This document proposes a "fourth way" for health care delivery that focuses on coverage and responsibility. It suggests: (1) insuring only chronic illnesses and inpatient care through universal coverage pools, (2) paying provider teams bundled payments for episodes of inpatient care, (3) having patients choose primary care providers who are paid fee-for-service but incentivized to reduce costs, (4) making providers and developers responsible for costs and rewarding innovation. The goal is to align incentives for improved and more efficient care while maintaining universal coverage.
An Investigation of the Factors Affecting Capitation Programme in Provision ...inventionjournals
International Journal of Business and Management Invention (IJBMI) is an international journal intended for professionals and researchers in all fields of Business and Management. IJBMI publishes research articles and reviews within the whole field Business and Management, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online
The Health Equity Fund an Insurance for the PoorIDS
This presentation was given by Bruno Meessen of the Institute of Tropical Medicine (Belgium) to a seminar on health insurance for the poor, November 2008. Bruno is part of the POVILL consortium (www.povill.com).
Upon completion of this discussion forum, participants will:
- Learn about governmental programs and eligibility criteria for accessing care
- Gain tools to reduce and manage outstanding medical costs
- Better understand benefits of the ACA relative to cancer care
- Become informed of laws protecting their right to health coverage
- Understand the Social Security Disability approval process
This document outlines the course content for a health insurance course. It will cover topics such as defining health insurance, the development of national health systems, the purpose of health insurance, relationships between public and private systems, underwriting principles and processes, and more. The course aims to provide a comprehensive overview of how health insurance works from both private insurer and public system perspectives internationally.
This document discusses health care costs, payment models, and insurance in the United States. It explains that health insurance status and type of coverage significantly impact out-of-pocket costs and ability to adhere to treatment recommendations. Various insurance types like private, employer, government, and uninsured are compared. Reimbursement models for providers like fee-for-service, diagnosis-related groups, and accountable care organizations are also overviewed. The document advocates for individualizing care based on insurance coverage to improve quality while decreasing unnecessary costs.
high value care to reduce waste in health caremukeshkakkar
This document discusses health care costs and payment models. It defines different types of health care costs including charges, reimbursements, and out-of-pocket costs. It describes how traditional payment models like fee-for-service can promote cost variation and lack transparency. It also discusses recent value-based reforms like accountable care organizations (ACOs) and pay for performance models that aim to improve quality and reduce costs. The document provides examples of estimating out-of-pocket costs and explores how insurance status impacts clinical recommendations and adherence.
This chapter discusses financing of the US healthcare system. It notes that healthcare spending has increased annually since 1960 and now accounts for nearly 18% of GDP. Funding comes from various sources including private insurance (34%), out-of-pocket payments (13%), and government programs like Medicare and Medicaid (49%). Medicare provides coverage for those over 65 and some disabled individuals, while Medicaid covers some poor populations. The money spent goes primarily towards personal healthcare services like hospital and physician care. Payment methods include fee-for-service, capitation, and value-based models. Despite high spending, over 50 million Americans still lack health insurance coverage.
The document provides an overview of health insurance, including definitions, history, principles, and types of health insurance systems. It discusses key concepts in health insurance like information problems, adverse selection, and moral hazard. It also describes major public health insurance schemes in India like the Employees' State Insurance (ESI) Scheme and the Central Government Health Scheme (CGHS), which provide coverage to government employees and their families.
An Investigation of the Factors Affecting Capitation Programme in Provision ...inventionjournals
International Journal of Business and Management Invention (IJBMI) is an international journal intended for professionals and researchers in all fields of Business and Management. IJBMI publishes research articles and reviews within the whole field Business and Management, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online
The Health Equity Fund an Insurance for the PoorIDS
This presentation was given by Bruno Meessen of the Institute of Tropical Medicine (Belgium) to a seminar on health insurance for the poor, November 2008. Bruno is part of the POVILL consortium (www.povill.com).
Upon completion of this discussion forum, participants will:
- Learn about governmental programs and eligibility criteria for accessing care
- Gain tools to reduce and manage outstanding medical costs
- Better understand benefits of the ACA relative to cancer care
- Become informed of laws protecting their right to health coverage
- Understand the Social Security Disability approval process
This document outlines the course content for a health insurance course. It will cover topics such as defining health insurance, the development of national health systems, the purpose of health insurance, relationships between public and private systems, underwriting principles and processes, and more. The course aims to provide a comprehensive overview of how health insurance works from both private insurer and public system perspectives internationally.
This document discusses health care costs, payment models, and insurance in the United States. It explains that health insurance status and type of coverage significantly impact out-of-pocket costs and ability to adhere to treatment recommendations. Various insurance types like private, employer, government, and uninsured are compared. Reimbursement models for providers like fee-for-service, diagnosis-related groups, and accountable care organizations are also overviewed. The document advocates for individualizing care based on insurance coverage to improve quality while decreasing unnecessary costs.
high value care to reduce waste in health caremukeshkakkar
This document discusses health care costs and payment models. It defines different types of health care costs including charges, reimbursements, and out-of-pocket costs. It describes how traditional payment models like fee-for-service can promote cost variation and lack transparency. It also discusses recent value-based reforms like accountable care organizations (ACOs) and pay for performance models that aim to improve quality and reduce costs. The document provides examples of estimating out-of-pocket costs and explores how insurance status impacts clinical recommendations and adherence.
