Signs of discontent with the health care system are growing. Calls for health care reform are largely motivated by the continued increase in health care costs and the large number of people without adequate health insurance. For the past 20 years, health care spending has risen at rates higher than the gross national product. As many as 35 million people are without health insurance. As proposals for health care reform are developed, it is useful to understand the roots of the cost problem. Causes of spiraling health care costs include "market failure" in the health care market, expansion in technology, excessive administrative costs, unnecessary care and defensive medicine, increased patient complexity, excess capacity within the health care system, and low productivity. Attempts to control costs, by the federal government for the Medicare program and then by the private sector, have to date been mostly unsuccessful. New proposals for health care reform are proliferating, and important changes in the health care system are likely.
The government of Morocco approved two reforms in 2005 to expand health insurance coverage. The first is a payroll-based mandatory health insurance plan for public-and formal private–sector employees to extend coverage from the current 16 percent of the population to 30 percent. The second creates a publicly financed fund to cover services for the poor. Both reforms aim to improve access to high-quality care and reduce disparities in access and financing between income groups and between rural and urban dwellers. In this paper we analyze these reforms: the pre-reform debate, benefits covered, financing, administration, and oversight. We also examine prospects and future challenges for implementing the reforms.
In this paper, we use publicly available data from the Medical Expenditure Panel Survey - Insurance Component (MEPS-IC) to investigate the effect of Massachusetts’ health reform plan on employer-sponsored insurance premiums. We tabulate premium growth for private-sector employers in Massachusetts and the United States as a whole for 2004 – 2008. We estimate the effect of the plan as the difference in premium growth between Massachusetts and the United States between 2006 and 2008—that is, before versus after the plan—over and above the difference in premium growth for 2004 to 2006. We find that health reform in Massachusetts increased single-coverage employer-sponsored insurance premiums by about 6 percent, or $262. Although our research design has important limitations, it does suggest that policy makers should be concerned about the consequences of health reform for the cost of private insurance.
How realistic are proposals to expand the financing of Canadian health care through private insurance, either in a parallel stream or an expanded supplementary tier? Any successful business requires that revenues exceed expenditures. Under a voluntary health insurance plan those at highest risk would be the most likely to seek coverage; insurers working within a competitive market would have to limit their financial risk through such mechanisms as "risk selection" to avoid clients likely to incur high costs and/or imposing caps on the costs covered. It is unlikely that parallel private plans will have a market if a comprehensive public insurance system continues to exist and function well. Although supplementary plans are more congruous with insurance principles, they would raise costs for purchasers and would probably not provide full open-ended coverage to all potential clients. Insurance principles suggest that voluntary insurance plans that shift costs to the private sector would damage the publicly funded system and would be unable to cover costs for all services required.
In the transition from a planned economy to a market-oriented economy, China’s state funding for health care declined and traditional coverage plans collapsed, leaving China’s poor exposed to potentially ruinous health care costs. In reforming health care for the 21st century, equity in health care financing has become a major policy goal. To assess progress towards this goal, this paper examines the equity characteristics of health care financing in a province of northwestern China, comparing the equity performance between urban and rural areas at two different points in time.
Analysis of whether health care financing contributions were progressive according to income were made using the Kakwani index for each of the four health care financing channels of general taxes, public and private health insurance, and out-of-pocket payments. Two rounds of surveys were conducted, the first in 2003 (13,619 individuals in 3946 households) and the second in 2008 (12,973 individuals in 3958 households). Household socio-economic, health care payment, and utilization information were recorded in household interviews.
Low-income households have undertaken a larger share of the health care financing burden in recent years, reflected by negative Kakwani indices, which indicate a regressive system. We found that the indices for general taxation were −0.0024 (urban) and −0.0281 (rural) in 2002, and −0.0177 (urban) and −0.0097 (rural) in 2007. Public health insurance presented different financing distributions in urban and rural areas (urban: 0.0742 in 2002, 0.0661 in 2007; rural: –0.0615 in 2002,–0.1436 in 2007.). Out-of-pocket payments were progressive but not equitable. Public health insurance coverage has expanded but financing equity has decreased.
