign a system that is efficient, effective, and economical. It is imperative that individual nurses and physicians as well as organized medicine and nursing work with each other and with other health care providers, payors, regulators, suppliers, and most especially consumers to restructure health care and redefine roles. Doing so requires divestment of self-interests and a dispassionate focus on the mission and goals of the system. Using a conceptual model facilitates analysis of the literature, specific issues, and their impact on the system. However, resolution of the issues and improving the health care system's functionality requires commitment to the goal regardless of personal cost. This is the challenge confronting all of us.

Economic Competition↗
PubMed2004

What men and women value at work: implications for workplace health.

BACKGROUND: Current research suggests that workplace culture can influence health outcomes. OBJECTIVE: This study was conducted to determine what men and women value at work, how each defines a healthy workplace, and what work factors best predict their health outcomes and stress. METHODS: A national study was conducted by LLuminari, Inc., a health education company, via a Harris Interactive Inc. online panel that screened for US participants who were employed full-time in organizations with >1000 employees. The online questionnaire used stimulus words/phrases to which respondents verbally free-associated. Each verbatim response was given a weighted score based on the order in which it was written, then thermatically clustered with similar responses to form categories for each stimulus item. RESULTS: A total of 1123 individuals participated in the study (608 males, 515 females). Results indicated that men and women value the same aspects of work but ranked them differently. Men valued pay, money, and benefits, as well as power, authority, and status significantly more than women did (P < 0.001). Women valued the following significantly more than men did: friends and relationships (P < 0.05); recognition and respect (P < 0.001); communication (P < 0.001); fairness and equity (P < 0.001); teams and collaboration (P < 0.001); family and home (P < 0.001). The results also indicated that men underestimate and are generally unaware of women's work-related values (P < 0.05). In comparison, women overestimate how men value pay, money, and benefits, and power, authority, and status (P < 0.05). Although little difference was observed in health status between the sexes, women did report being slightly more distressed at work. Findings also suggested that the cultural and environmental aspects of work best predicted women's health outcomes; for men, health outcomes were related to supervision and management factors. The health of both sexes was significantly predicted by their perceived home life (P < 0.001). Men and women also defined a healthy workplace differently, with women more than men emphasizing understanding, support, communication (P < 0.05), relationships, and ethics (P < 0.001). CONCLUSIONS: Knowing and managing gender differences may help to effectively motivate employees, increase productivity, foster loyalty, and improve physical and mental well-being.

Adult↗