Canada could slash public-health expenditures by 15% with no reduction in Canadians' health status by substituting less costly types of delivery and forms of treatment in more appropriate settings, says the recently released report of the Queen's-University of Ottawa Project on Cost-effectiveness of the Canadian Health Care System. Sustainable Health Care for Canada concludes that the system could be made more efficient by reducing the number of acute-care beds and cutting patients' length of stay in hospital. It also suggests substituting continuing care for acute care and relying less on institutionalization of the elderly and more on alternatives such as residential or community care. The report also suggests that as Canada experiments with decentralization, it may be time to look at other regulatory models for health care, including the mixed-market approach.
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.
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
China’s healthcare system is experiencing significant growth from expanded government-backed insurance, greater public-sector spending on hospitals, and the introduction of private insurance and for-profit clinics. An incremental reform process has sought to develop market incentives for medical innovation and liberalize physician compensation and hospital finance while continuing to keep basic care affordable to a large population that pays for many components of care out-of-pocket. Additional changes presently under consideration by policymakers are likely to further restructure insurance and the delivery of care and will alter competitive dynamics in major healthcare industries, notably pharmaceuticals, medical devices, and diagnostic testing. This article describes the institutional history of China’s healthcare system and identifies dilemmas emerging as the country negotiates divisions between public and private in healthcare. Building on this analysis, the article considers opportunities for public-private partnerships and greater systems integration to reconcile otherwise incommensurable approaches to rewarding innovation and improving access. The article concludes with observations on the public function of health insurance and its significance to further development of China’s healthcare system.
China; Healthcare reform; Clinical trials; Electronic medical records; Insurance; Pharmaceuticals
The insulation of Canada’s healthcare system from trade treaty obligations is crucial to the legitimacy of Canada’s trade policy. Legal analysis has suggested, however, that competitive and for-profit delivery of the kind contemplated by the Kirby Report and some provinces may make healthcare more vulnerable to challenges under NAFTA and GATS. The Government of Canada has tried to counter this interpretation by stressing the importance of public financing as the principal criterion for exemption of healthcare from trade treaties, but now the potential for private financing of essential medical services indicated by the Supreme Court’s decision in Chaoulli v. Quebec has made that line of argument look risky as well. It is apparent that Canada failed to anticipate the possible interactions of domestic, international and constitutional law when it made commitments in the area of private health insurance at the WTO in 1997. Accordingly, the time has come to acknowledge the fragility of the boundary between health and trade policies, to take the risks and costs associated with trade treaty obligations fully into account when undertaking healthcare reform and to strengthen the separation between private and public health insurance.
Since 1960, numerous concepts of health-care reform have been submitted to the US Congress and the American public with different viewpoints and objectives. The priority for the US Congress to pass a bipartisan health-reform plan has been circumvented by the newly elected majority Republican Congress. Nevertheless, health-care cost containment, quality control, and health-care delivery concepts have been implemented gradually into the concept of competitive managerial health care. A few of the serious problems in the African-American community are the efficiency and quality of the health-care delivery system and the effects of managed care on African-American primary physicians and surgical specialists. The critical shortages of this group, especially the latter, may create a dilemma in the implementation of a quality surgical care delivery system. The Association of American Medical Colleges, the American College of Surgeons, and other affiliating organizations should become sensitized to the African-American community's health needs, deficiencies, and the rational institution of an equitable, efficient, comprehensive, and quality health-care plan coupled with a sustained and increasing supply of certified, diversified, and experienced African-American surgical manpower in company with family practice physicians and primary care physicians.
The health sector, a foremost service sector in Nigeria, faces a number of challenges; primarily, the persistent under-funding of the health sector by the Nigerian government as evidence reveals low allocations to the health sector and poor health system performance which are reflected in key health indices of the country.Notwithstanding, there is evidence that the private sector could be a key player in delivering health services and impacting health outcomes, including those related to healthcare financing. This underscores the need to optimize the role of private sector in complementing the government’s commitment to financing healthcare delivery and strengthening the health system in Nigeria. There are also concerns about uneven quality and affordability of private-driven health systems, which necessitates reforms aimed at regulation. Accordingly, the argument is that the benefits of leveraging the private sector in complementing the national government in healthcare financing outweigh the challenges, particularly in light of lean public resources and finite donor supports. This article, therefore, highlights the potential for the Nigerian government to scale up healthcare financing by leveraging private resources, innovations and expertise, while working to achieve the universal health coverage.
