A simple simulation model as a tool to assess alternative health care provider payment reform options in Vietnam

Vietnam is currently considering a revision of its 2008 Health Insurance Law, including the regulation of provider payment methods. This study uses a simple spreadsheet-based, micro-simulation model to analyse the potential impacts of different provider payment reform scenarios on resource allocation across health care providers in three provinces in Vietnam, as well as on the total expenditure of the provincial branches of the public health insurance agency (Provincial Social Security [PSS]). The results show that currently more than 50% of PSS spending is concentrated at the provincial level with less than half at the district level. There is also a high degree of financial risk on district hospitals with the current fund-holding arrangement. Results of the simulation model show that several alternative scenarios for provider payment reform could improve the current payment system by reducing the high financial risk currently borne by district hospitals without dramatically shifting the current level and distribution of PSS expenditure. The results of the simulation analysis provided an empirical basis for health policy-makers in Vietnam to assess different provider payment reform options and make decisions about new models to support health system objectives.     

Strengthening health management: experience of district teams in The Gambia

The lack of basic management skills of district-level health teams is often described as a major constraint to implementation of primary health care in developing countries. To improve district-level management in The Gambia, a 'management strengthening' project was implemented in two out of the three health regions. Against a background of health sector decentralization policy the project had two main objectives: to improve health team management skills and to improve resources management under specially-trained administrators. The project used a problem-solving and participatory strategy for planning and implementing activities. The project resulted in some improvements in the management of district-level health services, particularly in the quality of team planning and coordination, and the management of the limited available resources. However, the project demonstrated that though health teams had better management skills and systems, their effectiveness was often limited by the policy and practice of the national level government and donor agencies. In particular, they were limited by the degree to which decision making was centralized on issues of staffing, budgeting, and planning, and by the extent to which national level managers have lacked skills and motivation for management change. They were also limited by the extent to which donor-supported programmes were still based on standardized models which did not allow for varying and complex environments at district level. These are common problems despite growing advocacy for more devolution of decision making to the local level.     

The Structure and Financing of Health Care Systems Affected How Providers Coped With COVID‐19

Policy Points

• We compared the structure of health care systems and the financial effects of the COVID‐19 pandemic on health care providers in the United States, England, Germany, and Israel: systems incorporating both public and private insurers and providers.
• The negative financial effects on health care providers have been more severe in the United States than elsewhere, owing to the prevalence of activity‐based payment systems, limited direct governmental control over available provider capacity, and the structure of governmental financial relief.
• In a pandemic, activity‐based payment reverses the conventional financial positions of payers and providers and may prevent providers from prioritizing public health because of the desire to avoid revenue loss caused by declines in patient visits.

Financial distress in the health care sector is a nonintuitive consequence of a pandemic. Yet, in the United States, the budgets of health care providers are under considerable strain as the COVID‐19 pandemic continues.Analysts anticipate that these continuing financial challenges will generate a wave of consolidation among hospitals and physician practices through 2021. ¹ Critical access hospitals, hospitals serving vulnerable populations, and independent primary care practices are particularly threatened. ² , ³ These dire financial outcomes arose through the interaction of the public health measures taken in response to the COVID‐19 epidemic, particularly the shutdown of elective procedures, along with the underlying structure of US health care financing and the US government''s emergency response.But COVID‐19 is a global epidemic. The twin effects of COVID‐19 treatment and reduced non‐COVID treatment have dramatically changed the number and case mix of patients treated in similar ways across high‐income countries. In all countries, the number of acutely ill patients with COVID rose while the number of patients with other conditions fell. The effects of these changes on health care providers’ finances have varied, however, depending on how health care systems are ordinarily structured and financed and to what extent government actions protected health care providers. By comparing the financial effects of the COVID‐19 pandemic in the United States and three other health care systems (England, Germany, and Israel) that incorporate both public and private insurers and providers, we can identify the governmental and policy factors that contributed to the severity and distribution of the effects of COVID‐19 on US providers.In all four countries, the impacts of COVID on the utilization of health care were similar. During infection surges, the number of COVID patients stressed hospitals, and as a result, nonurgent services for non‐COVID patients were postponed or forgone. The governments of all four countries directly supported health care providers with funding for increased COVID‐related expenditures (such as for personal protective equipment). The governments of all four countries also protected and compensated health care providers for their financial losses, but they did so in different ways, reflecting the structure of their health systems. In Israel, which uses relatively little activity‐based financing, the government saw less need for dedicated financial assistance. The governments of Germany and England shifted the form of payment away from activity‐based financing toward budgets to provide financial protection to health care providers, particularly in hospitals. Finally, in the United States, where activity‐based payment is prevalent and the health care–financing system is far too fragmented to permit a rapid switch in the method of payment, the government directly compensated providers for lost revenue.     

