Regulation and selection of patients

During the past decades health legislation and regulation have been on the increase in most industrialized countries. The growing role of government in the provision and financing of health care, the need to correct given aspects of health care and the mandate to protect the underprivileged have been some of the many reasons for increased regulation. Different regulatory approaches and their respective advantages and disadvantages are reviewed in this paper. Particular attention is given to the crucial issue of how to regulate the access to scarce resources and how to cope within a legislative approach with the resulting patient selection.     

International comparison of minimum volume standards for hospitals

IntroductionMinimum volume standards have been implemented in various countries for quality or safety policies. We present minimum volume standards in an international comparison, focusing on regulatory approaches, selected sets of procedures and thresholds as well as predetermined consequences of non-compliance.Materials and methodsWe combined a comprehensive literature search in electronic databases in March 2016 with a hand-search of governmental and related organisations’ webpages. We also contacted international experts to verify the information we found in the literature and to obtain additional data.ResultsMinimum volume standards have been introduced in different countries predominantly for highly specialized surgical procedures. The same evidence has led to different definitions and ways of implementation of minimum volume standards in Germany, Canada (Ontario), the Netherlands, Switzerland, and Austria. The regulatory approaches to minimum volume standards and the predetermined consequences of non-compliance differ across the countries.ConclusionThe sets of procedures for which minimum volume standards and corresponding thresholds have been introduced vary across countries, possibly due to different regulatory approaches. In addition, key attributes of the health care system might affect the development and implementation of minimum volume standards. Therefore, it is not feasible to formulate uniform recommendations that are applicable to all countries. Our results provide a comprehensive overview of international minimum volume standards and can be used to inform policy decisions.     

Health care technology in Australia and New Zealand: contrasts and cooperation

Australia and New Zealand are neighbouring countries with similarities due to their settlement by Europeans, but with major differences in their economies, populations, geography and political systems. These differences have led to contrasting approaches to the introduction and control of health care technologies. New Zealand has historically had greater success in limiting the use of health technologies which have often been adopted more widely and rapidly in Australia. Recent initiatives in health technology assessment have involved participation by both countries, giving the potential for a joint approach to policy formulation on use of some medical devices and procedures.     

Regulating private health insurance to serve the public interest: policy issues for developing countries

Private health insurance plays a large and increasing role around the world. This paper reviews international experiences and shows that private health insurance is significant in countries with widely different income levels and health system structures. It contrasts trends in private health insurance expansion across regions and highlights countries with particularly important experiences of private coverage. It then discusses the regulatory approaches and policies that can structure private health insurance markets in ways that mobilize resources for health care, promote financial risk protection, protect consumers and reduce inequities. The paper argues that policy makers need to confront the role that private health insurance will play in their health systems and regulate the sector appropriately so that it serves public goals of universal coverage and equity.     

Assessing quality of primary diabetes care in South Korea and Taiwan using avoidable hospitalizations

Quality of primary diabetes care is a key health policy concern in many OECD countries with an aging population. This cross-national, population-based study examined the extent and attributes of diabetes-related avoidable hospitalizations (DRAHs) in South Korea and Taiwan, both of which have social health insurance-based health systems with limited gate-keeping for hospitalizations. We analyzed comparable, nationally representative health insurance beneficiary datasets for the two countries (2002–2013), linked with community health resource data. The age- and sex-standardized DRAH rates were calculated, and multivariate, multi-level longitudinal modeling approaches were adopted. The DRAH rate decreased in Taiwan consistently during 2002–2013 and in Korea after 2011 only. Under the universal health coverage, people enjoyed high accessibility to care. A higher number of physician visits reduced DRAHs in Korea but not in Taiwan. Socio-economic disparities in DRAHs still existed in both countries, especially in Taiwan. We found a different trajectory in two similar health systems for the selected health system performance indicator for primary diabetes care. This can be partly explained by different policy approaches to diabetes management in the two countries over the years. Necessary are policy efforts to improve the quality and equality of primary diabetes care and better control of hospital admissions in these two health systems that provide generous access to care at a low cost in East Asia.     

Multi-jurisdictional expert opinion for improving children's environmental health protection

Expert opinion from Canada, the United States and European Union countries was solicited to examine the regulatory and non-regulatory approaches used to protect children's environmental health. Thirty-five experts were interviewed by telephone from June 2004 to March 2005 using an open-ended survey questionnaire. Experts were asked to name legislative and non-legislative tools used to protect children's environmental health in their jurisdiction as well as the effectiveness of approaches taken, barriers, facilitators, methods of evaluation, and recommendations for improving children's health protection. A number of common themes were revealed by experts in different countries as well as novel approaches that could be used to improve children's environmental health. Determining what types of governance and non-governance instruments are most effective based on experience from other jurisdictions, allows for the determination of common, effective, policy choice from shared children's health environmental risks. It also provides a broad classification of different approaches that have been used for children's environmental health. Three main areas suggested for strengthening children's environmental health protection included: research and surveillance, institutional organization, and regulatory capacity.     

