Physician payments under health care reform

This study examines the impact of major health insurance reform on payments made in the health care sector. We study the prices of services paid to physicians in the privately insured market during the Massachusetts health care reform. The reform increased the number of insured individuals as well as introduced an online marketplace where insurers compete. We estimate that, over the reform period, physician payments increased at least 11 percentage points relative to control areas. Payment increases began around the time legislation passed the House and Senate—the period in which their was a high probability of the bill eventually becoming law. This result is consistent with fixed-duration payment contracts being negotiated in anticipation of future demand and competition.     

Catastrophic risk associated with out-of-pocket payments for long term care in Spain

ObjectivesThis study analyses the financial burden associated with the introduction of copayment for long-term care (LTC) in Spain in 2012 for dependent individuals.Material and methodsWe analyse and identify households for which the dependency-related out-of-pocket payment exceeds the defined catastrophic threshold (incidence), and the gap between the copayment and the threshold for the catastrophic copayment (intensity), for the full population sample and for subsamples based on the level of long-term care dependency and on regional characteristics (regional income and political ideology of party ruling the region).ResultsThe results obtained show there is a higher risk of impoverishment due to copayment among relatively well-off dependents, although the financial burden falls more heavily on less well-off households. Our findings also reveal interesting regional patterns of inequity in financing and access to long-term care services, which appear to be explained by an uneven development of LTC services (monetary transfers versus formal services) and varying levels of copayment across regions.ConclusionsThe new copayment for long-term care dependency in Spain is an important factor of catastrophic risk, and more attention should be addressed to policies aimed at improving the progressivity of out-of-pocket payments for LTC services within and between regions. In addition, formal services should be prioritised in all regions in order to guarantee equal access for equal need.     

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.     

Catastrophe and impoverishment in paying for health care: with applications to Vietnam 1993-1998

This paper presents and compares two threshold approaches to measuring the fairness of health care payments, one requiring that payments do not exceed a pre-specified proportion of pre-payment income, the other that they do not drive households into poverty. We develop indices for 'catastrophe' that capture the intensity of catastrophe as well as its incidence and also allow the analyst to capture the degree to which catastrophic payments occur disproportionately among poor households. Measures of poverty impact capturing both intensity and incidence are also developed. The arguments and methods are empirically illustrated with data on out-of-pocket payments from Vietnam in 1993 and 1998. This is not an uninteresting application given that 80% of health spending in that country was paid out-of-pocket in 1998. We find that the incidence and intensity of 'catastrophic' payments - both in terms of pre-payment income as well as ability to pay - were reduced between 1993 and 1998, and that both incidence and intensity of 'catastrophe' became less concentrated among the poor. We also find that the incidence and intensity of the poverty impact of out-of-pocket payments diminished over the period in question. Finally, we find that the poverty impact of out-of-pocket payments is primarily due to poor people becoming even poorer rather than the non-poor being made poor, and that it was not expenses associated with inpatient care that increased poverty but rather non-hospital expenditures.     

Opportunities for independent living using direct payments in mental health

Mental health service users have yet to reap the benefits of greater choice, control and independent living, which direct payments have facilitated in other groups of community care users, particularly people with physical disabilities. To redress this imbalance a national pilot to promote direct payments to people with mental health needs in five local authority sites across England was set up and evaluated. The evaluation used a multi-method approach incorporating both qualitative and quantitative data, including individual semi-structured interviews and group discussions with key stakeholders across the pilot sites. This article draws on findings from the pilot evaluation to provide a preliminary understanding of how applicable the independent living philosophy is to mental health and what opportunities direct payments offer for service users. When given the opportunity, service users were able to use direct payments creatively to meet a range of needs in ways which increased their choice, control and independence. This suggests that the benefits of greater independent living through direct payments may be realisable in mental health. However, a number of ways in which the principles of direct payments in mental health could be 'downgraded' were identified. The evaluation results indicate that a thorough understanding of the independent living philosophy needs to be developed in the context of mental health.     

Evolution of a 90-day model of care for bundled episodic payments for congestive heart failure in home care

The Centers for Medicare and Medicaid Services Innovation Center’s Episode-Based Payment initiatives propose a large opportunity to reduce cost from waste and variation and stand to align hospitals, physicians, and postacute providers in the redesign of care that achieves savings and improve quality. Community-based organizations are at the forefront of this care redesign through innovative models of care aimed at bridging gaps in care coordination and reducing hospital readmissions. This article describes a community-based provider’s approach to participation under the Bundled Payments for Care Improvement initiative and a 90-day model of care for congestive heart failure in home care.     