This chapter discusses financing of the US healthcare system. It notes that healthcare spending has increased annually since 1960 and now accounts for nearly 18% of GDP. Funding comes from various sources including private insurance (34%), out-of-pocket payments (13%), and government programs like Medicare and Medicaid (49%). Medicare provides coverage for those over 65 and some disabled individuals, while Medicaid covers some poor populations. The money spent goes primarily towards personal healthcare services like hospital and physician care. Payment methods include fee-for-service, capitation, and value-based models. Despite high spending, over 50 million Americans still lack health insurance coverage.
The document provides an overview of health insurance, including definitions, history, principles, and types of health insurance systems. It discusses key concepts in health insurance like information problems, adverse selection, and moral hazard. It also describes major public health insurance schemes in India like the Employees' State Insurance (ESI) Scheme and the Central Government Health Scheme (CGHS), which provide coverage to government employees and their families.
The document summarizes issues around rising costs, competition, risk, and regulation in Australia's private health insurance system. Key points include:
- Private health insurance incentives introduced in 1997-2000 aimed to relieve pressure on public hospitals but had negligible impact on reducing public hospital pressures or waiting times.
- While private health insurance coverage increased following incentives like Lifetime Health Cover, premiums continued rising and the incentives became part of the problem for public patients.
- There is policy paralysis around reforming the large subsidy for private health insurance due to the politics of high population coverage, despite evidence it is an ineffective policy.
This document defines key concepts related to health care financing including definitions of health care financing, sources of health service financing, and mechanisms or types of health financing. It also outlines principles of health care financing. Specifically, it discusses five main mechanisms of health financing: general taxes, social insurance, private insurance, community financing, and direct out-of-pocket payments. It then outlines 10 principles that health care financing systems should uphold, including being focused on health, universal, publicly administered, free at the point of access, equitable, centered on care, responsive to needs, rewarding quality, cost-effective, and accountable.
This document discusses health insurance and life insurance. It defines health insurance as insurance that covers medical and surgical expenses. It lists the main types of health insurance plans including HMOs, PPOs, and high-deductible plans. It provides steps for obtaining life insurance and outlines advantages like tax benefits and disadvantages such as pre-existing conditions not being covered. The document also describes how to plan health insurance and the process for surrendering a health insurance policy.
This document discusses the principles of healthcare ethics in Canada, focusing on four main principles: autonomy, beneficence, nonmaleficence, and justice. It defines each principle and provides examples of how they apply in healthcare settings and clinical decision making. Additionally, it briefly discusses the principles of veracity (truthfulness) and fidelity (loyalty), which are important for maintaining trust between healthcare providers and patients. The document aims to outline an ethical approach to healthcare in Canada based on these established principles.
Universal health refers to a system that provides equal access to healthcare based on medical need rather than ability to pay. There are various approaches to funding universal healthcare, including compulsory insurance, tax-based models, and social health insurance. The debate in Ireland has focused on developing a system that balances universality, equity, quality, choice, and affordability while addressing open questions around funding, the appropriate model, and the role of private insurers.
This document provides an overview of health insurance. It defines key terms related to insurance such as the insured, insurer, and premium. It describes the purpose of health insurance as providing protection against costs of unforeseen sickness. Various principles of insurance are outlined, including utmost good faith, insurable interest, indemnity, subrogation, and loss minimization. The history and development of health insurance is summarized, including early programs in Germany, the UK, and India. Major public health insurance schemes currently operating in India are described briefly, including ESI, CGHS, and RSBY. Characteristics, terminology, types, advantages, and limitations of health insurance are also summarized.
Presentation by Adrienne Chattoe-Brown, Lead Specialist- Health Systems and Service Delivery, HLSP, at the WHO/TNO/Dutchgovernment Congres 'Connecting Health and Labour' 29 - 1 December 2012
The Affordable Care Act requires Medicare patients to pay out-of-pocket for colorectal cancer screenings if a polyp is found and removed. However, if no polyp is found, patients pay nothing. This creates a disincentive for screenings and is an unintended consequence that needs fixing. Earlier cancer detection through screening reduces costs and saves lives. Representatives need to be educated on this oversight so they can quickly correct the Medicare policy and remove barriers to important cancer screenings.
This document discusses and compares various global healthcare systems models including the Beveridge model, Bismarck model, national health insurance model, and out-of-pocket model. It provides details on the characteristics of each model such as universal coverage, funding mechanisms, provider types, and coverage levels. Examples are given of countries that follow each model including the UK (Beveridge), Germany (Bismarck), Canada (national health insurance), and less developed nations (out-of-pocket). The document concludes that no single system is perfect and that many countries utilize hybrid approaches.
Employment-based health benefits have declined over the past decade while costs have increased dramatically. Some employers are considering moving to private health insurance exchanges that offer employees defined contributions to purchase plans, rather than traditional defined benefit plans. While private exchanges may help control costs, they also introduce new complexities and uncertainties for both employers and employees. Employers will still need to make choices around contribution levels and plan selection support.
