Preconditions for efficiency and affordability in competitive healthcare markets: Are they fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland? Ten years later.

From the mid-1990s several countries have introduced elements of the model of regulated competition in healthcare. In 2012 we assessed the extent to which in five countries ten important preconditions for achieving efficiency and affordability in competitive healthcare markets were fulfilled. In this paper we assess to what extent the fulfilment of these preconditions has changed ten years later. In 2022, as in 2012, in none of the five countries all preconditions are completely fulfilled. In the period 2012-2022 on balance there have been some improvements in the fulfillment of the preconditions, although to a different extent in the five countries. The only preconditions that were improved in most countries were 'consumer information and transparency' and 'cross-subsidies without incentives for risk selection'. On balance the Netherlands and Switzerland made most progress in the number of better fulfilled preconditions. For Belgium these preconditions no longer seem relevant because the idea of regulated competition has been completely abandoned. In Germany, Israel and Switzerland, the preconditions 'effective competition policy' and 'contestability of the markets' are not sufficiently fulfilled in 2022, just as in 2012. In Germany and Switzerland this also holds for the precondition 'freedom to contract and integrate'. Overall, the progress towards realizing the preconditions has been limited.

Real World Cost-Effectiveness Analysis of Population Screening for BRCA Variants among Ashkenazi Jews Compared with Family History-Based Strategies.

Identifying carriers of pathogenic BRCA1/BRCA2 variants reduces cancer morbidity and mortality through surveillance and prevention. We analyzed the cost-effectiveness of BRCA1/BRCA2 population screening (PS) in Ashkenazi Jews (AJ), for whom carrier rate is 2.5%, compared with two existing strategies: cascade testing (CT) in carrier's relatives (≥25% carrier probability) and international family history (IFH)-based guidelines (>10% probability). We used a decision analytic-model to estimate quality-adjusted life-years (QALY) gained, and incremental cost-effectiveness ratio for PS vs. alternative strategies. Analysis was conducted from payer-perspective, based on actual costs. Per 1000 women, the model predicted 21.6 QALYs gained, a lifetime decrease of three breast cancer (BC) and four ovarian cancer (OC) cases for PS vs. CT, and 6.3 QALYs gained, a lifetime decrease of 1 BC and 1 OC cases comparing PS vs. IFH. PS was less costly compared with CT (−3097 USD/QALY), and more costly than IFH (+42,261 USD/QALY), yet still cost-effective, from a public health policy perspective. Our results are robust to sensitivity analysis; PS was the most effective strategy in all analyses. PS is highly cost-effective, and the most effective screening strategy for breast and ovarian cancer prevention. BRCA testing should be available to all AJ women, irrespective of family history.

Economic costs of cigarette smoking among adolescents in Nigeria.

Background: Cigarette smoking is an established cause of preventable death and often initiated during adolescence. We estimated the short- and long-term costs of cigarette smoking among currently smoking adolescents in Nigeria. Methods: A cross-sectional survey among adolescents in Oyo state, Nigeria and a review of mortality records of patients managed for lung cancer in a tertiary facility in Ibadan, Nigeria were conducted. Short-term costs estimated were: (a) average weekly costs of purchasing cigarettes by currently smoking adolescents, and (b) costs of managing at least an episode of chronic cough occurring within 12 months of the survey. Long-term costs were limited to: (a) life-time expenditure on purchasing cigarettes, and (b) direct medical and non-medical (transportation) costs of managing lung cancer. Long-term costs were first projected to the approximate year when the adolescents (mean age:16.0 ± 1.8 years) might be diagnosed with lung cancer based on the average age at presentation with symptoms of lung cancer obtained from the records (59.8 years), and then discounted to 2020 prices. This was estimated as 44 years from the base year (2020). Costs were reported in 2020 prices in Nigerian Naira (NGN) and US dollar (USD) equivalent using the Central Bank of Nigeria, June 2020 exchange rate of USD 1: NGN 360.50. Results: Approximately 3.8% of the adolescents were current cigarette smokers. Average weekly expenditure on cigarettes was NGN 306.82 ± 5.74 (USD 0.85 ± 0.02). About 26% had experienced at least an episode of chronic cough which cost them an average of NGN 1226.81 ± 6.18 (USD 3.40 ± 0.02) to manage. Total future costs of cigarette smoking in 2020 prices for the 43 adolescents who were current smokers in the event that they develop lung cancer were approximately NGN 175.7 million (USD 487.3 thousand), NGN 871.8 million (USD 2.4 million) and NGN 4.6 trillion (USD 12.7 million) at assumed annual inflation rates of 10%, 15%, and 20% respectively and discount rate of 4.25%. Conclusion: The estimated economic costs of smoking were very high. Efforts to prevent smoking initiation among adolescents in our study area should be intensified. Interventions to subsidize the medical cost of health-related consequences of cigarette smoking are also required, especially as treatment costs are currently largely borne out-of-pocket. Supplementary Information: The online version contains supplementary material available at 10.1007/s10389-021-01644-5.

