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PubMed2002

Shared treatment decision making in a collectively funded health care system: possible conflicts and some potential solutions.

In recent years there has been a growth in the advocacy of shared decision making (SDM) between clinicians and patients as a way of practicing medicine. Although there is a range of perspectives on what SDM means, in essence it refers to greater involvement of the individual patient in deliberations about appropriate forms of clinical management. The patient's perception of the role of the doctor in SDM is crucial: for it to work successfully, the patient needs to be able to be confident that the doctor is focused on which treatment will generate the greatest benefit for them. However, the doctor also has responsibilities to others, in particular to other patients and potential patients within the collectively funded health care system. This dual responsibility can create a range of dilemmas for the clinician in the context of SDM: Should they inform patients about all effective treatments or just those that the health care system considers cost-effective? Do they risk losing patients from their books if they inform patients about their responsibilities to the health care system? SDM also raises questions about the wider principles of the health care system: Are its equity principles consistent with SDM? Should patients with a strong preference for an effective but non-cost-effective treatment be permitted to pay for it privately? This paper describes the nature of the conflicts that are likely to emerge if SDM diffuses within collectively funded health care systems, and considers a range of policy responses. It argues that the risk of conflict may be reduced by making a clear distinction between clinical guidelines (focusing on effectiveness) and system guidelines (focusing on cost-effectiveness).

Communication↗
PubMed2005

Difficulties in provision of bariatric surgical services to the morbidly obese.

Morbid obesity (defined as having a body mass index [BMI] > 40 kg/m(2), or BMI > 35 kg/m(2) with obesity-related comorbidities) is a medical disorder associated with increased morbidity and mortality. Management guidelines published by the National Health and Medical Research Council and by similar US and UK bodies have recommended surgery as the most effective treatment available for selected patients with morbid obesity. A recent meta-analysis of obesity surgery has documented its safety and effectiveness in resolving some of the major medical comorbidities that occur in obese patients. To date, no intervention other than surgery has proven either effective or cost-effective in treating severe obesity and its associated medical conditions. Targeting patients with metabolic complications of obesity (eg, type 2 diabetes) could lead to substantial cost savings for the public health system. Currently, Medicare pays for privately insured patients to undergo obesity surgery, while uninsured patients are denied access to surgery in public hospitals. This raises significant equity issues that should be addressed.

Australia↗
PubMedDate not supplied

[Tobacco, equity and primary health care].

BACKGROUND: Antitobacco campaigns in industrialized countries (USA, Canada, United Kingdom, Sweden, Finland, Australia) have been less effective FOR low social classes, except for Australia. In order to attain further reductions of tobacco consumption, these countries have to pay attention to tobacco use amongst people of low socioeconomic status. This paper seeks to analyze the causes of it to summarize relevant lessons for our own country. METHODS: Literature review in relation to tobacco consumption, social status, mediating variables between these two elements, and variety of possible interventions. RESULTS: Low social classes bear higher tensions, more compelling economic, familiar, affective and social relations problems, with a lower capability to adapt, neutralize or change their situation; therefore making their emotional dependence on tobacco, stronger. Family physician's intervention and community participation appear as the recommended alternatives to mass-media public campaigns. CONCLUSIONS: These two interventions should be fostered through the national Primary Health Care Network, as a complement to public campaigns, to guarantee in equity in reducing tobacco consumption and its consequences.

Adult↗
PubMed1995

The paradox of the contented working woman in intercollegiate athletics administration.

We investigated the paradox of the contented working woman among middle and first-line intercollegiate athletics administrators. In this paradox, women report lower salaries than men but express comparable job satisfaction. The sample comprised 143 women and 371 men in 106 National Collegiate Athletic Association (NCAA) Division I-A institutions. Job satisfaction was measured with the Job Descriptive Index (Smith, Kendall & Hulin, 1969) and Job in General (Ironson, Smith, Brannick, Gibson & Paul, 1989) scales. Analyses revealed the existence of the paradox: Women were paid significantly less, but were equally satisfied with their jobs. Neither gender was satisfied with promotion opportunities or pay, but both were highly satisfied with their jobs in general--another apparent paradox. The disproportionate number of male respondents raised questions about gender equity in athletics administration.

Administrative Personnel↗
PubMed1986

The impact of public opinion on medical technology: the case of artificial heart implants.