This document discusses various methods of financing dental care, including private fee-for-service, post-payment plans, and private third party payment plans like commercial insurance companies and nonprofit health service corporations. It provides definitions for key terms like coinsurance, copayments, deductibles, participating dentists, and more. The history of dental financing is reviewed, from traditional fee-for-service to the establishment of programs in the US and UK in the 1940s-1950s. Common third party payment mechanisms like usual/customary/reasonable fees and fee schedules are also summarized.
Health insurance helps cover the cost of medical care. It protects individuals financially from expensive medical bills. Health insurance is commonly offered through employers and is important for anyone to have, as medical costs continue to rise. When choosing a health insurance plan, consider the health benefits covered, the costs including premiums and out-of-pocket maximums, the network of physicians covered, and whether any prescriptions are included. Health insurance terminology includes deductibles, coinsurance, networks, and other terms that define coverage and costs. Understanding these terms is key to utilizing health insurance benefits.
Health insurance helps cover the cost of medical care. It protects individuals financially from expensive medical bills. Health insurance is commonly offered through employers and is important for anyone to have, as medical costs continue to rise. When choosing a health insurance plan, consider the health benefits covered, the costs including premiums and out-of-pocket maximums, the network of physicians covered, and which prescriptions are included. Health insurance terminology includes deductibles, coinsurance, networks, and other terms that define coverage and costs. Understanding these terms is key to utilizing health insurance benefits.
This document discusses the scope and forms of healthcare insurance. It provides information on:
- Healthcare insurance normally covers treatment of acute conditions but not chronic or preventative care.
- The main forms of health insurance are medical insurance, personal accident/sickness, income protection, critical illness, and long-term care.
- Healthcare policies can be personal, covering individuals and families, or group policies arranged by employers to cover employees. Group policies are typically paid for by the employer.
The Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents is an initiative designed to improve care for people living in nursing facilities who are enrolled in Medicare and Medicaid.
Through this initiative, CMS will partner with independent organizations to improve care for long-stay nursing facility residents. These organizations will collaborate with nursing facilities and States to provide coordinated, person-centered care with the goal of reducing avoidable hospital stays.
In this webinar, staff from the Medicare-Medicaid Coordination Office (MMCO) and the CMS Innovation Center will provide an overview of the initiative, and offer information about how to apply.
More at: http://innovations.cms.gov/resources/Duals_rahnfr_apply.html
- - -
CMS Innovation
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The document discusses various mechanisms for paying for dental care, including:
1. Private fee-for-service, the traditional model where patients pay providers directly. This remains popular but limits access for many.
2. Prepayment plans like insurance, where a third party pays providers on behalf of subscribers. This includes commercial plans, non-profit Delta Dental plans, and prepaid group practices.
3. Public programs like Medicaid provide dental coverage for specific groups but have limitations in eligibility and coverage. Overall the document analyzes different payment systems and their ability to improve access to dental care.
This document provides an overview of long-term care planning and options. It discusses that long-term care is needed when one can no longer independently care for themselves, and may involve assistance with daily tasks. Common places of long-term care include home care, assisted living facilities, adult day care, hospice, and nursing homes. The costs of long-term care are significant and most individuals and families are not adequately prepared to pay for extended care needs. Private long-term care insurance can help cover costs and protect assets from being depleted by long-term care expenses. The document encourages planning early for long-term care needs through exploring insurance options.
The document discusses the Ohio Health Care Security Act, which proposes a single-payer universal health care system for Ohio. It would be administered by the Ohio Health Care Agency under an Ohio Health Care Board. All Ohio residents would be covered for comprehensive health care services. It would be financed through payroll taxes on employers up to 3.85% of payroll, business gross receipts taxes up to 3%, and income taxes above certain thresholds. The system aims to reduce costs, provide coverage for all residents, and offer freedom of choice.
Este documento resume las actividades realizadas por la Junta Directiva de la Asociación de Economía de la Salud (AES) entre 2010 y 2011 para cumplir con los acuerdos de la Asamblea de socios de 2010 y las tareas de la Junta. Las actividades se centraron en tres áreas estratégicas: mejorar la visibilidad y capacidad de influencia de la AES, impulsar relaciones estratégicas con otras instituciones, e implementar mejoras en el funcionamiento de la asociación. Algunas de las acciones más destacadas fueron la organización
Este documento resume las actividades realizadas por la Asociación Española de Economía de la Salud (AES) entre 2009 y 2010. La AES organizó las XXIX Jornadas de Economía de la Salud en Málaga, con más de 300 asistentes y 200 presentaciones. También mejoró su visibilidad a través de nuevas publicaciones, premios, y colaboraciones con otras instituciones como el Ministerio de Sanidad y el Instituto de Estudios Fiscales. La AES busca cumplir objetivos estratégicos como mejorar su influencia, fomentar asoci
The document summarizes issues around rising costs, competition, risk, and regulation in Australia's private health insurance system. Key points include:
- Private health insurance incentives introduced in 1997-2000 aimed to relieve pressure on public hospitals but had negligible impact on reducing public hospital pressures or waiting times.