Social solidarity in healthcare: The Israeli case.

While solidarity is at the basis of all social health insurance systems, little has been done to define and analyze it empirically. Equity in the delivery of medical care and progressivity of its finance are socially important, but miss the main principle of social health insurance systems - mutual help. The present study views social solidarity not as a value but as cross-subsidies among individuals, which are necessary to achieve a separation between finance and delivery of care in order to make healthcare affordable universally. A solidarity index, derived from the Kakwani Progressivity Index, is suggested and applied to the Israeli national health insurance system in 2010. The observed solidarity index for 2010 Israel is 0.242. Adjusting for possible barriers in use does not change the index. About 85% of the solidarity index originates from income solidarity. If the entire health budget was financed by the general revenue, the solidarity index would rise to 0.259. The level of solidarity in Israel is close to the one found in Canada, Finland and France. More comparative results over time and over systems will enable further insights and uses. The sustainability of solidarity requires, however, some altruism among the rich with respect to the health state of the poor.

Cost-effectiveness analysis of screening for first-degree relatives of patients with bicuspid aortic valve.

AIMS: Bicuspid aortic valve (BAV) is the commonest congenital heart valve malformation, and is associated with life-threatening complications. Given the high heritability index of BAV, many experts recommend echocardiography screening for first-degree relatives (FDRs) of an index case. Here, we aim to evaluate the cost-effectiveness of such cascade screening for BAV. METHODS AND RESULTS: Using a decision-analytic model, we performed a cost-effectiveness analysis of echocardiographic screening for FDRs of a BAV index case. Data on BAV probabilities and complications among FDRs were derived from our institution's BAV familial cohort and from the literature on population-based BAV cohorts with long-term follow-up. Health gain was measured as quality-adjusted life years (QALYs). Cost inputs were based on list prices and literature data. One-way and probabilistic sensitivity analyses were performed to account for uncertainty in the model's variables. Screening of FDRs was found to be the dominant strategy, being more effective and less costly than no screening, with savings of €644 and gains of 0.3 QALY. Results were sensitive throughout the range of the main model's variables, including the full range of reported BAV rates among FDRs across the literature. A gradual decrease of the incremental effect was found with the increase in screening age. CONCLUSION: This economic evaluation model found that echocardiographic screening of FDRs of a BAV index case is not only clinically important but also cost-effective and cost-saving. Sensitivity analysis supported the model's robustness, suggesting its generalization.

Economic costs of terminal care for selected non-communicable diseases from a healthcare perspective: a review of mortality records from a tertiary hospital in Nigeria.

INTRODUCTION: WHO revealed that morbidity and mortality from non-communicable diseases (NCDs) are on the increase and NCDs accounted for approximately 29% of all deaths in Nigeria in 2016. This study was conducted to estimate the economic cost of selected NCDs-lung cancer, liver cancer and liver cirrhosis. These diseases are known to be associated with key modifiable health risk behaviours (smoking and alcohol use), which are prevalent in Nigeria and often commence during the adolescent years. METHODS: Data were obtained between 2016 and 2017, from mortality records of patients managed for the selected diseases in the University College Hospital, a major referral centre in Nigeria. Information on costs of treatment, clinic visits, admission and transportation was obtained. Average costs of terminal in-patient care and transportation costs (in 2020 prices) were computed per patient. Costs were converted to the US dollar equivalent using the current official rate of US$1: ₦360.50. RESULTS: Twenty-two (out of 90 cases recorded) could be retrieved and all the patients had been diagnosed in the terminal stages of the disease. The average direct costs were ₦510 152.62 (US$1415.13) for an average of 49.2 days of terminal care for lung cancer; ₦308 950.27 (US$857.00) and ₦238 121.83 (US$660.53) for an average of 16.6 and 21.7 days of terminal care for patients managed for liver cancer and liver cirrhosis, respectively. CONCLUSION: The economic costs of each of the diseases were very high. Findings emphasise the need for aggressive efforts to promote primary prevention, improve early diagnosis and provide affordable treatment in view of the fact that the monthly minimum wage is less than US$85.00 and treatment costs are borne out-of-pocket by the generality of the population in Nigeria.