A public opinion survey was conducted in the spring of 1985 in Kentucky to assess public attitudes toward artificial heart technology. The data, based on consumer and citizen perspectives, indicate that the public is interested in and aware of the technology and recent implant surgeries. More knowledgeable respondents are more likely to support Humana's involvement, but less likely to want an artificial heart and other organs to continue life, and less willing to support equitable access and increased taxes to achieve this equity. Technological optimists are more willing to have the heart and other organs as needed and more willing to have their taxes increased to pay for the technology for all in need. Optimists also see nothing wrong with Humana's involvement in this technology. People's judgments on artificial heart technology vary, depending on whether they see it as potentially desirable for themselves as opposed to possible implications for others and the broader society. Although both perspectives are crucial for understanding the role of public opinion on the further development of this technology, it must be recognized that the two perspectives might have different impacts, depending on societal judgment of whether the decision to proceed with further development of the technology is mostly a public or private choice.

Attitude to Health↗
PubMed1992

Women and access to health care.

This paper is concerned with access to health care for women in developing countries, with specific reference to Latin American and Caribbean countries. It reviews the available literature on the concept of access as it relates to other variables such as accountability, affordability and acceptability of health services, taking into consideration the effects of the generalized socio-economic crisis that has affected most countries during the last decade, as well as equity objectives. Various approaches to defining variables affecting access to health care appear in the literature reviewed. While some of them indicate that ability to pay for services act as a major determinant of access to health care, others point to behavioral issues related to motivation, health seeking behavior or perception of illness as a deterrent to women in the low socioeconomic strata, while others indicate that sociocultural issues, such as values, education, religion or demographic variables related to age, influence access to health care. The paper concludes with some comments on policies and strategies for securing access to health and healthcare, indicating the need to move away from traditional solutions including framing gender-based health differences in status and access adequately, promoting and strengthening social participation of women in policy making.

Americas↗
PubMed1996

Distributing scarce livers: the moral reasoning of the general public.

The transplant system has been criticized for not paying enough attention to efficiency in distributing scarce organs. But little research has been done to see how the general public views tradeoffs between efficiency and equity. We surveyed members of the general public to see how they would distribute organs among patients with varying chances of benefiting from them. In addition, we asked subjects to explain their decisions and to tell us about any other information they would have liked in order to make the decisions. We found that the public places a very high value on giving everyone a chance at receiving scarce resources, even if that means a significant decrease in the chance that available organs will save people's lives. Our results raise important questions about whether the aims of outcomes research and cost-effective studies agree with the values of the general public.

Adult↗
PubMed2003

Differential pricing for pharmaceuticals: reconciling access, R&D and patents.

This paper reviews the economic case for patents and the potential for differential pricing to increase affordability of on-patent drugs in developing countries while preserving incentives for innovation. Differential pricing, based on Ramsey pricing principles, is the second best efficient way of paying for the global joint costs of pharmaceutical R&D. Assuming demand elasticities are related to income, it would also be consistent with standard norms of equity. To achieve appropriate and sustainable price differences will require either that higher-income countries forego trying to "import" low drug prices from low-income countries, through parallel trade and external referencing, or that such practices become less feasible. The most promising approach that would prevent both parallel trade and external referencing is for payers/purchasers on behalf of developing countries to negotiate contracts with companies that include confidential rebates. With confidential rebates, final transactions prices to purchasers can differ across markets while manufacturers sell to distributors at uniform prices, thus eliminating opportunities for parallel trade and external referencing. The option of compulsory licensing of patented products to generic manufacturers may be important if they truly have lower production costs or originators charge prices above marginal cost, despite market separation. However, given the risks inherent in compulsory licensing, it seems best to first try the approach of strengthening market separation, to enable originator firms to maintain differential pricing. With assured market separation, originators may offer prices comparable to the prices that a local generic firm would charge, which eliminates the need for compulsory licensing. Differential pricing could go a long way to improve LDC access to drugs that have a high income market. However, other subsidy mechanisms will be needed to promote R&D for drugs that have no high income market.

Developing Countries↗
PubMed2003

Funding fertility: issues in the allocation and distribution of resources to assisted reproduction technologies.

