Health Policy - Articles in Press

Calculating an intervention's (cost-)effectiveness for the real-world target population: The potential of combining strengths of both RCTs and observational data - Corrected Proof

Mattias Neyt, Irina Cleemput, Nancy Thiry, Chris De Laet — 2012-05-18

Abstract: Economic evaluations most often use results from randomised controlled trials (RCTs) to model effectiveness. Inconsiderate application of the absolute treatment effect from RCTs may result in unrealistic estimates of an intervention's benefit for the real-world target population. The baseline risk of events in this target population may differ significantly from the baseline risk in the RCT population.An approach to handle this problem is to combine observational data with evidence from RCTs. Reliable administrative or register data can provide an estimate of the real-world baseline risks. In combination with the relative treatment effect from well-performed RCTs this results in an estimate of the absolute benefit for the relevant target population. Applying this approach, one must remain cautious about the validity of the assumption of a constant relative treatment effect.

Predicting the place of out-of-hours care—A market simulation based on discrete choice analysis - Corrected Proof

2012-05-17

Abstract: Background: Increasing cost pressure and changing patients’ needs in the healthcare sector have led to new delivery models for primary care. Researchers and practitioners need to establish innovative methods to obtain insights into patients’ preferences and effectiveness of healthcare services.Aim: This study reveals the crucial decision criteria of patients in choosing out-of-hours services and provides a projection of a future market share of the newly established central out-of-hours service, called General Practitioner Cooperative.Design: A computer-aided discrete choice experiment.Method: Respondents were 350 patients in a European city who decided for a service when confronted with a medical emergency in an out-of-hours case; two scenarios called ‘adult’ and ‘child’, describing the persons requiring medical assistance, were used to increase generalizability.Results: The two most important attributes were ‘explanation by the doctor’ and ‘waiting time’ while the others – ‘availability of technical equipment’, ‘ease of access’, ‘type of consultation’ and ‘payment method’ – were of less importance. The market share projections predict that the new General Practitioner Cooperative will capture about one third of the market (‘adult’: 39.1%, ‘child’: 31.3%), ahead of the emergency department, the second most preferred service (‘adult’: 32.7%, ‘child’: 30.7%).Conclusions: This study quantifies the adoption of a new medical service. As a result, it extends current research approaches on eliciting and matching patient's needs and assists policy makers in establishing adequate service capacities.

Association between family doctors’ practices characteristics and patient evaluation of care - Corrected Proof

Zalika Klemenc-Ketis, Davorina Petek, Janko Kersnik — 2012-05-14

Abstract: Background: Patients’ evaluations of primary care are influenced by three major dimensions: patients’, family doctors’ and practices’ characteristics. A lot of primary care practices use possibilities of new information technologies, such as chronic patients’ electronic registers, clinical guideline support systems, electronic medical records and clinical decision system. The aim of this study was to determine possible effects of quality characteristics of family doctors’ practices on patients’ satisfaction.Methods: This observational cross-sectional study in 36 randomly selected family doctors’ practices, stratified to practices’ size and urbanization was performed between 2008 and 2009. Each practice included 100 randomly selected adult patients: 30 high-risk patients for CVD, but without a history of CVD, 30 patients with an established coronary disease, and 40 healthy adult patients (aged 18–45 years). Data was collected with a questionnaire, used in European Practice Assessment of Cardiovascular risk management (EPA Cardio study), and with European Patients Evaluation of general practice care (EUROPEP) questionnaire.Results: Final sample consisted of 2482 patients (68.9% response rate). Higher satisfaction scores were associated with worse self-rated patients’ health status, with patients visiting practices where quality report was provided, where clinical audit in the past 12 months existed, where number of population attending practice quarterly was lower, where systematic reviewing of prescribed medication was not available, where annual report was not provided, where doctor did not have access to medical literature, and where patients’ attendance rate for preventive check-ups was not available. Patients with higher risk for CVD were also more satisfied.Conclusion: The effect of practice characteristics associated with organisational access to services, chronic patients’ management and some quality improvement factors is unclear and not always in favour of higher satisfaction score. Further studies are needed.

Exploring non-health outcomes of health promotion: The perspective of participants in a lifestyle behaviour change intervention - Corrected Proof

2012-05-11

Abstract: Objective: To provide insights into health promotion outcomes that are not captured by conventional measures of health outcome used in economic evaluation studies, such as EQ5D based QALYs.Methods: Twelve semi-structured interviews and five focus group discussions were conducted with participants of a randomized controlled trial (n=52) evaluating the effectiveness of a theory-based lifestyle intervention in Dutch adults at risk for diabetes mellitus and/or cardiovascular disease. Transcripts were analysed by two independent researchers using a thematic analysis approach.Results: In total we identified twelve non-health outcome themes that were important from the participant perspective. Four of these were reported as direct outcomes of the lifestyle intervention and eight were reported as consequences of lifestyle behaviour change. Our findings also suggest that lifestyle behaviour change may have spillover effects to other people in the participants’ direct environment.Conclusion: This study provides evidence that in the context of lifestyle behaviour change EQ5D based QALYs capture health promotion outcomes only partially. More insights are needed into non-health outcomes and spillover effects produced by health promotion in other contexts and how participants and society value these. Methods to account for these outcomes within an economic evaluation framework need to be developed and tested.