Toward risk adjustment in mental health in Israel: calculation of risk adjustment rates from large outpatient and inpatient databases.

BACKGROUND: In 2015, mental health services were added to the Israeli National Health Insurance package of services. As such, these services are financed by the budget which is allocated to the Health Plans according to a risk adjustment scheme. An inter-ministerial team suggested a formula by which the mental health budget should be allocated among the Health Plans. Our objective in this study was to develop alternative rates based on individual data, and to evaluate the ones suggested. METHODS: The derivation of the new formula is based on our previous study of all psychiatric inpatients in Israel in the years 2012-2013 (n = 27,446), as well as outpatients in one psychiatric clinic in the same period (n = 6115). Based on Ministry of Health and clinic data we identified predictors of mental health services consumption. Age, gender, marital status and diagnosis were used as risk adjusters to calculate the capitation rates for outpatient care and inpatient care, respectively. All prices of services were obtained from the Ministry of Health tariffs. These rates were modified to include non-users using restricted models. RESULTS: The mental health capitation scales are typically "humped" with regard to age. The rates for ambulatory care varied from a minimum 0.19 of the average consumption for males above the age of 85 to a maximum of 1.93 times the average for females between the ages of 45-54. For inpatient services the highest rate was 409.25 times the average for single, male patients with schizophrenia spectrum diagnoses, aged 45-54. The overall mental health scale ranges from 2.347 times the average for men aged 45-54, to 0.191 for women aged 85+. The modified scale for the entire post-reform package of benefits (including both mental health care and physical health care) is increasing with age to 4.094 times the average in men aged over 85. The scale is flatter than the pre-reform scale. CONCLUSIONS: The risk adjustment rates calculated for outpatient care are substantially different from the ones suggested by the inter-ministerial team. The inpatient rates are new, and indicate that for patients with schizophrenia, a separate risk-sharing arrangement might be desirable. Adopting the rates developed in this analysis would decrease the budget shares of Clalit and Leumit with their relatively older populations, and increase Maccabi and Meuhedet's shares. Future research should develop a risk-adjustment scheme which covers directly both mental and physical care provided by the Israeli Health Plans, using their data.

Impact of the free healthcare initiative on wealth-related inequity in the utilization of maternal & child health services in Sierra Leone.

BACKGROUND: As a result of financial barriers to the utilization of Maternal and Child Health (MCH) services, the Government of Sierra Leone launched the Free Health Care Initiative (FHCI) in 2010. This study aimed to examine the impact of the FHCI on wealth related inequity in the utilization of three MCH services. METHODS: We analysed data from 2008 to 2013 Sierra Leone Demographic Health Surveys (SLDHS) using 2008 SLDHS as a baseline. Seven thousand three hundred seventy-four and 16,658 women of reproductive age were interviewed in the 2008 and 2013 SLDHS respectively. We employed a binomial logistic regression to evaluate wealth related inequity in the utilization of institutional delivery. Concentration curves and indices were used to measure the inequity in the utilization of antenatal care (ANC) visits and postnatal care (PNC) reviews. Test of significance was performed for the difference in odds and concentration indexes obtained for the 2008 and 2013 SLDHS. RESULTS: There was an overall improvement in the utilization of MCH services following the FHCI with a 30% increase in institutional delivery rate, 24% increment in more than four focused ANC visits and 33% increment in complete PNC reviews. Wealth related inequity in institutional delivery has increased but to the advantage of the rich, highly educated, and urban residents. Results of the inequity statistics demonstrate that PNC reviews were more equally distributed in 2008 than ANC visits, and, in 2013, the poorest respondents ranked by wealth index utilized more PNC reviews than their richest counterparts. For ANC visits, the change in concentration index was from 0.008331[95% CI (0.008188, 0.008474)] in 2008 to - 0.002263 [95% CI (- 0.002322, - 0.002204)] in 2013. The change in concentration index for PNC reviews was from - 0.001732 [95% CI (- 0.001746, - 0.001718)] in 2008 to - 0.001771 [95% CI (- 0.001779, - 0.001763)] in 2013. All changes were significant (p value < 0.001). CONCLUSION: The FHCI appears to be improving access to and utilization of MCH services, narrowing the inequity in ANC visits and PNC reviews, but is insufficient in addressing wealth- related inequity that exists for institutional deliveries. If Sierra Leone is to realize a significant reduction in maternal and child mortality rates, it needs to strengthen the effective implementation of FHCI considering incorporating a sector wide approach (SWAp) or a "Health in all Policy" framework to reach the less educated, rural residents and ensuring culturally sensitive quality services.