The appropriate level and source of funds for assisted reproduction technologies (ARTs), in particular IVF, have been controversial in most developed economies. Funding of fertility services internationally is characterized by low public (or other third party) funding, a greater reliance on user-pays than in most other health services, and variations in funding and provision. This article describes the characteristics of infertility as a condition and its treatment that have been used as a rationale for its exclusion from an otherwise comprehensive coverage of health services. The challenges these characteristics pose for the use of economic evaluation to inform resource allocation are discussed. Most economic evaluations have focused on the cost effectiveness of alternative infertility treatments. These evaluations provide important information, but do not inform the real issue at stake: what is the appropriate allocation of funds to ARTs, given that it involves sacrificing improvements in health in other areas? Cost utility analysis - the method of economic appraisal preferred by most agencies charged with making such decisions (including the National Institute of Clinical Excellence in the UK) - is ill-equipped to deal with the benefits produced by ARTs. Alternative methods are available, but require decision makers to weigh up very different sorts of evidence. Demonstration of the willingness to pay for the benefits of ARTs can be used to support public decisions but, conversely, also implies that those who can pay will pay in a private market. Ultimately, decisions about the inclusion or otherwise of ARTs in collectively funded health systems probably rest as much on judgments about equity in access as value for money. Given that this is the case, public funding of IVF should be accompanied by the development of agreed criteria for the prioritization of potential recipients, to ensure treatment is targeted at those for whom it is most effective and that access is consistent and fair.

Adult↗
PubMed2003

Negotiating the spirit of the deal.

Most experienced negotiators are comfortable working out the terms of an economic contract--they bargain for the best price, haggle over equity splits, and finesse detailed exit clauses. Yet these same seasoned professionals spend so much time ironing out the letter of the deal that they often pay little attention to the spirit of the deal--the social contract. And that can lead to major problems, say the authors, because even though the parties agree to the same terms on paper, they may have very different expectations about how to meet them. Those on one side, for instance, might think they're entering into a long-term partnership, while those on the other believe they're simply making a series of discrete transactions. Because the parties have failed to have a true meeting of the minds, they sign a deal that is likely to fall apart. To avoid such a disastrous outcome, negotiators should explicitly discuss the details of their social contract before inking the deal. They should talk about the underlying social contract, which answers the question, What? For instance, what is the real nature, extent, and duration of the agreement? And they should discuss the ongoing social contract, which answers the question, How? For instance, in practice, how will we make decisions, handle unforeseen events, communicate with one another, and resolve disputes? Drawing on real-life examples, the authors explore the problems that arise when the letter and spirit of the deal are at odds and suggest ways to dovetail them so they are both independently strong and mutually reinforcing. They also highlight risk factors that can lead to misunderstandings and expose common misperceptions about the social contract.

Commerce↗
PubMed2002

Quality and equity of private sector care for sexually transmitted diseases in South Africa.

The private sector plays a major role in the delivery of health care in South Africa. Over the past two decades, the quality and equity of such provision has been questioned internationally. A study was conducted in Gauteng Province to explore these issues, using care for sexually transmitted disease (STD) as a case study. Private general practitioners (GPs) were interviewed by telephone. Each was presented with a set of STD syndromes and requested to describe how s/he would manage the patient, first if the patient was insured, then secondly if the patient was paying cash (uninsured). Reported prescriptions were costed and assessed for effectiveness against main causative pathogens using local standard clinical guidelines. Knowledge of recent developments in STD syndromic management and effectiveness of prescribed drugs was poor, especially for genital ulcer and pelvic inflammatory disease, and less than half the prescriptions overall were judged as effective. Although the effectiveness of prescriptions for insured and uninsured patients were similar, for most syndromes uninsured patients were offered significantly cheaper and less convenient antibiotic regimens. Effective regimens were also significantly more expensive than ineffective regimens. The results suggest that GPs' perceptions of patients' willingness or ability to pay for drugs have a bearing on quality of care. The paper concludes that STD patients who present to GPs are often offered poor quality of care, and the choice of inconvenient antibiotics impacts disproportionately on the poor. Improvements in the quality and equity of GP care will require interventions that address the factors that determine their behaviour.

Anti-Bacterial Agents↗
PubMed1993

Universal access to health care: a practical perspective.

