Helping members of a community-based health insurance scheme access quality inpatient care through development of a preferred provider system in rural Gujarat

We describe and analyse the experience of piloting a preferred provider system (PPS) for rural members of Vimo SEWA, a fixed-indemnity, community-based health insurance (CBHI) scheme run by the Self-Employed Women's Association (SEWA). The objectives of the PPS were (i) to facilitate access to hospitalization by providing financial benefits at the time of service utilization; (ii) to shift the burden of compiling a claim away from members and towards Vimo SEWA staff; and (iii) to direct members to inpatient facilities of acceptable quality. The PPS was launched between August and October 2004, in 8 subdistricts covering 15,000 insured. The impact of the scheme was analysed using data from a household survey of claimants and qualitative data from in-depth interviews and focus group discussions. The PPS appears to have been successful in terms of two of the three primary objectives--it has transferred much of the burden of compiling a health Insurance claim onto Vimo SEWA staff, and it has directed members to inpatient facilities with acceptable levels of technical quality (defined in terms of structural Indicators). However, even under the PPS, user fees pose a financial barrier, as the insured have to mobilize funds to cover the costs of medicines, supplies, registration fee, etc. before receipt of cash payment from Vimo SEWA. Other barriers to the success of the PPS were the geographic Inaccessibility of some of the selected hospitals, lack of awareness about the PPS among members and a variety of administrative problems. This pilot project provides useful lessons relating to strategic purchasing by CBHI schemes and, more broadly, managed care in India. In particular, the pragmatic approach taken to assessing hospitals and identifying preferred providers is likely to be useful elsewhere.     

城镇居民基本医疗保险与城镇贫困人群医疗救助制度衔接刍议

城镇居民基本医疗保险与城镇贫困人群医疗救助制度是社会保障体系的重要组成部分和社会保障领域改革的重要环节,两者衔接对缓解城镇贫困人员“看病难、看病贵”,提高卫生服务可及性、公平性有重要现实意义。结合两制度衔接现状,探讨两个制度衔接的必要性和可能性,以及当前两个制度衔接存在困难和问题,并提出相关的政策建议。     

Healthcare financing: approaches and trends in India

Despite the importance of healthcare for the well-being of society, there is little public debate in India on issues relating to it. The 'human capital approach' to finance healthcare largely relies on private investment in health, while the 'human development approach' envisages the State as the guarantorof preventive as well as curative care to achieve universalization of healthcare. The prevailing health indices of India and challenges in the field of public health require a human developmentapproach to healthcare. On the eve of independence, India adopted the human development approach, with the report of the Bhore Committee emphasizing the role of the State in the development and provision of healthcare. However, more recently, successive governments have moved towards the human capital approach. Instead of increasing state spending on health and expanding the public health infrastructure, the government has been relying more and more on the private sector. The public-private partnership has been touted as the new-age panacea for the ills of the Indian healthcare system. This approach has led to a stagnation of public health indices and a decrease in the access of the poor to healthcare.     

Private health insurance and access to healthcare

The health insurance business in India has seen a growth of over 25% per annum in the last few years with the expansion of the private health insurance sector. The premium incomes of health insurance have crossed the Rs 8,000 crore mark with the share of private companies increasing to over 41%. This is despite the fact that from the perspective of patients, health insurance is not a good deal, especially when they need it most. This raises a number of ethical issues regarding how the health insurance business runs and how medical practice adjusts to it for profiteering. This article uses the personal experience of the author to argue that health insurance in an unregulated environment can only lead to unethical practices, further victimising the patient. Further, publicly financed healthcare which operates in an environment regulating both public and private healthcare provisioning is the only way to assure access to ethical and equitable healthcare to people.     