The potential role of risk-equalization mechanisms in health insurance: the case of South Africa

International agencies such as the World Bank have widely advocated the use of health insurance as a way of improving health sector efficiency and equity in developing countries. However, in developing countries with well-established, multiple-player health insurance markets, such as South Africa, extension of insurance coverage is now inhibited by problems of moral hazard, and associated cost escalation and fragmentation of insurer risk-pools. Virtually no research has been done on the problem of risk selection in health insurance outside developed countries. This paper provides a brief overview of the problem of risk fragmentation as it has been studied in developed countries, and attempts to apply this to middle-income country settings, particularly that of South Africa. A number of possible remedial measures are discussed, with risk-equalization funds being given the most attention. An overview is given of the risk-equalization approach, common misconceptions regarding its working and the processes that might be required to assess its suitability in different national settings. Where there is widespread public support for social risk pooling in health care, and government is willing and able to assume a regulatory role to achieve this, risk-equalization approaches may achieve significant efficiency and equity gains without destroying the positive features of private health care financing, such as revenue generation, competition and free choice of insurer.     

The Rise of Independent Regulation in Health Care

In all countries where health care access is considered a social right, regulation is both a tool of performance improvement as well as an instrument of social justice. Both social (equity in access) and economical (promoting competition) regulation are at stake due to the nature of the good itself. Different modalities of regulation do exist and usually new regulatory cycles include the creation of stronger regulatory agencies. Indeed, health care regulation is rising steadily in most developed countries as a consequence of the introduction of the New Public Management perspective to provide essential public goods.Health care is delivered by different organisations with very different cultural backgrounds--public and private (profit and non-profit)--that should be accountable for their decisions. Control by regulatory agencies is instrumental to accomplish this goal. However, there is some dispute with regards the degree of regulatory autonomy. The objective of this paper is to determine if independent regulatory agencies (IRAs) are effective in carrying out health care regulation. The authors apply Walshe's analytical framework to the Regulatory Authority of Health (Portugal) to answer the question if independent regulation works.In conclusion, the two year experience of the Regulatory Authority of Health is important not only because the primary goals of independent regulation were achieved but also because this authority is now a full partner in the health care sector. However, independent agencies need to develop strong mechanisms of accountability because good regulatory governance is the paradigm of this institutional innovation.     

Technological change around the world: evidence from heart attack care

Although technological change is a hallmark of health care worldwide, relatively little evidence exists on whether changes in health care differ across the very different health care systems of developed countries. We present new comparative evidence on heart attack care in seventeen countries showing that technological change--changes in medical treatments that affect the quality and cost of care--is universal but has differed greatly around the world. Differences in treatment rates are greatest for costly medical technologies, where strict financing limits and other policies to restrict adoption of intensive technologies have been associated with divergences in medical practices over time. Countries appear to differ systematically in the time at which intensive cardiac procedures began to be widely used and in the rate of growth of the procedures. The differences appear to be related to economic and regulatory incentives of the health care systems and may have important economic and health consequences.     

Accreditation: what can we learn from the Anglophone model?

There is growing interest in the development and application of standards for the health care to both promote quality assurance but also to improve the processes by which health services are held accountable to the public. This paper maps the development of organisational accreditation systems in the USA, Canada, Australia and the United Kingdom. In the USA, accreditation, which began as a means of ensuring the correct environment for clinical practice has developed into a form of public regulation. In the United Kingdom, many different approaches to the setting of standards and their assessment has created a variety of accreditation systems. The case studies demonstrate that as the concept of accreditation diffuses into the health care systems of different countries, it is being adapted to meet the wider policy needs of different national circumstances.     

An innovation platform for diffusing public health practices across a global network

Hospitals and health systems in high-income countries (HIC) develop the capacities of peer healthcare organizations around the world by diffusing clinical, quality, and public health improvement practices in lower and middle-income countries (LMIC). In turn, these HIC healthcare institutions are exposed to innovative approaches developed and used by global communities to advance care despite resource constraints in the LMIC contexts. Attention has been growing in recent years to the potential these innovations can have to improve care delivery, lower costs, and drive quality within resource-constrained communities in HIC. Often referred to as “reverse innovations,” the identification, adaptation, and diffusion of these practices face challenges in uptake related to limited evidence, perceptions of poor quality or irrelevance, and a complicated regulatory and policy environment. This paper suggests the development of an approach to improve the capacity of the healthcare organizations in the HIC as well, based on lessons learned from diffusing practices in LMIC. It concludes with the need for a knowledge platform to support innovation diffusion in both directions.     