The role of proximity to death in need-based approaches to health care - Corrected Proof

2012-05-09

Abstract: Objectives: This study examines the role of proximity to death (PTD) in need-based approaches to health care by: (1) investigating whether PTD is a statistically significant, independent predictor of health-care use; and (2) estimating PTD's marginal impact on need-based allocation of health-care resources.Methods: The primary data source is the Canadian National Population Health Survey (NPHS), a longitudinal survey that uses vital statistics to confirm deaths of the respondents. We use two-part models separately for general practitioner, specialist, and short stay inpatient hospital services. We calculate per-capita allocation, with and without PTD, from the Canadian federal government to its ten provinces and by income groups.Results: PTD is a robust and important predictor of health-care resource use for each service even after adjustment for other need and non-need factors. PTD's marginal impact on allocation is relatively small in the contexts we examined, but failure to include PTD could introduce inequity in allocation by disadvantaging populations with greater need.Conclusions: PTD is an important need indicator when modeling health-care resource requirements. It deserves greater attention in need-based approaches to health-care planning and resource allocation.

Rebalancing brain drain: Exploring resource reallocation to address health worker migration and promote global health - Corrected Proof

Timothy Ken Mackey, Bryan Albert Liang — 2012-05-09

Abstract: Global public health is threatened by an imbalance in health worker migration from resource-poor countries to developed countries. This “brain drain” results in health workforce shortages, health system weakening, and economic loss and waste, threatening the well-being of vulnerable populations and effectiveness of global health interventions. Current structural imbalances in resource allocation and global incentive structures have resulted in 57 countries identified by WHO as having a “critical shortage” of health workers. Yet current efforts to strengthen domestic health systems have fallen short in addressing this issue. Instead, global solutions should focus on sustainable forms of equitable resource sharing. This can be accomplished by adoption of mandatory global resource and staff-sharing programs in conjunction with implementation of state-based health services corps.

Health policy reform in tough times: The case of Portugal - Corrected Proof

Pedro Pita Barros — 2012-05-09

Abstract: The financial rescue plan for the Portuguese economy details a number of adjustments to be made in the National Health Service. We review the changes on user charges. The requirement of the rescue plan on user charges is twofold: structure of user charges and the levels of user charges. Adoption of measures occurred within the timeframe required.The first part, structure of user charges, is already present in the Portuguese NHS and has been for a decade. The crucial decisions are therefore on the level of user charges. Increases in levels of user charges were substantial (roughly doubling their previous levels) although exemptions also expanded considerably the fraction of the population that is not required to pay user charges. The net effect is not clearly predictable.

Comparing health policy agendas across eleven high income countries: Islands of difference in a sea of similarity - Corrected Proof

Tim Tenbensel, Samantha Eagle, Toni Ashton — 2012-05-09

Abstract: Does the way in which health systems are financed influence whether health policymakers are more or less interested in accessible and equitable health services? Are social democratic governments more interested in primary health care reform than conservative governments? Have particular domains of health policy really become more important over the past decade across a range of countries? In this exploratory article, we investigate the similarities and differences in patterns of attention in health policy in eleven high income countries using data from the Health Policy Monitor database from 2003 to 2010. Our study suggests significant ‘islands of difference’ in an overall ‘sea of similarity’ between the health policy agendas of the selected countries. The key findings are: (i) that improving population health outcomes is more likely to be on the agenda under tax-based systems and when centre-left parties are dominant in government; (ii) health systems funded through social insurance are more preoccupied with efficiency and cost-containment than tax-funded systems; (iii) the political complexion of governments is not a major factor shaping health policy agendas; and (iv) since 2003 there has been an increasing interest in initiatives that address public health concerns, access and equity, and population health outcomes.

Organizational changes in the course of the PHC reform in Lithuania from 1994 to 2010 - Corrected Proof

Ida Liseckiene, Irena Miseviciene, Mindaugas Dudonis — 2012-05-07

Abstract: Objectives: To assess the organizational changes in Lithuanian Primary Health Care (PHC) in the period from 1994 to 2010, and to highlight the differences with respect to the background of family physicians, the level of urbanization and the type of PHC centers.Methods: Three cross-sectional, comparative questionnaire surveys were conducted before the start of the PHC reform (in 1994) and in the course of the PHC reform (in 2004 and 2010) in Lithuania. The anonymous questionnaires were sent by mail to district physicians (i.e. internists, who provided health care for adults, and pediatricians, who provided care for children younger than 18 years old) in 1994, and to family physicians (i.e. retrained district physicians and family physicians-graduates from residency in family medicine) in 2004 and 2010.Results: The differences observed in 1994 between former district physicians and those who had completed residency in family medicine, private and public PHC centers and different level of urbanization dissolved in the years of the PHC reform. Physicians’ age tended to be higher in the course of the PHC reform. Numbers of patients’ consultations were increasing in the period after 1994 till 2010, though numbers of CME hours and home visits were decreasing.Conclusions: The idea to retrain district physicians into family physicians was a valuable decision. In the years of the PHC reform the workload of family physicians in Lithuania approached the level existing in the EU. The aging of workforce, high workload and reduction of CME hours are the major concerns for future PHC policy.

