Commoditization of the international teleradiology market

Telemedicine improves access to medical care. However, telemedicine will also increase market volatility because of its ability to stimulate price competition and the insidious way it shifts liability for providing medical services. To cope with increased volatility, other economic sectors have evolved commodities markets by making greater use of standardized forward/future contracts. In the past, the need for medical services to be produced and consumed locally and a lack of an objective definition for medical quality, prohibited the use of forward contracts for health-care services. However, telemedicine, and the increasing use of statistical definitions of medical quality now make standardized forward contracts for health-care services conceivable. Commoditization of teleradiology would offer several advantages including increasing market transparency, a mechanism for ensuring medical quality, and a means for bringing capital into the health-care sector. To reap the benefits of a commodities market in teleradiology, the key will be for market stakeholders to overcome their fear of the unknown in order to organize a central exchange.     

Applying economic principles to health care

Applying economic thinking to an understanding of resource use in patient care is challenging given the complexities of delivering health care in a hospital. Health-care markets lack the characteristics needed to determine a "market" price that reflects the economic value of resources used. However, resource allocation in a hospital can be analyzed by using production theory to determine efficient resource use. The information provided by hospital epidemiologists is critical to understanding health-care production processes used by a hospital and developing economic incentives to promote antibiotic effectiveness and infection control.     

The monopolistic integrated model and health care reform: the Swedish experience

This article reviews recent reforms geared to creating internal markets in the Swedish health-care sector. The main purpose is to describe driving forces behind reforms, and to analyse the limitations of reforms oriented towards internal markets within a monopolistic integrated health-care model. The principal part of the article is devoted to a discussion of incentives within Swedish county councils, and of how these incentives have influenced reforms in the direction of more choices for consumers and a separation between purchasers and providers. It is argued that the current incentives, in combination with criticism against county council activities in the early 1990's, account for the present inconsistencies as regards reforms. Furthermore, the article maintains that a weak form of separation between purchasers and providers will lead to distorted incentives, restricting innovative behaviour and structural change. In conclusion, the process of reforming the Swedish monopolistic integrated health-care model in the direction of some form of internal market is said to rest on shaky ground.     

Using HMOs to serve the Medicaid population: what are the effects on utilization and does the type of HMO matter?

States have increasingly used Health Maintenance Organizations (HMOs) to provide medical services to the Medicaid population. However, the effects of these initiatives on total health-care expenses, the mix of utilization, and access to care remain unclear. We examine the effect of changes in Medicaid HMO penetration between 1996 and 2002 on these outcomes using data for the nonelderly Medicaid population in the Community Tracking Study's Household Survey. We develop market-level measures of Medicaid HMO penetration from CMS and InterStudy data, distinguish whether the HMOs specialize in serving the Medicaid population, and use a market fixed-effects model to focus on changes in HMO penetration rates over time. Although limited by imprecise estimates, we find some evidence that utilization and access are related to the market penetration rates of commercial and Medicaid-dominant HMOs, but the pattern of results we observe does not appear to be consistent with welfare improvements.     

Promoting innovation in small markets: Evidence from the market for rare and intractable diseases

In many medical care markets with limited profit potential, firms often have little incentive to innovate. These include the market for rare diseases, “neglected” tropical diseases, and personalized medicine. Governments and not-for-profit organizations promote innovation in such markets but empirical evidence on the policy effect is limited. We study this issue by analyzing the impact of a demand-side policy in Japan, which reduces the cost sharing of patients with some rare and intractable diseases and attempts to establish and promote the treatment of those diseases. Using clinical trials data taken from public registries, we identify the effect of the policy using a difference-in-difference approach. We find that the demand-side policy increased firms’ incentive to innovate: firm-sponsored clinical trials increased 181% (0.16 per disease per year) when covered by the policy. This result indicates that the demand-side policy can be an important part of innovation policies in markets with limited profit potential.     

A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context

Two decades after the Safe Motherhood campaigns 1987 launch in India, half a million women continue to die from pregnancy-related causes every year. Key health-care interventions can largely prevent these deaths, but their use is limited in developing countries, and is reported to vary between population groups. We reviewed the use of maternal health-care interventions in developing countries to assess the extent, strength and implications of evidence for variations according to women's place of residence and socioeconomic status. Studies with data on use of a skilled health worker at delivery, antenatal care in the first trimester of pregnancy and medical settings for delivery were assessed. We identified 30 eligible studies, 12 of which were of high or moderate quality, from 23 countries. Results of these studies showed wide variation in use of maternal health care. Methodological factors (e.g. inaccurate identification of population in need or range of potential confounders controlled for) played a part in this variation. Differences were also caused by factors related to health-care users (e.g. age, education, medical insurance, clinical risk factors) or to supply of health care (e.g. clinic availability, distance to facility), or by an interaction between such factors (e.g. perceived quality of care). Variation was usually framed by contextual issues relating to funding and organization of health care or social and cultural issues. These findings emphasize the need to investigate and assess context-specific causes of varying use of maternal health care, if safe motherhood is to become a reality in developing countries.     