Health care financing policies in China need ongoing reform. Given the inequity of general consumption taxes, elimination of these would improve financing equity considerably. Optimizing benefit packages in public health insurance is as important as expanding coverage, both for health care financing and for utilization management as well. Although they are progressive, out-of-pocket payments are not equitable in China and have the effect of excluding the poor from health care as they cannot afford to pay for medical care and so withdraw from treatment.
Equity; Chinese health care reform; Financing; Kakwani index
The North American health care sector is being reformed to enhance collaboration among health care professionals to render patient care and improve outcomes. Changing educational frameworks will play a key role in achieving this goal. It is therefore important to gain an understanding of the application of interprofessional health care education and collaborative models of education. Chiropractic and other health care faculties would need to have an effective understanding and clarification of the characteristics of interprofessional care and its foundation in education from which appropriate educational and curricular models could be developed.
Collaboration; Curriculum; Education; Health Professional Curriculum; Interprofessional Education
The use of primary and managed care is likely to increase under proposed federal health care reform. I review the definition of primary care and primary care physicians and show that this delivery model can affect access to medical care, the cost of treatment, and the quality of services. Because the use of primary care is often greater in managed care than in fee-for-service, I compare the two insurance systems to further understand the delivery of primary care. Research suggests that primary care can help meet the goal of providing accessible, cost-effective, and high-quality care, but that changes in medical education and marketplace incentives will be needed to encourage students and trained physicians to enter this field.
WE ADDRESSED THE QUESTION OF WHETHER PRIVATE HEALTH CARE IS ILLEGAL in Canada by surveying the health insurance legislation of all 10 provinces. Our survey revealed multiple layers of regulation that seem to have as their primary objective preventing the public sector from subsidizing the private sector, as opposed to rendering privately funded practice illegal. Private insurance for medically necessary hospital and physician services is illegal in only 6 of the 10 provinces. Nonetheless, a significant private sector has not developed in any of the 4 provinces that do permit private insurance coverage. The absence of a significant private sector is probably best explained by the prohibitions on the subsidy of private practice by public plans, measures that prevent physicians from topping up their public sector incomes with private fees.
The Patient Protection and Affordable Care Act (ACA), more commonly known as health reform, is designed to expand health coverage to 32 million uninsured Americans by 2019 and makes significant changes to public and private health insurance systems that will affect providers of HIV care. We review the major features of the legislation and when they will be implemented, discuss the ways in which it will affect HIV care for different patient populations, and outline implementation challenges that are relevant for HIV care. We conclude with ways in which HIV providers can get involved to learn more about the law and help their patients take advantage of the new opportunities for health coverage.
Affordable Care Act; health insurance coverage; Medicaid; Medicare; Ryan White HIV/AIDS Program
In an era of rising health care costs, many Americans experience difficulty paying for needed health care services. With costs expected to continue rising, changes to private insurance plans and public programs aimed at containing costs may have a negative impact on Americans' ability to afford care.
To provide estimates of the number of adults who avoid health care due to cost, and to assess the association of income, functional status, and type of insurance with the extent to which people with health insurance report financial barriers.
Cross-sectional observational study using data from the Commonwealth Fund 2001 Health Care Quality Survey, a nationally representative telephone survey.
U.S. adults age 18 and older (N=6,722).
Six measures of avoiding health care due to cost, including delaying or not seeking care; not filling prescription medicines; and not following recommended treatment plan.
The proportion of Americans with difficulty affording health care varies by income and health insurance coverage. Overall, 16.9% of Americans report at least 1 financial barrier. Among those with private insurance, the poor (28.4%), near poor (24.3%), and those with functional impairments (22.9%) were more likely to report avoiding care due to cost. In multivariate models, the uninsured are more likely (OR, 2.3; 95% CI, 1.7 to 3.0) to have trouble paying for care. Independent of insurance coverage and other demographic characteristics, the poor (OR, 3.6; 95% CI, 2.1 to 4.6), near poor (OR, 2.1; 95% CI, 1.9 to 3.7), and middle-income (OR, 1.8; 95% CI, 1.3 to 2.5) respondents as well as those with functional impairments (OR, 1.6; 95% CI, 1.3 to 2.0) are significantly more likely to avoid care due to cost.
