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PubMed2000

A need for managed care in Saudi Arabia.

Is the Kingdom of Saudi Arabia getting value for money invested in health? Quality care is being provided throughout health facilities in the Kingdom, however there is minimal control of utilization in all health sectors, consequently leading to abuse and over utilization, particularly in the public sector. Managed care programs have proven effective in reducing unnecessary inpatient and ancillary service utilization by reducing use of expensive procedures and unnecessary, highly specialized services, and shifting to less expensive care options. Health maintenance organizations are the best example of a managed health care model; tracking good performance and cost savings averaging between 20-40% compared to more traditional health plans. Key features of health maintenance organizations include serving a defined population voluntarily enrolled in the health plan; assumption of contractual responsibility and financial risk by plan to provide a range of services, and payment of a fixed periodic payment by the enrollee, independent of the actual use of services. The key characteristic that distinguishes health maintenance organizations from other delivery systems is prepayment for the care that is provided. Preferred Provider Organizations offer discounts for services received from a selected set of physicians and hospitals. Services received by enrollees are not fully reimbursed from this selected list of providers. Preferred Provider Organizations use health maintenance organizations administrative processes for controlling costs but do not include some of the intrinsic cost and quality controls of health maintenance organizations. Review of several studies indicate that patients enrolled in prepaid group practices (managed care organizations) were hospitalized 15-40% less often than those enrolled in fee-for-service health plans.

Cost-Benefit Analysis↗
PubMed2003

[New models in the model (Managerial challenges in the Hungarian managed care model)].

The Hungarian managed care model integrates the different levels of health care services. Its goal is a more efficient resource allocation within the health care system, quality improvement of services, developing incentives and financing methods. The basic concept of the model is to introduce the benefits of the American managed care and the British fundholding system. The managed care model brought a new approach in the Hungarian health care system and meets a lot of expectation in both professional and political context. The model has certain problems, but these are handled at macro level. Without an integrated approach of macro, meso and micro levels is hardly believable the efficient and effective functioning of the model. Such macro level problems are the cost-efficiency versus high quality health services, financing incentives, and risk taking. At meso and micro level we are facing with questionable efficiency and effectiveness of the MCOs other health care organisations, which are based on strong bureaucratic paradigms and are convicted to a long lasting crisis in their changing environment. The integrated use of Mintzberg's management models (machine model, network model, performance-control model, virtual government model and normative-control model) adapted by us for the Hungarian managed care model could resolve certain problems or make them at least more solvable. In the changing environment of the health cares organisations the top management has to frame the change-scenario, to initiate, realise and sustain organisational changes. Achieving this, the proposed management models are a useful support. Their practical application could contribute to the efficient and effective functioning of the Hungarian managed care model at macro, meso and micro levels, as well.

Health Care Reform↗
PubMed1998

Health care reform and quality initiatives in Brazil.

BACKGROUND: The pursuit of equity in health care and universal entitlement to access of services, as health care reform concerns, were addressed at a Brazilian national health conference in 1986, in a new constitution in 1988, and in subsequent legislative and administrative actions. However, in the early 1990s, economic policies affected the federal government's ability to fund the necessary services. QUALITY IMPROVEMENT (QI): In 1994 the Ministry of Health introduced a formal QI program, whose main purpose was to disseminate a culture of QI among health care providers, payers, and users of health services. The minister of health then established a national commission on QI, which played an important role in making QI activities an important activity. A NATIONAL ACCREDITATION PROGRAM: Efforts to create an accreditation program began in 1986. Since 1994 work has proceeded on organization of a nongovernmental accreditation agency, development of national standards and procedures for the accreditation of health services, and dissemination of methods and procedures for health care quality management. QI PROGRAMS: Examples of QI programs that have been successfully implemented include those at the State of Rio de Janeiro Blood Center and the National Institute of Cancer. Since 1996, many national societies have begun to produce consensus statements and guidelines. Progress has also been made in consumer rights and protection. CONCLUSIONS: The public, health care professionals, providers, and the government are increasingly aware of the need to strengthen and develop QI initiatives for health care in Brazil. Awareness of the opportunities for improvements in health care which outcomes trigger should help contribute to their application.

Accreditation↗
PubMedDate not supplied

[Round Table "Role of scientific and professional associations in proposing occupational health programs to regional and national authorities].