The health care resource allocation debate. Defining our terms

The problem of health care distribution in the United States demands immediate action. Many different solutions have been proposed to slow rising health care costs and to improve access to care for the poor and uninsured. Debate among proponents of these various proposals might be advanced if a common language were adopted with regard to certain key terms instead of the various meanings currently assigned to these terms. For this reason, we propose and defend the following three definitions: (1) rationing is the societal toleration of inequitable access to health services acknowledged to be necessary by reference to necessary-care guidelines; (2) health care needs are desires for services that have been reasonably well demonstrated to provide significant net benefit for patients with specified clinical conditions; and (3) basic benefit plans are insurance packages that provide for all and only acknowledged health care needs, again by reference to appropriate clinical guidelines.     

The equity of admissions to the University Hospital of Brasilia

Background

Brazil has a highly stratified population with large socioeconomic disparities, as evidenced by marked differentiation in health status and access to health services by the population. In addition, the fact that the universal national healthcare system and a liberalised private care model exist side by side leads to increasingly inequitable health outcomes.

Aims

This study aims to appraise the equity of access to the University Hospital in Brasilia, Brazil, in 2013.

Methods

This study was a quantitative analysis of hospital admissions data. The sample included all patients admitted over a six-month period in 2013. Patient data was crossed with socioeconomic data (income and private health insurance status). Frequency tabulations and chi-square calculations were used to describe the patient mix, observe trends and appraise equity of admissions.

Results

Analysis of the data showed that the number of patients from each neighbourhood relative to the neighbourhood population was equitable. However, when assessed on the basis of insurance status (i.e., deducting the population covered by private health insurance), a high level of inequity was detected (chi-square 71.828, df 3, p<0,0001) whereby patients from wealthier neighbourhoods were overrepresented compared to those from poorer neighbourhoods.

Conclusion

This study has shown that access to the University Hospital in Brasilia is not equitable when individual access to private healthcare is accounted for. The results show that dual access to both public and private healthcare is likely to be common, increasing some of the population’s access to healthcare while decreasing access for others, and therefore contributing to inequity of access to healthcare services.     

A Privacy-Strengthened Scheme for E-Healthcare Monitoring System

Recent Advances in Wireless Body Area Networks (WBANs) offer unprecedented opportunities and challenges to the development of pervasive electronic healthcare (E-Healthcare) monitoring system. In E-Healthcare system, the processed data are patients' sensitive health data that are directly related to individuals' privacy. For this reason, privacy concern is of great importance for E-Healthcare system. Current existing systems for E-Healthcare services, however, have not yet provided sufficient privacy protection for patients. In order to offer adequate security and privacy, in this paper, we propose a privacy-enhanced scheme for patients' physical condition monitoring, which achieves dual effects: (1) providing unlinkability of health records and individual identity, and (2) supporting anonymous authentication and authorized data access. We also conduct a simulation experiment to evaluate the performance of the proposed scheme. The experimental results demonstrate that the proposed scheme achieves better performance in terms of computational complexity, communication overheads and querying efficiency compared with previous results.     

Incorporating broadband durability in measuring geographic access to health care in the era of telehealth: A case example of the 2-step virtual catchment area (2SVCA) Method

The COVID-19 (coronavirus disease 2019) pandemic has expanded telehealth utilization in unprecedented ways and has important implications for measuring geographic access to healthcare services. Established measures of geographic access to care have focused on the spatial impedance of patients in seeking health care that pertains to specific transportation modes and do not account for the underlying broadband network that supports telemedicine and e-health. To be able to measure the impact of telehealth on healthcare access, we created a pilot augmentation of existing methods to incorporate measures of broadband accessibility to measure geographic access to telehealth. A reliable measure of telehealth accessibility is important to enable policy analysts to assess whether the increasing prevalence of telehealth may help alleviate the disparities in healthcare access in rural areas and for disadvantaged populations, or exacerbate the existing gaps as they experience “double burdens.”     