The financial crisis in Italy: Implications for the healthcare sector - Corrected Proof

2012-05-01

Abstract: The global economic and financial crisis is having and impact on the Italian healthcare system which is undergoing a devolution process from the central government to regions and where about one third of the regional governments (mainly in the central and southern part of the country) are facing large financial deficits. The paper briefly describes the current macro scenario and the main responses taken to face the crisis and highlights the downside risks of introducing “linear” cuts in the allocation of resources. While justified by the risk of a national debt default, present fiscal policies might increase inequalities in access to care, deteriorate overall health indicators and population wellbeing, and sharpen existing difference in the quality of care between regions. Preliminary evidence shows that the crisis is affecting the quality of nutrition and the incidence of psychiatric disorders. During this difficult financial situation Italy is also facing the risk of a major reduction in investments for preventive medicine, Evidence Based Medicine infrastructures, health information systems and physical capital renewal. This cost-cutting strategy may have negative long term consequences Also, important achievement in terms of limiting waiting lists, improving continuity of care and patients’ centeredness, and promoting integration between social and health care may be negatively affected by unprecedented resources’ cuts. It is essential that in such a period of public funding constraints health authorities monitor incidence of diseases and access to care of the most vulnerable groups and specifically target interventions to those who may be disproportionally hit by the crisis.

Public health actions to improve palliative care in Germany: Results of a three-round Delphi study - Corrected Proof

Mareike Behmann, Saskia Jünger, Lukas Radbruch, Nils Schneider — 2012-04-30

Abstract: Background: In previous studies, key targets for public health initiatives to improve palliative care in Germany were defined. The aim of this study was the identification and prioritisation of actions to achieve these targets.Methods: A three-round Delphi study with 107 stakeholders acting on the meso and macrolevel of the healthcare system was undertaken. First round: proposing actions for each of the key targets; second round: assessment of the actions regarding their relevance; third round: ranking of the actions.Results: 37 actions were generated (first round) of which 14 actions were rated as relevant (second round). In the third round, the action ranked highest was “close collaboration between specialist palliative care services, general practitioners and community nursing services”, followed by “Implementing specialist palliative care in the community consequently” and “Strengthening generalist palliative care through training and education of general practitioners and nursing services”.Conclusions: The range and the ranking of the actions provide an empirical basis to improve palliative care in Germany on different levels of policy, education and clinical practice. A focus should be on strengthening the collaboration between primary health care providers and specialist palliative care services.

Reforming the Greek health system: A role for non-medical, clinical bioscientists - Corrected Proof

Ilias Kazanis — 2012-04-26

Abstract: Within the context of the recent debt crisis and the subsequently adopted austerity measures, the Greek health system faces important challenges including the necessity to rationalize public spending. One domain where there is scope for reducing expenses is laboratory medicine services, that are provided by both public and private facilities. Specialized non-medical, clinical bioscientists (such as molecular biologists, biochemists and geneticists) massively participate in the provision of laboratory medicine services in both sectors; however, they are excluded from key positions, such as the direction of laboratories and sitting in regulatory bodies. This is in breach with European standards of practice and also constitutes an impediment to the much anticipated rationalization of spending; therefore has to be addressed by the Greek health services authorities.

Ensuring access to health care—Germany reforms supply structures to tackle inequalities - Corrected Proof

Susanne Ozegowski, Leonie Sundmacher — 2012-04-26

Abstract: Germany's ruling coalition has recently introduced a new bill to Parliament, the Care Structures Act (CSA), which aims to improve outpatient care supply structures, decentralize decision-making, facilitate cross-sectoral treatment, and strengthen innovation in the nation's health care sector. These objectives are to be achieved through a variety of measures, including changes in financial incentives for physicians, the transfer of decision-making to the regional level, and the creation of a new sector for highly specialized care.The opposition parties in Parliament and most health care stakeholders agree on the objectives of the reform package, but their evaluation of the bill is mixed. Physicians’ representative organizations generally deem the law to be headed in the right direction, while the opposition parties, sickness funds, patients’ rights groups and a majority of German federal states (Bundesländer) feel it does not adequately address the issues of supply inequity and sectoral division.This skepticism seems well founded. The reforms aimed at attracting physicians to high-need regions have significant shortcomings, and the measures to overcome sectoral barriers between the outpatient care and hospital sectors remain weak. Furthermore, the new procedure for including innovative treatment methods in the SHI benefits catalogue falls short of internationally recognized standards.