Building the infrastructure for primary health care: an overview of vertical and integrated approaches

In the past four decades there has been a succession of different approaches to the development of infrastructure for the delivery of health services. There have been striking similarities among these approaches in both direction and timing in many different countries, particularly in the developing world. While the general trend has been strongly in the direction of a more comprehensive, integrated health infrastructure, there have been important regressions from this path. It is suggested that the recent attention given to the delivery of 'selective' packages of interventions has often diverted energy and resources from the essential task of developing comprehensive, efficient and effective health services. This paper begins with an historical review of trends in the development of health services infrastructure in recent decades. It proceeds to analyse the implications for the organization of health services and for resource allocation when the health services infrastructure is viewed as part of a health system based on primary health care. Finally, we maintain that district health systems based on primary health care provide an excellent practical model for health development, including an appropriate health system infrastructure. Within this model the concerns with accelerating the application of known and effective technologies and the concerns with strengthening of community involvement and intersectoral action for health are both accommodated. The district health system provides a realistic setting for dialogue and planning involving both professionals and non-professionals concerned with health and social development.     

An overview of pharmaceutical policy in four countries: France, Germany, the Netherlands and the United Kingdom

The regulation of pharmaceutical markets is an important policy concern in many countries, and is generally undertaken with cost containment, efficiency, quality and equity objectives in mind. This article presents an overview of the demand-side and supply-side regulatory measures that have been introduced in four European countries, namely France, Germany, the Netherlands and the United Kingdom. More specifically, after considering some of the trends in pharmaceutical expenditure in these four countries over recent decades, the article considers the policies that have been introduced to influence patient demand, health care provider behaviour and the pharmaceutical industry. Since many of the policies are concurrently applied, it is difficult to assess the isolated impact of each, particularly because the effect of particular policies may often be country specific. However, it is clear that there is no over-riding perfect solution to balancing the cost containment, efficiency, quality and equity objectives in pharmaceutical policy. No one policy or policy combination is right for all countries, and different countries will need to meet their own objectives through policy approaches that reflect their own particular environment.     

Containing health costs in the Americas

In recent years, a series of policy measures affecting both demand and supply components of health care have been adopted in different Latin American and Caribbean countries, as well as in Canada and the United States. In applying these measures various objectives have been pursued, among them: to mobilize additional resources to increase operating budgets; to reduce unnecessary utilization of health services and consumption of pharmaceuticals; to control increasing production costs; and to contain the escalation of health care expenditures. In terms of demand management, some countries have established cost-recovery programmes in an attempt to offset declining revenues. These measures have the potential to generate additional operating income in public facilities, particularly if charges are levied on hospital care. However, only scant information is available on the effects of user charges on demand, utilization, or unit costs. In terms of supply management, corrective measures have concentrated on limiting the quantity and the relative prices of different inputs and outputs. Hiring freezes, salary caps, limitations on new construction and equipment, use of drug lists, bulk procurement of medicines and vaccines, and budget ceilings are among the measures utilized to control production costs in the health sector. To moderate health care expenditures, various approaches have been followed to subject providers to 'financial discipline'. Among them, new reimbursement modalities such as prospective payment systems offer an array of incentives to modify medical practice. Cost-containment efforts have also spawned innovations in the organization and delivery of health services. Group plans have been established on the basis of prepaid premiums to provide directly much or all health care needs of affiliates and their families. The issue of intrasectorial co-ordination, particularly between ministries of health and social security institutions, has much relevance for cost containment. In various countries, large-scale reorganization processes have been undertaken to eliminate costly duplications of resources, personnel, and services that resulted from the multiplicity of providers in the public subsector. Given the pluralistic character of the region's health systems, an important challenge for policy-makers is to find ways to redefine the role of state intervention in health from the simple provision of services to one that involves the 'management' of health care in the entire sector.     

The efficient use of pharmaceuticals: does Europe have any lessons for a Medicare drug benefit?