Ethical issues in healthcare financing

The four goals of good healthcare are to relieve symptoms, cure disease, prolong life and improve quality of life. Access to healthcare has been a perpetual challenge to healthcare providers who must take into account important factors such as equity, efficiency and effectiveness in designing healthcare systems to meet the four goals of good healthcare. The underlying philosophy may designate health as being a basic human right, an investment, a commodity to be bought and sold, a political demand or an expenditure. The design, policies and operational arrangements will usually reflect which of the above philosophies underpin the healthcare system, and consequently, access. Mechanisms for funding include fee-for-service, cost sharing (insurance, either private or government sponsored) free-of-fee at point of delivery (payments being made through general taxes, health levies, etc) or cost-recovery. For each of these methods of financial access to healthcare services, there are ethical issues which can compromise the four principles of ethical practices in healthcare, viz beneficence, non-maleficence, autonomy and justice. In times of economic recession, providing adequate healthcare will require governments, with support from external agencies, to focus on poverty reduction strategies through provision of preventive services such as immunization and nutrition, delivered at primary care facilities. To maximize the effect of such policies, it will be necessary to integrate policies to fashion an intersectoral approach.     

Why mental health services in low- and middle-income countries are under-resourced, underperforming: an indian perspective

The inadequacies of mental health services in low- and middleincome countries are often attributed to inadequate allocation of resources. This may not be entirely true. The experience in India suggests that a top-down approach to planning, divorced from the ground realities, poor governance, managerial incompetence and unrealistic expectations from low-paid/poorly motivated primary healthcare personnel play an important role and may result in the failure of even adequately funded programmes. The ambitious National Mental Health Programme (NMHP), launched in 1983 and aimed at providing basic mental health services through the existing primary healthcare system, using the Bellary model, failed to achieve any of its targets over the subsequent decades. In early 2001, the NMHP was radically revamped. It was re-launched as part of the Tenth Five-Year Plan (2002-07) and the budgetary allocation was increased more than 7-fold. However, the programme faltered due to techno-managerial underperformance and the initial momentum was lost. The reasons for this failure are analysed and possible remedial strategies suggested. While the experience documented in the paper is country-specific and relates to India, it may hold useful lessons for other low- and middle-income countries.     

四川贫困地区农村孕产妇保健服务利用现状分析

目的 了解四川省贫困地区农村孕产妇保健服务利用的现状,并分析其影响因素.方法 采用分层整群抽样的方法,采用自行设计的"孕产妇卫生保健服务调查表"对1998以来分娩过或目前怀孕的妇女进行面对面访谈.结果 共调查了462名孕产妇,其中接受过产前保健服务的孕产妇人数最多,有387人(83.77%);接受了产后访视的人数最少,仅有144人(31.17%).不同年龄段、不同文化程度孕产妇,其孕前保健利用率、产前保健利用率和住院分娩率差异有统计学意义(P<0.05),年收入低(<1000元)的孕产妇在利用保健服务方面的情况明显差于年收入较高(>5000)元的孕产妇(P<0.05),享受合作医疗保险和贫困医疗保险的孕产妇在孕前保健、产前检查、住院分娩和接受产后访视方面的情况都明显好于完全是自费的孕产妇(P<0.05.结论 四川贫困地区农村孕产妇保健利用状况仍不容乐观,这可能与该地区经济水平较低,育龄妇女文化程度不高,医疗保险普及率较低有关.     

Voluntary village health workers in Papua New Guinea

The aid post orderly system remains the cornerstone of primary health services in Papua New Guinea (PNG). Inadequate supervision limits its impact. Recent promotion of voluntary village health aides (VVHA) is leading some provincial Divisions of Health to start large-scale projects, which are even more likely to break down through poor supervision. VVHAs are in general inappropriate to provide widespread curative care in PNG. Health personnel should rather reinforce and support existing services. However, voluntary village aide schemes may be appropriate in localized disadvantaged areas. Health planners should consider carefully their goals in setting up such schemes; how they are going to develop projects; and, if villagers want VVHA schemes, the staff required for training and supervision. Monitoring and evaluation should be incorporated into the initial design and provide feedback to participants. Intensive supervision may be appropriate for a defined period, with subsequent closure of the project, or its absorption into the existing health care framework.     

