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PubMed2001

Public subsidies for employees' contributions to employer-sponsored insurance.

Proposals to provide or subsidize health insurance for low-income families must take account of the fact that many workers have access to employer-sponsored insurance (ESI), but decline it because of required employee premium contributions. This article considers a tax credit for the employee share of ESI in the context of a broader program of income-based health insurance tax credits. Helping uninsured workers pay for available ESI could be more cost-effective than subsidizing their coverage in the nongroup market. The credit would also be available to workers who were already covered, both for equity reasons and to reduce the incentives for employers to drop coverage or for workers to shift to subsidized individual plans. One key issue is how to prevent employers from reducing their current health plan contributions to take advantage of the new funding. Other design questions considered by the article include whether workers should be able to choose between ESI and nongroup coverage, whether minimum benefit standards should apply for employer plans, and how to achieve a fair balance in subsidies for group and nongroup coverage.

Cost-Benefit Analysis↗

PubMed1994

Global trends in health care reform.

Health systems throughout the world are hard pressed to curb costs and safeguard quality. In general, the users of health services are having to pay more for them, and in some cases this is making the system unsustainable. Even where costs can be met, the payment mechanisms used can make a decisive difference in terms of equity and efficiency.

Financing, Government↗

PubMed1999

Priority care for employees: a blessing in disguise?

This paper discusses the efficiency and equity effects of priority care for employees. Recent privatization of workers' compensation insurance in the Netherlands caused an increasing tension between public responsibility for health care cost-containment and private responsibility for sick pay. As a result of strict supply side regulation, waiting lists increased, while at the same time employers became fully responsible for sick pay. To reduce sick pay and production losses, employers are prepared to pay for priority care by using available excess capacity. We argue that the criteria of Pareto and Rawls can provide a rationale for the resulting differential treatment of employees and non-employees. However, such a justification crucially depends on weights society assigns to absolute versus relative improvements in access to health care.

Cost-Benefit Analysis↗

PubMed2006

Getting women to hospital is not enough: a qualitative study of access to emergency obstetric care in Bangladesh.

OBJECTIVE: To explore what happened to poor women in Bangladesh once they reached a hospital providing comprehensive emergency obstetric care (EmOC) and to identify support mechanisms. DESIGN: Mixed methods qualitative study. SETTING: Large government medical college hospital in Bangladesh. SAMPLE: Providers and users of EmOC. METHODS: Ethnographic observation in obstetrics unit including interviews with staff and women using the unit and their carers. RESULTS: Women had to mobilise significant financial and social resources to fund out of pocket expenses. Poorer women faced greater challenges in receiving treatment as relatives were less able to raise the necessary cash. The official financial support mechanism was bureaucratic and largely unsuitable in emergency situations. Doctors operated a less formal "poor fund" system to help the poorest women. There was no formal assessment of poverty; rather, doctors made "adjudications" of women's need for support based on severity of condition and presence of friends and relatives. Limited resources led to a "wait and see" policy that meant women's condition could deteriorate before help was provided. CONCLUSIONS: Greater consideration must be given to what happens at health facilities to ensure that (1) using EmOC does not further impoverish families; and (2) the ability to pay does not influence treatment. Developing alternative finance mechanisms to reduce the burden of out of pocket expenses is crucial but challenging. Increased investment in EmOC must be accompanied by an increased focus on equity.

Academic Medical Centers↗

PubMed1994

The Clinton health-care reform plan: does it serve the underserved?

During the 1992 presidential campaign, Governor Clinton promised, if elected, to provide leadership from the Oval Office for sweeping, comprehensive reform of the U.S. health-care system to benefit all Americans. The President's ambitious blueprint, as outlined on September 22, 1993, falls short of this pledge. For the majority of the nation's poor and underserved, the proposed plan insufficiently ensures universal access, social equity, comprehensiveness of benefits, affordability, and high-quality health-care services. Requiring all employers to provide, and employees to share the cost of, health-insurance coverage could decrease take-home pay for many of the working poor. In addition, the President's proposed cost-containment efforts, which include global budgetary targets and reductions in Medicare and Medicaid reimbursement, could result in the elimination of over 1.0 million positions in the healthcare field. These potential outcomes are alien to the President's earlier axioms to reform the U.S. health-care system, and to improve the nation's economic climate to foster the creation of more and better-paying jobs.