Five payment models: the pros, the cons, the potential

Among the leading strategies to reform health care is the development and implementation of new payment models. The goal is to change the way physicians, hospitals, and other care providers are paid in order to emphasize higher quality at lower costs--in other words, to improve value. In an effort to build on its health care reform activities that began in 2005, the Minnesota Medical Association convened a work group in 2010 to develop recommendations on how payment reform can best be advanced. Among the work group's output was a comparative review of five payment models with respect to how they can support a value-driven health care system. This article summarizes the pros and cons of the five models--fee for service, pay for coordination, pay for performance, episode or bundled payment, and comprehensive care or total cost of care payment. It also offers the work group's recommendations for how these models might be applied in a reformed health care system.     

The district concept for primary health care planning: attempts at implementation in The Netherlands.

Strengthening district-level primary health care systems has high priority in the WHO's 'Health for All' strategy. This article reviews governmental efforts to implement district health care systems in the Netherlands. Up to 1987, these activities corresponded to the WHO objectives, but their impact was limited. In 1987, government policy drifted away from these goals; the regulation of market forces and the increased influence of financing institutions have replaced planning by local government. Attempts to implement the district concept have, in fact, set primary health care planning back without offering the prospect of a leap forward.     

The impact of DRGs on the cost and quality of health care in the United States.

The prospective Payment System (PPS) represents a fundamental change in the way the United States government reimburses hospitals for medical services covered under Medicare, a federal health care insurance program for the elderly and disabled. PPS replaced the retrospective cost-based system of payment for Medicare services with a prospective payment system. Under PPS, a predetermined specific rate for each discharge dictates payment according to the diagnosis related group (DRG) in which the discharge is classified. The PPS was intended to create financial incentives that encourage hospitals to restrain the use of resources while providing high-quality inpatient care. Both objectives appear to have been met under PPS. Hospital utilization has declined, average length of stay has fallen, and the locus of care has shifted from the inpatient setting to less costly outpatient settings. The growth in inpatient hospital benefits has slowed and the impending insolvency of the Medicare trust fund has been forestalled. Studies have found no deterioration in the quality of care rendered to Medicare beneficiaries. Neither the mortality rate nor the rate of re-admission (presumably related to premature discharge) increased under PPS. Indeed, PPS appears to have enhanced the quality of inpatient care by discouraging unnecessary and potentially harmful procedures, and by encouraging the concentration of complex procedures in facilities in which the high frequency of these procedures promotes efficiency. Incentive-based reimbursement also appears to have contributed to the growth in alternative delivery systems, such as HMOs and PPOs, which contain costs by maintaining a high volume of a limited range of services. The success of the PPS/DRG system in controlling costs and promoting quality in this country suggests its application in other countries, either as a method of reimbursement or as a product line management tool.     

Health care financing in Asia: key issues and challenges

This article examines the major elements of health care financing such as financial risk protection, resource generation, resource pooling, and purchasing and payment; provides key lessons; and discusses the challenges for health care financing systems of Asian countries. With the exception of Japan, Korea, Taiwan, and Thailand, most health care systems of Asia provide very limited financial risk protection. The role of public prepaid schemes such as tax and social health insurance is minimal, and out-of-pocket payment is a major source of financing. The large informal sector is a major challenge to the extension of population coverage in many low-income countries of Asia, which must seek the optimal mix of tax subsidy and health insurance for universal coverage. Implementation of effective payment systems to control the behavior of health care providers is also a key factor in the success of health care financing reform in Asia.     

银行承兑汇票在医院财务管理中的作用

在当今医疗市场竞争日益激烈的时代,医院要稳步发展,必须在各方面学会精打细算,特别是对外经济业务活动款项的支付方式上,选择合理、经济的支付方式将对医院的发展起到一定的促进作用,对业务量相对较大、信誉较好的单位,选择银行承兑汇票支付方式,对拓宽医院融资渠道、加强医院资金管理、降低财务成本、提高资金的利用率等方面具有重要的作用,同时也给医院带来一定的经济效益和社会效益。     

