Health Care Financing (health + care_financing)

Distribution by Scientific Domains

Selected Abstracts

A Comparison of HMO Efficiencies as a Function of Provider Autonomy

Patrick L. Brockett
Current debates in the insurance and public policy literatures over health care financing and cost control measures continue to focus on managed care and HMOs. The lower utilization rates found in HMOs (compared to traditional fee-for-service indemnity plans) have generally been attributed to the organization's incentive to eliminate all unnecessary medical services. As a consequence HMOs are often considered to be a more efficient arrangement for delivering health care. However, it is important to make a distinction between utilization and efficiency (the ratio of outcomes to resources). Few studies have investigated the effect that HMO arrangements would have on the actual efficiency of health care delivery. Because greater control over provider autonomy appears to be a recurrent theme in the literature on reform, it is important to investigate the effects these restrictions have already had within the HMO market. In this article, the efficiencies of two major classes of HMO arrangements are compared using "game-theoretic" data envelopment analysis (DEA) models. While other studies confirm that absolute costs to insurance firms and sponsoring companies are lowered using HMOs, our empirical findings suggest that, within this framework, efficiency generally becomes worse when provider autonomy is restricted. This should give new fuel to the insurance companies providing fee-for-service (FFS) indemnification plans in their marketplace contentions. [source]

New Directions for Health Insurance Design: Implications for Public Health Policy and Practice

Sara Rosenbaum
ABSTRACT National attention on issues of public health preparedness necessarily brings into sharp focus the question of how to assure adequate, community-wide health care financing for preventive, acute care, and long-term medical care responses to public health threats. In the U.S., public and private health insurance represents the principal means by which medical care is financed. Beyond the threshold challenge of the many persons without any, or a stable form of, coverage lie challenges related to the structure and characteristics of health insurance itself, particularly the commercial industry and its newly emerging market of consumer-driven health plans. States vary significantly in how they approach the regulation of insurance and in their willingness to support various types of insurance markets. This variation is attributable to the size and robustness of the insurance market, the political environment, and regulatory tradition and custom. Reconciling health insurance markets with public health-related health care financing needs arising from public health threats should be viewed as a major dimension of national health reform. [source]

Honesty As Good Policy: Evaluating Maryland's Medicaid Managed Care Program

Throughout the 1990s, the states launched many large-scale innovations in health care financing and delivery. The demands associated with designing, implementing, and managing such initiatives compete for those resources needed to evaluate the impact of the innovations. But without a good faith effort to launch a credible evaluation, innovative and controversial programs may not be able to be sustained. Striking a balance between advocating for change and honestly determining how well the desired changes have been achieved is a delicate and daunting task, and state policymakers often do not spend much time evaluating their efforts, even though this may be critical to the success of their programs. This article describes one state's assessment of a statewide, prepaid, Medicaid managed care program. We look at the evaluation as both an exercise in policy analysis and an indication of the response to various constituencies' concerns. Three of us either worked for the state or contracted with the state to help evaluate the program. [source]

Principles of pharmacoeconomics and their impact on strategic imperatives of pharmaceutical research and development

József Bodrogi
The importance of evidence-based health policy is widely acknowledged among health care professionals, patients and politicians. Health care resources available for medical procedures, including pharmaceuticals, are limited all over the world. Economic evaluations help to alleviate the burden of scarce resources by improving the allocative efficiency of health care financing. Reimbursement of new medicines is subject to their cost-effectiveness and affordability in more and more countries. There are three major approaches to calculate the cost-effectiveness of new pharmaceuticals. Economic analyses alongside pivotal clinical trials are often inconclusive due to the suboptimal collection of economic data and protocol-driven costs. The major limitation of observational naturalistic economic evaluations is the selection bias and that they can be conducted only after registration and reimbursement. Economic modelling is routinely used to predict the cost-effectiveness of new pharmaceuticals for reimbursement purposes. Accuracy of cost-effectiveness estimates depends on the quality of input variables; validity of surrogate end points; and appropriateness of modelling assumptions, including model structure, time horizon and sophistication of the model to differentiate clinically and economically meaningful outcomes. These economic evaluation methods are not mutually exclusive; in practice, economic analyses often combine data collection alongside clinical trials or observational studies with modelling. The need for pharmacoeconomic evidence has fundamentally changed the strategic imperatives of research and development (R&D). Therefore, professionals in pharmaceutical R&D have to be familiar with the principles of pharmacoeconomics, including the selection of health policy-relevant comparators, analytical techniques, measurement of health gain by quality-adjusted life-years and strategic pricing of pharmaceuticals. [source]

Trauma Center Utilization for Children in California 1998,2004: Trends and Areas for Further Analysis

N. Ewen Wang MD
Abstract Background: While it is known that trauma systems improve the outcome of injury in children, there is a paucity of information regarding trauma system function amid changes in policies and health care financing that affect emergency medical systems for children. Objectives: To describe the trends in the proportion of pediatric trauma patients acutely hospitalized in trauma-designated versus non,trauma-designated hospitals. Methods: This was a retrospective observational study of a population-based cohort obtained by secondary analysis of a publicly available data set: the California Office of Statewide Health Planning and Development Patient Discharge Database from 1998 to 2004. Patients were included in the analysis if they were 0,19 years old, had International Classification of Disease, Ninth Revision (ICD-9) diagnostic codes and E-codes indicative of trauma, had an unscheduled admission, and were discharged from a general acute care hospital (N= 111,566). Proportions of patients hospitalized in trauma-designated hospitals versus non,trauma-designated hospitals were calculated for Injury Severity Score and death. Injury Severity Scores were calculated from ICD-9 codes. Primary outcomes were hospitalization in a trauma center and death two or more days after hospitalization. Results: Over the study period, the proportion of children aged 0,14 years with acute trauma requiring hospitalization and who were cared for in trauma-designated hospitals increased from 55% (95% confidence interval [CI] = 54% to 56%) in 1998 to 66% (95% CI = 65% to 67%) in 2004 (p < 0.01). For children aged 15,19 years, the proportion increased from 55% (95% CI = 54% to 57%) in 1998 to 74% (95% CI = 72% to 75%) in 2004 (p < 0.0001). When trauma discharges were stratified by injury severity, the proportion of children with severe injury who were hospitalized in trauma-designated hospitals increased from 69% (95% CI = 66% to 72%) in 1998 to 84% (95% CI = 82% to 87%) in 2004, a rate higher than in children with moderate injury (59% [95% CI = 58% to 61%] in 1998 and 75% [95% CI = 74% to 76%] in 2004) and mild injury (51% [95% CI = 50% to 52%] in 1998 and 63% [95% CI = 62% to 64%] in 2004) (p < 0.0001 for each injury severity category and both age groups). Of the hospitalized children who died two or more days after injury (n= 502), 18.1% died in non,trauma-designated hospitals (p < 0.002 for children aged 0,14 years; p = 0.346 for children aged 15,19 years). Conclusions: An increasing majority of children with trauma were cared for in trauma-designated hospitals over the study period. However, 23% of children with severe injuries, and 18.1% of pediatric deaths more than two days after injury, were cared for in non,trauma-designated hospitals. These findings demonstrate an important opportunity for improvement. If we can characterize those children who do not access the trauma system despite severe injury or death, we will be able to design clinical protocols and implement policies that ensure access to appropriate regional trauma care for all children in need. [source]