- While private health insurance coverage increased following incentives like Lifetime Health Cover, premiums continued rising and the incentives became part of the problem for public patients.
- There is policy paralysis around reforming the large subsidy for private health insurance due to the politics of high population coverage, despite evidence it is an ineffective policy.
This document defines key concepts related to health care financing including definitions of health care financing, sources of health service financing, and mechanisms or types of health financing. It also outlines principles of health care financing. Specifically, it discusses five main mechanisms of health financing: general taxes, social insurance, private insurance, community financing, and direct out-of-pocket payments. It then outlines 10 principles that health care financing systems should uphold, including being focused on health, universal, publicly administered, free at the point of access, equitable, centered on care, responsive to needs, rewarding quality, cost-effective, and accountable.
This document discusses health insurance and life insurance. It defines health insurance as insurance that covers medical and surgical expenses. It lists the main types of health insurance plans including HMOs, PPOs, and high-deductible plans. It provides steps for obtaining life insurance and outlines advantages like tax benefits and disadvantages such as pre-existing conditions not being covered. The document also describes how to plan health insurance and the process for surrendering a health insurance policy.
This document discusses the principles of healthcare ethics in Canada, focusing on four main principles: autonomy, beneficence, nonmaleficence, and justice. It defines each principle and provides examples of how they apply in healthcare settings and clinical decision making. Additionally, it briefly discusses the principles of veracity (truthfulness) and fidelity (loyalty), which are important for maintaining trust between healthcare providers and patients. The document aims to outline an ethical approach to healthcare in Canada based on these established principles.
Universal health refers to a system that provides equal access to healthcare based on medical need rather than ability to pay. There are various approaches to funding universal healthcare, including compulsory insurance, tax-based models, and social health insurance. The debate in Ireland has focused on developing a system that balances universality, equity, quality, choice, and affordability while addressing open questions around funding, the appropriate model, and the role of private insurers.
This document provides an overview of health insurance. It defines key terms related to insurance such as the insured, insurer, and premium. It describes the purpose of health insurance as providing protection against costs of unforeseen sickness. Various principles of insurance are outlined, including utmost good faith, insurable interest, indemnity, subrogation, and loss minimization. The history and development of health insurance is summarized, including early programs in Germany, the UK, and India. Major public health insurance schemes currently operating in India are described briefly, including ESI, CGHS, and RSBY. Characteristics, terminology, types, advantages, and limitations of health insurance are also summarized.
Presentation by Adrienne Chattoe-Brown, Lead Specialist- Health Systems and Service Delivery, HLSP, at the WHO/TNO/Dutchgovernment Congres 'Connecting Health and Labour' 29 - 1 December 2012
The Affordable Care Act requires Medicare patients to pay out-of-pocket for colorectal cancer screenings if a polyp is found and removed. However, if no polyp is found, patients pay nothing. This creates a disincentive for screenings and is an unintended consequence that needs fixing. Earlier cancer detection through screening reduces costs and saves lives. Representatives need to be educated on this oversight so they can quickly correct the Medicare policy and remove barriers to important cancer screenings.
This document discusses and compares various global healthcare systems models including the Beveridge model, Bismarck model, national health insurance model, and out-of-pocket model. It provides details on the characteristics of each model such as universal coverage, funding mechanisms, provider types, and coverage levels. Examples are given of countries that follow each model including the UK (Beveridge), Germany (Bismarck), Canada (national health insurance), and less developed nations (out-of-pocket). The document concludes that no single system is perfect and that many countries utilize hybrid approaches.
Employment-based health benefits have declined over the past decade while costs have increased dramatically. Some employers are considering moving to private health insurance exchanges that offer employees defined contributions to purchase plans, rather than traditional defined benefit plans. While private exchanges may help control costs, they also introduce new complexities and uncertainties for both employers and employees. Employers will still need to make choices around contribution levels and plan selection support.
This document discusses various methods of financing dental care, including private fee-for-service, post-payment plans, and private third party payment plans like commercial insurance companies and nonprofit health service corporations. It provides definitions for key terms like coinsurance, copayments, deductibles, participating dentists, and more. The history of dental financing is reviewed, from traditional fee-for-service to the establishment of programs in the US and UK in the 1940s-1950s. Common third party payment mechanisms like usual/customary/reasonable fees and fee schedules are also summarized.
Health insurance helps cover the cost of medical care. It protects individuals financially from expensive medical bills. Health insurance is commonly offered through employers and is important for anyone to have, as medical costs continue to rise. When choosing a health insurance plan, consider the health benefits covered, the costs including premiums and out-of-pocket maximums, the network of physicians covered, and whether any prescriptions are included. Health insurance terminology includes deductibles, coinsurance, networks, and other terms that define coverage and costs. Understanding these terms is key to utilizing health insurance benefits.
Health insurance helps cover the cost of medical care. It protects individuals financially from expensive medical bills. Health insurance is commonly offered through employers and is important for anyone to have, as medical costs continue to rise. When choosing a health insurance plan, consider the health benefits covered, the costs including premiums and out-of-pocket maximums, the network of physicians covered, and which prescriptions are included. Health insurance terminology includes deductibles, coinsurance, networks, and other terms that define coverage and costs. Understanding these terms is key to utilizing health insurance benefits.
