Revisiting out-of-pocket requirements: trends in spending, financial access barriers, and policy in ten high-income countries.

BACKGROUND: Countries rely on out-of-pocket (OOP) spending to different degrees and employ varying techniques. The article examines trends in OOP spending in ten high-income countries since 2000, and analyzes their relationship to self-assessed barriers to accessing health care services. The countries are Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. METHODS: Data from three sources are employed: OECD statistics, the Commonwealth Fund survey of individuals in each of ten countries, and country-specific documents on health care policies. Based on trends in OOP spending, we divide the ten countries into three groups and analyze both trends and access barriers accordingly. As part of this effort, we propose a conceptual model for understanding the key components of OOP spending. RESULTS: There is a great deal of variation in aggregate OOP spending per capita spending but there has been convergence over time, with the lowest-spending countries continuing to show growth and the highest spending countries showing stability. Both the level of aggregate OOP spending and changes in spending affect perceived access barriers, although there is not a perfect correspondence between the two. CONCLUSIONS: There is a need for better understanding the root causes of OOP spending. This will require data collection that is broken down into OOP resulting from cost sharing and OOP resulting from direct payments (due to underinsurance and lacking benefits). Moreover, data should be disaggregated by consumer groups (e.g. income-level or health status). Only then can we better link the data to specific policies and suggest effective solutions to policy makers.

Work-Family Conflict Among Newly Licensed Registered Nurses: A Structural Equation Model of Antecedents and Outcomes.

Conflict between work and family is a human resource management issue that is particularly relevant for nurses. Nursing is a demanding profession, and a high proportion of nurses are women, who tend to have greater family responsibilities than men. Little is known regarding work-family conflict among nurses, and even less is known about how this affects newly licensed registered nurses (NLRNs), who can be stressed from their new jobs and careers. This study empirically tests a model of antecedents and outcomes of work-family and family-work conflict among a sample of NLRNs. We developed a model of the relationships between personal and work environment characteristics, work-family and family-work conflicts, job satisfaction, and intent to leave the job and profession. We used structural equation modeling (Amos, IBM SPSS) to test the model with data from.a survey of NLRNs. We examined a number of latent variables, as well as direct and mediating relationships. The measurement models for all latent variables were validated. The final model indicated that age, health, and family responsibilities are antecedents of family-work conflict; job demands lead to work-family conflict; family-work conflict contributes to job difficulties, which lowers job satisfaction, which, in turn, increases the intent to leave the job and profession; and work-family conflict increases the intent to leave the job and profession (but does not directly affect job satisfaction). Policies to help NLRNs with family responsibilities could reduce family-work conflict, which might reduce job difficulties and improve satisfaction and retention. In addition, policies to reduce job demands could reduce work-family conflict and improve retention.

Challenges facing the United States of America in implementing universal coverage.

In 2010, immediately before the United States of America (USA) implemented key features of the Affordable Care Act (ACA), 18% of its residents younger than 65 years lacked health insurance. In the USA, gaps in health coverage and unhealthy lifestyles contribute to outcomes that often compare unfavourably with those observed in other high-income countries. By March 2014, the ACA had substantially changed health coverage in the USA but most of its main features--health insurance exchanges, Medicaid expansion, development of accountable care organizations and further oversight of insurance companies--remain works in progress. The ACA did not introduce the stringent spending controls found in many European health systems. It also explicitly prohibits the creation of institutes--for the assessment of the cost-effectiveness of pharmaceuticals, health services and technologies--comparable to the National Institute for Health and Care Excellence in the United Kingdom of Great Britain and Northern Ireland, the Haute Autorité de Santé in France or the Pharmaceutical Benefits Advisory Committee in Australia. The ACA was--and remains--weakened by a lack of cross-party political consensus. The ACA's performance and its resulting acceptability to the general public will be critical to the Act's future.

En 2010, juste avant que les États-Unis d'Amérique aient mis en œuvre les principales caractéristiques de la loi Affordable Care Act (ACA, loi sur les soins abordables), 18% des résidents des États-Unis d'Amérique âgés de moins de 65 ans de disposaient d'aucune assurance-maladie. Aux États-Unis d'Amérique, les insuffisances dans la couverture maladie et les modes de vie malsains contribuent aux résultats qui sont souvent comparés de manière défavorable avec les résultats observés dans les autres pays à revenu élevé. En mars 2014, l'ACA a considérablement modifié la couverture maladie aux États-Unis d'Amérique, mais il reste encore beaucoup à faire concernant la plupart de ses caractéristiques principales - échanges d'assurance-maladie, développement du Medicaid, création d'organisations de soins responsables et surveillance accrue des compagnies d'assurances. L'ACA n'a pas introduit les contrôles rigoureux des dépenses qui existent dans de nombreux systèmes de santé européens. Elle interdit également explicitement la création d'instituts ­ pour l'évaluation du rapport coût-efficacité des produits pharmaceutiques, des services et des technologies de santé ­ comparables au National Institute for Health and Care Excellence du Royaume-Uni de Grande-Bretagne et d'Irlande du Nord, à la Haute Autorité de Santé en France ou au Pharmaceutical Benefits Advisory Committee en Australie. L'ACA était ­ et reste ­ affaiblie par le manque de consensus entre les partis politiques. La performance de l'ACA et son acceptabilité par le grand public seront déterminantes pour l'avenir de la loi.