Policy disconnected from economic reality is bad policy. Neither government financed health insurance nor an employer mandated health insurance approach are in the national interest. Higher national priorities compel a reallocation of resources from consumption to investment. This need not, however, cause an abandonment of efforts to deal with the problems of the uninsured and other health reforms. Successful health care reform is achievable provided it is responsive to higher priorities for economic growth. A strong economy and the production of wealth are indispensable to economic justice. Toward this end, a program of universal access is proposed whereby families and individuals are required to pay for their own health insurance up to a fixed percentage of disposable personal income before public payments kick in. Government's chief role is to establish a standard package of cost-effective benefits to be offered by all insurance carriers, the cost of which is approximately 40 percent less than conventional insurance coverage because of the elimination of reimbursement for clinically non-efficacious and cost-ineffective services. Public financing is relegated to a residual role in which subsidies are targeted on the needy. Much of the momentum for cost control is transferred to consumers and private insurers, both of whom acquire a vested interest in obtaining value for money. Uniform rules for underwriting, eligibility, and enrollment practices guard against socially harmful practices such as experience rating and exclusion of preexisting conditions. The household responsibility and equity plan described herein could free up as much as $90 billion or more for public investment in economic growth and national debt reduction while assuring access to health care regardless of ability to pay. Economic revitalization will be assisted by changes in household savings. With health care no longer a free good and government social programs concentrated on the truly needy, individual propensity to save will increase, thereby enlarging the pool of capital for financing investments in economic growth. Putting more responsibility for health care financing on households with an ability to pay also serves to reinforce and expand the work ethic. Privatizing responsibility by severing health insurance from the workplace connection improves the geographic and occupational mobility of labor, diminishes employer tendencies to discriminate against hiring the disabled and older employees, and eliminates a major source of labor unrest.(ABSTRACT TRUNCATED AT 400 WORDS)

Community Participation↗
PubMed1996

The economics of independent living: efficiency, equity and ethics.

People with disabilities are routinely denied the exercise of choice in their daily lives. There are strong efficiency arguments for the promotion of greater choice and autonomy for disabled people. There are equally strong moral arguments for an investment in the capabilities of disabled people to allow them to participate in both the educational system and the labour market. This investment will not come cheaply nor will the pay-off always be of such magnitude to justify the expenditure on narrow cost-benefit criteria. Those who value efficiency above everything else must, however, set out the system of justice implied by such a choice. The conclusions of a narrow efficiency argument may turn out to be unacceptable to the majority of citizens. Likewise, however, those who value equity at all costs must consider the implications of their approach for individual freedom, economic growth and technical efficiency. This paper is an attempt to explore the meaning of efficiency and equity in the context of independent-living programmes for people with disabilities.

Activities of Daily Living↗
PubMed2005

The economic value of an improved malaria treatment programme in Zambia: results from a contingent valuation survey.

BACKGROUND: Zambia is facing a double crisis of increasing malaria burden and dwindling capacity to deal with the endemic malaria burden. The pursuit of sustainable but equity mechanisms for financing malaria programmes is a subject of crucial policy discussion. This requires that comprehensive accounting of the economic impact of the various malaria programmes. Information on the economic value of programmes is essential in soliciting appropriate funding allocations for malaria control. AIMS AND OBJECTIVES: This paper specifically seeks to elicit a measure of the economic benefits of an improved malaria treatment programme in Zambia. The paper also studies the equity implications in malaria treatment given that demand or malaria treatment is determined by household socio-economic status. METHODS: A contingent valuation survey of about 300 Zambian households was conducted in four districts. Willingness-to-pay (WTP) was elicited for an improved treatment programme for malaria in order to generate a measure of the economic benefits of the programme. The payment card method was used in eliciting WTP bids. FINDINGS: The study reports that malaria treatment has significant economic benefits to society. The total economic benefits of an improved treatment programme were estimated at an equivalent of USD 77 million per annum, representing about 1.8% of Zambia's GDP. The study also reports the theoretically anticipated association between WTP and several socio-economic factors. Our income elasticity of demand is positive and similar in magnitude to estimates reported in similar studies. Finally, from an equity standpoint, the constraints imposed by income and socio-economic status are discussed.

Adult↗
PubMed2003

Health plans--enforcement of right to reimbursement not available under ERISA section 502(a)(3). Great-West Life & Annuity Insurance Company v. Knudson.