This document discusses the scope and forms of healthcare insurance. It provides information on:
- Healthcare insurance normally covers treatment of acute conditions but not chronic or preventative care.
- The main forms of health insurance are medical insurance, personal accident/sickness, income protection, critical illness, and long-term care.
- Healthcare policies can be personal, covering individuals and families, or group policies arranged by employers to cover employees. Group policies are typically paid for by the employer.
The Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents is an initiative designed to improve care for people living in nursing facilities who are enrolled in Medicare and Medicaid.
Through this initiative, CMS will partner with independent organizations to improve care for long-stay nursing facility residents. These organizations will collaborate with nursing facilities and States to provide coordinated, person-centered care with the goal of reducing avoidable hospital stays.
In this webinar, staff from the Medicare-Medicaid Coordination Office (MMCO) and the CMS Innovation Center will provide an overview of the initiative, and offer information about how to apply.
More at: http://innovations.cms.gov/resources/Duals_rahnfr_apply.html
- - -
CMS Innovation
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The document discusses various mechanisms for paying for dental care, including:
1. Private fee-for-service, the traditional model where patients pay providers directly. This remains popular but limits access for many.
2. Prepayment plans like insurance, where a third party pays providers on behalf of subscribers. This includes commercial plans, non-profit Delta Dental plans, and prepaid group practices.
3. Public programs like Medicaid provide dental coverage for specific groups but have limitations in eligibility and coverage. Overall the document analyzes different payment systems and their ability to improve access to dental care.
This document provides an overview of long-term care planning and options. It discusses that long-term care is needed when one can no longer independently care for themselves, and may involve assistance with daily tasks. Common places of long-term care include home care, assisted living facilities, adult day care, hospice, and nursing homes. The costs of long-term care are significant and most individuals and families are not adequately prepared to pay for extended care needs. Private long-term care insurance can help cover costs and protect assets from being depleted by long-term care expenses. The document encourages planning early for long-term care needs through exploring insurance options.
The document discusses the Ohio Health Care Security Act, which proposes a single-payer universal health care system for Ohio. It would be administered by the Ohio Health Care Agency under an Ohio Health Care Board. All Ohio residents would be covered for comprehensive health care services. It would be financed through payroll taxes on employers up to 3.85% of payroll, business gross receipts taxes up to 3%, and income taxes above certain thresholds. The system aims to reduce costs, provide coverage for all residents, and offer freedom of choice.
Este documento resume las actividades realizadas por la Junta Directiva de la Asociación de Economía de la Salud (AES) entre 2010 y 2011 para cumplir con los acuerdos de la Asamblea de socios de 2010 y las tareas de la Junta. Las actividades se centraron en tres áreas estratégicas: mejorar la visibilidad y capacidad de influencia de la AES, impulsar relaciones estratégicas con otras instituciones, e implementar mejoras en el funcionamiento de la asociación. Algunas de las acciones más destacadas fueron la organización
Este documento resume las actividades realizadas por la Asociación Española de Economía de la Salud (AES) entre 2009 y 2010. La AES organizó las XXIX Jornadas de Economía de la Salud en Málaga, con más de 300 asistentes y 200 presentaciones. También mejoró su visibilidad a través de nuevas publicaciones, premios, y colaboraciones con otras instituciones como el Ministerio de Sanidad y el Instituto de Estudios Fiscales. La AES busca cumplir objetivos estratégicos como mejorar su influencia, fomentar asoci
This document discusses measuring health services in national accounts. It notes the challenges in measuring non-market health services given rapid technological change and non-market provision. It outlines different approaches to capturing quality change and volume output, including through stratification of treatments, explicit quality adjustment, and measuring marginal contribution to outcomes. Capturing quality change is difficult but important for accurately measuring real output growth in the health sector.
Professor Mike Pringle presented on the impact of the Quality and Outcomes Framework (QoF) in the UK. He addressed whether QoF improved health outcomes, reduced inequality gaps, and was cost-effective. While some metrics like blood pressure monitoring rates increased after QoF, improvements were already occurring before 2004. QoF initially widened inequality gaps but practices in deprived areas were exempted, and gaps have since narrowed. Potential downsides include reduced professionalism and displaced activities, but exemption code use has declined. Whether QoF is cost-effective is debated as effects of socioeconomics on health are greater than QoF incentives.
1) Adolescent cognitive ability and non-cognitive traits are associated with better adult physical and mental health and fewer depressive symptoms.
2) Adding family background factors attenuates but does not eliminate the associations, suggesting both shared family environments and individual attributes matter.
3) Further adding education and health behaviors further reduces the associations, indicating cognitive/non-cognitive traits may influence health through these mediating factors.
Este documento presenta la historia de una idea sobre la epidemiología contextual y los análisis de multinivel. Explica la diferencia entre la epidemiología individual y contextual, y cómo los análisis ecológicos tradicionales tienen limitaciones al no considerar factores individuales. También introduce el concepto de "agrupamiento" y cómo los análisis de multinivel pueden estimar efectos contextuales comunes y específicos de manera más válida que los análisis ecológicos.