En 2010, inmediatamente antes de que los Estados Unidos aplicaran características clave de la Ley de Cuidado de la Salud Asequible (ACA, por sus siglas en inglés), el 18 % de los residentes de Estados Unidos menores de 65 años carecían de seguro de salud. En los E.E.U.U., las brechas en la cobertura de salud y los estilos de vida insanos contribuyen a unos resultados que a menudo son peores que los observados en otros países con ingresos altos. En marzo de 2014, la ACA modificó sustancialmente la cobertura de salud en los Estados Unidos, pero la mayoría de sus características principales, es decir, el intercambio de seguros médicos, la expansión de Medicaid, el desarrollo de organizaciones de atención médica responsable y la mayor supervisión de las compañías de seguros son aún tareas pendientes. La ACA no introdujo controles de gastos estrictos como los presentes en muchos sistemas de salud europeos. Además, prohíbe explícitamente la creación de institutos para la evaluación de la rentabilidad de productos farmacéuticos, servicios y tecnologías de la salud, similares al Instituto Nacional de Salud y Excelencia Clínica en el Reino Unido de Gran Bretaña e Irlanda del Norte, la Haute Autorité de Santé en Francia o el Comité Asesor de Beneficios Farmacéuticos en Australia. La aplicación de la ACA era (y sigue siendo) insuficiente por la falta de consenso político entre todos los partidos. El cumplimiento de la ACA y su aceptación consiguiente por la población general serán decisivos para el futuro de la ley.

Credentialing: the need for a national research agenda.

A national research agenda is needed to promote inquiry into the impact of credentialing on health care outcomes for nurses, patients, and organizations. Credentialing is used here to refer to individual credentialing, such as certification for nurses, and organizational credentialing, such as American Nurses Credentialing Center Magnet recognition for health care organizations or accreditation of providers of continuing education in nursing. Although it is hypothesized that credentialing leads to a higher quality of care, more uniform practice, and better patient outcomes, the research evidence to validate these views is limited. This article proposes a conceptual model in which both credentials and standards are posited to affect outcomes in health care. Potential research questions as well as issues in research design, measurement, data collection, and analysis are discussed. Credentialing in nursing has implications for the health care professions and national policy. A growing body of independent research that clarifies the relationship of credentialing in nursing to outcomes can make important contributions to the improvement of health care quality.

Nurse staffing and patient safety in hospitals: new variable and longitudinal approaches.

BACKGROUND: Most studies of the relationship between nurse staffing and patient outcomes in hospitals have shown that worse patient outcomes are associated with lower registered nurse (RN) staffing. However, inconsistent results exist, possibly because of the use of a variety of nurse staffing and patient outcomes measures and because of statistical methods that employ static, instead of change, relationships. OBJECTIVES: The aim of the study was to examine the relationship between changes in RN staffing and patient safety events in Florida hospitals from 1996 through 2004. METHODS: Using 9 years of data from 124 Florida hospitals, latent growth curve models were used to assess the impact on patient safety of RN staffing changes in hospitals. Patient safety measures were 4 of the 20 provider-level patient safety indicators (PSIs) developed by the Agency for Healthcare Research and Quality. Two measures of RN staffing-RN full-time equivalents and RN per adjusted patient day-were analyzed. RESULTS: Changes in RN full-time equivalents were positively related to changes in RN per adjusted patient day. All PSIs were negatively and significantly related to one or both RN staffing measures. Failure to rescue had the strongest relationship to RN staffing. Models of change relationships between staffing and PSIs were more likely to show significant relationships than models using initial levels. Initial levels of RN staffing tended to be unrelated to initial levels of PSIs. DISCUSSION: A negative relationship between RN staffing and PSIs was strongly supported with failure to rescue and was weakly supported with decubitus ulcers, selected infections, and postoperative sepsis. The PSIs should be retested in an expanded change model study using multistate or national sample Healthcare Cost and Utilization Project data.