Financing health care in Bangladesh: Policy responses and challenges towards achieving universal health coverage

Bangladesh has attained notable progress in most of the health indicators, but still, health system of the country is suffering badly from poor funding. Issues like burden of out‐of‐pocket expenditure, low per capita share in health, inadequate service facilities, and financial barriers in reducing malnutrition are being overlooked due to inadequacy and inappropriate utilization of allocated funds. We aimed to review the current status of health care spending in Bangladesh in response to national health policy (NHP) and determine the future challenges towards achieving universal health coverage (UHC). National health policy suggested a substantial increase in budgetary allocation for health care, although government health care expenditures in proportion to total public spending plummeted down from 6.2% to 4.04% in the past 8 years. Overall, 67% of the health care cost is being paid by people, whereas global standard is below 32%. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. The country is experiencing demographic dividend with a concurrent rise of aged people, but there seems no financial protection schemes for the aged and working age populations. Such situation results in multiple obstacles in achieving financial risk protection as well as UHC. Policy makers must think effectively to develop and adapt systems in order to achieve UHC and ensure health for all.     

Out-of-pocket payments for health care in Serbia

BackgroundThis study focuses on out-of-pocket payments for health care in Serbia. In contrast to previous studies, we distinguish three types of out-of-pocket patient payments: official co-payments, informal (under-the-table) payments and payments for “bought and brought goods” (i.e. payments for health care goods brought by the patient to the health care facility).MethodsWe analyse the probability and intensity of three different types of out-of-pocket patient payments in the public health care sector in Serbia and their distribution among different population groups. We use data from the Serbian Living Standard Measures Study carried out in 2007. Out-of-pocket patients payments for both outpatient and inpatient health care are included. The data are analysed using regression analysis.ResultsThe majority of health care users report official co-payments (84.7%) and payments for “bought and brought goods” (61.1%), whereas only 5.7% health care users declare that they have paid informally. Regarding the regression results, users with an income below the poverty line, those from rural areas and who are not married are more likely to report payments for “bought and brought goods, while young and more educated users are more likely to report informal patient payments.ConclusionOverall, the three types of out-of-pocket payments are not correlated. Payments for “bought and brought goods” take the highest share of the total annual household budget. Serbian policymakers need to consider different strategies to deal with informal payments and to eliminate the practice of “bought and brought goods”.     

大病卫生支出及其影响

在讨论大病卫生支出界定标准的基础上,运用文献研究和实证分析方法,研究大病卫生支出及其对家庭经济的影响。表明发生大病支出的家庭易陷入因病致贫。卫生费用自付比例、家庭经济状况、卫生服务利用、健康及年龄因素等影响家庭大病卫生支出,低收入组更易于发生大病卫生支出;医疗保障制度对灾难性卫生支出发生率改善不明显,低收入组下降幅度相对小。低收入组应成为大病卫生筹资主要的保护对象,关注对他们的大病医疗保障问题,以减轻其大病医药负担。     

卫生筹资公平性研究--家庭灾难性卫生支出分析

借鉴国内外关于灾难性卫生支出的研究成果，简要介绍其分析思路和方法，并利用WHO提供的方法学做了模拟测算与分析，以探究中国家庭发生灾难性卫生支出的相关影响因素。     

The impact of out‐of‐pocket health expenditure on household impoverishment: Evidence from Morocco

Health financing in Morocco relies mainly on out‐of‐pocket (OoP) payments. World Health Organization (WHO) has shown that these payments can expose households to catastrophic health expenditure (hereinafter CHE) and impoverish them. The study examines the financial burden of OoP health payments on Moroccan households. Two approaches—that developed by Wagstaff and Doeslear and the one advocated by WHO—are adopted to estimate the extent of CHE. These show that 1.77% of households incurred CHE at the 40% threshold for nonfood expenditure. At the 10% threshold for total consumption expenditure, 12.8% of households incurred CHE. We find that these OoP payments have made 1.11% of Moroccan households poorer. In analyzing the determinants of CHE, we estimated an ordered probit model. It appears that any of (a) hospitalization, (b) presence of an elderly person in the household, or (c) the level of poverty increases significantly the likelihood of health expenditure becoming catastrophic. On the other hand, we find that coverage by health insurance protects against CHE.     

灾难性卫生支出分析方法研究

“灾难性卫生支出分析方法”是《卫生领域公平性系列研究方法》的组成部分。该研究在借鉴国际研究成果的基础上，结合我国实际情况对其分析方法进行探索性研究，旨在从卫生筹资公平性角度，详细阐述灾难性卫生支出的基本概念和分析方法。     

Reducing avoidable inequalities in health: a new criterion for setting health care capitation payments

Traditionally, most health care systems which pretend to any sort of rationality and cost control have sought to allocate their limited funds in order to secure equal opportunity of access for equal need. The UK government is implementing a fundamental change of resource allocation philosophy towards 'contributing to the reduction of avoidable health inequalities'. The purpose of this essay is to explore some of the economic issues that arise when seeking to allocate health care resources according to the new criterion. It indicates that health inequalities might arise because of variations in the quality of health services, variations in access to those services, or variations in the way people produce health, and that the resource allocation consequences differ depending on which source is being addressed. The paper shows that an objective of reducing health inequalities is not necessarily compatible with an objective of equity of access, nor with the objective of maximising health gain. The results have profound consequences for approaches towards economic evaluation, the role of clinical guidelines and performance management, as well as for resource allocation methods.     