1) New methods are required to value health states in the EQ-5D-5L descriptive system due to the increased number of possible health states and greater sensitivity between levels.
2) Known problems with conventional TTO methods include inability to value states worse than dead and extreme values for such states. Lead time TTO is a proposed alternative.
3) Computer-aided methods allow more complex valuation tasks and automated data collection and analysis. Ongoing research is testing variants of lead time TTO and exploring discrete choice modeling with VAS.
The researchers developed official 5-level versions of the EQ-5D for the UK and Spain through a two-phase process. In phase 1, they selected severity labels for the 5-level versions through response scaling interviews in each country. In phase 2, they tested the face and content validity of two alternative 5-level versions in focus groups. Based on participant feedback and preferences, they selected a final 5-level version for each country. The new versions aimed to improve sensitivity while maintaining the robustness and validity of the original EQ-5D.
Este documento describe un proyecto de investigación para desarrollar e implementar índices de calidad de vida relacionados con la salud (CVRS) a través de software. El proyecto tiene como objetivo crear una herramienta de fácil uso que permita calcular índices CVRS como el EQ-5D de manera estandarizada y comparable con otros estudios. El software, llamado EQIS, se desarrolló en Visual Studio y calcula índices basados en datos de salud recopilados usando cuestionarios como el EQ-5D.
Professor Mike Pringle presented on the impact of the Quality and Outcomes Framework (QoF) in the UK. He addressed whether QoF improved health outcomes, reduced inequality gaps, and was cost-effective. While some metrics like blood pressure monitoring rates increased after QoF, improvements pre-dated it. QoF risks included box-ticking and reduced professionalism. Initially, inequality gaps widened but narrowed over time as deprived areas improved. While QoF cost £1 billion annually, its effects were smaller than socioeconomic factors. It remains unclear if QoF is truly cost-effective.
This document summarizes evidence on pay-for-performance (P4P) schemes for chronic disease management. It finds that while P4P can have positive effects, the evidence is limited and heterogeneous. Careful design is needed to avoid unintended consequences. Effective elements include incentives at multiple levels, emphasis on protocols and record-keeping, and risk-adjusting payments. More research is still needed to understand optimal incentive sizes, measures, and interactions with existing payment systems.
The Quality and Outcomes Framework (QOF) was introduced in 2004 as part of the new GP contract to incentivize and measure quality in primary care. It contains clinical, organizational, and patient experience indicators and practices are financially rewarded for meeting targets. While QOF improved quality initially, its effects have plateaued with average achievement over 90%. There are also concerns it does not optimally target the interventions that could most improve population health and that some gaming of the system occurs through exception reporting. Reforms are needed to make QOF more challenging and better aligned with local health priorities.
The European Union has taken several actions to address rare diseases at the EU level. This includes establishing an Orphan Medicinal Product Regulation to incentivize research and development of treatments for rare diseases. The EU has also adopted the Second EU Health Programme for 2008-2013, which prioritizes rare diseases. More recently, the EU issued a Commission Communication and Council Recommendation on rare diseases calling on member states to develop national plans or strategies for rare diseases by 2013.
Este documento proporciona información sobre la gestión farmacoterapéutica de los medicamentos huérfanos. Se discuten estrategias para evaluar, adquirir, utilizar y realizar un seguimiento de estos medicamentos, los cuales a menudo tienen un alto coste y una evidencia limitada de eficacia. También se proponen medidas para mejorar el acceso y uso de los medicamentos huérfanos de forma equitativa.
This document discusses orphan drugs and cost-effectiveness analysis in the UK. It notes that drugs for rare diseases are often deemed too expensive based on standard HTA methods. While measures have been taken to encourage orphan drug development, questions remain about whether a premium should be paid for these drugs. The UK's NICE concluded that no changes are needed for drugs treating diseases affecting over 1 in 50,000 people, but may develop special processes for rarer diseases. The document examines arguments for special status for orphan drugs and their implications for resource allocation decisions.
El documento describe la evolución de la demanda de asistencia odontológica en España en los últimos 25 años. Se ha producido un aumento del 266% en el número de dentistas debido al incremento de la oferta educativa en los años 80 y al fenómeno de inmigración. Sin embargo, las cargas de trabajo por dentista han disminuido un 57% debido al aumento del porcentaje de población que visita al dentista y al incremento de la población total. El cambio generacional también ha influido en el aumento de la demanda odontol
Este documento describe la evolución de la organización y financiación de los servicios de salud oral en España. Se destaca que el miedo al dolor y al coste de los tratamientos dentales ha disminuido gracias al aumento en el número de visitas al dentista. Sin embargo, la aparición de franquicias dentales y la saturación del mercado con nuevos dentistas ha creado presión sobre los precios. Además, las compañías de seguros ahora controlan entre el 16-42% del mercado de servicios dentales en España a través de la vent
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1. 6/29/2010
Overview
Aligning Incentives to Achieve the • What makes health care delivery different?