IS THE MEDICAL LOSS RATIO A GOOD TARGET MEASURE FOR REGULATION IN THE INDIVIDUAL MARKET FOR HEALTH INSURANCE?

Effective January 1, 2011, individual market health insurers must meet a minimum medical loss ratio (MLR) of 80%. This law aims to encourage ‘productive’ forms of competition by increasing the proportion of premium dollars spent on clinical benefits. To date, very little is known about the performance of firms in the individual health insurance market, including how MLRs are related to insurer and market characteristics. The MLR comprises one component of the price–cost margin, a traditional gauge of market power; the other component is percent of premiums spent on administrative expenses. We use data from the National Association of Insurance Commissioners (2001–2009) to evaluate whether the MLR is a good target measure for regulation by comparing the two components of the price–cost margin between markets that are more competitive versus those that are not, accounting for firm and market characteristics. We find that insurers with monopoly power have lower MLRs. Moreover, we find no evidence suggesting that insurers' administrative expenses are lower in more concentrated insurance markets. Thus, our results are largely consistent with the interpretation that the MLR could serve as a target measure of market power in regulating the individual market for health insurance but with notable limited ability to capture product and firm heterogeneity. Copyright © 2013 John Wiley & Sons, Ltd.     

Human exposure to antimicrobial resistance from poultry production: Assessing hygiene and waste-disposal practices in Bangladesh

The unregulated use of antibiotics is linked with intensive poultry farming in developing economies. In low-and middle-income countries, the dissemination of antimicrobial resistance (AMR) has also been attributed to contamination, poor public health infrastructure and inadequate waste disposal practices. There are limited data on hygiene and waste disposal practices in small-scale commercial and household poultry farming and market sales in Bangladesh. Our objective was to explore human exposures, hygiene and waste disposal practices in poultry raising and processing to identify probable pathways for transmission of AMR bacteria.We employed mixed methods approaches of in-depth interviews and structured observations to assess exposures, hygiene behaviours and waste-disposal practices relating to poultry production in Bangladesh. Interviews (n = 18) were conducted with commercial poultry farmers, backyard poultry owners, and live poultry market workers. Structured observations were conducted for 6-h in five households, five commercial farms and five urban live bird markets to assess the frequency of transmission/exposure events in these settings.Interviews highlighted existing practices that can contribute to transmission of antimicrobial resistant bacteria from poultry to humans. In households and farms, untreated poultry waste and carcasses were disposed of on agricultural fields and in water bodies which may contaminate surface water and soil with poultry faeces. Biosecurity precautions were not used, and hands were rarely washed with soap after handling poultry. In urban markets, live poultry slaughter and processing was done on site with bare hands which were subsequently rinsed in water stored in containers without soap. Solid waste from poultry processing was disposed into municipal waste disposal stations and liquid waste was discarded into open drains.Structured observations revealed that workers in live poultry markets had the highest direct contact with poultry and poultry waste, almost tenfold higher than those working in poultry farms or with domestic poultry (59 vs 544 observed direct poultry exposure events) placing them at particularly high risk of exposure to faecal bacteria. Biosecurity measures were limited; in some cases, workers in commercial farms and urban markets had gloves and masks but often did not use them. In 88% (606/689) of exposure events no handwashing took place. Eating and drinking after handling poultry and without washing hands was observed in all three settings. These data suggest effective intervention strategies to reduce environmental contamination and to decrease risks of transmission should be prioritized. Data on prevalence of risk behaviours and AMR transmission to humans along environmental pathways can inform policy and intervention strategies.     

Strategies for a crowded marketplace

Today's crowded marketplace demands that health care organizations use sophisticated marketing techniques. One technique is for the organization to differentiate itself in order to attract clients away from competing organizations. Another is for the organization to focus its resources on a limited number of market segments with the understanding that it will not devote resources to segments that have not been specifically designated as target markets.     