Primary health care reform in Uzbekistan

In recent years, primary health care in Uzbekistan has seen dramatic changes in organization, management and financing. The Soviet multi-tiered system of primary care is being replaced by a two-tiered system, consisting in rural areas of rural physician points (SVPs) and outpatient clinics of central rayon hospitals. A state-guaranteed benefits package of primary care services has been introduced and financing is increasingly based on capitation. In addition, a considerable number of physicians and nurses have been trained in general practice. There are, however, a number of challenges that remain. One of them is the considerable regional differences that exist in health financing. Another challenge is that some rural areas have difficulties attracting primary care workers. Overall, the institutional and financial link between primary and secondary care needs to be strengthened, as at present GPs have an incentive to refer patients to higher levels of care, which is financially inaccessible for large parts of the population.     

居民个人现金卫生支出的致贫影响研究

本文通过对全国和部分省个人现金卫生支出的致贫影响研究，进一步分析卫生筹资机制对居民因病致贫的作用，以及卫生筹资在国家扶贫工作中的重要性。研究发现个人现金卫生支出是致贫的重要影响因素，而且在城乡之间、不同经济水平人群之间的致贫影响存在巨大差异。研究还发现经济的快速发展不能自发地解决贫困问题，需要制定政策进行必要的干预。     

我国常见病与罕见病住院患者医疗服务需求特点分析

目的:探索不同疾病类患者住院医疗服务需求的经济成本与治疗选择之间的关系。方法:通过计算家庭卫生筹资贡献率划分灾难性卫生支出疾病类型,应用需求函数模型预测常见病和罕见病患者住院需求的弹性系数。结果:罕见病成为灾难性疾病的比例更高;11种常见病和11种罕见病患者住院需求的价格弹性和收入弹性系数的估计值分别为-0.967、1.253和2.354、1.805。结论:我国常见病和罕见病患者的住院医疗服务均属奢侈性服务,罕见病患者的住院医疗服务需求短期呈现吉芬商品需求特点。     

Informal patient payments in maternity hospitals in Kiev,Ukraine

Maternity care in Ukraine is a government priority. However, it has not undergone substantial changes since the collapse of the Soviet Union. Similar to the entire health care sector in Ukraine, maternity care suffers from inefficient funding, which results in low quality and poor access to services. The objective of this paper is to explore the practice of informal payments for maternity care in Ukraine, specifically in cases of childbirth in Kiev maternity hospitals. The paper provides an ethnographic study on the consumers' and providers' experiences with informal payments. The results suggest that informal payments for childbirth are an established practice in Kiev maternity hospitals. The bargaining process between the pregnant woman (incl. her partner) and the obstetrician is an important part of the predelivery arrangement, including the informal payment. To deal with informal payments in Kiev maternity hospitals, there is a need for the following: (i) regulation of the “quasi‐official” patient payments at the health care facility level; and (ii) improvement of professional ethics through staff training. These strategies should be coupled with improved governance of the health care sector in general, and maternity care in particular in order to attain international quality standards and adequate access to facilities. Copyright © 2012 John Wiley & Sons, Ltd.     

Towards incentivising integration: A typology of payments for integrated care

Traditional provider payment mechanisms may not create appropriate incentives for integrating care. Alternative payment mechanisms, such as bundled payments, have been introduced without uniform definitions, and existing payment typologies are not suitable for describing them. We use a systematic review combined with example integrated care programmes identified from practice in the Horizon2020 SELFIE project to inform a new typology of payment mechanisms for integrated care. The typology describes payments in terms of the scope of payment (Target population, Time, Sectors), the participation of providers (Provider coverage, Financial pooling/sharing), and the single provider/patient involvement (Income, Multiple disease/needs focus, and Quality measurement). There is a gap between rhetoric on the need for new payment mechanisms and those implemented in practice. Current payments for integrated care are mostly sector- and disease-specific, with questionable impact on those with the most need for integrated care. The typology provides a basis to improve financial incentives supporting more effective and efficient integrated care systems.     

Local inequality and departures from publicly provided health care in Canada

This paper examines the relationship between changes in income inequality and the provision of resources in a health care system (the public‐private mix). Specifically, we investigate whether increases in income inequality, as separate from overall income levels and growth, have changed the availability of both private clinics and privately financed physicians in a context where the dominant market player is the public system. Our findings provide reasonable evidence that increases in income inequality have led to substantial increases in both. We find that moving from median level of inequality across neighborhoods to the top 1% level of inequality increases the probably of a private clinic by 40% and the probability of having physicians who have opted out of the public system by 170%.