Improved training in primary health care: field follow-up essential

A strategy was developed for the evaluation of a management course for medical officers assigned to rural hospitals in the Sudan. The training program on primary care and rural hospital management was designed by the Faculty of Medicine of the University of Gezira, the Center for Population and Family Health of Columbia University, and the Sudanese Ministry of Health. The 3-week training program was designed to deal with: primary care strategy and priority measures such as immunization, oral rehydration, nutrition and growth monitoring, antenatal care, the identification and referral of high-risk pregnancies, and child-spacing; the planning, implementation and evaluation functions of management, using the community as a learning laboratory; and the selected policies and rules of the Ministry of Health, with emphasis on the control of epidemics an the management of drug supplies and information reporting systems. Assessment tools were introduced during the training for use during field visits to trainees 3-5 months later. These follow-up visits involved both conversational interviews and structured data collection. During the field visits 26 rural medical officers gave information on locations of hospitals and durations of assignments; areas served; hospital and primary care unit personnel, vehicles, petrol allowances, refrigeration, maternal and child health records, immunization equipment and supplies, and drugs; road conditions and distances between regional hospitals and outlying units; key events since training; primary care and hospital problems, assessment of needs and resources, objectives and strategies for the next 12 months; 12-month implementation plans and training activities undertaken or planned; planning and perception of supervision; supervisory visits made to rural hospitals by senior officers of the Ministry of Health; use of training materials; management audit exercies; trainees' impressions of the course; and support given by projects of the Ministry of Health or nongovernmental organizations. The field assessment revealed that 60-80% of the trainees were using newly learned techniques and initiating new primary care activities and viewed the fieldvisits as supportive and important to continuation with their new undertakings.     

Financial information at district level: experiences from five countries

Management information systems are intended to help managersmake decisions. But few management information systems in primaryhealth care include information on costs, even though resourceallocation and budgeting are key functions of primary healthcare managers. Drawing on five papers presented to a WHO conferenceon strengthening district health systems, this article illustratesthe potential usefulness of financial data to district managers.The examples come from individual districts in Ethiopia, Indonesia,Kenya, Sri Lanka and Tanzania.No original data were collectedfor the studies - much can be learned from budgets and expenditureledgers. Some problems were encountered with the reliabilityof the data - a particular confusion was between allocated andrealized budgets. Allocated budgets area stated intention tospend money; realized budgets show that the expenditure actuallyoccurred. For planning purposes, realized amounts are of moreinterest.Managers can use financial information to questionthe allocation of resources in various ways. Providing informationon how much is being spent on what activities enables an explicitconsideration of the desirability of the existing use of resources,relative to priorities. Comparing unit costs can raise questionsabout the relative efficiency of different units, be they healthcentres, vaccination points or wards. Looking at the distributionof resources according to geographical areas, or other waysof grouping people, provides background data for the considerationof equity. Finally, the paper discusses how financial informationmight be used to identify areas of wastage.The paper concludesthat health systems already produce a good deal of financialinformation. At present, however, this information is oftenonly used by accountants or finance officers. Financial informationshould be incorporated into the larger management informationsystem.     

浙江省级公立医院规模扩张路径及其影响因素分析

目的:探索影响省级公立医院规模的主要路径因素,为我国公立医院规模控制提供证据支持。方法:基于2012〜2016年浙江省级综合医院面板数据,在分析公立医院规模扩张路径基础上,分别从政策、医院和市场竞争角度对影响医院规模的因素进行数据回归分析。结果:床位扩张是公立医院规模扩张的主要路径。公立医院财政补助收入占医院总收入越低、医保支付金额越多,药品加成率越低医院规模越大。医院资产负债率和床位利用率增长对医院规模影响显著为正,市场竞争越激烈(HHI指数越低),医院规模越大。结论:在取消公立医院药品加成同时加快完善财政补助机制,提高医保定点医疗机构管理,严格控制公立医院举债经营,完善政府对医疗服务市场管制。     

东欧部分经济转型国家医疗费用支付方式的改革与发展趋势

随着经济全球化趋势的不断增强，许多原来采取单一的计划经济体制的国家正逐步向多元化的经济模式转变，而这些处于经济转型期的国家的卫生保健体制随着经济体制的转轨也正面临着一个全新的、充满挑战的环境，因此这些国家都寻求以新的医疗费用支付方式来取代旧的费用预算体制从而提高医院的绩效。本总结了近年来东欧一些最具代表性的经济转轨国家在医疗费用支付方式改革中的经验与教训，并探讨了医疗费用支付方式的未来发展趋势。     

Balancing financial incentives during COVID-19: A comparison of provider payment adjustments across 20 countries

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries.We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff.We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care.     

Financial viability, medical technology, and hospital closures

Informed investments in medical technology and information systems are associated with the financial viability of community hospitals. Financially distressed facilities are 3 to 4 years behind proactive hospitals in supporting high-speed data, voice, and image transmissions to physicians in various locations. Impact of the Balanced Budget Act of 1997, fraud and abuse activities, Y2K issues, and lack of information systems support for physicians will result in 800 hospital closures and mergers of distressed hospitals over the next 60 months. These findings are based on the application of an eight-step framework for classifying information systems in health care entities. This framework is validated by survey instruments, site visits, interviews with senior management in 44 health care entities containing 576 hospitals, and judgments on the financial status of the health care entities.     