Economies of scale and scope in the Danish hospital sector prior to radical restructuring plans - Corrected Proof

2012-04-25

Abstract: Objective: The Danish hospital sector faces a significant rebuilding program driven by recent regional reform and guidelines for acute admission hospitals. Within the next 5–10 years, the number of public hospitals offering acute admission will be reduced from 35 to approximately 20 larger hospitals. As the administrative data may be biased during the middle of a restructuring process our objective was to analyze whether the configuration of Danish public hospitals was subject to economies of scale and scope prior to the restructuring plans.Methods: We estimated a quadratic cost function using panel data on the total costs for somatic treatment, casemix adjusted DRG-production values, and other cost drivers for the three years before the 2007 reforms. A short-run cost function was used to derive estimates of a long-run cost function by applying the envelope condition. Next, we estimated economies of scale and scope.Results: We identified moderate-to-significant economies of scale and scope. This indicates that the Danish hospital sector was characterized by unexploited gains from consolidation.Conclusions: Our results suggest that the proposed plans have the potential to result in hospitals that are more efficient. However, post-restructuring studies elsewhere show that the strategy of horizontal integration has failed.

The impacts of DRG-based payments on health care provider behaviors under a universal coverage system: A population-based study - Corrected Proof

Shou-Hsia Cheng, Chi-Chen Chen, Shu-Ling Tsai — 2012-04-25

Abstract: Objective: To examine the impacts of diagnosis-related group (DRG) payments on health care provider's behavior under a universal coverage system in Taiwan.Methods: This study employed a population-based natural experiment study design. Patients who underwent coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty, which were incorporated in the Taiwan version of DRG payments in 2010, were defined as the intervention group. The comparison group consisted of patients who underwent cardiovascular procedures which were paid for by fee-for-services schemes and were selected by propensity score matching from patients treated by the same group of surgeons. The generalized estimating equations model and difference-in-difference analysis was used in this study.Results: The introduction of DRG payment resulted in a 10% decrease (p<0.001) in patient's length of stay in the intervention group in relation to the comparison group. The intensity of care slightly declined with p<0.001. No significant changes were found concerning health care outcomes measured by emergency department visits, readmissions, and mortality after discharge.Conclusion: The DRG-based payment resulted in reduced intensity of care and shortened length of stay. The findings might be valuable to other countries that are developing or reforming their payment system under a universal coverage system.

The opportunity cost of exercise: Do higher-earning Australians exercise longer, harder, or both? - Corrected Proof

Shiko Maruyama, Qing Yin — 2012-04-23

Abstract: Despite the widely documented benefits of exercise, very little is known about how individuals make the decision on exercise. In particular, the decision on the intensity of exercise has attracted only one US study to date, which tests the hypothesis that individuals shift toward less time-intensive but more physically intensive forms of exercise as their wages increase. In this article, we revisit this hypothesis by employing a more credible empirical framework. Studying Australian data we confirm that higher-income Australians tend to exercise more frequently with a longer duration and a higher intensity of exercise. Exercise regimens individualised based on the behavioural patterns of exercise across socio-economic groups will contribute to the efficiency and efficacy of the exercise promotion.

Priority setting and policy advocacy by nursing associations: A scoping review and implications using a socio-ecological whole systems lens - Corrected Proof

2012-04-23

Abstract: Objective: We undertook an interpretative scoping review to examine organizational priority setting and policy advocacy and the factors that influence nursing associations’ cross-sector public policy choices and actions.Method: Evidence was drawn from research, narrative, and theoretical sources that described priority setting and policy advocacy undertaken by non-governmental, non-profit, and nursing associations. Text was extracted from selected papers, imported into NVivo 8, coded, and analyzed using a descriptive-analytical narrative method.Results: Many internal and external factors are shown to shape organizations’ policy choices and actions including governance and governance structures, membership arrangements, legislative, professional, and jurisdictional mandates, perceived credibility, and external system disruptions.Conclusions: Internal and external factors are identified in the literature as critical to how organizations succeed or fail to set achievable priorities and advance their advocacy goals. Case comparisons and longitudinal research are needed to understand nursing associations’ policy choices and actions for cross-sector public policy given their complex organizational structures and dynamic professional–legal–social–economic–political–ecological environments. A socio-ecological systems perspective can inform the development of theoretical frameworks and research to understand leverage points and blockages to guide nursing associations’ public policy choices and actions at varying points in time.

Ten years of structural reforms in Danish healthcare - Corrected Proof

Terkel Christiansen — 2012-04-23

Abstract: A major structural reform of the Danish public sector took place in 2007 when the number of administrative units at the regional and municipal levels was reduced. The larger administrative units allowed for a new hospital structure with a reduced number of acute hospitals covering a population of between 200,000 and 400,000 inhabitants. The restructuring involves creation of acute hospitals with a 24-h acute service by a range of specialists. The idea was to weight quality higher than geographical closeness to the nearest hospital. Concurrently, the pre-hospital service will be expanded. The National Board of Health was given authority to approve regional plans for specialties rather than provide guidelines. The use of private hospitals was increased as a means to fulfil a waiting time guarantee of between 2 and 1 month. Increased use of private insurance also increased use of private hospitals. A new way of financing health care was intended to give municipalities incentives to invest in health prevention and health promotion. Concurrent reforms included economic incentives to increase hospital production as measured by DRGs; quality programmes to secure high quality and patient safety; and electronic patient records and increased use of IT systems.