Nigeria; Healthcare Financing; Health System; Private Sector
America's health care system is characterized by rising costs, increasing numbers of Americans who lack health insurance coverage, and poor quality of health care delivery. The convergence of these factors is adversely affecting not only the health of Americans but also the ability of businesses to compete successfully in a global marketplace. AARP and other nonprofit organizations are collaborating with the private sector to have more people covered by health insurance and to educate them to make behavioral choices that prevent chronic disease and ultimately lower costs.
Policy on medical education has a major bearing on the outcome of health care delivery system. Countries plan and execute development of human resource in health, based on the realistic assessments of health system needs. A closer observation of medical education and its impact on the delivery system in India reveals disturbing trends. Primary care forms backbone of any system for health care delivery. One of the major challenges in India has been chronic deficiency of trained human resource eager to work in primary care setting. Attracting talent and employing skilled workforce seems a distant dream. Talking specifically of the medical education, there are large regional variations, urban - rural divide and issues with financing of the infrastructure. The existing design of medical education is not compatible with the health care delivery system of India. Impact is visible at both qualitative as well as quantitative levels. Medical education and the delivery system are working independent of each other, leading outcomes which are inequitable and unjust. Decades of negligence of medical education regulatory mechanism has allowed cropping of multiple monopolies governed by complex set of conflict of interest. Primary care physicians, supposed to be the community based team leaders stand disfranchised academically and professionally. To undo the distorted trajectory, a paradigm shift is required. In this paper, we propose expansion of ownership in medical education with academic institutionalization of community health services.
Community based medical education; medical education reforms; family medicine
Health care in the United States has entered a period of economic upheaval. Episodic, fee-for-service care financed by indemnity insurance is being replaced by managed care financed by fixed-price, capitated health plans. The resulting focus on reducing costs, especially in areas where there is competition fueled by oversupply of health services providers and facilities, poses new threats to the livelihood of medical libraries and medical librarians but also offers new opportunities. Internet services, consumer health education, and health services research will grow in importance, and organizational mergers will provide librarians with opportunities to assume new roles within their organizations.
While health IT is thought to be critical to the success of new models of care delivery, we know little about the extent to which those pursuing these models are relying on HIT. We studied a large patient-centered medical home (PCMH) demonstration project, a new model of care delivery that has received substantial policy attention, in order to assess which types of HIT were most widely used, and how adoption rates changed over time as PCMH practices matured. We found that clinically-focused HIT tools were both widely adopted, and increasingly adopted, in PCMH practices compared to non-PCMH practices. In contrast, HIT that supports patient-engagement, patient portals and personal health records, was neither in widespread use nor more likely to be adopted over time by PCMH practices compared to other practices. This suggests that these tools may not yet support the types of patient engagement and interactions that PCMH practices seek.
The medical component of workers' compensation programs-now costing over $24 billion annually-and the rest of the nation's medical care system are linked. They share the same patients and providers. They provide similar benefits and services. And they struggle over who should pay for what. Clearly, health care reform and restructuring will have a major impact on the operation and expenditures of the workers' compensation system. For a brief period, during the 1994 national health care reform debate, these two systems were part of the same federal policy development and legislative process. With comprehensive health care reform no longer on the horizon, states now are tackling both workers' compensation and medical system reforms on their own. This paper reviews the major issues federal and state policy makers face as they consider reforms affecting the relationship between workers' compensation and traditional health insurance. What is the relationship of the workers' compensation cost crisis to that in general health care? What strategies are being considered by states involved in reforming the medical component of workers compensation? What are the major policy implications of these strategies?
Accounting for 36% of public spending on health care in Canada, hospitals are a major target for cost reductions through various efficiency initiatives. Some provinces are considering payment reform as a vehicle to achieve this goal. With few exceptions, Canadian provinces have generally relied on global and line-item budgets to contain hospital costs. There is growing interest amongst policy-makers for using activity based funding (ABF) as means of creating financial incentives for hospitals to increase the 'volume' of care, reduce cost, discourage unnecessary activity, and encourage competition. British Columbia (B.C.) is the first province in Canada to implement ABF for partial reimbursement of acute hospitalization. To date, there have been no formal examinations of the effects of ABF policies in Canada.
This study proposal addresses two research questions designed to determine whether ABF policies affect health system costs, access and hospital quality. The first question examines the impact of the hospital funding policy change on internal hospital activity based on expenditures and quality. The second question examines the impact of the change on non-hospital care, including readmission rates, amount of home care provided, and physician expenditures.
