In Japan, all-payer rate setting under tight government control has proved to be an effective approach to containing costs

In Japan's health insurance system, the prices paid by multiple payers for nearly all health care goods and services are codified into a single fee schedule and are individually revised within the global rate set by the government. This single payment system has allowed total health care spending to be controlled despite a fee-for-service system with its incentives for increased volume of services; Japan's growing elderly population; and the regular introduction of new technologies and therapies. This article describes aspects of Japan's approach, as well as how that nation has expanded payment for inpatient hospital care based on case-mix. The result of the payment system is that Japan's rate of health spending growth has been well below that of other industrial nations. The percentage of gross domestic product spent on health increased from 7.7 percent in 2000 to 8.5 percent in 2008, compared to an increase from 13.7 percent to 16.4 percent in the United States. Japan's approach confirms that enlightened government regulation can maintain access to care, avoid rationing, make use of the latest technology, and allow for multiple insurance plans and an aging population--all while restraining the growth of health care spending.     

Cost-Shifting from Private to Public Payers: The Scene Before Parity Legislation

BACKGROUND: Analyses that have been conducted previously on the implications of parity have focused on the concern that mental health costs of private payers will substantially increase. A complete analysis of the cost implications of parity, however, also needs to consider whether the mental health costs of public payers may increase particularly if employers or private insurers attempt to extrude enrollees with severe mental illness. This study examines the extent of mental health cost shifting from private to public payers during two separate two-year periods prior to the implementation of parity legislation. The results of the analyses can serve as a necessary baseline against which the consequences of parity legislation on this direction of cost-shifting can be examined. METHODS: The study utilizes an all payer data set that contains information on the use of specialty mental health services (excluding private practitioners) by adults in an urban and a rural county in New York State. For each year of two time periods -1991/1992 and 1995/ 1996 - consumers were classified into payer groups based on whether their services were paid for by "Private Only", "Public Only", "Private/Public", "Self Pay" or "Other" payers. The proportion of individuals who moved from one payer group to another from one year to the following year of each time period and the average yearly costs under these payers were examined. Logistic regression models were used to identify the characteristics of persons most likely to remain with Private Only Payers in contrast to those likely to shift to Private/Public Only payers or to Public Only Payers. RESULTS: In both two-year time periods, the percent of persons who shifted in one year from Private Only to either Private/Public or Public Only payers was small. In contrast, a person in the Private/Public group has more than a 12 percent likelihood of shifting to a Public Only payer in the subsequent year. The average annual costs of the Private/Public group were higher than that of any other payer group. The average annual costs of persons who shifted into the Private/Public group from any other payer group or remained there from the previous year were even higher. The logistic regression analyses for both time periods showed that persons who shifted from Private Only to Private/Public or Public Only payers in contrast to those who remained with Private Only payers were more likely to have subsidized incomes, be younger and have a mental health disability. In 1995, the likelihood of the shift was also increased for those who were nonwhite and/or had a substance abuse disability. IMPLICATIONS: This study has found that individuals rarely shift directly from private payers to public payers. Rather, they first shift to having services reimbursed by both private and public payers, and during this period their average total service costs are extremely high. Persons who shift from private payers to having at least some of their services paid by public payers in subsequent years appear to be either young employees or young dependents who have severe mental illness or mental illness disabilities. Abusing substances and/or being nonwhite also increase the likelihood of a shift to public payers. Along with parity mandates, there has been an increase in managed care controls. The extent to which these controls will be used to accelerate the movement of these high cost persons from private to public payers needs close watch.     

Physicians' responses to their changing environment

The loss of physician autonomy, the changing shape of physicians' practices, and efforts to control the cost of health care have left American physicians increasingly dissatisfied with the U.S. health care system. A survey of 300 office and hospital-based physicians shows 59 percent favor reform of the U.S. system; only 31 percent favor retaining the current system. Doctors face increased competition for patients (the supply of physicians has increased three times faster than the population), reduced autonomy because of intervention by government and other third party payers, pressure from patients to provide unnecessary care including expensive new technology, and increased cost containment. Yet a majority of physicians believe the causes of rising health care costs are patient demand for services and the current medical malpractice system. A minority (23 percent) blame hospitals and physicians for rising costs.     