Public and private health-care financing with alternate public rationing rules

We develop a model to analyze parallel public and private health-care financing under two alternative public sector rationing rules: needs-based rationing and random rationing. Individuals vary in income and severity of illness. There is a limited supply of health-care resources used to treat individuals, causing some individuals to go untreated. Insurers (both public and private) must bid to obtain the necessary health-care resources to treat their beneficiaries. Given individuals' willingnesses-to-pay for private insurance are increasing in income, the introduction of private insurance diverts treatment from relatively poor to relatively rich individuals. Further, the impact of introducing parallel private insurance depends on the rationing mechanism in the public sector. We show that the private health insurance market is smaller when the public sector rations according to need than when allocation is random.     

Dropped out or pushed out? Insurance market exit and provider market power in Medicare Advantage

This paper explores how provider and insurer market power affect which markets an insurer chooses to operate in. A 2011 policy change required that certain private insurance plans in Medicare form provider networks de novo; in response, insurers cancelled two-thirds of the affected plans. Using detailed data on pre-policy provider and insurer market structure, I compare markets where insurers built networks to those they exited. Overall, insurers in the most concentrated hospital and physician markets were 9 and 13 percentage points more likely to exit, respectively, than those in the least concentrated markets. Conversely, insurers with more market power were less likely to exit than those with less, and an insurer's market power had the largest effect on exit in concentrated hospital markets. These findings suggest that concentrated provider markets contribute to insurer exit and that insurers with less market power have more difficulty surviving in concentrated provider markets.     

COMPETITION AND QUALITY IN HOME HEALTH CARE MARKETS

Market‐based solutions are often proposed to improve health care quality; yet evidence on the role of competition in quality in non‐hospital settings is sparse. We examine the relationship between competition and quality in home health care. This market is different from other markets in that service delivery takes place in patients' homes, which implies low costs of market entry and exit for agencies. We use 6 years of panel data for Medicare beneficiaries during the early 2000s. We identify the competition effect from within‐market variation in competition over time. We analyze three quality measures: functional improvements, the number of home health visits, and discharges without hospitalization. We find that the relationship between competition and home health quality is nonlinear and its pattern differs by quality measure. Competition has positive effects on functional improvements and the number of visits in most ranges, but in the most competitive markets, functional outcomes and the number of visits slightly drop. Competition has a negative effect on discharges without hospitalization that is strongest in the most competitive markets. This finding is different from prior research on hospital markets and suggests that market‐specific environments should be considered in developing polices to promote competition. Copyright © 2013 John Wiley & Sons, Ltd.     

Factors affecting interstate use of inpatient care by Medicare beneficiaries.

This article examines the extent to which interstate inflow and outflow of patients affects their observed use of Medicare Part A inpatient care. Interstate patient flow can bias utilization rates and may be due to seasonal migration, interstate inpatient care market areas, or purposive seeking of specialized/high-quality care. Examination of state level patient flow data drawn from 1987 Medicare discharge indicate that most interstate patient flow occurs between adjacent states probably as an outgrowth of interstate markets. Regression analyses of patient flow data suggest that while seasonal migration is an important determinant of patient flow, its importance is secondary to that of indicators of the availability of specialized services. These findings suggest research questions that may be best answered in detailed analyses of inpatient utilization in interstate market areas and seasonal migration.     

Establishing the Cost-Effectiveness of New Pharmaceuticals under Conditions of Uncertainty—When Is There Sufficient Evidence?

Decisions about which health-care interventions represent adequate value to collectively funded health-care systems are as widespread as they are unavoidable. In the case of new pharmaceuticals, many countries now require formal cost-effectiveness analysis to inform this decision-making process. This requires evidence on parameters associated with health-related utilities, treatment effects, resource use, and costs, for which data from available regulatory trials are invariably absent or highly uncertain. This uncertainty results from a number of factors including the predominance of intermediate end points in the clinical evidence-base and the limited period of follow-up of patients in clinical studies. Despite these imperfections in the evidence base, decisions about whether new pharmaceuticals are sufficiently cost-effective for reimbursement cannot be side-stepped. Data limitations do, however, require the use of rigorous analytical methods to support decision making. Probabilistic decision models and value of information analysis offer a means of structuring decision problems, synthesizing all available data, characterizing the uncertainty in the decision, quantifying the cost of uncertainty, and establishing the expected value of perfect information. This analytical framework is important because it addresses two fundamental questions about new pharmaceuticals. First, is the product expected to be cost-effective on the basis of existing evidence? Second, is additional research concerning the product itself cost-effective? In addressing these questions, the analytical framework can establish when sufficient evidence exists to sustain a claim for a new pharmaceutical to be cost-effective.     