The six participants at the round table were experts in the field of Occupational Prevention working respectively in the Ministry of Health, the National Institute of Occupational Health, the Health Council of Lombardy, the Law-court of Milan, the CGIL Trade Union, and the Lombard Employers Association. All the participants were of one mind on the establishment of working groups within the scientific and professional associations with the aim of preparing and updating occupational exposure limits, diagnostic records, programs of biological and environmental monitoring, etc. Moreover, they stressed the need to establish permanent cooperation between the scientific and professional associations and the regional and national health authorities. These associations can make an important contribution, for example in preparing new preventive guidelines, because they can act faster than the legislative bodies. The validity of these proposals was confirmed by the judge attending the round table. He stated that technical standards proposed by groups of professionals or by scientific associations have usually been taken into consideration when relevant legislation has been applied.

Government↗
PubMed2003

Assessing the effect of Taiwan's outpatient prescription drug copayment policy in the elderly.

OBJECTIVES: This study uses variance cost analysis and regression analysis as tools for investigating the initial effects of Taiwan's outpatient prescription drug copayment program in the elderly. Under its new National Health Insurance program, Taiwan implemented a prescription drug cost-sharing program August 1, 1999. We compare an elderly population's prescription drug use after the policy was implemented with an elderly population's prescription drug use before the policy change to describe initial and general consequences of the drug cost-sharing program. METHODS: Approximately 240,000 patients aged 65 and over representing 1,600,000 outpatient prescriptions were drawn from 21 hospitals in the Taipei area for the study using a stratified random sampling method. Variance analysis, as used primarily in accounting, was applied to decompose overall cost variance of the policy into the sum of variances of several specific factors that are important to policymakers. The cost variances of each specific factor can be further decomposed into sublevels of analyses. Regression analysis is then applied to better understand covariates that might influence drug cost variances of significant magnitude. RESULTS: The initial effects of the policy change did not reverse the trend of drug cost increases. Instead, there was a significant increase in total prescription drug costs in the cost-sharing group (approximately 12.86%) and an even higher increase rate in the non-cost-sharing group (approximately 51.42%). The main reason for the drug cost increase for the cost-sharing group was attributed to an increase in average drug costs per prescription (explaining 69.20% of the variance). We found physicians seemed to prescribe more expensive drugs and extend prescription duration, especially when drug costs exceed the upper bound of the cost-sharing schedule. By contrast, the main factor contributing to the increase in drug costs for the non-cost-sharing group was an increase in average prescription duration (explaining 64.98% of the variance). The increase mainly results from the effect of extended prescriptions for chronic diseases that were designed to reduce unnecessary visits for refills. DISCUSSION: The significant increase in average drug price per prescription indicates that many prescriptions could move above the upper bound of the cost-sharing schedule. The results suggest that the Bureau of National Health Insurance should increase the upper bound. We do not think these effects are unique to Taiwan. Rather, these effects should be considered as countries change their outpatient drug benefit programs. We also found a decrease in utilization of essential drugs with an increase in utilization of nonessential drugs for patients subject to copayments. The results suggest potential adverse effects on patients' health outcome.

Accreditation↗
PubMed2003

Medical care use and selection in a social health insurance with an equalization fund: evidence from Colombia.

This paper studies the relationship between health status and insurance participation, and between insurance status and medical use in the context of a social health insurance with an equalization fund (SHIEF). Under this system, revenues from a mandatory payroll tax are collected into a single pool (equalization fund) that reimburses for-profit insurance companies according to a capitated formula. Although competition should induce insurers to control costs without reducing the quality of service necessary to attract consumers, limitations in the capitation formula might induce insurers to select against bad risks, and limitations in the contribution system might induce more healthy individuals to evade enrollment. A three-equation model having social health insurance, private health insurance, and using medical services is estimated using a 1997 Colombian household survey. Consistent with similar studies, participation in SHIEF increases medical care use. On the other hand, the evidence on selection is somewhat mixed: individuals who report good health status are more likely to participate in SHIEF, while those without a chronic condition are less likely to participate in SHIEF.

Capitation Fee↗
PubMed2002

Private medical practitioners and managed care in Malaysia: a survey of knowledge and attitudes held by Federal Territory based doctors.