Privately and publicly insured individuals who have low incomes or functional impairments encounter significant financial barriers to care despite having health insurance. Proposals to expand health insurance will need to address these barriers in order to be effective.
health care affordability; insurance coverage; low-income populations; functional impairment
The Patient Protection and Affordable Care Act (PPACA) aims to provide affordable health insurance and expanded health care coverage for some 32 million Americans. The PPACA makes provisions for using technology, evidence-based treatments, and integrated, patient-centered care to modernize the delivery of health care services. These changes are designed to ensure effectiveness, efficiency, and cost-savings within the health care system.
To gauge the addiction treatment field’s readiness for health reform, the authors developed a Health Reform Readiness Index (HRRI) survey for addiction treatment agencies. Addiction treatment administrators and providers from around the United States completed the survey located on the http://www.niatx.net website. Respondents self-assessed their agencies based on 13 conditions pertinent to health reform readiness, and received a confidential score and instant feedback.
On a scale of “Needs to Begin,” “Early Stages,” “On the Way,” and “Advanced,” the mean scores for respondents (n = 276) ranked in the Early Stages of health reform preparation for 11 of 13 conditions. Of greater concern was that organizations with budgets of < $5 million (n = 193) were less likely than those with budgets > $5 million to have information technology (patient records, patient health technology, and administrative information technology), evidence-based treatments, quality management systems, a continuum of care, or a board of directors informed about PPACA.
The findings of the HRRI indicate that the addiction field, and in particular smaller organizations, have much to do to prepare for a future environment that has greater expectations for information technology use, a credentialed workforce, accountability for patient care, and an integrated continuum of care.
Health care reform; Addiction treatment; Substance use disorder treatment; SUD; Behavioral health; Organizational change; Care delivery; Health reform readiness index
American health plans can make a substantial contribution to the control of cardiometabolic risk (CMR), a condition associated with both adverse health outcomes and increased cost of care. Our goal was to determine health plan interest in and ability to provide CMR control services.
In January 2008, America's Health Insurance Plans, in collaboration with the HealthPartners Research Foundation, surveyed the chief medical officers of 74 member health insurance plans that offer commercial health maintenance organization, point of service, and preferred provider organization insurance. The response rate was 47%.
The 35 responding chief medical officers reported that their plans identify members with CMR through referral from case or care management (89%), health risk assessment data (86%), claims data (82%), and pharmaceutical use data (79%). Nearly all (97%) plans currently offer interventions for tobacco use, obesity/overweight, and nutrition. Ninety-four percent of plans offer interventions to increase physical activity. All plans offer health risk appraisal or assessment with feedback and education, 91% use Web-based tools, and 85% use health coaching to help plan members lower their risk. Perceived barriers to broader implementation of risk control programs included lack of resources (79%), limited available enrollee data (74%), and lack of reporting systems (79%). Few health plan officers viewed lack of purchaser interest to be a barrier to program implementation.
Health plans appear to be positioned to provide CMR control services that could improve health outcomes, reduce health care costs, and increase workplace productivity in the United States.
In Finland, dental services are provided by a public (PDS) and a private sector. In the past, children, young adults and special needs groups were entitled to care and treatment from the public dental services (PDS). A major reform in 2001 – 2002 opened the PDS and extended subsidies for private dental services to all adults. It aimed to increase equity by improving adults' access to oral health care and reducing cost barriers. The aim of this study was to assess the impacts of the reform on the utilization of publicly funded and private dental services, numbers and distribution of personnel and costs in 2000 and in 2004, before and after the oral health care reform. An evaluation was made of how the health political goals of the reform: integrating oral health care into general health care, improving adults' access to care and lowering cost barriers had been fulfilled during the study period.