Higher fees paid to US physicians drive higher spending for physician services compared to other countries

Higher health care prices in the United States are a key reason that the nation's health spending is so much higher than that of other countries. Our study compared physicians' fees paid by public and private payers for primary care office visits and hip replacements in Australia, Canada, France, Germany, the United Kingdom, and the United States. We also compared physicians' incomes net of practice expenses, differences in financing the cost of medical education, and the relative contribution of payments per physician and of physician supply in the countries' national spending on physician services. Public and private payers paid somewhat higher fees to US primary care physicians for office visits (27 percent more for public, 70 percent more for private) and much higher fees to orthopedic physicians for hip replacements (70 percent more for public, 120 percent more for private) than public and private payers paid these physicians' counterparts in other countries. US primary care and orthopedic physicians also earned higher incomes ($186,582 and $442,450, respectively) than their foreign counterparts. We conclude that the higher fees, rather than factors such as higher practice costs, volume of services, or tuition expenses, were the main drivers of higher US spending, particularly in orthopedics.     

Pronounced gender and age differences are evident in personal health care spending per person

This paper examines differences in national health care spending by gender and age. Our research found significant variations in per person spending by gender across age groups, health services, and types of payers. For example, in 2004 per capita health care spending for females was 32 percent more than for males. Per capita differences were most pronounced among the working-age population, largely because of spending for maternity care. Except for children, total spending for and by females was greater than that for and by males, for most services and payers. The gender difference in total spending was most pronounced in the elderly, as a result of the longer life expectancy of women.     

Monitoring health spending increases: incremental budget analyses reveal challenging tradeoffs

With each passing decade, health care has consumed a larger share of gross domestic product (GDP) and Federal budgets. By the 2000-2004 period, society was willing to devote over 20 percent of the cumulative increase in GDP and the cumulative increase in Federal outlays towards health care. The financing challenges are expected to become more acute for private payers as well as Federal, State, and local budgets. With the implementation of Part D in 2006, the U.S. Office of Management and Budget projects that Federal budget pressures will heighten, bringing increased attention to Medicare's long-term fiscal outlook.     

A decade of health care cost growth has wiped out real income gains for an average US family

Although a median-income US family of four with employer-based health insurance saw its gross annual income increase from $76,000 in 1999 to $99,000 in 2009 (in current dollars), this gain was largely offset by increased spending to pay for health care. Monthly spending increases occurred in the family's health insurance premiums (from $490 to $1,115), out-of-pocket health spending (from $135 to $235), and taxes devoted to health care (from $345 to $440). After accounting for price increases in other goods and services, the family had $95 more in monthly income to devote to nonhealth spending in 2009 than in 1999. By contrast, had the rate of health care cost growth not exceeded general inflation, the family would have had $545 more per month instead of $95-a difference of nearly $5,400 per year. Even the $95 gain was artificial, because tax collections in 2009 were insufficient to cover actual increases in federal health spending. As a result, we argue, the burdens imposed on all payers by steadily rising health care spending can no longer be ignored.     

An agenda for improving compassionate care: a survey shows about half of patients say such care is missing

As the US health care system undergoes restructuring and pressure to reduce costs intensifies, patients worry that they will receive less compassionate care. So do health care providers. Our survey of 800 recently hospitalized patients and 510 physicians found broad agreement that compassionate care is "very important" to successful medical treatment. However, only 53 percent of patients and 58 percent of physicians said that the health care system generally provides compassionate care. Given strong evidence that such care improves health outcomes and patients' care experiences, we recommend that national quality standards include measures of compassionate care; that such care be a priority for comparative effectiveness research to determine which aspects have the most influence on patients' care experiences, health outcomes, and perceptions of health-related quality of life; and that payers reward the provision of such care. We also recommend the development of systematic approaches to help health care professionals improve the skills required for compassionate care.     

Recession contributes to slowest annual rate of increase in health spending in five decades

In 2009, US health care spending grew 4.0 percent--a historically low rate of annual increase--to $2.5 trillion, or $8,086 per person. Despite the slower growth, the share of the gross domestic product devoted to health spending increased to 17.6 percent in 2009 from 16.6 percent in 2008. The growth rate of health spending continued to outpace the growth of the overall economy, which experienced its largest drop since 1938. The recession contributed to slower growth in private health insurance spending and out-of-pocket spending by consumers, as well as a reduction in capital investments by health care providers. The recession also placed increased burdens on households, businesses, and governments, which meant that fewer financial resources were available to pay for health care. Declining federal revenues and strong growth in federal health spending increased the health spending share of total federal revenue from 37.6 percent in 2008 to 54.2 percent in 2009.     

Measuring the movement to electronic claims

Congressional inaction on health care reform during 1994 spelled a temporary halt to efforts to enact government mandates for the use of automated transactions. But even without the added pressure of government mandates, the steady shift to automated health care transactions continued during the year. Now that more of the nation's 1,500 health care payers and 700,000 providers are linked to regional and national electronic data interchange networks, more than one-third of all health care claims are transmitted electronically.     

