Equity in healthcare financing: a case of Iran.

BACKGROUND: Fair financial contribution in healthcare financing is one of the main goals and challengeable subjects in the evaluation of world health system functions. This study aimed to investigate the equity in healthcare financing in Shiraz, Iran in 2018. MATERIALS AND METHODS: This was a cross- sectional survey conducted on the Shiraz, Iran households. A sample of 740 households (2357 persons) was selected from 11 municipal districts using the multi-stage sampling method (stratified sampling method proportional to size, cluster sampling and systematic random sampling methods). The required data were collected using the Persian format of "World Health Survey" questionnaire. The collected data were analyzed using Stata14.0 and Excel 2007. The Gini coefficient and concentration and Kakwani indices were calculated for health insurance premiums (basic and complementary), inpatient and outpatient services costs, out of pocket payments and, totally, health expenses. RESULTS: The Gini coefficient was obtained based on the studied population incomes equal to 0.297. Also, the results revealed that the concentration index and Kakwani index were, respectively, 0.171 and - 0.125 for basic health insurance premiums, 0.259 and - 0.038 for health insurance complementary premiums, 0.198 and - 0.099 for total health insurance premiums, 0.126 and - 0.170 for outpatient services costs, 0.236 and - 0.061 for inpatient services costs, 0.174 and - 0.123 for out of pocket payments (including the sum of costs related to the inpatient and outpatient services) and 0.185 and - 0.112 for the health expenses (including the sum of out of pocket payments and health insurance premiums). CONCLUSION: The results showed that the healthcare financing in Shiraz, Iran was regressive and there was vertical inequity and, accordingly, it is essential to making more efforts in order to implement universal insurance coverage, redistribute incomes in the health sector to support low-income people, strengthening the health insurance schemes, etc.

Clinical Ethicists Awakened: Addressing Two Generations of Clinical Ethics Issues Involving Undocumented Patients.

Because the United States has failed to provide a pathway to citizenship for its long-term undocumented population, clinical ethicists have more than 20 years of addressing issues that arise in caring for this population. I illustrate that these challenges fall into two sets of issues. First-generation issues involve finding ethical ways to treat and discharge patients who are uninsured and ineligible for safety-net resources. More recently, ethicists have been invited to help address second-generation issues that involve facilitating the presentation for care of undocumented patients. In the current environment of widespread fear of deportation in the immigrant community, ethicists are working with health care providers to address patient concerns that prevent them from seeking care. I illustrate that in both generations of issues, values implicit within health care, namely, caring, efficiency, and promotion of public health, guide the strategies that are acceptable and recommended.

Financial Conflicts of Interest in Public Comments on Medicare National Coverage Determinations of Medical Devices.

This study reviewed public comments for all Medicare National Coverage Determinations between June 2019 and 2022 on select pulmonary and cardiac devices to determine whether financial conflicts of interest were disclosed.

Autonomy-Centered Healthcare.

In this paper, I aim to demonstrate that the consequences of the current United States health insurance scheme on both physician and patient autonomy is dire. So dire, in fact, that the only moral solution is something other than what we have now. The United States healthcare system faces much criticism at present. But my focus is particular: I am interested in the ways in which insurance interferes with physician and patient autonomy. (I do not consider The Affordable Care Act much of a change in this aspect of the system, for it still relies heavily on private insurance, albeit often subsidized.) I will argue in favor of an expansion of the traditional conception of what I call "medical autonomy" or "healthcare autonomy" and the usual role it plays in bioethical discussions. More generally, I show that in morally designing or evaluating any healthcare system, serious attention should be paid to how this system helps foster what I call active autonomy.

Restrictions of Hepatitis C Treatment for Substance-Using Medicaid Patients: Cost Versus Ethics.

Medicaid programs provide health insurance coverage for many patients with hepatitis C, a public health problem for which effective but very expensive treatments are now available. Facing constrained budgets, most states adopted prior authorization criteria for sofosbuvir, the first of these agents. Using fee-for-service utilization data from 42 Medicaid programs in 2014, we found that strict behavioral criteria-those that limited coverage on the basis of drug or alcohol use and included specific abstinence or treatment requirements-were associated with significantly less spending on sofosbuvir. Despite the potential cost savings, such criteria raise troubling questions in terms of public health as well as medical ethics, clinical evidence, and potentially federal law. Decision-makers should reject these requirements in Medicaid coverage policy and pursue national and state policy strategies to balance short-term budgetary realities with long-term public health benefits.

The ethics of insurance limiting institutional medical care: It's all about the money.

Dr F. Inest practices surgery at a renowned medical center but is concerned because increasing numbers of medical insurers are excluding his institution from coverage. Many of his former referring physicians are beginning to send their patients elsewhere for this reason. The marketing people have been busy increasing their advertising buys and exploring new business models. There is even talk about reducing expensive clinical trials. However, regardless of his affiliation, he has little control over these and other organizational decisions that directly impact his practice clinically and fiscally. What should he do?

When psychiatric diagnosis becomes an overworked tool.