National registers were used as data sources for the study. Use of dental services, personnel resources and costs in 2000 (before the reform) and in 2004 (after the reform) were compared.
In 2000, when access to publicly subsidised dental services was restricted to those born in 1956 or later, every third adult used the PDS or subsidised private services. By 2004, when subsidies had been extended to the whole adult population, this increased to almost every second adult. The PDS reported having seen 118 076 more adult patients in 2004 than in 2000. The private sector had the same number of patients but 542 656 of them had not previously been entitled to partial reimbursement of fees.
The use of both public and subsidised private services increased most in big cities and urban municipalities where access to the PDS had been poor and the number of private practitioners was high. The PDS employed more dentists (6.5%) and the number of private practitioners fell by 6.9%. The total dental care expenditure (PDS plus private) increased by 21% during the study period. Private patients who had previously not been entitled to reimbursements seemed to gain most from the reform.
The results of this study indicate that implementation of a substantial reform, that changes the traditionally defined tasks of the public and private sectors in an established oral health care provision system, proceeds slowly, is expensive and probably requires more stringent steering than was the case in Finland 2001 – 2004. However, the equity and fairness of the oral health care provision system improved and access to services and cost-sharing improved slightly.
To determine the impact of rising health insurance premiums on coverage rates.
Data Sources & Study Setting
Our analysis is based on two cohorts of nonelderly Americans residing in 64 large metropolitan statistical areas (MSAs) surveyed in the Current Population Survey in 1989–1991 and 1998–2000. Measures of premiums are based on data from the Health Insurance Association of America and the Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits.
Probit regression and instrumental variable techniques are used to estimate the association between rising local health insurance costs and the falling propensity for individuals to have any health insurance coverage, controlling for a rich array of economic, demographic, and policy covariates.
More than half of the decline in coverage rates experienced over the 1990s is attributable to the increase in health insurance premiums (2.0 percentage points of the 3.1 percentage point decline). Medicaid expansions led to a 1 percentage point increase in coverage. Changes in economic and demographic factors had little net effect. The number of people uninsured could increase by 1.9–6.3 million in the decade ending 2010 if real, per capita medical costs increase at a rate of 1–3 percentage points, holding all else constant.
Initiatives aimed at reducing the number of uninsured must confront the growing pressure on coverage rates generated by rising costs.
Health care costs; health insurance coverage; health care spending growth; uninsured; insurance premiums
Twenty-five years ago, private insurance plans were introduced into the Medicare program with the stated dual aims of (1) giving beneficiaries a choice of health insurance plans beyond the fee-for-service Medicare program and (2) transferring to the Medicare program the efficiencies and cost savings achieved by managed care in the private sector.
In this article we review the economic history of Medicare Part C, known today as Medicare Advantage, focusing on the impact of major changes in the program’s structure and of plan payment methods on trends in the availability of private plans, plan enrollment, and Medicare spending. Additionally, we compare the experience of Medicare Advantage and of employer-sponsored health insurance with managed care over the same time period.
Beneficiaries’ access to private plans has been inconsistent over the program’s history, with higher plan payments resulting in greater choice and enrollment and vice versa. But Medicare Advantage generally has cost more than the traditional Medicare program, an overpayment that has increased in recent years.
Major changes in Medicare Advantage’s payment rules are needed in order to simultaneously encourage the participation of private plan, the provision of high-quality care, and to save Medicare money.
Medicare; managed care; health care costs
The Government of the Republic of Kenya is in the process of implementing health care reforms. However, poor knowledge about costs of health care services is perceived as a major obstacle towards evidence-based, effective and efficient health care reforms. Against this background, the Ministry of Health of Kenya in cooperation with its development partners conducted a comprehensive costing exercise and subsequently developed the Kenya Health Sector Costing Model in order to fill this data gap.