成立乡镇防保所及其职能与效果的评价

目的 评价乡镇防保所的职能与效果。方法 采用描述流行病学宏观思维方法,对中山市独立防保所运行1年的情况进行分析。结果 中小学生健康知识知晓率达97．11％;儿童基础免疫和加强免疫接种率均达95％以上;传染病发病数比上一年下降44．19％;结核病防治完成率138．46％。肿瘤和麻风病人年均访视次数从无分别到1．38次和2．29次。公共食品卫生从业人员体检率达100％,合格率为93．65％。餐具抽检合格率为76．23％。食品抽查合格率为96．36％：25名乡村医生业务培训达175次,市级系统培训每人各1次。结论 独立运作的乡镇防保所,改变了我国沿袭几十年的农村基层预防保健工作由乡镇卫生院完成的管理模式,对组织实施农村基层预防保健、疾病控制、社区卫生、食品监督与监测工作切实到位,“人人享有初级卫生保健”的目标得到充分体现。     

Health spending projections through 2015: changes on the horizon

Growth in national health spending is projected to slow in 2005 to 7.4 percent, from a peak of 9.1 percent in 2002. Private health insurance premiums are projected to slow to 6.6 percent in 2005, with a rebound expected in 2007. The introduction of Medicare Part D drug coverage in 2006 produces a dramatic shift in spending across payers but has little net effect on aggregate spending growth. Health spending is expected to consistently outpace gross domestic product (GDP) over the coming decade, accounting for 20 percent of GDP by 2015.     

Self-medication of mental health problems: new evidence from a national survey

OBJECTIVE: To evaluate the association between past 30-day use of alcohol, marijuana, and other illicit drugs and past year unmet need for and use of mental health care. DATA SOURCE: A subsample of 18,849 respondents from the 2001 National Household Survey on Drug Abuse and the 2002 National Survey on Drug Use and Health. Subjects were between the ages of 18 and 65 years and had least one past year mental disorder symptom and no past year substance dependency. STUDY DESIGN: Logistic regressions of past 30-day substance use on past 12-month unmet need for mental health care and past 12-month use of mental health services controlling for clinical and sociodemographic characteristics. Predicted probabilities and corresponding standard errors are reported. PRINCIPAL FINDINGS: Use of illicit drugs other than marijuana increased with unmet need for mental health care (4.4 versus 3.2 percent, p=.046) but was not reduced with mental health-care use. Heavy alcohol use was not associated with increased unmet need for mental health care, but was higher among individuals with no mental health care use (4.4 percent versus 2.7 percent, p<.001). By contrast, marijuana use did not appear associated with either unmet need or mental health care use. CONCLUSIONS: Substance use varies with past year unmet need for mental health care and mental health care use in ways consistent with the self-medication hypothesis. Results suggest that timely screening and treatment of mental health problems may prevent the development of substance-use disorders among those with mental disorders. Further research should identify subgroups of individuals for whom timely and appropriate mental health treatment would prevent the development of substance-use disorders.     

Banking on privacy. Hospitals must protect patient information--and their own liability--as banks balk at HIPAA

Thanks to HIPAA, banks stand to earn billions of dollars in new business by processing electronic claims for health care providers and payers. And the health care industry could realize $35 billion a year in efficiency gains and cost savings. But overshadowing it all is the question of how protected patient information will be--and how liable hospitals will be for any breach of that information by their business partners.     

National health expenditure projections: modest annual growth until coverage expands and economic growth accelerates

For 2011-13, US health spending is projected to grow at 4.0 percent, on average--slightly above the historically low growth rate of 3.8 percent in 2009. Preliminary data suggest that growth in consumers' use of health services remained slow in 2011, and this pattern is expected to continue this year and next. In 2014, health spending growth is expected to accelerate to 7.4 percent as the major coverage expansions from the Affordable Care Act begin. For 2011 through 2021, national health spending is projected to grow at an average rate of 5.7 percent annually, which would be 0.9 percentage point faster than the expected annual increase in the gross domestic product during this period. By 2021, federal, state, and local government health care spending is projected to be nearly 50 percent of national health expenditures, up from 46 percent in 2011, with federal spending accounting for about two-thirds of the total government share. Rising government spending on health care is expected to be driven by faster growth in Medicare enrollment, expanded Medicaid coverage, and the introduction of premium and cost-sharing subsidies for health insurance exchange plans.