Health Care Reform↗

PubMed1994

Converting existing real estate assets to cash through off-balance sheet financing.

Hospitals are realizing that they can tap hidden equity tied up in their medical office buildings and other ancillary facilities and use the capital to grow their core health care business, retool patient rooms, purchase equipment, technology, and physician practices, or simply pay down debt. Through selling their ancillary real estate assets, they can generate much-needed capital liquidity, yet still retain the control they need through restrictive covenants on uses and tenancies, repurchase options, rights of first refusal, and master leasing with creative options to expand or contract.

Ambulatory Care Facilities↗

PubMed1990

Improving payments for Medicare patients with unrelated surgical procedures.

The Medicare prospective payment system (PPS) pays hospitals a fixed payment for patients in 474 categories of diagnosis-related groups (DRGs). Since the beginning of PPS, many DRGs have been modified to improve the accuracy of patient classification and the equity of hospital payments. There are continuing problems, however, in classifying surgical patients who have no procedure related to their reason for admission. Until recently, these patients were classified into a single miscellaneous category (DRG 468) and paid the same amount, despite considerable variation in their clinical conditions and resource use. Three options for improving the payment and classification of such cases were examined. Improvements are possible using each of the options examined. The greatest improvement, however, was achieved by reassigning patients to existing surgical DRGs, because patients with the same surgery tend to have similar costs, regardless of their original reason for entering the hospital. This change in assignment methodology would increase payments to teaching hospitals, where the most costly DRG 468 cases are concentrated. It also would remove potential incentives to deny access to or withhold appropriate treatments from patients needing high-cost surgical procedures. It was concluded that this change should be implemented for hospital payment under PPS.

Diagnosis-Related Groups↗

PubMed1989

Case-mix reimbursement for nursing homes: objectives and achievements.

Six state Medicaid programs currently use case-mix reimbursement (CMR) systems to pay nursing homes. Quality of care is not decreased under these payment systems and may actually have increased in some instances, while access for heavy-care Medicaid patients appears to have improved. As for equity of payment, CMR methods when compared with others tend to redistribute funds more in accord with resident care needs. Not all of the six states have made cost containment an explicit objective, and program administration costs typically increase. Since CMR systems primarily affect relative payments, however, they can be shaped to achieve total program expenditure objectives.

Cost Control↗

PubMed1987

Health expenditure by area in Finland--an indicator of equity.

The responsibility of organizing and funding health services has in Finland been delegated to small local government units (to 461 communes, average pop. about 11,000), but not to counties or provinces like e.g. in other Nordic countries. PHC is organized by one or few communes and for the specialist level services they have formed 21 Central Hospital Regions (CHR). The central government pays per cent subsidies which are weighted on the basis of income of each community. In 1982 the average share of central government was 44.3% and the communes were responsible for 28.6% of the total expenditure. The national sickness insurance is subventing mainly private services. Its share was in 1982 about 11%. Direct personal costs were about 16%. There are no marked regional differences in the structure of services, e.g. the average share of inpatient care expenditure was 53% and the differences between regions small (z 6%). Total expenditure varied as indexes between regions from 82 tot 119. One reason is the high costs of some university hospitals which do not receive full compensation for services made available to other regions. The expenditure by region did not correlate at all with indicators of ageing. The same can be said of areal differences in income level. Only SMR, a crude indicator of the level of health, correlated positively with expenditure. It is concluded that the areal equity is acceptable if measured with expenditure. The general structure of services does not markedly differ between CHRs. The total health expenditure has been and will remain at the relatively low level of 6.5-7.0% of the GNP. The involvement of small communes is seen as a favourable basis of controlling the expenditure and developing an efficient service system.

Catchment Area, Health↗

PubMed1987

Fair rental systems: paying nursing homes for capital costs.

Fair rental systems pay an imputed rent for the housing a nursing home provides for its residents. The rent is paid in place of reimbursement for capital costs covered by the system--depreciation, interest, lease payments, and return on equity capital. It is an approach that is intended to overcome the inflationary incentives of cost-based reimbursement. Several state Medicaid programs have adopted fair rental systems using different approaches. And although it is too early to tell which approach is best, one point seems clear--a fair rental system can be a distinct improvement over cost-based reimbursement, depending on design and administration.

Capital Financing↗

PubMedDate not supplied

The value of electronic health records in community health centers: policy implications.