Based on standard methodology of costing of health care services in developing countries, standard questionnaires and analyses were employed in 207 health care facilities representing different trustees (e.g. Government, Faith Based/Nongovernmental, private-for-profit organisations), levels of care and regions (urban, rural). In addition, a total of 1369 patients were randomly selected and asked about their demand-sided costs. A standard step-down costing methodology was applied to calculate the costs per service unit and per diagnosis of the financial year 2006/2007.
The total costs of essential health care services in Kenya were calculated as 690 million Euros or 18.65 Euro per capita. 54% were incurred by public sector facilities, 17% by Faith Based and other Nongovernmental facilities and 23% in the private sector. Some 6% of the total cost is due to the overall administration provided directly by the Ministry and its decentralised organs. Around 37% of this cost is absorbed by salaries and 22% by drugs and medical supplies. Generally, costs of lower levels of care are lower than of higher levels, but health centres are an exemption. They have higher costs per service unit than district hospitals.
The results of this study signify that the costs of health care services are quite high compared with the Kenyan domestic product, but a major share are fixed costs so that an increasing coverage does not necessarily increase the health care costs proportionally. Instead, productivity will rise in particular in under-utilized private health care institutions. The results of this study also show that private-for-profit health care facilities are not only the luxurious providers catering exclusively for the rich but also play an important role in the service provision for the poorer population. The study findings also demonstrated a high degree of cost variability across private providers, suggesting differences in quality and efficiencies.
With an estimated adult HIV prevalence of 15%, Namibia is in need of innovative health financing strategies that can alleviate the burden on the public sector. Affordable and private health insurances were recently developed in Namibia, and they include coverage for HIV/AIDS. This article reports on the efficacy of HIV workplace surveys as a tool to increase uptake of these insurances by employees in the Namibian formal business sector. In addition, the burden of HIV among this population was examined by sector.
Cross-sectional anonymous HIV prevalence surveys were conducted in 24 private companies in Namibia between November 2006 and December 2007. Non-invasive oral fluid-based HIV antibody rapid tests were used. Anonymous test results were provided to the companies in a confidential report and through presentations to their management, during which the advantages of affordable private health insurance and the available insurance products were discussed. Impact assessment was conducted in October 2008, when new health insurance uptake by these companies was evaluated.
Of 8500 targeted employees, 6521 were screened for HIV; mean participation rate was 78.6%. Overall 15.0% (95% CI 14.2-15.9%) of employees tested HIV positive (range 3.0-23.9% across companies). The mining sector had the highest percentage of HIV-positive employees (21.0%); the information technology (IT) sector had the lowest percentage (4.0%). Out of 6205 previously uninsured employees, 61% had enrolled in private health insurance by October 2008. The majority of these new insurances (78%) covered HIV/AIDS only.
The proportion of HIV-positive formal sector employees in Namibia is in line with national prevalence estimates and varies widely by employment sector. Following the surveys, there was a considerable increase in private health insurance uptake. This suggests that anonymous HIV workplace surveys can serve as a tool to motivate private companies to provide health insurance to their workforce. Health insurance taken up by those who are able to pay the fees will alleviate the burden on the public sector.
This article considers some of the effects of health sector reform on human resources for health (HRH) in developing countries and countries in transition by examining the effect of fiscal reform and the introduction of decentralisation and market mechanisms to the health sector.
Fiscal reform results in pressure to measure the staff outputs of the health sector. Financial decentralisation often leads to hospitals becoming "corporatised" institutions, operating with business principles but remaining in the public sector. The introduction of market mechanisms often involves the formation of an internal market within the health sector and market testing of different functions with the private sector. This has immediate implications for the employment of health workers in the public sector, because the public sector may reduce its workforce if services are purchased from other sectors or may introduce more short-term and temporary employment contracts.
Decentralisation of budgets and administrative functions can affect the health sector, often in negative ways, by reducing resources available and confusing lines of accountability for health workers. Governance and regulation of health care, when delivered by both public and private providers, require new systems of regulation.