Balancing economic freedom against social policy principles: EC competition law and national health systems - Corrected Proof

Elias Mossialos, Julia Lear — 2012-04-16

Abstract: EU Health policy exemplifies the philosophical tension between EC economic freedoms and social policy. EC competition law, like other internal market rules, could restrict national health policy options despite the subsidiarity principle. In particular, European health system reforms that incorporate elements of market competition may trigger the application of competition rules if non-economic gains in consumer welfare are not adequately accounted for. This article defines the policy and legal parameters of the debate between competition law and health policy. Using a sample of cases it analyses how the ECJ, national courts, and National Competition Authorities have applied competition laws to the health services sector in different circumstances and in different ways. It concludes by considering the implications of the convergence of recent trends in competition law enforcement and health system market reforms.

Public support for smoke-free areas in Israel: A case for action - Corrected Proof

2012-04-16

Abstract: Objective: Secondhand smoke exposure (SHSe) harms adults and children. Though most governments are obliged by international health treaty to protect nonsmokers from SHSe, few adequately do so. Public opinion can provide a powerful mandate for smoke-free policies, but a representative public voice is often absent from the political discussion. For example, following Cabinet approval of a national tobacco control plan, Israel remains embroiled in stormy debate about smoke-free legislation. This debate has unfolded without benefit of current empirical evidence on nationwide public support. The present study reports and assesses public opinion regarding smoke-free places.Methods: A nationally representative survey (n=505) was conducted in December, 2010. The response rate was 61%.Results: Public opinion supports smoke-free air in many places. There was broad consensus among current, former, and never-smokers for smoke-free cars carrying children (94.4%), and smoke-free healthcare facility entrances (92.6%). A clear majority (67.0%) supportedcompletely smoke-free bars and pubs. Nearly half (47.3%) supported eliminating school staff smoking rooms.Conclusions: These data strengthen the case for the recent government-approved tobacco control plan. Valid data regarding public opinion on tobacco control can facilitate passage and implementation of smoke-free legislation, thus speeding transition to smoke-free societies.

Public procurement of health technologies in Greece in an era of economic crisis - Corrected Proof

2012-04-16

Abstract: Public procurement is generally an important sector of the economy and, in most countries, is controlled by the introduction of regulatory and policy mechanisms. In the Greek healthcare sector, recent legislation redefined centralized procurement through the reestablishment of a state Health Procurement Committee (EPY), with an aim to formulate a plan to reduce procurement costs of medical devices and pharmaceuticals, improve payment time, make uniform medical requests, transfer redundant materials from one hospital to another and improve management of expired products. The efforts described in this paper began in early 2010, under the co-ordination of the Ministry of Health (MoH) and with the collaboration of senior staff from the International Monetary Fund (IMF), the European Commission (EC) and the European Central Bank (ECB). The procurement practices and policies set forth by EPY and the first measurable outcomes, in terms of cost savings, resulting from these policies are presented. The importance of these measures is discussed in light of the worst economic crisis faced by Greece since the restoration of democracy in 1974, as a result of both the world financial crisis and uncontrolled government spending.

Responses to increasing cigarette prices in France: How did persistent smokers react? - Corrected Proof

Peretti-Watel Patrick, L’haridon Olivier, Seror Valerie — 2012-04-16

Abstract: Objectives: (1) To build a typology of persistent smokers’ reactions to increasing cigarette prices (persistent smokers were defined as smokers who did not quit because of such increases) and (2) to investigate which factors were correlated with their reactions (we considered three categories: no reaction, trying to quit or smoking less, reducing the cost of smoking).Methods: We used a French national telephone survey (n=2000; 621 smokers) that included questions about smokers’ reactions to increasing cigarette prices, as well as questions about their socio-demographic background, personal time perspective, smoking behavior and reasons for smoking. We used logistic regressions to identify which of these factors were linked to smokers’ reactions.Results: In response to the increasing cigarette prices, 24% of persistent smokers did not change their smoking habits at all, 31% only reduced the cost of smoking (they neither reduced their consumption nor tried to quit) and 45% tried to give up smoking or reduced their consumption (they also frequently reduced the cost of smoking). Male and older smokers, the more educated ones and the wealthier ones more frequently reported no reaction at all, as did those who smoked to improve their concentration or keep their weight down. Younger and unemployed smokers more frequently opted for spending less on cigarettes, as did those who smoked to forget about their problems. Finally, present-oriented smokers were less prone to try to quit or to reduce their consumption.Conclusion: These findings show the need to increase the price of all tobacco products in cooperation with neighboring states. People's reasons for smoking and their personal time perspectives contribute to their reactions to price increases, and different preventive measures are required for each category of persistent smokers.

New Zealand's post-2008 health system reforms: Toward re-centralization of organizational arrangements - Corrected Proof

Robin Gauld — 2012-04-16

Abstract: The election of a centre-right government in 2008 has spawned a series of ongoing reforms to the structures for governing New Zealand's health system. These mainly involve creation of a series of new national agencies designed to stimulate national coordination and centralization of some planning and service delivery functions along with performance improvements in specific areas, namely quality, information technology, service efficiency, reduction of administrative costs, and comparative-effectiveness research. This brief article provides an overview of the post-2008 reforms. It notes that, while there appears to be agreement within the health system that the reforms are moving in the right direction, the new institutional arrangements are perhaps overly complicated.