This paper analyzes the costs and benefits of electronic health records (EHRs) in six community health centers (CHCs) that serve disadvantaged patients. EHR-related benefits for most study CHCs did not pay for ongoing EHR costs, yet quality improvement (QI) was substantial. Compared to private practices, CHCs cannot use EHRs to increase visit coding levels and revenues, yet they likely use EHRs more aggressively for QI, which raises equity questions. The evidence suggests that policies are needed that help CHCs to afford EHRs and produce more EHR-related QI gains, including through grants and QI performance rewards.

Ambulatory Care Information Systems↗

PubMed2004

Out-of-pocket and informal payments in health sector: evidence from Georgia.

This study presents an in-depth investigation of out-of-pocket payments for health services, formal and informal, in the Republic of Georgia. The main purpose of the study is to: (a) analyze the process of collection and distribution of out-of-pocket or direct payments and particularly of the informal component; (b) explain why they seem to be so prevalent; (c) investigate their consequences, especially on access and quality of health care services. The findings of this study are derived from in-depth interviews and focus group discussions with users as well as providers. The study found that in general paying for health services in Georgia has become a really common and mostly accepted practice, and that a significant share of these payments are completely unrecorded. The extent of direct payments for health services are producing severe consequences on both equity and efficiency, making services unaffordable for most people, and leading to under funding of essential inputs. The policy implications of the study findings are challenging. First, the study clearly points out the deep-rooted and multidimensional reasons why out-of-pocket payments are pervasive, and why an important share of them is collected informally. Second, the study highlights that there is no simple solution. In particular, some of the solutions frequently proposed in the international debate, such as simply formalizing user charges, in the Georgian context appear impractical.

Financing, Personal↗

PubMed1995

Audience sceptical as critic challenges current system for paying Canada's MDs.

A recent CMA-sponsored conference on negotiations brought medical leaders from across Canada to Ottawa in September to hear experts discuss the current health care environment. Among the speakers was Dr. Michael Rachlis, a widely quoted critic of physicians' current role in the health care system. He said physicians and patients currently face major "equity issues," as some patients have a difficult time finding medical help because their serious illnesses are "worth" less to doctors, many of whom prefer to see patients with simple problems that can be dealt with in a few minutes. Several physicians reacted strongly to the criticism.

Canada↗

PubMed2000

Challenges for health systems in member countries of the Organisation for Economic Co-operation and Development.

For reasons of equity most OECD countries have chosen to base their funding of health care mainly on public sources. There is an almost universal problem of affordability in the health systems of these countries, arising from the tension between the willingness of populations to pay taxes and the eagerness of patients to use health services where these are free or heavily subsidized at the point of use. These tensions are likely to be exacerbated by a surge of new medical technologies adding to demands for health care. Some observers have predicted the breakdown of publicly funded systems of health care under new spending pressures. However, governments can deploy a range of policies for handling new demands. They can also take comfort from the fact that many of them have already coped with successive waves of technological change in health care without abandoning their core commitment to the public funding of health systems. Furthermore, if standards of living continue to rise, public and private insurers should find it easier to obtain the revenues needed to pay for the improved health care expected by consumers.

Delivery of Health Care↗

PubMed2006

The distribution of net benefits under the National Health Insurance programme in Taiwan.

The redistributive effects of a social insurance programme are determined by how the programme is paid for-who pays and how much do they pay?-and how the benefits are distributed. As a result, the redistributive effects of a social health insurance programme should be evaluated on the basis of its net benefit-the difference between benefits and payment. Among the rich body of empirical analysis on equity in health care financing, however, most studies have relied on partial analysis, assessing equity by source of financing while ignoring the benefit side, or looking at equity in benefits but ignoring the funding side. Either approach risks misleading findings. In this study, therefore, the primary objective was to assess the distribution of net benefits across income groups under Taiwan's National Health Insurance (NHI) programme. This study observed a nationally representative sample of 74 012 NHI enrolees from 1996 to 2000. The unique NHI databases in Taiwan provide comprehensive enrolment and utilization information, and allowed linkage to each enrolee's income tax files. In addition to crude estimates, two-part models and ordinary least-square models were used to adjust inpatient and outpatient benefits for health care needs (age, sex, major disease status and physical disability). After adjusting for health care needs, the distribution of net benefits showed an apparent pro-poor pattern, with the lowest income group receiving the highest net benefits (NT$3353) and the top income group receiving the lowest net benefits (-NT$3072) in 1996. Although a clear pro-poor pattern was observed among those enrolees who paid wage-based premiums, this vertically equitable pattern was less evident among the enrolees who paid fixed premiums. Overall, a trend of increasing net benefits was observed in all income groups between 1996 and 2000, and all the NHI enrolees can be considered better off over time. In addition to contributing to the limited literature on equity in net benefits, the study provides an important policy reference to developing countries with large underground economies and relatively small populations of regular wage-earners as it indicates that using fixed premiums as a major financing scheme may pose a serious equity concern and policy challenge.

