Private payers of health care in Brazil: characteristics, costs and coverage

The private sector is the predominant provider of health care in Brazil, particularly for inpatient services, and financing is a mix of public (through a prospective reimbursement system) and private. Roughly a quarter of the population has private insurance coverage, reflecting rapid growth in the past decade fuelled by the crisis in the public reimbursement system and the perceived deterioration of publicly provided care. Four major forms of insurance exist: (1) prepaid group practice; (2) medical cooperatives, physician owned and operated preferred provider organizations; (3) company health plans where employers ensure employee access to services under various types of arrangements from direct provision to purchasing of private services; and (4) health indemnity insurance. Each type of plan includes a wide variety of subplans from basic individual/family coverage to comprehensive executive coverage. The paper discusses the characteristics, costs and utilization patterns of all types of privately financed care, as well as the major problems associated with private financing: the limited package of benefits and low payout ceilings, inadequate consumer information and virtually no regulation.     

Private medicine and the privatisation of health care in South Africa

Health services in the Republic of South Africa (RSA) are provided by a mixture of public and private providers and institutions. Estimates of total health-related expenditure for 1985 range between 5.3% and 5.9% of gross national product (GNP), divided on approximately a 55:45 basis between public and private sectors. Basic preventive and curative services are provided by a hospital- and clinic-based public system. The public system does not adequately serve the rural areas and African tribal bantustans, and racial discrimination and/or segregation are obvious in its organisation and funding. The public sector's strength is the provision of state-subsidised care to many citizens who are unable to afford private medicine. The vast majority of hospitals are operated on a non-profit basis by government, industries, and voluntary agencies. Excluding hospitals that receive state subsidies, private investor-owned hospitals control about 10% of all hospital beds in the RSA. One-third of these investor-owned beds are held by state-dependent contractors providing long-term care. Two-thirds are wholly independent. Growth has been rapid in the independent hospital sector, and major corporations have entered the market. In 1985, over 85% of the white population was privately insured by a variety of prepayment programmes, including those organised through parastatal corporations and government departments. Despite major enrollment growth in the preceding decade, only 8% of blacks held private insurance by 1985; their coverage also tended to be less comprehensive. Faced with deficit financing, a sluggish economy, complaints from its white constituency about taxation levels, and pressure from private sector interest groups, the Nationalist government has endorsed the concept of privatisation of health care. Exponents of privatisation claim that it will permit differentiation by income to supplant discrimination by race. However, the direct links between disposable income and race, the rapidly rising costs of private insurance, and the still-limited extent of private coverage among the black majority, indicate that privatisation is likely to co-opt a comparatively small proportion of the total black population. It may exacerbate the urban-rural imbalance in health status and health services, promote growth of hospital-intensive curative services rather than needed expansion of community-centred preventive and primary care, and create financial barriers to access for low-income patients.(ABSTRACT TRUNCATED AT 400 WORDS)     

Reforming China's urban health insurance system

China's urban health insurance system is mainly consisted of labor insurance schemes (LIS) and government employee insurance scheme (GIS). LIS is a work unit-based self-insurance system that covers medical costs for the workers and often their dependents as well. GIS covers employees of the State institutions, is financed by general revenues. Since 1980s, China has implemented series of health insurance system reforms, culminating in the government's major policy decision in December of 1998 to establish a social insurance program for urban workers. Compared with the old insurance systems under LIS and GIS, the new system expands coverage to private sector employees and provides a more stable financing with its risk pool at the city level. Despite of these advantages, implementation of China's health insurance reform program is faced with several major challenges, including risk transfer from work units to municipal governments, diverse need and demand for health insurance benefits, incongruent roles of the central and regional governments. These challenges may reflect practical difficulties in policy implementation as well as some deficiencies in the original program design.     

If they get sick, they are in trouble: health care restructuring, user charges, and equity in Vietnam.

The transition from a centrally planned economy in the 1980s and the implementation of a series of neoliberal health policy reform measures in 1989 affected the delivery and financing of Vietnam's health care services. More specifically, legalization of private medical practice, liberalization of the pharmaceutical industry, and introduction of user charges at public health facilities have effectively transformed Vietnam's near universal, publicly funded and provided health services into a highly unregulated private-public mix system, with serious consequences for Vietnam's health system. Using Vietnam's most recent household survey data and published facility-based data, this article examines some of the problems faced by Vietnam's health sector, with particular reference to efficiency, access, and equity. The data reveal four important findings: self-treatment is the dominant mode of treatment for both the poor and nonpoor; there is little or no regulation to protect patients from financial abuse by private medical providers, pharmacies, and drug vendors; in the face of a dwindling share of the state health budget in public hospital revenues and low salaries, hospitals increasingly rely on user charges and insurance premiums to finance services, including generous staff bonuses; and health care costs, especially hospital costs, are substantial for many low- and middle-income households.     