A longitudinal study design will be used, incorporating comprehensive population-based datasets of all B.C. residents; hospital, continuing care and physician services datasets will also be used. Data will be linked across sources using anonymized linking variables. Analytic datasets will be created for the period between 2005/2006 and 2012/2013.
With Canadian hospitals unaccustomed to detailed scrutiny of what services are provided, to whom, and with what results, the move toward ABF is significant. This proposed study will provide evidence on the impacts of ABF, including changes in the type, volume, cost, and quality of services provided. Policy- and decision-makers in B.C. and elsewhere in Canada will be able to use this evidence as a basis for policy adaptations and modifications. The significance of this proposed study derives from the fact that the change in hospital funding policy has the potential to affect health system costs, residents' access to care and care quality.
Primary care reform initiatives in Ontario are proceeding with little information about the views of practicing family physicians.
A postal questionnaire was sent to 1200 randomly selected family physicians in Ontario five months after the initial invitation to join the Ontario Family Health Network. It sought information about their practice characteristics, their intention to participate in the Network and their views about the organization and financing of primary care.
The response rate was 50.3%. While many family physicians recognize the need for change in the delivery of primary care, the majority (72%) did not expect to join the Ontario Family Health Network by 2004, or by some later date (60%). Nor did they favour capitation or rostering, 2 key elements of the proposed reforms. Physicians who favour capitation were 5.5 times more likely to report that they expected to join the Network by 2004, although these practices comprise 5% of the sample.
The results of this survey, conducted five months after the initial offering of primary care reform agreements to all Ontario physicians, suggest that an 80% enrollment target is unrealistic.
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 surveyed residents and fellows at the University of Louisville School of Medicine (N = 600) to (1) explore their perceptions and knowledge of issues related to health care business and health care reforms, and (2) seek their input on what instructional content concerning health care business and health care reform they would like to receive and what instruction venue they would prefer. We will use the findings to make decisions about curriculum content and delivery.
All residents were invited to complete a 4-part, web-based survey that included questions on demographics, attitudes, and perceptions; a baseline-knowledge quiz about health care costs; and 2 open-ended questions about what they wanted to learn and how they preferred to be taught.
The survey response rate was 24%. Residents' agreement was stronger for statements relating to the role of physicians as “gatekeepers,” patient-centered care, and the value of learning to work as a team than it was for statements about the benefits of government intervention in health care. International medical graduates, when compared with US medical graduates, had statistically significant differences in perceptions (P ≤ .004) on 3 questions related to government impact on health care. There was a slight decrease in overall knowledge about health care cost issues by residents in later postgraduate years.
Residents are aware of gaps in their knowledge on business aspects of health care and health care reform. Their narrative responses identified coding and billing, legal issues, and comparative health systems as topics of interest, and the best venues for teaching included grand rounds and noon conferences. Residents indicated a preference for brief, highly focused, interactive sessions with knowledgeable guest speakers.
McDonough’s perspective on healthcare reform in the US provides a clear, coherent analysis of the mix of access and delivery reforms in the Affordable Care Act (ACA) aka Obamacare. As noted by McDonough, this major reform bill is designed to expand access for health coverage that includes both prevention and treatment benefits among uninsured Americans. Additionally, this legislation includes several financial strategies (e.g. incentives and penalties) to improve care coordination and quality in the hospital and outpatient settings while also reducing healthcare spending and costs. This commentary is intended to discuss this mix of access and delivery reform in terms of its potential to achieve the Triple Aim: population health, quality, and costs. Final remarks will include the role of the US federal government to reform the American private health industry together with that of an informed consume
US Healthcare Reform; Obamacare; Affordable Care Act (ACA); Healthcare Exchanges; Triple Aim
The role of defensive medicine in driving up health care costs is hotly contended. Physicians and health policy experts in particular tend to have sharply divergent views on the subject. Physicians argue that defensive medicine is a significant driver of health care cost inflation. Policy analysts, on the other hand, observe that malpractice reform, by itself, will probably not do much to reduce costs. We argue that both answers are incomplete. Ultimately, malpractice reform is a necessary but insufficient component of medical cost containment. The evidence suggests that defensive medicine accounts for a small but non-negligible fraction of health care costs. Yet the traditional medical malpractice reforms that many physicians desire will not assuage the various pressures that lead providers to overprescribe and overtreat. These reforms may, nevertheless, be necessary to persuade physicians to accept necessary changes in their practice patterns as part of the larger changes to the health care payment and delivery systems that cost containment requires.
defensive medicine; medical malpractice; health care costs; health care reform
Healthcare reform efforts include a push to limit copayments. The potential consequen ces suggest there may be better ways to remove access barriers and improve care delivery.