北京市基层医疗卫生机构经常性卫生费用分析

目的　了解北京市基层医疗卫生机构经常性卫生费用筹集及消耗情况,为卫生政策的制定提供依据。方法　2016年7月—2017年6月,以卫生费用核算体系2011为基础,核算2015年北京市基层医疗卫生机构费用概况、筹资方案构成、服务功能流向（包括治疗服务费用分析和预防服务费用分析）。其中卫生费用总量数据来源于中国统计年鉴2016、北京统计年鉴2016、北京市政府卫生投入监测系统、北京市公共卫生信息中心、2015年北京市卫生总费用核算报告等;分摊系数通过北京市卫生医疗价格监测数据平台的个案库以及医疗卫生机构抽样调查数据计算得到。结果　2015年北京市基层医疗卫生机构经常性卫生费用为138.11亿元,其筹资方案以社会医疗保险方案、政府方案为主（占比分别为56.14%、27.20%）。2015年北京市基层医疗卫生机构仅提供治疗服务和预防服务,其费用占比分别为86.96%、13.04%。2015年北京市基层医疗卫生机构的治疗服务费用按全球疾病负担（GBD）分类,主要由慢性非传染性疾病消耗（占比为70.90%）;按国际疾病分类（ICD-10）标准分类,主要由循环系统疾病消耗（占比为25.88%）;按年龄段分类,其主要由50~69岁患者消耗（占比为58.05%）。2015年北京市基层医疗卫生机构预防服务费用以免疫规划（占比为24.86%）、慢病防治（占比为13.33%）、老年人健康管理（占比为10.37%）、居民健康档案管理（占比为10.05%）为主。结论　公共筹资方案在北京市基层医疗卫生机构卫生筹资中起主导作用;经常性卫生费用核算结果与基层医疗卫生机构的治疗服务功能定位相符;基层医疗卫生机构是北京市预防服务的主要提供机构之一。     

National health insurance: A new imperative

When viewed from the perspective of the policy analyst, observed inequities in the access to health services and the rising costs of physician and hospital care are among the most important issues confronting the American health delivery system. Recognizing that publicly financed health insurance programs result in a more equitable distribution of medical services, this paper focuses on the components of a national health insurance scheme that not only offers a comprehensive range of benefits but also employs prospective payment and a set of financial incentives to control the costs of care provided by physicians, hospitals, and other health facilities. The national health insurance program proposed in this paper is designed to eliminate or reduce unwarranted expenditures on plant and equipment; the responsibility for approving and funding capital acquisitions is also regarded as an integral component of the program.     

我国加入WTO医院面临的机遇与挑战

我国加入WTO以后医院面临着良好的机遇与严峻的挑战,机遇着重体现为增加投入扩大服务规模、交流提高管理水平、引进先进技术和设施,降低进口药品及设备价格、主动参与国际有关规则制定,开拓国际医疗市场等,挑战则体现为竞争激烈、人才流失、信息资源侵犯、医药产业的冲击、医疗保险业及中介机构的影响等,并有针对性地提出了对策设想.     

保定市城市居民卫生服务利用公平性分析

目的　了解保定市居民卫生服务利用 (包括社区卫生服务利用 )的公平性情况。方法　通过两阶段抽样方法 (随机整群抽样和系统抽样 )调查了河北省保定市南市区、北市区和新市区 3个区的 962户居民的卫生服务利用情况 ,采用调查表的方式入户调查 ,并将被调查家庭分成 3组 :相对贫困组、贫困临界组和一般家庭组进行公平性分析。结果　一般家庭组中医疗费用支付自费者占 41 0 % ;而相对贫困组为 61 1 % ,贫困临界组为 65 3 % ;相对贫困组年住院率为 1 9 86 % ,贫困临界组为 4 2 9% ,一般家庭组为 7 2 7%。 3组人群两周就诊率分别为 1 9 86 %、 1 0 71 %和 7 66 % ;3组人群的年人均自负医疗费用占年人均收入的比例分别为 2 4 5 %、 2 68%和 1 55 % ;相对贫困组和贫困临界组家庭中接受心理咨询家庭数所占比重分别为 4 76 %和 6 82 %。结论　 (1 )相对贫困人群的卫生服务需求较大 ,但医疗费用支付能力较弱 ,相对贫困人群的医疗疾病负担较重 ;(2 )不同经济条件人群的综合社区卫生服务利用差异不大。     

It's time for CMA to put the lid on privatization.