Performance One Cannot • Standard solutions:
(Micro) Manage • Private delivery via insurance
• Public delivery via budgets
• Choice among health plans (HMOs)
Harold S. Luft, Ph.D.
• Problems with the standard solutions
Palo Alto Medical Foundation Research Institute
and
• A 4th way: Focused Coverage and Responsibility
University of California San Francisco
• Inpatient vs. outpatient care
XXX Jornadas de Economia de la Salud • Patient responsibilities
Valencia, Spain • Provider incentives
23 June 2010 • Drug developers and “insurers”
Health Care Delivery: Health Care Delivery:
What Makes it Different?—1 What Makes it Different?—2
• Medical care is a mixture of (relatively) • The services needed, however are not readily
affordable and commonly used services assessed—expertise is relied upon for:
Some of these are similar to other things we routinely — diagnosis (figuring out what is needed)
purchase: massages, cosmetics, piercings, OTC drugs
— delivering treatments experienced just once
• And infrequently used, but very expensive ones
but these are not like homes, cars, or vacations • The former leads to a reliance on physicians
• Only someone with special training understands what
• Expensive “usual” items are optional is needed in a specific situation
• But in medicine, need can be unpredictable • The latter leads to reliance on professionalism
and existential (utility preference changing) • Only someone with special training understands
• Resulting in a demand for insurance (Arrow, 1963) whether the treatment was performed correctly
The Role of Uncertainty Dealing with Uncertainty
• When one’s car or house is damaged, an • Before insurance, patients would bear the
insurance “adjuster” estimates repair costs risk of occurrence and physicians were paid
• The insurer, bears only the risk of occurrence on a fee-for-service basis
• The maximum payout is usually fixed by contract • But this was largely for physician time
• So the costs were not that substantial
• It is often difficult, however, for even a highly
• Physicians carried the risk of not being paid
skilled physician to determine in advance
exactly what needs a patient needs • As the costs of care increased, people
• So, one needs to consider both the (patients and physicians) wanted insurance
— risk of occurrence ~ f(patient risk factors) • Insurers then carried both the occurrence and
— production risks ~ f(patient and provider factors) production risk
2. 6/29/2010
The Usual “Solutions” Private Delivery with Health
(Sickness) Insurance
• Private delivery with health insurance • Designed to cover the costs of medical care
• Public delivery with budgets • Typically, payment for services rendered, vs. just
having the “insured” bear the cost
• Competition among health plans (HMOs)
• Sometimes this is actually “reimbursement”
• But often it is simply “payment” of specific fees
• …and then the problems with each • How those fees are determined is often controversial
• As with much insurance, it relies on deductibles,
coinsurance, and sometimes copayments
Competition Among Health Plans or
Public Delivery with Budgets Health Maintenance Organizations (HMOs)
• An alternative to a personal insurance model • A middle ground between classic FFS insurance
and government budget models
• Establish budgets for specific types of
providers, e.g., hospitals, physicians, drugs • People enroll in one of several health plans
• Government pays the providers directly • Premiums are paid by government, employers,
• budgets for facilities
enrollees, or a combination of the above
• salaries for professionals • Plans cover all (or most) medical services
• negotiated prices for drugs
• Enrollees may pay small copayments for care
• Patients seek care at little or no direct cost
• although copayments are sometimes levied • Plans pay providers in varying ways, from
budgets and salaries to modified FFS
Assessing the Alternatives (Logical) Problems with Insurance
• Often simply reflects ideologies: • Deductibles create strong incentives to avoid
• Right: likes voluntary insurance and private delivery using services at the beginning of the year
• Left: likes tax-based coverage and public delivery
• Coinsurance doesn’t make much sense for
• Middle: universal coverage, delivery system choice
inpatient services that the patient can’t assess
• But, empirical assessment of each is impossible
• Fees for individual services offer providers no
• Results of “demonstrations” are artificial
payment for coordination and similar activities
• Overall payment systems function as “ecologies”
• Separate aspects cannot be assessed • And no rewards to those who appropriately
• Politics governs the “rules of the system” reduce the use of services of others
• And systems reflect national cultures and values
• No natural focus for assessing quality of care
3. 6/29/2010
Problems with Budgets Problems with Relying on HMOs
• When HMOs are paid a fixed premium,
• Lack of patient financial responsibility (“all is competition leads to avoiding sicker enrollees
free”) leads to the perception of rationing
• This can be partially addressed with risk
• Budgets are often set by category, e.g., adjustment, but probably never perfectly
hospitals, physicians, or drugs, with no easy way • (Reimbursing HMOs is like FFS, once removed)
to substitute services across categories
• Internal HMO payments to providers bring the
problems of either FFS or budgets (or both)
• Within categories, no way to incentivize micro-
level decision-makers (MDs) to be more efficient • Quality may focus on the HMO, but providers may
belong to several HMOs
• Quality focus is typically global or departmental
• Lack of patient involvement in costs leads to the
perception of rationing or profiteering
• Centralization creates an easy political “target”
Beyond Insuring Financial Risk A fourth way–
Focused Coverage…
• Patients can’t directly “discipline” providers
• Focus the coverage of the enrollee on:
• Insurance just covers financial costs • (1) chronic illnesses
• (2) inpatient (or equivalent) care