Newly licensed registered nurses' perceptions of job difficulties, demands and control: individual and organizational predictors.

AIMS: To determine predictors of newly licensed registered nurses' perceptions of job difficulties, job demands and job control. BACKGROUND: In previous studies, new registered nurses describe their work environment as stressful, yet little is known about factors that influence these experiences. METHODS: We surveyed a random sample of newly licensed registered nurses in Florida. Dependent variables included indicators of job difficulty, job demand and job control. Independent variables included individual and organizational characteristics hypothesized to be related to the dependent variables. Logistic and ordinary least squares regressions were used to analyse survey data. RESULTS: Inadequate orientation, working the day shift, working a greater number of hours and caring for a higher number of patients were significantly related to a greater likelihood of perceptions of job difficulty and job demand. Less adequate orientation and a greater number of float shifts were related to a lower likelihood of perceptions of job control. CONCLUSIONS AND IMPLICATIONS: Adequacy of orientation, patient load, work hours, shift work and floating are priority items that need improvement in the work environment of newly licensed registered nurses. IMPLICATIONS FOR NURSING MANAGEMENT: The present study identified factors involved with newly licensed registered nurses' perceptions of job difficulties, job demands and job control which will help managers redesign work settings to retain new nurses.

Health reforms in the United States: The outlook after Biden's first 100 days.

The November 2020 election of Joe Biden, coupled with the election of a Congress controlled by the Democratic Party, has the potential to dramatically alter the direction of health policy in the United States. Donald Trump failed to repeal the Affordable Care Act (ACA) but he managed to whittle down aspects of coverage protection. Historically, the first 100 days of a presidency are a bellwether of accomplishments to come. During this period Biden reversed several of Trump policies through both executive orders and a large economic stimulus bill. The stimulus bill substantially increased premium subsidies to encourage people to purchase health insurance coverage, albeit with funding guaranteed only for a two-year period. Larger accomplishments, such as making these enhanced premium subsidies permanent, reining in prescription drug spending, enacting a public health insurance option to compete with private insurers, and improving public health and health equity, will require further legislation. The political environment in the U.S. is now extraordinarily contentious. Each of these proposed initiatives faces major political hurdles and the window of opportunity for enacting each of these goals very well may be brief.

United States: Health System Review.

This analysis of the US health system reviews the developments in organization and governance, health financing, healthcare provision, health reforms and health system performance. The US health system has both considerable strengths and notable weaknesses. It has a large and well-trained health workforce and a wide range of high-quality medical specialists, as well as secondary and tertiary institutions, a robust health sector research programme and, for selected services, among the best medical outcomes in the world. But it also suffers from incomplete coverage of its citizenry, health expenditure levels per person far exceeding all other countries, poor measures on many objective and subjective measures of quality and outcomes, and an unequal distribution of resources and outcomes across the country and among different population groups. It is difficult to determine the extent to which deficiencies are health-system related, though it is clear that at least some of the problems are a result of poor access to care. The adoption of the Affordable Care Act in 2010 resulted in greatly improved coverage through subsidies for the uninsured to purchase private insurance, expanded eligibility for Medicaid (in some states), and greater protection for insured persons. Furthermore, primary care and public health received increased funding, and quality and expenditures were addressed through a range of measures such as financial rewards for providing higher-value care. At the same time, a change in political administration resulted in subsequent efforts to scale back the legislation. Many key issues remain, including further reducing the number of uninsured people, alleviating some of the burdensome patient cost-sharing requirements, and considering some new cost-containment methods such as allowing the government to negotiate drug prices with pharmaceutical manufacturers. The direction of future health policy will almost certainly depend on which political party is in power.

Universal coverage reforms in the USA: From Obamacare through Trump.

Since the election of Donald Trump as President, momentum towards universal health care coverage in the United States has stalled, although efforts to repeal the Affordable Care Act (ACA) in its entirety failed. The ACA resulted in almost a halving of the percentage of the population under age 65 who are uninsured. In lieu of total repeal, the Republican-led Congress repealed the individual mandate to purchase health insurance, beginning in 2019. Moreover, the Trump administration is using its administrative authority to undo many of the requirements in the health insurance exchanges. Partly as a result, premium increases for the most popular plans will rise an average of 34% in 2018 and are likely to rise further after the mandate repeal goes into effect. Moreover, the administration is proposing other changes that, in providing states with more flexibility, may lead to the sale of cheaper and less comprehensive policies. In this volatile environment it is difficult to anticipate what will occur next. In the short-term there is proposed compromise legislation, where Republicans agree to provide funding for the cost-sharing subsidies if the Democrats agree to increase state flexibility in some areas and provide relief to small employers. Much will depend on the 2018 and 2020 elections. In the meantime, the prospects are that the number of uninsured will grow.