Spanish health care cuts: Penny wise and pound foolish? - Corrected Proof

Joan Gené-Badia, Pedro Gallo, Cristina Hernández-Quevedo, Sandra García-Armesto — 2012-04-11

Abstract: The purpose of this paper is to convey the specific health care actions and policies undertaken by the Spanish government, as well as by regional governments, as a result of the economic crisis. Throughout the last two years we have witnessed a number of actions in areas such as human capital, activity and processes, outsourcing and investment that, poorly coordinated, have shaped the nature of financial cuts on public services. This paper discloses the size and magnitude of these actions, the main actors involved and the major consequences for the health sector, citizens and patients.We further argue that there are a number of factors which have been neglected in the discourse and in the actions undertaken. First, the crisis situation is not being used as an opportunity for major reforms in the health care system. Further, the lay public and professionals have remained as observers in the process, with little to no participation at any point. Moreover, there is a general perception that the solution to the Spanish situation is either the proposed health care cuts or an increase in cost sharing for services which neglects alternative and/or complementary measures. Finally, there is a complete absence of any scientific component in the discourse and in the policies proposed.

The human factor: Re-organisations in public health policy - Corrected Proof

Kathryn Oliver, Martin Everett, Arpana Verma, Frank de Vocht — 2012-04-11

Abstract: Introduction: Public health policy-making activities are currently split between local authority and NHS organisations. Despite an increasing body of research on evidence-based policy (EBP), few studies explore the process of policy-making. Little is known about how policies are made in a local context, or how (scientific) evidence is used. Previous research has ignored the ‘human element’ in EBP. Social network analysis (SNA) techniques are becoming increasingly important in health policy. This paper describes an innovative study giving a fresh perspective on policy-making processes in public health.Methods: A social network analysis of public health policy making networks in Greater Manchester based on publicly available data (documents, websites and meeting papers) and an electronic survey, asking actors to nominate those who influenced their own views, those who were powerful, and those who were a source of evidence or information.Results and conclusions: Policy-making networks are described. Formal executive roles are loosely related to perceived influence and power. Evidence-seeking networks are less coherent, with key organisations not represented. These data indicate the importance of collaboration and good relationships between researchers and policy-makers, but few academic researchers with a direct impact on health policy were identified within the networks.

General practitioners’ preferences for the organisation of primary care: A discrete choice experiment - Corrected Proof

Line Bjørnskov Pedersen, Trine Kjær, Jakob Kragstrup, Dorte Gyrd-Hansen — 2012-04-10

Abstract: Objectives: To examine GPs’ preferences for organisational characteristics in general practice with focus on aspects that can potentially mitigate problems with GP shortages.Methods: A simple random sample of 1823 GPs (corresponding to half of all GPs in Denmark) was drawn at the beginning of 2010, and a response rate of 68% was obtained. A discrete choice experiment (DCE) is applied, and attributes included are: practice type (solo/shared), number of GPs in general practice, collaboration with other practices (yes/no), change in weekly working hours (administrative versus patient related) and change in yearly surplus. Multinomial logit analyses (with and without interaction variables) are used, and marginal rates of substitution are calculated.Results: GPs working in solo practices have different preferences for the organisational attributes compared to GPs in shared practices. The compensation needed for GPs to re-organise from solo to shared practice is associated with the size of the practice. GP characteristics such as age, working hours and surplus affect their willingness to undergo organisational changes.Conclusions: Our results are of relevance to decision makers in designing policies aimed at influencing GPs’ organisation in order to overcome problems related to shortages.

Differential effects of negative publicity on beef consumption according to household characteristics in South Korea - Corrected Proof

Hyungho Youn, Byung In Lim, Hyun Joung Jin — 2012-04-06

Abstract: This paper examines how South Korean households responded to an unprecedented boycott campaign against US beef from spring to summer of 2008, and investigates differential responses in relation to households’ characteristics. It was found that beef consumption reduced by 4.8% immediately after the so-called candle-light demonstration. Instead, pork and chicken consumption increased by 17.2% and 16.6%, respectively. This confirms a substitution effect due to the negative publicity concerning US beef. It was also found that the negative publicity effect was transitory and the reactions of consumers were not uniform; they differed depending on their socio-economic characteristics. The econometric model revealed that younger, less-educated, and/or lower-income households were more susceptible to the negative publicity, and reduced their beef consumption more than other households.

The challenge and the future of health care turnaround plans: Evidence from the Italian experience - Corrected Proof

Francesca Ferrè, Corrado Cuccurullo, Federico Lega — 2012-04-06

Abstract: Over the last two decades, health policy and governance in Italy have undergone decentralisation at the regional level. The central government was expected to play a guiding role in defining minimum care standards and controlling health expenditures at the regional level in order to keep the entire Italian National Health System (INHS) on track. Although health performance trends have been consistent across regions, public health expenditures have been variable and contributed to a cumulative deficit of 38 billion Euros from 2001 to 2010. To address the deficit, the government called for a resolution introducing a partial bail-out plan and later institutionalised a process to facilitate a turnaround. The upturn started with the development of a formal regional turnaround plan that proposed strategic actions to address the structural determinants of costs. The effectiveness of this tool was widely questioned, and many critics suggested that it was focused more on methods to address short-term issues than on the long-term strategic reconfiguration that is required for regional health systems to ultimately address the structural causes of deficits.We propose an interpretative framework to understand the advantages and disadvantages of turnaround plans, and we apply the findings to the development of policy recommendations for the structure, methods, processes and contexts of the implementation of this tool.