• Budgets just limit outlays That is, the sources of financial risk warranting insurance
• What is being purchased is unclear • Have everyone in the same risk pool, called
• And there is little assessment of its quality here the Universal Coverage Pool (UCP),
thereby:
• Medical care is often highly personal, yet this • Avoiding the selection problems due to voluntarism
is rarely taken into account • And that arising from people choosing among HMOs
…and Responsibility Paying Providers—Inpatient
•
Care
Physicians and hospitals form care delivery teams
• Patient responsibility for things patients control
(CDTs), these are typically non-overlapping
They pay for minor, repetitive interventions
o But not for inpatient care • UCP pays a bundled amount for an episode of
• Although one can have deductibles (perhaps time- care (including pre- and post-discharge)
scaled) for discretionary procedures
o No deductibles for chronic illness care
• Payment is based on average costs incurred by
those CDTs achieving above average outcomes
But consumers bear the costs of differences (at the
margin) in “practice style” and fees among providers • CDT members are free to split the payments
among themselves however they choose
• Provider responsibility (indirect) for incremental
costs associated with inefficient production • CDTs are not allowed to encourage admissions
4. 6/29/2010
Paying for Outpatient Care Patient Responsibilities
• Each patient chooses a primary care provider • The PI transfers charges (after the UCP’s chronic
(PCP); either an individual or a clinic illness offsets) each month to the patient’s bank
account—primarily the costs of minor acute care
• Each PCP chooses a payment intermediary (PI) to
• The PI offers various “insurance” options and
handle billing, much like a credit card company
copayment levels to smooth out payments
• The PI gets monthly chronic illness management
• In either case, government reduces the patient’s
payments from the UCP based on identified (not burden with an income-based subsidy, which is
predicted) chronic illnesses of the PCP’s patients totally “behind the scenes” (providers don’t know)
• Providers are essentially paid FFS, but they can • The patient’s net cost reflects the subsidies, the
determine these, e.g., they can bill for phone fees and practice styles of the PCP chosen and
calls, care coordination and set their own fees the providers usually used by that PCP’s patients
Provider Incentives—Inpatient Provider Incentives—Outpatient
• CDTs have strong incentives to reduce the costs of • PCPs attract more patients by offering them
care for each episode, i.e., technical efficiency— better service at lower “net premiums”
because excess charges are passed on to the PIs • Reflects their own fees and excess costs of CDTs
• “Gold stars” given CDTs with superior outcomes
• MD time is less expensive than what MDs order
(positive deviants) encourage a quality focus
• PCPs will want patients to feel cared-for, but will
• CDTs can use whatever inputs they want
also help them care for themselves
• CDTs will demand information on which tests, drugs,
etc., add the most value • The “fee schedule” is irrelevant because PCPs
can set their own structures and charges
• CDTs, especially referral sites, have incentives to
provide better data for improved risk adjustment • PCPs will demand information on best practices
from the PIs or others able to analyze data
Outpatient Specialists Drug and Device Developers
• Demand will favor those innovations that:
• Want to be attractive to PCPs to gain their referrals
• Lower cost while maintaining patient outcomes
• Their net costs are reflected in PCP-based premiums • Or markedly enhance quality at some extra cost
• Like PCPs, they can be paid more for their time if • Direct marketing to patients will not pay off very
they reduce the overall costs of what they “order” well because of physician push-back
• Build experience-based relationships with PCPs to • Physicians will scrutinize developer claims and
reduce marginally needed specialist visits demand independent head-to-head assessments
• They will question the value provided by expensive • All claims data will be in the public domain (de-
new tests, procedures, and drugs identified) to be analyzed by many parties
5. 6/29/2010
Payment Intermediaries Focused Coverage and Responsibility
• Recognizes the different types of medical care
PIs compete for the business of PCPs, offering: • Public assurance of universality and subsidy
• low-priced claims administration • Links responsibility & reward with risk & control
• PCP-focused performance assessments • Inpatient teams get responsibility with flexibility
contrasted with “positive deviants” nationally
• Risk adjustment occurs via direct payment for
• to represent PCPs achieving lower inpatient inpatient care and offsets based on chronic illness
use—arguing with the UCP to shift resources • PCP practice styles (including referrals) and fees
are summarized in PCP-based premiums
• to provide the interfaces, infrastructure and
support for electronic health records • Direct patient incentives are primarily in minor
acute care and choosing efficient PCPs
Incentives for Improvement De-politicization of Health Care
• Providers can take home more money by • Universal coverage for the insurance risk
lowering the costs of treating their patients • Government doesn’t try to control fees
• Public recognition of “positive deviants” who • But excess fees flow to patients who can
self-identify and can be scrutinized change providers
• Public use data files allow multiple assessments • Income-based subsidies for patient share
of performance
• Specialty societies do not control guidelines
• Knowledge transfer is demanded by providers
• Patients can pay for more “intense”
• “Bending the (technology) curve” in medicine treatments, the UCP sees if they work
For more information, see:
Harold S. Luft, Total Cure: The Antidote to the
Health Care Crisis, Harvard University Press,
2008
http://www.SecureChoice.info