Patient turnover and nursing staff adequacy.

OBJECTIVE: To assess the relative validity of patient turnover adjustments and the difference in nurse staffing using measures that adjust for patient turnover and severity versus those that do not. DATA SOURCES: Numbers of registered nurses (RNs), adjusted patient days of care (APDC), length of stay, and patient severity information from acute care general hospitals in Pennsylvania 1994-2001, obtained from the Pennsylvania Department of Health, the American Hospital Association, and the Atlas MediQual system. STUDY DESIGN: After examining the trends in patient turnover and severity and their relationship to RN staffing, we apply two-patient turnover indices, with and without patient severity adjustments, to RN staffing measures, and test the difference between the original and adjusted measures using paired sample t-tests. DATA EXTRACTION METHODS: Data sets were match merged by hospital ID, and patient turnover and severity indices were created, using 1994 as the base year. RN staffing measures were developed using unadjusted APDC, and APDC adjusted for patient turnover and both patient turnover and severity. PRINCIPAL FINDINGS: Patient turnover increased significantly from 1994 to 2001. The difference between RN staffing measures adjusted for patient turnover and severity and those not adjusted was increasingly significant from 1995 onward. Unadjusted RN staffing showed a 1 percent decline over the 8-year-period compared with decreases of from 9 to 26 percent after adjustments. CONCLUSIONS: These results indicate that the assessment of unadjusted RN staffing by RN to patient ratios alone underestimates nursing workload and overstates RN staffing levels. Patient turnover, as well as severity, should be taken into account in staffing assessment and decision making.

Consumer determinants of the use of health plan information in plan selection.

One of the major issues in achieving optimum levels of performance in health-care markets is to enhance consumer understanding of their health plan choices in order to facilitate the expansion of 'high-value' health plans at the expense of 'low-value' health plans. The Federal government offers employees many choices of health plans and provides large amounts of information on all of these options through (1) comparative written health plan information, (2) information from the health plans themselves, and (3) comparative health plan information on the Internet. The present study examines the degree to which 1722 Federal employees in the Department of Health and Human Services utilized health plan information from the above three sources in making their annual health plan selection. Results indicate that most employees (64%) used at least one information source, with written information from health plans the most common (53%), followed by comparative written information in The Guide (32%) and the Internet (16%). Those employees who regularly search for information prior to making an important purchase, those with a short time in their current plan, those with family coverage, Whites, African-Americans, and men were all more likely to use health plan information to make their annual choice. The Internet was accessed more often by younger and higher paid employees. Implications for policy and future research are discussed.

The Impact of State Nursing Home Staffing Standards on Nurse Staffing Levels.

This study investigated the impact of state nursing home staffing standards on nurse staffing levels for the year 2011. Specifically, the study attempted to measure state staffing standards at facility level (i.e., nurse staffing levels that each individual nursing home must retain by its state staffing standards) and analyzed the policy impact. The study findings indicated that state staffing standards for the categories of registered nurse, licensed nurse, or total nurse are positively related to registered nurse, licensed nurse, or total nurse staffing levels, respectively. Nursing homes more actively responded to licensed staffing requirements than total staffing requirements. However, nursing homes did not increase their staffing levels as much as those required by state staffing standards. It is possibly because the quality-oriented inspection allows flexibility in nursing homes' control of nurse staffing levels.

Improving nurse staffing measures: discharge day measurement in "adjusted patient days of care".

Previous research cannot account for the discrepancy between registered nurse (RN) reports of understaffing and studies showing slight improvement. One reason may be that "adjusted patient days of care" (APDC) underestimates patient load. Using data from all Pennsylvania acute care general hospitals for the years 1994 through 1997, we found that APDC is underestimated by two hours. After adjusting APDC, we examined the difference in nurse staffing over the period 1991-2000 before and after the adjustment. We found a significant difference between unadjusted and adjusted measures. However, when applied to the changes in nurse staffing between 1991 and 2000, the difference was not enough to account for the discrepancy between reports and data. Other measurement and conceptual problems may exist in terms of patients' increasing acuity levels, patients' declining lengths of stay and the associated greater proportion of nurse time devoted to admission and discharge, and lack of recent data in some empirical studies.

Newly licensed registered nurse job turnover and turnover intent.