Gender sensitivity in national health plans in Latin America and the European Union - Corrected Proof

Erica Briones-Vozmediano, Carmen Vives-Cases, Rosana Peiró-Pérez — 2012-04-05

Abstract: Objectives: To evaluate the situation regarding gender sensitivity in national health plans in Latin America and the European Union for the decade 2000–2010.Methods: A systematic search and content analysis of national health plans were carried out within 37 countries. Gender sensitivity, defined as the extent to which a health plan considers gender as a central category and develops measures to reduce any gender-related inequalities, was analysed through an ad hoc checklist.Results: The description of health problems by sex was more frequent than intervention proposals aimed at reducing gender health disparities. The greatest number of specific intervention proposals targeted at overcoming gender-based health inequalities were associated with sexual and/or reproductive health, gender based violence, the working environment and human resources training. Compared to the European Union member states, Latin American health plans were found to be generally more gender sensitive.Conclusions: National health plans are still generally lacking in gender sensitivity. Disparities exist in health policy formulation in favour of men, whilst women's health continues to be identified mainly with reproductive health. If gender sensitivity is not taken into account, efforts to improve the quality of clinical care will be insufficient as gender inequalities will persist.

An economic analysis of tobacco elimination policies in Turkey - Corrected Proof

Selin Arslanhan, Asena Caner, Kerem Helvacioglu, Ismail Saglam, Tuncay Teksoz — 2012-04-03

Abstract: Objective: We aim to evaluate the costs and benefits of various tobacco elimination policies, specifically, an immediate taxation option and eight tax-combined long-term cessation programs.Methods: We combine demographic projections for the period 2012–2050 with incidence and mortality rates of four major cigarette related diseases, price elasticity of cigarette demand and unit costs of nonprice measures to reduce demand in order to estimate the net present discounted values of policy alternatives.Results: The tax-combined cessation programs yield lower net costs to households and the society when they phase out smoking earlier. However, immediate taxation option is found to be superior, for both households and the society, to all tax-combined cessation programs irrespective of the duration of intervention. While all policies are estimated to yield significant reductions in the expected number of smoking related diseases and deaths, a class-based 20-year intervention is found to be the most effective program.Conclusions: Although immediate taxation policy and tax-combined class-based 20-year intervention program emerge as the best tobacco elimination policies for the society, more research is needed on assessing the cost-effectiveness, applicability and social desirability of these alternatives and on designing additional policies to overcome their limitations.

(De)centralization of social support in six Western European countries - Corrected Proof

Madelon Kroneman, Mieke Cardol, Roland Friele — 2012-03-30

Abstract: Introduction: Participation of disabled or chronically ill persons into the society may require support in the sense of human or technical aid. In this study we look into the decision making power of governments and the way citizens are involved in these processes. Decision making power can be political, financial and administrative and may be organized at national, regional or local level.Methods: This is a cross-sectional descriptive study of the decision making power in Belgium, France, Germany, the Netherlands, Sweden and the United Kingdom in 2010. We focused on acts and regulations for human and technical aids and for making the environment accessible.Results: Several acts and regulations were identified in relation to social support. In the Netherlands and Sweden social support was mainly organized in one act, whereas in the other countries social support was part of several acts or regulations. Citizen's voice appeared to be represented in boards or advisory committees. Descriptions of entitlements varied from explicitly formulated to globally described.Conclusions: The level of decision making power varies between the countries en between the types of decision making power. Citizens’ participation is mainly represented through patient associations. Countries with strongly decentralized decision making make use of framework legislation at national level to set general targets or aims.

What characterises the privately insured in universal health care systems? A review of the empirical evidence - Corrected Proof

Astrid Kiil — 2012-03-29

Abstract: Objectives: This paper reviews the empirical literature on what characterises individuals with voluntary private health insurance (VPHI) in universal health care systems and assesses how well the empirical evidence corresponds with the theoretical predictions.Methods: Empirical studies were identified by performing searches in electronic databases.Results: The literature search identified a total of 24 articles and 15 working papers, the majority of which were published within the recent decade. Socioeconomic characteristics are generally found to be important determinants of VPHI coverage. In accordance with economic theory, the probability of taking out VPHI on an individual basis is consistently found to increase with income. Likewise, the empirical evidence generally supports the theoretical prediction of individuals selecting themselves into duplicate VPHI based on the quality of care available within the universal health care system, just as the demand for VPHI is consistently found to be negatively affected by the insurance premium. On the contrary, the empirical evidence on the importance of risk preferences is sparse and points in different directions. Finally, with a few exceptions, the privately insured are found to be in equal or better health compared to the remaining population. In most settings, the positive association between health and VPHI coverage may be attributed to risk rating of insurance premiums and eligibility requirements, while it may be interpreted as evidence of advantageous selection in their absence.