Adult↗

PubMed1990

Financing long-term care. An insurance-based approach.

A joint public-private insurance program is the best approach to resolving the problem of financing long-term care. In this report, we describe one possible approach in detail. A modest expansion of the current (ie, after repeal of the Medicare Catastrophic Coverage Law of 1988) Medicare benefit for persons needing relatively short-term nursing home and home care services would be a first step. For those with extended long-term service needs, a non-means tested, publicly funded program with joint federal-state financing and administration would provide coverage after a substantial elimination period and with an income-related copayment. Private long-term care insurance purchased through employers before retirement or in the periretirement period, through use of income or equity accumulated in life insurance, pension funds, or home ownership, would be used to fund the exclusionary period or copayments of the public program by those who wish to have greater protection for income or assets. The role of Medicaid would be limited to paying for the deductible, copayments, and initial long-stay expenses of those with low incomes and limited assets.

Cost Allocation↗

PubMed2005

Monitoring of National Drug Policy (NDP) and its standardized indicators; conformity to decisions of the national drug selecting committee in Iran.

BACKGROUND: Pharmaceuticals have made an important contribution to global reductions in morbidity and mortality. To help save lives and improve health, it is important to be sure about equity to access to drugs, drug efficacy, quality and safety, and rational use of drugs, which are standardized National Drug Policy (NDP) objectives. NDP's indicators are useful to evaluate the pharmaceutical system performance in a country. Iran has adapted a National Drug List (NDL). Since management of drug supply in Iran takes place only for drugs that have been selected in NDL and this list is selected by the member of Iran Drug Selecting Committee (IDSC), thus evaluation of IDSC's decision making during last 5 years is an appropriate way to evaluate the implementation of drug supply system in the country. METHODS: To identify strengths and weaknesses of pharmaceutical policy formation and implementation in Iran, four standard questionnaires of the World Health Organization (WHO) were used. To assess the agreement between decisions of IDSC and standardized NDP indicators in the last 5 years (1998-2002), a weighted questionnaire by nominal group technique based on the questions that should be answered during discussion about one drug in IDSC was designed and used. RESULTS: There is a totally generics based NDP with 95% local production, that provides affordable access to drugs. The system, structures, and mechanisms were in place; however, they did not function properly in some topics. Assessment of 59 dossiers of approved drugs for adding to NDL during last 5 years showed that IDSC's members pay more attention to efficacy, safety, and rationality in use rather than accessibility and affordability. CONCLUSION: Revision of drug system in term of implementation of the processes to achieve NDP's objectives is necessary to save public health. Clarification of NDP's objectives and their impact for IDSC's members will result in improvement of the equity in access to pharmaceuticals.

Journal Article↗

PubMed1996

Subtractive versus Ratio Model of "Fair" Allocation: Can the Group Level Analyses Be Misleading?

Two models of equity judgments are ratio and subtraction. Proponents of the former assume a linear relationship between the subjective feelings of equity and their overt expressions; those of the latter assume a monotonic relationship. Consequently, the ratio and subtractive rules are tested with the raw and monotonically rescaled data, respectively. I evaluated these two approaches with managers and students from India. Experiment 1 varied merit and pay of two persons and obtained judgments of difference between unfairness to them. Experiments 2 and 3 manipulated two inputs of two persons and studied "fair" reward for them. I analyzed both the raw and rescaled data at the group and individual levels. The group analyses supported the ratio model; the individual analyses showed that majority was consistent with the subtractive model. Discrepant results from these analyses were due to individual differences in the models employed and use of the response scale. Implications of the findings are discussed for cross-cultural and developmental research in "fair" allocation.

Journal Article↗