The economic burden of health disparities related to socioeconomic status in Israel.

BACKGROUND: Low socioeconomic status (SES) is often associated with excess morbidity and premature mortality. Such health disparities claim a steep economic cost: Possibly-preventable poor health outcomes harm societal welfare, impair the domestic product, and increase health care expenditures. We estimate the economic costs of health inequalities associated with socioeconomic status in Israel. METHODS: The monetary cost of health inequalities is estimated relative to a counterfactual with a more equal outcome, in which the submedian SES group achieves the average health outcome of the above-median group. We use three SES measures: the socioeceonmic ranking of localities, individuals' income, and individuals' education level. We examine costs related to the often-worse health outcomes in submedian SES groups, mainly: The welfare and product loss from excess mortality, the product loss from excess morbidity among workers and working-age adults, the costs of excess medical care provided, and the excess government expenditure on disability benefits. We use data from the Central Bureau of Statistics' (CBS) surveys and socio-health profile of localities, from the National Insurance Institute, from the Ministry of Health, and from the Israel Tax Authority. All costs are adjusted to 2014 terms. RESULTS: The annual welfare loss due to higher mortality in socioeconomically submedian localities is estimated at about 1.1-3.1 billion USD. Excess absenteeism and joblessness occasioned by illness among low-income and poorly educated workers are associated with 1.4 billion USD in lost product every year. Low SES is associated with overuse of inpatient care and underuse of community care, with a net annual cost of about 80 million USD a year. The government bears additional cost of 450 million USD a year, mainly due to extra outlays for disability benefits. We estimate the total cost of the estimated health disparities at a sum equal to 0.7-1.6% of Israel's GDP. CONCLUSIONS: Our estimates underline the substantial economic impact of SES-related health disparities in Israel. The descriptive evidence presented in this paper highlights possible benefits to the economy from policies that will improve health outcomes of low SES groups.

[IDENTIFYING PREDICTORS OF MENTAL HEALTH SERVICES CONSUMPTION IN ISRAEL].

INTRODUCTION: The budget for health services in Israel was recently increased to cover mental health. It was suggested to divide funds for psychiatric hospitalization between the HMOs based on their share of insured members. For ambulatory care, it was suggested to add risk adjustment based on age only to the capitation formula used for allocating health care funds. This simplistic measure encourages risk selection and discrimination of costly individuals. AIMS: To identify predictors of mental health services consumption in Israel, in order to implement them in the capitation formula. METHODS: Data were gathered on 27,446 individuals hospitalized in psychiatric wards in Israel in 2012-2013, and 6115 outpatients treated during this period in one mental health clinic. The association between demographic and clinical variables with services consumption was studied. RESULTS: The average annual expenses per person on mental health were NIS 50,000 for hospitalization, NIS 1,700 for ambulatory care and NIS 7,000 for all services. Adult age and schizophrenia spectrum diagnoses predicted increased expenditure on all services. Being a male, single, Jewish and living in the economic periphery predicted increased expenditure mainly on hospitalization. Regression analysis using these variables explained up to 30% of variance. CONCLUSIONS: It is possible to predict, at least partially, mental health consumption in Israel based on clinical and demographic variables. DISCUSSION: Limitations of the study call or re-analysis using full databases, which are available only to the state authorities. Predictors of mental health consumption in Israel can be used for the risk adjustment of allocating funds for services.

[FORCE-FEEDING OR LIFE-SAVING? - DEALING WITH HUNGER STRIKES IN ISRAEL].

INTRODUCTION: Although the management of quality of care by the health funds has contributed to its improvement, medical teams criticize the way it is performed. Many call for renewed values-driven thinking and to leave the concern for quality in the hands of the medical teams, relying on "self control and enforcement", based on values, compassion, concern for others, patient service, discipline and personal responsibility. This article aims to present an economic perspective on the measurement of quality of care. It places the development of "measuring the quality of care and its management" within the development of the organization of care, health insurance and payment arrangements for medical teams. The conclusion is that there is no "first best" method to improve the quality of care. Each method - including the quantitative-functional measurement-based method used in many systems and the value-driven, self enforced method proposed by many - has advantages and disadvantages. The choice of a method should be based on these two sides, discussed jointly by medical teams, the health funds, hospitals and the Health Ministry.