The increase in private sector provision has led health workers to move to the private sector. For those remaining in the public sector, there are often worsening working conditions, a lack of employment security and dismantling of collective bargaining agreements.
Human resource development is gradually being recognised as crucial to future reforms and the formulation of health policy. New information systems at local and regional level will be needed to collect data on human resources. New employment arrangements, strengthening organisational culture, training and continuing education will also be needed.
Everyone agrees that insurance for long-term care is inadequate in the United States. Disagreement exists, however, on whether such insurance should be provided through the private or public sector. Private insurance generally uses the experience-rating principle that persons with higher risk of illness are charged higher premiums. For private insurance for long-term care, this principle creates a dilemma. Most policies will be purchased by the elderly; yet, because the elderly have a high risk of needing long-term care, only about 20% of them can afford the cost of premiums. A public-private partnership by which the government partially subsidizes private long-term-care insurance is unlikely to resolve this dilemma. Only a social insurance program for long-term care can provide universal, affordable, and equitable coverage.
To describe the association between type of health insurance coverage and the quality of care provided to individuals with diabetes in the United States.
The 2000 Behavioral Risk Factor Surveillance System.
Our study cohort included individuals who reported a diagnosis of diabetes (n=11,647). We performed bivariate and multivariate logistic regression analyses by age greater or less than 65 years to examine the association of health insurance coverage with diabetes-specific quality of care measures, controlling for the effects of race/ethnicity, annual income, gender, education, and insulin use.
Most individuals with diabetes are covered by private insurance (39 percent) or Medicare (44 percent). Among persons under the age of 65 years, 11 percent were uninsured. The uninsured were more likely to be African American or Hispanic and report low incomes. The uninsured were less likely to report annual dilated eye exams, foot examinations, or hemoglobin A1c (HbA1c) tests and less likely to perform daily blood glucose monitoring than those with private health insurance. We found few differences in quality indicators between Medicare, Medicaid, or the Department of Veterans Affairs (VA) as compared with private insurance coverage. Persons who received care through the VA were more likely to report taking a diabetes education class and HbA1c testing than those covered by private insurance.
Uninsured adults with diabetes are predominantly minority and low income and receive fewer preventive services than individuals with health insurance. Among the insured, different types of health insurance coverage appear to provide similar levels of care, except for higher rates of diabetes education and HbA1c testing at the VA.
Quality of care; health insurance; diabetes
The break-up of the USSR brought considerable disruption to health services in Russia. The uptake of compulsory health insurance rose rapidly after its introduction in 1993. However, by 2000 coverage was still incomplete, especially amongst the disadvantaged. By this time, however, the state health service had become more stable, and the private sector was growing. This paper describes subsequent trends and determinants of healthcare insurance coverage in Russia, and its relationship with health service utilisation, as well as the role of the private sector.
Data were from the Russia Longitudinal Monitoring Survey, an annual household panel survey (2000–4) from 38 centres across the Russian Federation. Annual trends in insurance coverage were measured (2000–4). Cross-sectional multivariate analyses of the determinants of health insurance and its relationship with health care utilisation were performed in working-age people (18–59 years) using 2004 data.
Between 2000 and 2004, coverage by the compulsory insurance scheme increased from 88% to 94% of adults; however 10% of working-age men remained uninsured. Compulsory health insurance coverage was lower amongst the poor, unemployed, unhealthy and people outside the main cities. The uninsured were less likely to seek medical help for new health problems. 3% of respondents had supplementary (private) insurance, and rising utilisation of private healthcare was greatest amongst the more educated and wealthy.
Despite high population insurance coverage, a multiply disadvantaged uninsured minority remains, with low utilisation of health services. Universal insurance could therefore increase access, and potentially contribute to reducing avoidable healthcare-related mortality. Meanwhile, the socioeconomically advantaged are turning increasingly to a growing private sector.