Health care cost containment strategies: the Jordanian experience

Jordan's relative success in containing costs is the result of public financing of the health insurance system, the health care system reform strategy, and expanding the primary care network, which allows for cost containment and universal access based on the need for services rather than the ability to pay. The shift of costs from the public to the private sector must be curtailed. The determinants of health care (i.e. environment; human biology; life style; and health care system) are the main factors that determine future spending on health.     

Health care in China: the role of non-government providers

While China's health services are primarily financed by out-of-pocket spending (private financing), health care providers, especially the hospital industry, are still dominated by state ownership and government control (public provision). Even though the private sector plays an increasing role in the ambulatory sector, private services are not included in the social insurance benefit package, and thus, it primarily serves self-paying patients. The ambiguity of the government policy toward private provision stems from concerns that an increasing private sector would drive up costs and its services may be of questionable quality. This paper tries to gather evidence on the relative performance of private and public sector in China. Neither literature review nor our primary data analysis provides any support for the notion that the private sector charges a higher price and they serve primarily the better-off people. Quite on the contrary, available data seem to suggest that not only the private sector tends to serve disproportionately the low-middle income groups (this may well be due to its relative lower direct and indirect costs), consumer satisfaction also seems to be higher with regards to certain dimensions of the private than public sector.     

Reform follows failure: I. Unregulated private care in Lebanon

This first of two papers on the health sector in Lebanon describes how unregulated development of private care quickly led to a crisis situation. Following the civil war the health care sector in Lebanon is characterized by (i) ambulatory care provided by private practitioners working as individual entrepreneurs, and, to a small extent, by NGO health centres; and (ii) by a fast increase in hi-tech private hospitals. The latter is fuelled by unregulated purchase of hospital care by the Ministry of Health and public insurance schemes. Health expenditure and financing patterns are described. The position of the public sector in this context is analyzed. In Lebanon unregulated private care has resulted in major inefficiencies, distortion of the health care system, the creation of a culture that is oriented to secondary care and technology, and a non-sustainable cost explosion. Between 1991 and 1995 this led to a financing and organizational crisis that is the background for growing pressure for reform.     

Die Krankenhausversorgung im internationalen Vergleich

The article deals with data on expenditure, capacities and services of hospitals in comparative perspective and information on the structure of the health care systems and the hospital sector in OECD member states. International comparison shows that German hospitals by no means are particularly expensive. Therefore, the fact that Germany’s health care sector is very costly is explained by other factors, i.e. comparatively high costs of pharmaceuticals. In addition, the article shows that countries with social insurance-based health care systems usually favor the planning of hospital capacities by public authorities, not by the social health insurance funds. Like in Germany, in most other countries different systems for the financing of capital and running costs do exist. DRGs are getting more important everywhere, however, there is no example for a country using DRGs as a remuneration system for all hospital services.     

Out-of-pocket expenditures for hospital care in Iran: who is at risk of incurring catastrophic payments?

Since the beginning of 1980s, the Iranian health care system has undergone several reforms designed to increase accessibility of health services. Notwithstanding these reforms, out-of-pocket payments which create a barrier to access health services contribute almost half of total health are financing in Iran. This study aimed to provide a greater understanding about the inequality and determinants of the out-of-pocket expenditure (OOPE) and the related catastrophic expenditure (CE) for hospital services in Iran using a nationwide survey data, the 2003 Utilisation of Health Services Survey (UHSS). The concentration index and the Heckman selection model were used to assess inequality and factors associated with these expenditures. Inequality analysis suggests that the CE is concentrated among households in lower socioeconomic levels. The results of the Heckman selection model indicate that factors such as length of stay, admission to a hospital owned by private sector or Ministry of Health and Medical Education, and living in remote areas are positively associated with higher OOPE. Results of the ordered-probit selection model demonstrate that length of stay, lower household wealth index, and admission to a private hospital are major factors contributing to the increase in the probability of CE. Also, we find that households living in East Azarbaijan, Kordestan and Sistan and Balochestan face a higher level of CE. Based on our findings, the current employer-sponsored health insurance system does not offer equal protection against hospital expenditure in Iran. It seems that a single universal health insurance scheme that covers health services for all Iranian—regardless of their employment status—can better protect households from catastrophic health spending.     

我国长期护理保险试点方案比较研究——基于内容分析法

本文采用内容分析法,从政策出台部门、失能评估标准、筹资机制、护理服务方式和待遇支付5个方面,选取全国28个长期护理保险试点城市,对其政策进行比较.建议我国在建立长期护理保险制度的过程中发挥国家医保局在长期护理保险推行过程中的指导作用,并完善失能评估标准.各试点应逐步拓宽长期护理参保覆盖面,强调单位和个人的筹资责任,因地...     