Is there a contradiction between telemedicine and business?

Is there a contradiction between telemedicine and business? The driving forces in the telemedicine market are: competition within the health-care industry, newly developed cheap information technology (especially the Internet) and 21st-century health-care consumers, with their expectations of free choice and a high level of health-care. The market has four segments (citizens, patients, professionals and employees) and the boundaries between these segments are blurred. The telemedicine market is obviously growing, but it is still unstructured, fractured and disorganized. The telemedicine market needs a meeting place where the status of telemedicine and telecare can be reviewed. This would be a place in which to explore new ways to improve the efficiency of health-care services and a forum in which to draw a roadmap for future developments. One such place is the International Trade Event and Conference for eHealth, Telemedicine and Health ICT, Med-e-Tel. At the 2004 event, there were 32 exhibitors from 23 countries and over 400 industry and medical participants. A survey of participants showed that the event was judged to be a success. There is no conflict between telemedicine and business. On the contrary, telemedicine is a promising area of business development.     

Can health technologies be assessed using routine data?

OBJECTIVES: The potential of routine data for health technology assessment (HTA) in the United Kingdom was assessed. METHODS: Compiled were a comprehensive list of routine databases, their classification according to data characteristics, literature review on their current use, and their comparison with key topics identified as priorities for HTA. RESULTS: Two hundred seventy health-care databases for England or the English regions were identified. Twenty-four included data on both health technology and patient health state. Eleven found some published use in effectiveness evaluation. Of 140 prioritized health technologies, only 22 could be identified in routine databases. CONCLUSIONS: Routine data are plentiful but of limited use in HTA. The data sets usually do not include the effect of treatments. Coding is inadequate, and confidentiality regulations will make matters worse. Both need urgent attention.     

The quality of family relationships and use of maternal health-care services in India

Marital quality is well established as a determinant of health in Western contexts, yet the importance of relationship quality to health in non-Western contexts is largely limited to a focus on domestic violence. Using the Women's Reproductive Histories Survey, this study examines whether women with higher-quality family relationships are more likely than others to use maternal health-care services in Madhya Pradesh, India. Results show that among nuclear families, women with better marital relationships are more likely than others to use antenatal care services and to deliver in a health-care facility. Among joint families, women who have better relationships with their in-laws are more likely to use antenatal care services. The results further suggest that women's agency mediates some, but not all, of the effect of relationship quality on use of maternal health-care services.     

不完全竞争医疗保健市场的福利状况分析

医疗保健市场具有不同于其他商品市场的特点，并且是一个典型的不完全竞争市场，市场机制在配置卫生资源方面的作用是有限的，在这个市场上私人福利与社会福利的状况受着多种因素的影响，特别是当医疗保险介入时，情况更为复杂，因此难以用单一的经济指标来衡量。基于对医疗保健市场特殊性的考察，作者分别分析了有医疗保险介入和没有医疗保险介入两种条件下医疗保健市场的福利状况，从而得出结论——在无法达到“最优”的情况下，选择以“次优”为政策目标也许更为现实。     

Health delivery system changes required when integrating telemedicine into existing treatment flows of information and patients

Business model and financial recovery issues dominate discussions about using telemedicine to improve chronic disease management. The technical issues are numerous, daunting and complex, but many can be addressed using the resources and infrastructure available in large, well-integrated clinical information systems. The cost-benefit balance will change when it becomes possible to use devices that are owned by patients for everyday use, rather than installing special-purpose devices for telemedicine. Technology and communications capabilities are driven mainly by market factors other than uses for health care. Provider-side telemedicine capabilities, specifically for upload, storage and display of home medical data, will improve as technology develops. How health-care providers will process the larger amount of data made available by telemedicine is a clinical issue, but it is likely that software will emerge to assist in this task. The alignment of financial incentives for health-care providers is a decisive factor in understanding why telemedicine has had substantial deployment within the US Veterans Hospital Administration system, and to some extent within prison health systems and the Kaiser Permanente Health Plan, but much less widely in other settings.     

An economic approach to the daily activities of private general practitioners

The present crisis in general medicine centres around the contents of the health-care services provided by general practitioners. These services were examined in a survey, carried out in 1975, of GP's daily activities. Collected data have been used to describe the characteristics of the daily activities of a typical general practitioner. Variations from this model have been interpreted in terms of three factors that characterize the local situation under which primary medical care is delivered: the nature of the health-care market, GPs' relationships with potential clients and their relationships with the local medical profession and environment.