The promise of a universal, comprehensive, publicly funded system of medical care that was the foundation of the Medical Care Act passed in 1966 is no longer possible. Massive government debt, increasing health care costs, a growing and aging population and advances in technology have challenged the system, which can no longer meet the expectations of the public or of the health care professions. A parallel, private system, funded by a not-for-profit, regulated system of insurance coverage affordable for all wage-earners, would relieve the overstressed public system without decreasing the quality of care in that system. Critics of a parallel, private system, who base their arguments on the politics of fear and envy, charge that such a private system would "Americanize" Canadian health care and that the wealthy would be able to buy better, faster care than the rest of the population. But this has not happened in the parallel public and private health care systems in other Western countries or in the public and private education system in Canada. Wealthy Canadians can already buy medical care in the United States, where they spend $1 billion each year, an amount that represents a loss to Canada of 10,000 health care jobs. Parallel-system schemes in other countries have proven that people are driven to a private system by dissatisfaction with the quality of service, which is already suffering in Canada. Denial of choice is unacceptable to many people, particularly since the terms and conditions under which Canadians originally decided to forgo choice in medical care no longer apply.
This study examined the distribution of health-care insurance coverage by race/ethnicity using data on gender, age, income, and education to identify segments of the population with and without health-care insurance in 1993. Among all groups, whites were more likely to have health-care insurance coverage than blacks or Hispanics. The data also were cross-classified by type of insurance coverage, including private, Medicare, and Medicaid. Whites were more likely than minorities to have private coverage, whereas minorities, socially disadvantaged persons in all groups, and the elderly were more likely to be covered by Medicare and Medicaid.
Complementary and alternative medicine services in the United States are an approximately $9 billion market each year, equal to 3 percent of national ambulatory health care expenditures. Unlike conventional allopathic health care, complementary and alternative medicine is primarily paid for out of pocket, although some services are covered by most health insurance. Examining trends in demand for complementary and alternative medicine services in the United States reported in the Medical Expenditure Panel Survey during 2002–08, we found that use of and spending on these services, previously on the rise, have largely plateaued. The higher proportion of out-of-pocket responsibility for payment for services may explain the lack of growth. Our findings suggest that any attempt to reduce national health care spending by eliminating coverage for complementary and alternative medicine would have little impact at best. Should some forms of complementary and alternative medicine—for example, chiropractic care for back pain—be proven more efficient than allopathic and specialty medicine, the inclusion of complementary and alternative medicine providers in new delivery systems such as accountable care organizations could help slow growth in national health care spending.
Over the past two decades, health insurance in Vietnam has expanded nationwide. Concurrently, Vietnam's private health sector has developed rapidly and become an increasingly integral part of the health system. To date, however, little is understood regarding the potential for expanding public-private partnerships to improve health care access and outcomes in Vietnam.
To explore possibilities for public-private collaboration in the provision of ambulatory care at the primary level in the Mekong region, Vietnam.
We employed a mixed methods research approach. Qualitative methods included focus group discussions with health officials and in-depth interviews with managers of private health facilities. Quantitative methods encompassed facility assessments, and exit surveys of clients at the same private facilities.
Discussions with health officials indicated generally favorable attitudes towards partnerships with private providers. Concerns were also voiced, regarding the over- and irrational use of antibiotics, and in terms of limited capacity for regulation, monitoring, and quality assurance. Private facility managers expressed a willingness to collaborate in the provision of ambulatory care, and private providers facilites were relatively well staffed and equipped. The client surveys indicated that 80% of clients first sought treatment at a private facility, even though most lived closer to a public provider. This choice was motivated mainly by perceptions of quality of care. Clients who reported seeking care at both a public and private facility were more satisfied with the latter.
Public-private collaboration in the provision of ambulatory care at the primary level in Vietnam has substantial potential for improving access to quality services. We recommend that such collaboration be explored by Vietnamese policy-makers. If implemented, we strongly urge attention to effectively managing such partnerships, establishing a quality assurance system, and strengthening regulatory mechanisms.
public-private partnership; primary care; health care access; health care quality; Mekong; Vietnam; regulation; quality assurance