Family physician Cynthia Carver wasn't heartened by the CMA's "last-minute retreat" from a call to pursue privatization of health care. During its August annual meeting, the association not only supported a strong, publicly funded health care system but also passed a number of resolutions related to the private sector and the appropriate role for regulated private medical insurance in Canada. Carver proposes that the energy being expended on schemes to delist, privatize, define core services and design payment schemes should instead be applied to improving the existing system.     

Beyond universal health insurance to effective health care

The history of the U.S. governmental health care reform indicates that efforts toward universal health insurance cannot be expected from a financially strapped federal government. Ambitious governmental programs such as veterans' services and Medicaid have encountered accessibility problems associated with location, arbitrary limitations of reimbursement criteria, and opposition from taxpayers due to the higher taxes and premiums necessitated by program reform. Nonfinancial obstacles to access include physicians migration away from minorities and the poor, the strained conditions of many public hospitals, and immigrants' isolation due to language barriers and paranoia over citizenship status. Ginzberg presents interim targets for the expansion of access to health care: the expansion of Medicaid, subsidized coverage for the near poor, private sector catastrophic insurance policies, expansion of the Federal Community Health Center program, expansion of the National Health Service Corps and State Educational Debt Forgiveness Programs, and state subsidies for uncompensated care.     

Fine-grained Database Field Search Using Attribute-Based Encryption for E-Healthcare Clouds

An effectively designed e-healthcare system can significantly enhance the quality of access and experience of healthcare users, including facilitating medical and healthcare providers in ensuring a smooth delivery of services. Ensuring the security of patients’ electronic health records (EHRs) in the e-healthcare system is an active research area. EHRs may be outsourced to a third-party, such as a community healthcare cloud service provider for storage due to cost-saving measures. Generally, encrypting the EHRs when they are stored in the system (i.e. data-at-rest) or prior to outsourcing the data is used to ensure data confidentiality. Searchable encryption (SE) scheme is a promising technique that can ensure the protection of private information without compromising on performance. In this paper, we propose a novel framework for controlling access to EHRs stored in semi-trusted cloud servers (e.g. a private cloud or a community cloud). To achieve fine-grained access control for EHRs, we leverage the ciphertext-policy attribute-based encryption (CP-ABE) technique to encrypt tables published by hospitals, including patients’ EHRs, and the table is stored in the database with the primary key being the patient’s unique identity. Our framework can enable different users with different privileges to search on different database fields. Differ from previous attempts to secure outsourcing of data, we emphasize the control of the searches of the fields within the database. We demonstrate the utility of the scheme by evaluating the scheme using datasets from the University of California, Irvine.     

Transforming insurance coverage into quality health care: voltage drops from potential to delivered quality

Although the US health care system is often touted as one of the best in the world, disparities exist in quality of care received by different populations, in different regions, and across different institutions and clinicians. Initiatives to provide access to health insurance have been a major policy tool to ensure that Americans receive high-quality health care. However, availability of insurance coverage does not automatically lead to high-quality care. This article explores points of vulnerability in the US health care system at which the potential to achieve high-quality care can be lost: (1) access to insurance coverage; (2) enrollment in available insurance plans; (3) access to covered services, clinicians, and health care institutions; (4) choice of plans, clinicians, and health care institutions; (5) access to a consistent source of primary care; (6) access to referral services; and (7) delivery of high-quality health care services. Ensuring high-quality health care requires that each of these "voltage drops" be recognized and addressed. JAMA. 2000;284:2100-2107.