Paying the hospital: American problems and foreign solutions

Hospital financing in the United States suffers from many problems. Many persons lack access because they lack third-party coverage. Among those covered, benefits vary, and persons receive unequal services. Costs are high and are uncontrolled. The hospital is burdened by complicated relations with many payers. In order to cover their costs and earn extra cash, hospitals overcharge the more generous third parties, and recriminations result. All other developed countries have either statutory health insurance, national health services, or full public financing of privately managed hospitals. Whatever the financing method, all countries avoid the problems prevailing in the United States. All citizens are covered, all have access, and hospitals reject no one for financial reasons. All citizens have equal benefits and receive the same basic services. Regulation by government and negotiations with health insurance carriers guarantee the hospital's operating costs to service its catchment area adequately, but also prevent the hospital from installing excessive equipment and excessive staff. Each hospital is paid by all-payer standard rates, administration of reimbursement is simple, and shifting of costs among payers is both unnecessary and administratively impossible. Costs are contained by the total management of the system, not by fragmented efforts by separate insurance carriers. Considerable strategic thinking by government, the providers, and other interest groups sets guidelines for spending levels every year to meet the country's clinical needs but also to stay within its fiscal capacity. Capital investment for new treatments depends on government grants and evaluation of needs.     

An analysis of use of the health services by financing system: Brazil 1998-2008

This article analyzes the use of health services from the perspective of financing based on PNAD/IBGE micro-data related to 1998, 2003 and 2008. Among the main results, the following can be highlighted: 1) The Unified Health System (SUS) continues to be the major financing agent of most consultations and hospitalizations in Brazil; its participation increased significantly between 1998 and 2003 and remained almost stable between 2003 and 2008; 2) SUS participation in financing the use of the health services has been predominant in all Brazilian regions, especially in the North and North-East, which feature the most precarious socio-economic and health conditions; 3) SUS is the major financing agent of the two extreme levels of complexity of health care: primary care and high complexity services. 4) In spite of a significant rise in utilization rates of SUS services for consultations and hospitalizations, great inequities can still be observed between the population that exclusively uses SUS and that which has private health insurance; 5) There has been an increase in the use of SUS health services by part of the population with private health insurance plans.     

Should we abolish the private health insurance industry?

Health care financing can be based on one of two conflicting principles: health care as a right versus the insurance principle. The former assures equal access to care for all people regardless of income, while the latter requires each grouping in society to pay its own way. In the United States, health financing has utilized both principles, with employer-sponsored group health insurance approximating health care as a right. However, the insurance principle is increasingly eroding this right. In five major areas, the private health insurance industry has serious flaws: it has contributed to health care inflation; it wastes billions in administrative and marketing costs; it is unfair to many groups in society; it has undermined the positive features of health maintenance organization reform; and it has far too much political and economic power. In order to establish health care as a right as the guiding principle of U.S. health care financing, the private health insurance industry and the insurance principle should be abolished.     

Intramural health care budgeting.

In the last years endeavours have been made in several health systems to get a firm grip on the explosive cost development in hospitals which amounts to nearly half of all health care expenditures. The fee-for-service system for doctors coupled with the professional autonomy leads to expansion of quality and quantity of services provided. In many systems hospitals are financed on basis of output items as patient days, examinations and therapies. As hospital costs are in the short run preponderantly constant prices fixed at average costs are higher than marginal costs. This situation favours expansion of services as in that case marginal revenue exceeds marginal cost. Inversely the decrease of services provided generates losses for the hospital. In systems, where financing takes place in the way of budgets like the U.K., Denmark and Italy, the authorities have more influence on the cost development in the system. In systems where the hospitals are financed by social security on basis of output, arrangements are now made to bring budgetary elements in the financing of these institutions. In France the "Budget Global" will be applied to services financed by the Sécurité sociale. In Belgium arrangements have been made to contain the amount of patient days allowed for reimbursement and in the Netherlands in 1983 budget-financing has been introduced for all general and teaching hospitals. In 1984 this system also applies to all other intramural institutions. If a way has been found to focus the financing mechanism of these institutions on budgeted costs, the way is open for budgeting these institutions. A very important problem in this context is the budget formula, which will be used to determine the budgets. In this respect a distinction can be made between internal and external budgeting. Internal budgeting is understood here as a process whereby the hospital itself puts a limit to the use of resources or adapts its resources to budget constraints coming from the outside. External budgeting can be defined as the budgetary constraint given from the outside by third parties to the hospitals. Of course, both internal and external budgeting are narrowly interrelated. The distinction between these two ways of budgeting should be sought in the character of the budget formula. External budgeting should be based on global indications whilst internal budgeting should be more differentiated than the external budget formula.(ABSTRACT TRUNCATED AT 400 WORDS)     