A psychiatric diagnosis today is asked to serve many functions-clinical, research, medicolegal, delimiting insurance coverage, service planning, defining eligibility for state benefits (eg, for unemployment or disability), as well as providing rallying points for pressure groups and charities. These contexts require different notions of diagnosis to tackle the particular problem such a designation is meant to solve. In a number of instances, a 'status' definition (ie, a diagnostic label or category) is employed to tackle what is more appropriately seen as requiring a 'functional' approach (ie, how well the person is able to meet the demands of a test of performance requiring certain capabilities, aptitudes or skills). In these instances, a diagnosis may play only a subsidiary role. Some examples are discussed: the criteria for involuntary treatment; the determination of criminal responsibility; and, assessing entitlements to state benefits. I suggest that the distinction between 'status' versus 'function' has not been given sufficient weight in discussions of diagnosis. It is in the functional domain that some of the problematic relationships between clinical psychiatry and the social institutions with which it rubs shoulders are played out. A status, signified by a diagnosis, has often been encumbered with demands for which it is poorly equipped. It is a reductive way of solving problems of management, allocation or disposal for which a functional approach should be given greater weight.

Aetna's compassionate care program and end-of-life decisions.

In this article we describe the successes of Aetna's Compassionate Care Program in providing case management services for people with advanced illnesses.

The author replies.

A response to Anne Haehl's commentary, "Fertility Treatment: Medically Necessary?"

Why physicians ought to lie for their patients.

Sometimes physicians lie to third-party payers in order to grant their patients treatment they would otherwise not receive. This strategy, commonly known as gaming the system, is generally condemned for three reasons. First, it may hurt the patient for the sake of whom gaming was intended. Second, it may hurt other patients. Third, it offends contractual and distributive justice. Hence, gaming is considered to be immoral behavior. This article is an attempt to show that, on the contrary, gaming may sometimes be a physician's duty. Under specific circumstances, gaming may be necessary from the viewpoint of the internal morality of medicine. Moreover, the objections against gaming are examples of what we call the idealistic fallacy, that is, the fallacy of passing judgments in a nonideal world according to ideal standards. Hence, the objections are inconclusive. Gaming is sometimes justified, and may even be required in the name of beneficence.

Complex discharges and undocumented patients: growing ethical concerns.

A growing number of discharges at acute-care hospitals involve patients who are undocumented and lack legal status. Because such patients are ineligible for public assistance, long-term care facilities will routinely deny them admission. These discharges become complex discharges because of such financial barriers. If local family support is unavailable, discharging such patients to a safe and suitable location becomes increasingly difficult. These complex discharges implicate a number of ethical principles. We describe such complex discharge cases, apply various ethical frameworks, and call for potential policy solutions to address this growing ethical concern.

Anticipatory ex ante moral hazard and the effect of Medicare on prevention.

This paper extends the ex ante moral hazard model to allow healthy lifestyles to reduce the probability of illness in future periods, so that current preventive behaviour may be affected by anticipated changes in future insurance coverage. In the United States, Medicare is offered to almost all the population at the age of 65. We use nine waves of the US Health and Retirement Study to compare lifestyles before and after 65 of those insured and not insured pre 65. The double-robust approach, which combines propensity score and regression, is used to compare trends in lifestyle (physical activity, smoking, drinking) of the two groups before and after receiving Medicare, using both difference-in-differences and difference-in-differences-in-differences. There is no clear effect of the receipt of Medicare or its anticipation on alcohol consumption nor smoking behaviour, but the previously uninsured do reduce physical activity just before receiving Medicare.

Rationing just medical care.

U.S. politicians and policymakers have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for--as though health care is a commodity that needs no examination--or what health outcomes should receive priority in a just society, i.e., rationing. I present a rationing proposal, consistent with U.S. culture and traditions, that deals not with "health care," the terminology used in the current debate, but with the more modest and limited topic of medical care. Integral to this rationing proposal--which allows scope to individual choice and at the same time recognizes the interdependence of the individual and society--is a definition of a "decent minimum," the basic package of medical treatments everyone should have access to in a just society. I apply it to a specific example, diabetes mellitus, and track it through a person's life span.

Ethical and value issues in insurance coverage for cancer treatment.

Many new cancer drugs provide only limited benefits, but at very great cost, for example, $200,000-$300,000 per quality-adjusted life year produced. By most standards of value or cost-effectiveness, this does not represent good value. I first review several of the causes of this value failure, including monopoly patents, prohibitions on Medicare's negotiating on drug prices, health insurance protecting patients from costs, and financial incentives of physicians to use these drugs. Besides value or cost-effectiveness, the other principal aim in health care resource allocation should be equity among the population served. I examine several equity considerations-priority to the worse off, aggregation and special priority to life extension, and the rule of rescue-and argue that none justifies greater priority for cancer treatment on the grounds of equity. Finally, I conclude by noting two recent policy changes that are in the wrong direction for achieving value in cancer care, and suggesting some small steps that could take us in the right direction.