Through survey data, this study examines job leaving behaviors of newly licensed registered nurses and identifies educational and managerial issues that need to be addressed to retain them. Within 1.5-2.5 years of graduating, one third of all respondents had left their first job, most for work-related reasons. Predictors of job leaving or intentions to leave included not having had a good orientation, information issues, having difficulties doing a good job, not being rewarded fairly, and low job satisfaction.

United States of America: health system review.

This analysis of the United States health system reviews the developments in organization and governance, health financing, health-care provision, health reforms and health system performance. The US health system has both considerable strengths and notable weaknesses. It has a large and well-trained health workforce, a wide range of high-quality medical specialists as well as secondary and tertiary institutions, a robust health sector research program and, for selected services, among the best medical outcomes in the world. But it also suffers from incomplete coverage of its citizenry, health expenditure levels per person far exceeding all other countries, poor measures on many objective and subjective measures of quality and outcomes, an unequal distribution of resources and outcomes across the country and among different population groups, and lagging efforts to introduce health information technology. It is difficult to determine the extent to which deficiencies are health-system related, though it seems that at least some of the problems are a result of poor access to care. Because of the adoption of the Affordable Care Act in 2010, the United States is facing a period of enormous potential change. Improving coverage is a central aim, envisaged through subsidies for the uninsured to purchase private insurance, expanded eligibility for Medicaid (in some states) and greater protection for insured persons. Furthermore, primary care and public health receive increased funding, and quality and expenditures are addressed through a range of measures. Whether the ACA will indeed be effective in addressing the challenges identified above can only be determined over time.

Changes in nursing home staffing levels, 1997 to 2007.

A positive relationship has been demonstrated between the quality of care delivered in nursing homes and the quality of nursing staff providing the care. The general perception, however, is that there is a decline in registered nurses' staff hours in nursing homes. The primary objective of this study is to investigate whether the levels of registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs) as well as skill mix has changed in nursing homes between the years 1997 and 2007. A descriptive research design was employed on data derived from Online Survey Certification and Reporting System database. After accounting for facility size and ownership, it was found that more nursing homes have increased-rather than decreased-LPN and NA hours per resident day between 1997 and 2007. On the other hand, more nursing homes have decreased-rather than increased-RN hours per resident day and skill mix during the same time period.

The importance and challenge of paying for quality nursing care.

Historically, the economic value that nursing brings to the patient care process has not been recognized or quantified. Improving the quality of nursing care through work environment changes or increases in staffing is viewed by many as an added cost, but the benefits in terms of money saved through improved nursing satisfaction and patient outcomes are not considered. This article introduces nine articles that were originally presented at the Economics of Nursing Invitational Conference: Paying for Quality Nursing Care held at the Robert Wood Johnson Foundation in Princeton, New Jersey, June 13 and 14, 2007. Recommendations are to conduct research on the impact of policy and payment changes on the nursing workforce and quality of care and to correct the misalignment of socioeconomic and business case incentives for quality by payment systems and other changes.

United States of America: health system review

This analysis of the United States health system reviews the developmentsin organization and governance, health financing, health care provision,health reforms and health system performance. The United States health systemhas both considerable strengths and notable weaknesses. It has a large andwell trained health workforce, a wide range of high-quality medical specialistsas well as secondary and tertiary institutions, a robust health sector researchprogramme and, for selected services, among the best medical outcomes in theworld. But it also suffers from incomplete coverage of its citizenry, healthexpenditure levels per person far exceeding all other countries, poor measureson many objective and subjective measures of quality and outcomes, anunequal distribution of resources and outcomes across the country and amongdifferent population groups, and lagging efforts to introduce health informationtechnology. It is difficult to determine the extent to which deficiencies arehealth-system related, though it seems that at least some of the problems are aresult of poor access to care. Because of the adoption of the Affordable CareAct (ACA) in 2010, the United States is facing a period of enormous potential change.Improving coverage is a central aim, envisaged through subsidies for theuninsured to purchase private insurance, expanded eligibility for Medicaid (insome states) and greater protection for insured persons. Furthermore, primarycare and public health receive increased funding, and quality and expendituresare addressed through a range of measures. Whether the ACA will indeed beeffective in addressing the challenges identified above can only be determined over time.

Projections and trends in RN supply: what do they tell us about the nursing shortage?

This article presents an analysis of trends in the supply of RNs. When weighted for population growth, the U.S. Department of Health and Human Services' 2002 projection of future RN shortages indicates a more imminent and stronger decline in RN supply than initially presented. Analysis of national RN survey data from 1977 to 2000 finds recent decreased gains and increased losses from the RN license pool, a decline in RNs working or looking for work in nursing, and RN supply shifts away from bedside nursing. Policy implications to address these trends include regulatory/legislative and incentive approaches aimed at improving education and employment.