上海市高端社会办医发展的现状及趋势

目的:了解上海市高端社会办医发展的现状及趋势。方法:应用机构数量等7个指标分析其资源配置状况,应用门急诊人次等2个指标对其服务量进行分析,应用次均门诊费用等8个指标分析其费用情况,通过不同类别机构之间的横向比较分析2013年上海市高端社会办医机构的整体情况,并对2011—2013年高端社会办医情况进行纵向比较,分析其发展趋势。结果:目前上海市高端社会办医机构资源配置水平偏低,规模化建设尚处于初期阶段,医务人员结构欠合理;高端社会办医机构服务总量虽迅速增加,但仍远低于公立医院特需服务量;高端社会办医机构医疗费用总体处于较高水平,内部结构较为合理。结论与建议:当前上海市高端社会办医尚处于发展初期,但发展前景广阔。高端社会办医应在医疗技术、服务水平、管理能力、人力队伍建设、品牌发展等方面加以强化。     

NGOs in community health insurance schemes: examples from Guatemala and the Philippines

In poor rural communities, access to basic health care is often severely limited by inadequate supply as well as financial barriers to seeking care. National policies may introduce social health insurance, but these are likely to begin with the salaried public and private sector workers while the informal sector population may be the last to be covered. Community initiatives to generate health care financing require a complex development process. This paper covers attempts to develop such schemes in rural populations in Guatemala and the Philippines through non-government organizations and notes the major factors which have contributed to unequal progress in the two schemes. The scheme of the Association por Salud de Barillas (ASSABA) in Guatemala was not sufficiently established as an administrative body at the conceptual stage and there was no clear national policy on health care financing. By the time the necessary action was taken, local conflicts hindered progress. In the Philippines, the ORT Health Plus Scheme (OHPS) was implemented during the period of legislation of a national health insurance act. The appraisal after three years of operation shows that OPHS has made health care affordable and accessible to the target population, composed mainly of low and often unstable income families in rural areas. The major success factors are probably the administrative structure provided by a cooperative and controls in the delivery system and in expenditures, through the salaried primary health care team, referral process and the capitation agreement for hospital-based services. The proliferation of such schemes could benefit from national guidelines, a formal accreditation process and an umbrella organization to provide assistance in design, training and information services, involving government, non-government and academic institutions as an integral part of the development process.     

The Armenian healthcare system: recent changes and challenges

Background  Armenian healthcare reforms have been carried out since independence in 1991, but achieved their full scale starting in 1995–1996. Although the healthcare system has already been modified and changed for 10 years, there is a lack of research in this regard. Objectives  This paper aims to present the organization of the healthcare system in Armenia, its changes and challenges throughout the reform process. Methods  This paper is mainly based on a review of the relevant professional literature, a review and interpretation of legal acts in the healthcare field, and a review of research and assessment works done by several international and local organizations. Results  There are still large numbers of elements typical for the Soviet Semashko model in Armenian healthcare structures. Implemented reforms have separated the institutions of the public payer and the providers, but did not manage to change the model of financing to be based on compulsory insurance. The level of financing is similar to the average in Central and Eastern Europe, but is based mainly on out-of-pocket payments contributing to about 80% of all system resources. The informal payments reach even 45% of expenditures. The structure of hospital beds remains ineffective, and there are still no mechanisms of increasing the quality of services. Privatization has been applied, but the role of private providers is still limited. Conclusions  The reforms have not caused satisfactory improvement in healthcare performance, although the health indicators are better than at the beginning of the transformation period. The stability of the reforming processes in previous years as well as the engagement of international institutions is a chance for positive changes in the near future.     

Toward a health care financing strategy for the nation. Report of the National Health Policy Seminar.

All people in the United States have a need for access to comprehensive high quality health care. Such need is so universal and fundamental, not only to personal health, but also to equitable pursuit of all opportunity in a modern and just society, that it is viewed increasingly in the context of rights. Although the current array of health financing programs--Medicare, Medicaid, employer-based medical care insurance benefits, private medical care insurance, and other current insurance methods--have major accomplishments to their credit in providing access to care, the United States falls short in guaranteeing that conceptual right. The result is that 35 to 40 million people in the United States have no insurance coverage at all for medical care expenses, and an unknown number of people have coverage that is grossly inadequate. In addition, our current medical care system is characterized by: significant barriers to equitable access to care, apart from lack of coverage of the direct costs; major deficiencies in services for rehabilitation, long-term care, and home care; extreme variablity in the utilization and quality of care. We also must acknowledge failures in fundamental programs that directly affect the health of our people, such as health manpower, housing, education, and protection against occupational and environmental hazards. However, these matters are outside the purview of this statement. We propose a program, under the leadership of the federal government, with state and local government and the private sector having significant roles to play, that will respond to these shortcomings in our health care system. The program would finance health services comprehensively and equitably, minimize duplication, inefficiency, and the uneven quality of care, and would emphasize health promotion and disease prevention.