Adherence of patients with type 2 diabetes mellitus to medications: the role of risk preferences.

OBJECTIVE: To examine whether risk tolerance is associated with adherence to oral hypoglycemic agents (OHAs). METHODS: We performed a cross-sectional study among adult patients with type 2 diabetes mellitus (n = 308) presenting for routine out-patient visits, using validated questionnaires to estimate: risk preferences (risk-seeking, risk averse, risk neutral), motivation, self-efficacy, impulsivity, perception of the disease and of the interpersonal process of care, demographic and socioeconomic characteristics; computerized patient medical records to estimate disease severity and a computerized database for retrieval of medication adherence, 1 year before the interview. Adherence was estimated using prescription-based measures of proportion of days covered (PDC). Concurrent adherence was calculated as: PDC with ≥1 OHAs; average PDC; PDC of ≥80% for all OHAs. RESULTS: Multivariable ordered logit model revealed that compared to others, risk-seeking patients had lower PDC with ≥1 OHAs (ß = -0.50, p ≤ .1). Specifically, risk-seeking patients were 11.2 percentage points less likely to have ≥80% of the follow-up period covered with ≥1 OHAs available (p ≤ .1). In addition, risk-seeking patients had lower average PDC (ß = -0.85, p ≤ .05). Specifically, these patients were 19.5 percentage points less likely to have an average PDC of ≥80% (p ≤ .05). Multivariable logistic model revealed that risk-seeking was associated with lower probability of having PDC ≥80% for all OHAs in the follow-up period (OR; 90% CI: 0.59; 0.35-0.97). CONCLUSIONS: Risk-seeking patients are less adherent to OHA medications. Identifying these patients may enable practitioners to proactively tailor strategies to improve their adherence and health outcomes.

Do the equity-efficiency preferences of the Israeli Basket Committee match those of Israeli health policy makers?

BACKGROUND: Prioritization of medical technologies requires a multi-dimensional view. Often, conflicting equity and efficiency criteria should be reconciled. The most dramatic manifestation of such conflict is in the prioritization of new medical technologies asking for public finance performed yearly by the Israeli Basket Committee. The aim of this paper is to compare the revealed preferences of the 2006/7 Basket Committee's members with the declared preferences of health policy-makers in Israel. METHODS: We compared the ranking of a sample of 18 accepted and 16 rejected technologies evaluated by the 2006/7 Basket Committee with the ranking of these technologies as predicted based on the preferences of Israeli health policy-makers. These preferences were elicited by a recent Discrete Choice Experiment (DCE) which estimated the relative weights of four equity and three efficiency criteria. The candidate technologies were characterized by these seven criteria, and their ranking was determined. A third comparative ranking of these technologies was the efficiency ranking, which is based on international data on cost per QALY gained. RESULTS: The Committee's ranking of all technologies show no correspondence with the policy-makers' ranking. The correlation between the two is negative when only accepted technologies are ranked. The Committee's ranking is positively correlated with the efficiency ranking, while the health policy-makers' ranking is not. DISCUSSION: The Committee appeared to assign to efficiency considerations a higher weight than assigned by health policy-makers. The main explanation is that while policy-makers' ranking is based on stated preferences, that of the Committee reflects revealed preferences. Real life prioritization, made under a budget constraint, enhances the importance of efficiency considerations at the expense of equity ones. CONCLUSIONS: In order for Israeli health policy to be consistent and well coordinated across policy-makers, some discussions and exchanges are needed, to arrive at a common set of preferences with respect to equity and efficiency considerations.

Efficiency and equity considerations in the preferences of health policy-makers in Israel.