District health programmes and health-sector reform: case study in the Lao People's Democratic Republic

The Lao People's Democratic Republic (Lao PDR) is classified by the World Bank as a low-income country under stress. Development partners have sought to utilize effective aid instruments to help countries classified in this way achieve the Millennium Development Goals; these aid instruments include sector-wide approaches (SWAps) that support decentralized district health systems and seek to avoid fragmentation and duplication. In Asia and the Pacific, only Bangladesh, Papua New Guinea and the Solomon Islands have adopted SWAps. Since 1991, a comprehensive primary health care programme in the remote Sayaboury Province of Lao PDR has focused on strengthening district health management, improving access to health facilities and responding to the most common causes of mortality and morbidity among women and children. Between 1996 and 2003, health-facility utilization tripled, and the proportion of households that have access to a facility increased to 92% compared with only 61% nationally. By 2003, infant and child mortality rates were less than one-third of the national rates. The maternal mortality ratio decreased by 50% despite comprehensive emergency obstetric care not being available in most district hospitals. These trends were achieved with an investment of approximately 4 million US dollars over 12 years (equivalent to US 1.00 US dollars per person per year). However, this project did not overcome weaknesses in some national disease-control programmes, especially the expanded programme on immunization, that require strong central management. In Lao PDR, which is not yet committed to using SWAps, tools developed in Sayaboury could help other district health offices assume greater planning responsibilities in the recently decentralized system. Development partners should balance their support for centrally managed disease-specific programmes with assistance to horizontally integrated primary health care at the district level.     

Pathways to DRG-based hospital payment systems in Japan,Korea, and Thailand

Countries in Asia are working towards achieving universal health coverage while ensuring improved quality of care. One element is controlling hospital costs through payment reforms. In this paper we review experiences in using Diagnosis Related Groups (DRG) based hospital payments in three Asian countries and ask if there is an "Asian way to DRGs". We focus first on technical issues and follow with a discussion of implementation challenges and policy questions. We reviewed the literature and worked as an expert team to investigate existing documentation from Japan, Republic of Korea, and Thailand. We reviewed the design of case-based payment systems, their experience with implementation, evidence about impact on service delivery, and lessons drawn for the Asian region. We found that countries must first establish adequate infrastructure, human resource capacity and information management systems. Capping of volumes and prices is sometimes essential along with a high degree of hospital autonomy. Rather than introduce a complete classification system in one stroke, these countries have phased in DRGs, in some cases with hospitals volunteering to participate as a first step (Korea), and in others using a blend of different units for hospital payment, including length of stay, and fee-for-service (Japan). Case-based payment systems are not a panacea. Their value is dependent on their design and implementation and the capacity of the health system.     

What can developing economies learn from health system reforms of developed countries?

This paper outlines some general lessons developing nations can draw from the health system reform experiences of developed nations. Using the experiences of developed countries, developing countries should be better able to anticipate socio-economic changes and choose an optimal path for their health systems development to accompany those changes. Most developed countries have adopted rather common objectives and principles in their health systems because of market failure in health care; developing countries may start adopting those principles because they do not have market conditions in the first place. It is suggested that developing countries strengthen what is probably the most fundamental initial systemic asset they have: public finance. They should do so by attracting democratically, possibly through earmarked taxes, resources otherwise channelled through the private sector, competing with public finance for limited real resources. This effort can be promoted by giving consumers, mainly of high income groups and in urban areas, more say (through institutions performing the OMCC function) in the nature of care these groups have access to under auspices of public finance. Where feasible, private insurance as a major source of finance should be seen as a transitional phenomenon, giving way to the emergence of OMCC institutions which require similar financial and managerial market infrastructure. Private and competitive provision of care may be unrealistic in many developing areas because of both scarcity of real resources, mainly manpower, and health needs. The challenge of government is, as resources grow, to divest itself from the provision of care and stay involved in activities and facilities that are of 'public nature'--under specific circumstances--that foster private competitive provision. In general, the government should play an enabling role also by investing in health promotions and management skills for health systems.     

Management control in a publicly planned health system: a case study from Finland.

Implementing improved management control systems has become a high priority within publicly planned health care systems in recent years. This article explores present management control practices and dilemmas within the Finnish health care system. Based upon an intensive case study of one central hospital district, the article analyzes current intra-institutional and cross-institutional management efforts. Subsequently it evaluates implications from the study's findings for both the Finnish and other publicly planned health care systems.     

推进城市社区卫生服务合理利用卫生资源

针对城市卫生服务体系改革与发展社区卫生服务,合理利用卫生资源,对盐城市社区卫生服务供需状况进行了系统的调查,对收集到的数据进行了分析和研究,并结合盐城市的实际情况,提出了相应的对策及建议。     

杭州市公立医院财政投入分析

本文以市属公立医院财政投入为例,根据政府对医疗卫生财政投入、对公立医院投入、固定资产投资、经济运行补偿结构和成本费用数据进行分析,认为政府财政投入依据相对简单,提出政府应综合考虑医院成本核算、医疗服务价格和补偿机制等问题,有计划、科学地进行财政投入,并与医院综合考核结果相结合。