The healthcare reform debate has included discussion of some cost relief for patients by subsidizing their out-of-pocket costs. But employers and payers are looking at other options, such as linking the value of a healthcare intervention to its copayment, to try to improve health-care delivery and make its cost more equitable for all.
Over the past three decades, a limited range of market like mechanisms have been introduced into the hierarchically structured English National Health Service (‘NHS’), which is a nationally tax funded, budget limited healthcare system, with access to care for all, producing structures known as a quasi market. Recently, the Health and Social Care Act 2012 (‘HSCA’) has been enacted, introducing further market elements. The paper examines the theory and effects of these market mechanisms.
Using neo-classical economics as a primary theoretical framework, as well as new institutional economics and socio-legal theory, the paper first examines the fundamental elements of markets, comparing these with the operation of authority and resource allocation employed in hierarchical structures. Second, the paper examines the application of market concepts to the delivery of healthcare, drawing out the problems which economic and socio-legal theories predict are likely to be encountered. Third, the paper discusses the research evidence concerning the operation of the quasi market in the English NHS. This evidence is provided by research conducted in the UK which uses economic and socio-legal logic to investigate the operation of the economic aspects of the NHS quasi market. Fourth, the paper provides an analysis of the salient elements of the quasi market regime amended by the HSCA 2012.
It is not possible to construct a market conforming to classical economic principles in respect of healthcare. Moreover, it is not desirable to do so, as goals which markets cannot deliver (such as fairness of access) are crucial in England. Most of the evidence shows that the quasi market mechanisms used in the English NHS do not appear to be effective either. This finding should be seen in the light of the fact that the operation of these mechanisms has been significantly affected by the national political (i.e. continuingly hierarchical) and budgetary context in which they are operating.
The organisational structures of a hierarchy are more appropriate for the delivery of healthcare in the English NHS.
Unsafe abortion is a significant contributor to worldwide maternal mortality; however, abortion law and policy liberalization could lead to drops in unsafe abortion and related deaths. This review provides an analysis of changes in abortion mortality in three countries where significant policy reform and related service delivery occurred. Drawing on peer-reviewed literature, population data and grey literature on programs and policies, this paper demonstrates the policy and program changes that led to declines in abortion-related mortality in Romania, South Africa and Bangladesh. In all three countries, abortion policy liberalization was followed by implementation of safe abortion services and other reproductive health interventions. South Africa and Bangladesh trained mid-level providers to offer safe abortion and menstrual regulation services, respectively, Romania improved contraceptive policies and services, and Bangladesh made advances in emergency obstetric care and family planning. The findings point to the importance of multi-faceted and complementary reproductive health reforms in successful implementation of abortion policy reform.
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.
Uganda is proposing introduction of the National Health Insurance scheme (NHIS) in a phased manner with the view to obtaining additional funding for the health sector and promoting financial risk protection. In this paper, we have assessed the proposed NHIS from an equity perspective, exploring the extent to which NHIS would improve existing disparities in the health sector.
We reviewed the proposed design and other relevant documents that enhanced our understanding of contextual issues. We used the Kutzin and fair financing frameworks to critically assess the impact of NHIS on overall equity in financing in Uganda.
The introduction of NHIS is being proposed against the backdrop of inequalities in the distribution of health system inputs between rural and urban areas, different levels of care and geographic areas. In this assessment, we find that gradual implementation of NHIS will result in low coverage initially, which might pose a challenge for effective management of the scheme. The process for accreditation of service providers during the first phase is not explicit on how it will ensure that a two-tier service provision arrangement does not emerge to cater for different types of patients. If the proposed fee-for-service mechanism of reimbursing providers is pursued, utilisation patterns will determine how resources are allocated. This implies that equity in resource allocation will be determined by the distribution of accredited providers, and checks put in place to prohibit frivolous use. The current design does not explicitly mention how these two issues will be tackled. Lastly, there is no clarity on how the NHIS will fit into, and integrate within existing financing mechanisms.
Under the current NHIS design, the initial low coverage in the first years will inhibit optimal achievement of the important equity characteristics of pooling, cross-subsidisation and financial protection. Depending on the distribution of accredited providers and utilisation patterns, the NHIS could worsen existing disparities in access to services, given the fee-for-service reimbursement mechanisms currently proposed. Lastly, if equity in financing and resource allocation are not explicit objectives of the NHIS, it might inadvertently worsen the existing disparities in service provision.
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.