This paper considers the subject of managed care in Malaysia, providing a questionnaire-based analysis of the position adopted by private medical practitioners. Managed care is now seen as the dominant health care system in the United States, with many other countries around the world including Malaysia beginning to selectively use component parts to tackle particular health care problems. In this survey it was found that three out of four respondents have concerns regarding the implementation of managed care. The survey was used to identify and categorise these concerns. At the same time, three out of four respondents held the opinion that principles of managed care were already a reality or would be in the next 5 years. This group expressed an eagerness to be trained in managed care principles and be given the opportunity to be part of managed care organisations. It is argued that clinicians' knowledge and interest perceptions are an important influence on the implementation of managed care based systems. The survey-based evidence presented in this article is intended as a measure of current understandings and beliefs, in relation to clinical micro-management process associated with managed care.

Adult↗
PubMed1998

The National Comprehensive Cancer Network: present and future directions.

The National Comprehensive Cancer Network (NCCN) has developed an extensive set of practice guidelines that cover approximately 90% of all cancer patients. These guidelines are steadily becoming the standard for clinical and coverage policy. The guideline development process is integrated directly with the development of a multiinstitutional data base that will permit measurement of adherence of practice to the NCCN guidelines and provide important clinical and other outcomes data. The NCCN is forming partnerships with managed care companies in the guideline/data base area to facilitate the delivery of more effective and efficient care in oncology.

Cancer Care Facilities↗
PubMed1997

The effect of universal health insurance on health care utilization in Taiwan. Results from a natural experiment.

CONTEXT: The government of Taiwan introduced universal health insurance to cover all citizens in 1995. This national health insurance program was proposed to assure the accessibility to health care at reasonable cost. Evaluation of the consequences, including health care utilization and expenditure, is crucial for policy adjustment. OBJECTIVES: To evaluate the effect of Taiwan's national health insurance on health care utilization. DESIGN: Cohort survey conducted before and after the implementation of the national health insurance program. PARTICIPANTS: A total of 1021 randomly selected Taiwanese adults. MAIN OUTCOME MEASURES: Physician visits in the 2 weeks prior to the survey and hospital admissions and emergency department visits in the immediate past year. RESULTS: After the introduction of universal health insurance, the newly insured consumed more than twice the amount of outpatient physician visits (0.21 vs 0.48, P<.05) and hospital admissions (0.04 vs 0.11, P<.05) than before universal health insurance was implemented, bringing them to the same amount of health care contacts as the previously insured group. The newly insured also experienced an insignificant increase in emergency department visits. In contrast, the previously insured group had a small but statistically significant increase in outpatient visits (0.48 vs 0.59, P<.05) and insignificant changes in hospital admissions and emergency department visits. CONCLUSION: The universal health insurance removed some barriers to health care for those newly insured. The copayment design in the insurance scheme seemed to have an insignificant effect on curbing medical care utilization. Taiwanese health policy analysts should seriously consider the growth of health care expenditures since the implementation of universal health insurance.

Adult↗
PubMed1997

Bridging student health risks and academic achievement through comprehensive school health programs.

In the National Action Plan for Comprehensive School Health Education, representatives for over 40 health, education, and social service organizations viewed education and health as independent systems. Participation concluded that healthy children learn better, and they cautioned that no curriculum can compensate for deficiencies in student health status. While literature confirms the complexity of health issues confronting today's students, schools face enormous pressure to improve academic skills. Local school leaders and stakeholders often remain unconvinced that improving student health represents a means to achieving improved academic outcomes. A rich body of literature confirms a direct link between student health risk behavior and education outcomes, education behavior, and student attitudes about education. This article summarizes relevant information concerning the health risk behavioral categories of intentional injuries; tobacco; alcohol, and other drugs; dietary, physical activity, and sexual risk behaviors.

Adolescent↗
PubMed1997

A national strategy for research and development: lessons from England.

Increasing concern about the state of basic and clinical research in England during the 1980s led to an influential parliamentary review. Surprisingly, the review recommended the strengthening of public health and health services research through the establishment of a research and development (R&D) program for the National Health Service (NHS). The program that started in 1991 was unique in that it was fully integrated into the management structure of the NHS. No country had ever attempted such an ambitious approach. While a review of the first five years of the program reveals many achievements, it also raises several concerns: Debate about the philosophy and aims of the program continues; the need to maintain political support requires constant attention; policy changes in other areas need to be accommodated; central control of a national, coordinated R&D program has to be guarded; methods of priority setting need to be enhanced; insufficient human resources to run the program have to be contended with; and the program needs to be rigorously evaluated. Other countries with a unified health system could learn much from the English experience. Countries with pluralist systems might benefit from specific parts of the experience.

Health Policy↗