The United States Supreme Court reaffirmed its reluctance "to tamper with [the] enforcement scheme" embodied in ERISA by authorizing remedies not specifically authorized by ERISA's text, and held that section 502(c)(3) does not authorize a plan to bring an action to enforce the plan's reimbursement provisions because recovering monetary damages for reimbursement is not relief typically available in equity and, therefore, is not "other equitable relief" within the meaning of section 502(a)(3). An action to impose personal liability on the Knudsons for a contractual obligation to pay money is an action seeking legal, not equitable, relief and is not authorized by section 502(a)(3).

Employee Retirement Income Security Act↗
PubMed2002

Citizens' views on health insurance in Croatia.

AIM: To examine the citizens' attitudes toward health insurance and its reform in Croatia, and their views on private payments for health care services. METHOD: In 1999 and 2000, we surveyed 500 randomly selected adults from all regions of Croatia, aged 40 years and over. The questionnaire included questions on social health insurance, private payments for health care, and background information. The net response was 393 (79%). The analysis of the data collected included univariate and multivariate analyses to test the differences in the attitudes among sociodemographic and socioeconomic groups. RESULTS: Most interviewed Croatian citizens (83.2%) expressed the opinion that everybody should have access to health care services, irrespective of the health insurance contributions. However, 32.1% agreed that the utilization of services should depend on the payment of contribution; 39.1% believed that the money they contributed to health insurance corresponded to health care services they received; 60.1% agreed that insurance rate should increase proportionally to income. When asked about reforms, more than half (53.4%) thought that the current health insurance covered less benefits than 10 years earlier, whereas more than a third believed that changes offered more choice (36.9%) but less equity (37.7%), and 46% disagreed with the introduction of the basic package of health care benefits and supplementary insurance. About the same percentage of respondents thought that they had already been paying too much for health care out of their own pockets. CONCLUSION: Citizens in Croatia do not hold a positive opinion on health insurance reform. They fear the changes would bring about limitations in their social rights and increase their financial burden.

Adult↗
PubMed1999

Out-of-pocket payments for health care in Croatia: implications for equity.

AIM: To assess the distribution of out-of-pocket payments for health care in Croatia by income groups. METHODS: The study is based on data from 1994 out-of-pocket health expenditure survey carried out through interviews of randomly selected adults in two major cities of Croatia, Zagreb and Split. We analyzed co-payments for public health care services and other payments related to private practice, non-prescription medicaments, or informal payments to health care providers. Spending of each income group was analyzed as a share of its income and as proportion of total payments. RESULTS: We found an inequitable pattern of out-of-pocket health care payments. Burden of out-of-pocket expenditure was not equally distributed among income groups, with persons from the low income group paying about six times larger share of their income than the high income group. When we compared the proportions of income received by different groups with the proportions of their payments, the results indicated (again) that the low income persons payed proportionally more than those with high income. CONCLUSION: Distribution of out-of-pocket payments in Croatia is regressive, with a greater burden falling on lower income persons. Possible introduction of the mix of health care financing would need reconsideration of the policy measures to balance equity and efficiency.

Cost Sharing↗
PubMed1998

Towards the equitably efficient and transparently decidable use of public funds in the deep blue millennium.

Health economists concerned about the efficiency and equity of health care provision have focused their attention and evaluations on programmes and interventions at a population or group level. Clinicians, including those seeking to improve the quality of care by making it more evidence-based, see their task as using their clinical judgment to make the best use of the resources available to them as a result of policy decisions The existence of significant incoherence between the two (or more) levels is increasingly recognized, but clinical guidelines, the only current response, are analytically inadequate to the task of reducing it. 'Clinical Guidance Trees', on the other hand, not only have the potential to bridge the policy-clinical gap but also provide the means by which public funds can be allocated to individual patients on the basis of a societally determined willingness to pay per incremental unit of benefit. This paper aims to stimulate debate about a system in which all public funds are allocated on the basis of patient specific cost-effectiveness analyses, conducted on the basis of sociopolitically determined parameters (including equity weightings), but individualized 'quality of life' measures. The system, seeking to maximize 'equificiency', would do away with the increasingly unsustainable division between public and private sector provision and remove many expensive layers of health care decision making. While it would have many problems (including strategic behaviour various by parties), these need to be considered in the light of the problems of all alternative systems, including those of the status quo.

Decision Trees↗