Bundles: An opportunity to align incentives for continuing care in Canada? - Corrected Proof

Jason M. Sutherland, Erik Hellsten, Kevin Yu — 2012-03-05

Abstract: Over the past three decades, diagnosis related groups (DRG) have revolutionized hospital funding by successfully focusing hospitals attention on the ‘production’ process. However, using DRG for funding acute hospitals does little to create incentives outside of the hospital, or coordinate health care across providers and settings. With many health care quality and efficiency issues stemming from failures at the ‘seams’ in the system, there is increasing interest in creating new ‘bundles’ of care which includes acute and post-acute care services that align economic incentives for care coordination. Analysis of Ontario (Canada) datasets demonstrates that linking existing sources of clinical, administrative and cost data to create ‘bundles’ is technically feasible. However, key implementation challenges need to be addressed, such as administrative and contractual arrangements across multiple provider organizations, pricing and relations with physicians. Nonetheless, this analysis of Ontario data demonstrates that bundles provide an alternative policy option to DRG's in Canada's move toward activity-based funding.

Effects of the per diem prospective payment system with DRG-like grouping system (DPC/PDPS) on resource usage and healthcare quality in Japan - Corrected Proof

Hironori Hamada, Miho Sekimoto, Yuichi Imanaka — 2012-01-25

Abstract: Objectives: In 2003, Japan introduced the prospective payment system (PPS) with diagnosis-related groups (DRG) rearranged grouping system called the diagnostic procedure combination/per-diem payment system (DPC/PDPS). Even after eight years, little is known about the effects of DPC/PDPS. The purpose of this study was to examine the effects of DPC/PDPS on resource usage and healthcare quality.Methods: Using 2001–2009 (fiscal year) administrative data of acute myocardial infarction patients, four indices, including inpatient total accumulated medical charges, length of stay (LOS), mortality rate, and readmission rate, were compared between patients reimbursed by DPC/PDPS or by fee-for-service.Results: DPC/PDPS significantly reduced total accumulated medical charges by $1061 (95% confidence interval [CI], −2007, −116) and LOS by 2.29 days (95% CI, −3.71, −0.88) after risk adjustment. However, mortality rate (Odds ratio [OR], 0.94; 95% CI, 0.73, 1.21) was unchanged. Furthermore, DPC/PDPS increased the readmission rate (OR, 1.37; 95% CI, 1.03, 1.82).Conclusions: This study showed that DPC/PDPS was associated with reduced resource usage, but not improved healthcare quality, as with DRG/PPSs in other countries. To achieve successful healthcare reform, further discussion on additional motives will be required.

Leadership and governance in seven developed health systems - Corrected Proof

2012-01-24

Abstract: This paper explores leadership and governance arrangements in seven developed health systems: Australia, England, Germany, the Netherlands, Norway, Sweden and Switzerland. It presents a cybernetic model of leadership and governance comprising three fundamental functions: priority setting, performance monitoring and accountability arrangements. The paper uses a structured survey to examine critically current arrangements in the seven countries. Approaches to leadership and governance vary substantially, and have to date been developed piecemeal and somewhat arbitrarily. Although there seems to be reasonable consensus on broad goals of the health system there is variation in approaches to setting priorities. Cost-effectiveness analysis is in widespread use as a basis for operational priority setting, but rarely plays a central role. Performance monitoring may be the domain where there is most convergence of thinking, although countries are at different stages of development. The third domain of accountability is where the greatest variation occurs, and where there is greatest uncertainty about the optimal approach. We conclude that a judicious mix of accountability mechanisms is likely to be appropriate in most settings, including market mechanisms, electoral processes, direct financial incentives, and professional oversight and control. The mechanisms should be aligned with the priority setting and monitoring processes.

Assessing health care planning – A framework-led comparison of Germany and New Zealand - Corrected Proof

Stefanie Ettelt, Mihaly Fazekas, Nicholas Mays, Ellen Nolte — 2011-12-08

Abstract: Objectives: With markets and competition dominating much of the debate on health care reform, health care planning has received little scholarly attention in recent years. Yet in many high-income countries, governments have continued to plan some elements of their health care systems. We use a new framework for analysing health care planning organised around the dimensions of ‘vision’, ‘governance’ and ‘intelligence’ to assess the approach in two deliberately contrasting countries, Germany and New Zealand.Methods: A review of the literature on health care planning in general and specifically in Germany and New Zealand, supported by key participant interviews.Results: Planning in both countries largely reflects the different institutional arrangements of their wider health systems. Planning in Germany is fragmented, in part due to federalism and corporatism, with separate approaches in different health care sectors and regions. In contrast, New Zealand's NHS-style health system favours a more hierarchical, integrated approach, with clear lines of accountability, and central government capacity to define objectives and monitor developments. Both countries find it difficult to use planning to align demand for and supply of health care though New Zealand makes some use of population needs assessments to support this process while these are currently absent in Germany.Conclusions: While it remains challenging to compare health care systems that are institutionally very different, this new framework for analysing their approaches to planning draws attention to their advantages and disadvantages. It also generates an agenda for future research to improve our understanding of the role and effectiveness of different forms of planning versus, and in combination with, other policy tools to relating health care supply and demand.