Managing drug use in a way that maximizes the value obtained from total health care spending faces obstacles; hence, payers and policymakers tend to look at pharmaceutical expenditures in isolation from the rest of health care spending. Currently there are both regulatory and putative market-based approaches to containing pharmaceutical spending worldwide. But evidence suggests that regulatory efforts in Europe and elsewhere have not proved effective in containing costs or improving efficiency or access, and supposedly market-based solutions now in vogue, such as reference pricing, pose their own set of challenges and may in practice violate market principles. In the end, silo-based budgeting is short-sighted; the emphasis in Europe and in the United States should be on measures that achieve efficient health care rather than the containment of drug spending.     

Farmers' occupational health care--worldwide

This review will summarize the current state of preventive health care systems for farmers in the world. It is obvious that well-organized occupational health care systems for farmers occur sporadically in only a few countries, and generally are in the initial stages of development. Large cooperative farms and plantations may have industrialized occupational health care. In some countries in Europe, e.g., France and Austria, farmers' organizations may include a certain amount of health and safety activity within their social insurance systems for farmers. Moreso than in other places, the Scandinavian countries have tried different approaches to provide comprehensive health services among farmers. Regardless of the kind of system, it is obvious from experiences worldwide that agriculture is a risky occupation and farmers are exposed to numerous hazards which may result in injuries, work-related diseases, and death. It is promising to note an increased interest in this situation from many parts of the world.     

Health care reforms and developing countries--a critical overview

Although health care reforms have been implemented in both developed and developing countries since the 1980s, there has been little discussion of the historical, social and political contexts in which such reforms have taken place. Health care reforms in developing countries, for instance, have been an integral component of structural adjustment policies, yet scant attention has been paid to these connections nor to their implications. The basic assumptions behind the reforms, and in particular, the ideological underpinnings of health care reorganization, need to be taken into account when considering long-term strategies and policies to provide health services in developing countries.     

From cooperation to competition in national health systems--and back?: impact on professional ethics and quality of care

Ethical behaviour in health workers is the jewel in the crown of health services. Health system policies need to nurture a professional service ethic. The primary health care policy envisioned a national health system led by the public sector and based on a philosophy of cooperation. A common theme of 'health sector reform' in OECD countries, introduced in the context of neoliberalism, has been the use of 'managed competition' to increase efficiency. Some countries that flirted with health system competition have returned to cooperation. Market relationships tend to be oppositional and to stimulate self-seeking behaviour. Health system relationships should encourage patient and community centred behaviour. The World Bank and bilateral donors have exported health sector reform theories from the north to the south, involving privatization and marketization policies. This is despite the lack of evidence on their desirability or feasibility of implementing them. Private health care has increased in many developing countries, more as a result of economic crisis and liberalization than specific health sector reforms. Much of this private practice is unlicensed and unregulated, and informal privatization has had a damaging effect on health worker ethics. The lead policy should be reconstruction of the public health system, involving decentralization, democratization and improved management. Commonsense contracting of an existing private sector is different from a policy of proactive privatization and marketization. Underlying the two approaches is whether health care should be viewed as a human right best served by socialized provision or a private good requiring governments only to correct market failures and ensure basic care for the poor. It is a matter of politics, not economics.     

The role of doctors as health care managers: an international perspective.

The participation of physicians in health care management has followed different paths in developed and developing countries. However, we can say that in most of the countries the physicians have had cyclical patterns of participation and withdrawal from health care management. It is readily apparent that these patterns are different in each country. We propose to take into account three different levels of analysis in which different factors interact to define the country specific pattern of physician involvement in health care management, as well as to assess the international convergence and divergence paths on physician participation. We present here a conceptual framework that could facilitate the analysis of this theme under a comparative perspective. We start by discussing a conceptual framework of the determinants of physician participation in health care management. Then, we assess the current trends and perspectives in both developed and Latin American countries of physician participation in health care management.     

Primary care: choices and opportunities for racial/ethnic minority populations in the USA and UK--a comparative analysis

This paper examines and compares the choices made and the opportunities provided by the United States and the United Kingdom in delivering primary care services to their racial/ethnic minority populations. While both nations agree that the most effective strategy for health service delivery to a diverse population lies in primary care, their approaches to obtaining this goal have been quite different. Sociological theories of functionalism and conflict perspective provide the analytical and organizing framework of the paper. Within this theoretical context, the health systems in place in each country are examined as an outgrowth of the larger socio-political, economic and cultural structures of the US and UK. Analysis of the advance of managed care in the US and the recent NHS reforms are also discussed in terms of lessons learned and the difficulties that lay ahead in order to ensure that these new developments contribute significantly to eliminating the disproportionately worse health status of racial ethnic minorities. Towards that goal the paper identifies opportunities for collaboration and specific recommendations for future action by both countries.