BACKGROUND: There is a traditional tension in public policy between the maximization of welfare from given resources (efficiency) and considerations related to the distribution of welfare among the population and to social justice (equity). The aim of this paper is to measure the relative weights of the efficiency- and equity-enhancing criteria in the preferences of health policy-makers in Israel, and to compare the Israeli results with those of other countries. METHODS: We used the criteria of efficiency and equity which were adopted in a previous international study, adapted to Israel. The equity criteria, as defined in the international study, are: severity of the disease, age (young vs. elderly), and the extent to which the poor are subsidized. Efficiency is represented by the criteria: the potential number of beneficiaries, the extent of the health benefits to the patient, and the results of economic assessments (cost per QALY gained). We contacted 147 policy-makers, 65 of whom completed the survey (a response rate of 44%). Using Discrete Choice Experiment (DCE) methodology by 1000Minds software, we estimated the relative weights of these seven criteria, and predicted the desirability of technologies characterized by profiles of the criteria. RESULTS: The overall weight attached to the four efficiency criteria was 46% and that of the three equity criteria was 54%. The most important criteria were "financing of the technology is required so that the poor will be able to receive it" and the level of individual benefit. "The technology is intended to be used by the elderly" criterion appeared as the least important, taking the seventh place. Policy-makers who had experience as members of the Basket Committee appear to prefer efficiency criteria more than those who had never participated in the Basket Committee deliberations. While the efficiency consideration gained preference in most countries studied, Israel is unique in its balance between the weights attached to equity and efficiency considerations by health policy-makers. DISCUSSION: The study explored the trade-off between efficiency and equity considerations in the preferences of health policy-makers in Israel. The way these declarative preferences have been expressed in actual policy decisions remains to be explored.

Adherence to Self-Care Behaviors among Patients with Type 2 Diabetes-The Role of Risk Preferences.

OBJECTIVES: To examine whether the degree of risk aversion is associated with adherence to disease self-management among adults with type 2 diabetes. METHODS: This was a cross-sectional study of patients with type 2 diabetes (n = 408) aged 21 to 70 years who presented for routine visits in the diabetes clinic at a university medical center in Beer-Sheva, Israel. The authors used validated questionnaires to estimate adherence, risk preferences, motivation, self-efficacy, impulsivity, perceptions about the disease and the interpersonal process of care, and demographic and socioeconomic characteristics, in addition to retrieving data from computerized patient medical records of clinical indicators of disease severity. Multivariable linear and ordered-logit models examined predictors of adherence to each self-care behavior. RESULTS: Multivariable analyses revealed that, compared with others, risk-seeking patients reported lower general adherence (ß = -0.32; P ≤ 0.05), and specifically, lower adherence to healthful eating plan (ß = -0.48; P ≤ 0.1), consumption of low-fat food (ß = -0.47; P ≤ 0.1), exercise (ß = -0.73; P ≤ 0.05), blood glucose monitoring (ß = -0.69; P ≤ 0.05), and foot care (ß = -0.36; P ≤ 0.1). Risk-seeking patients did not report lower consumption of fruits and vegetables (ß = -0.19; P > 0.1). Because 96% of the study population reported optimal adherence to medication, determinants of this behavior could not be analyzed. CONCLUSIONS: Risk preference is associated with adherence to self-care behaviors. Identifying risk seekers may enable practitioners to target these patients with tailored strategies to improve adherence, thus more efficiently allocating scarce health care resources.

Private finance of services covered by the National Health Insurance package of benefits in Israel.

BACKGROUND: Private health expenditure in systems of national health insurance has raised concern in many countries. The concern is mainly about the accessibility of care to the poor and the sick, and inequality in use and in health. The concern thus refers specifically to the care financed privately rather than to private health expenditure as defined in the national health accounts. OBJECTIVES: To estimate the share of private finance in total use of services covered by the national package of benefits. and to relate the private finance of use to the income and health of the users. METHODS: The Central Bureau of Statistics linked the 2009 Health Survey and the 2010 Incomes Survey. Twenty-four thousand five hundred ninety-five individuals in 7175 households were included in the data. Lacking data on the share of private finance in total cost of care delivered, we calculated instead the share of uses having any private finance-beyond copayments-in total uses, in primary, secondary, paramedical and total care. The probability of any private finance in each type of care is then related, using random effect logistic regression, to income and health state. RESULTS: Fifteen percent of all uses of care covered by the national package of benefits had any private finance. This rate ranges from 10 % in primary care, 16 % in secondary care and 31 % in paramedical care. Twelve percent of all uses of physicians' services had any private finance, ranging from 10 % in family physicians to 20 % in pulmonologists, psychiatrists, neurologists and urologists. Controlling for health state, richer individuals are more likely to have any private finance in all types of care. Controlling for income, sick individuals (1+ chronic conditions) are 30 % in total care and 60 % in primary care more likely to have any private finance compared to healthy individuals (with no chronic conditions). CONCLUSIONS: The national accounts' "private health spending" (39 % of total spending in 2010) is not of much use regarding equity of and accessibility to medical care by the population. The mean share of uses financed privately in 2010, a more relevant measure, is 15 % with large variation between types of care and physicians. While, as under national health insurance, richer persons contribute more into the finance of (private) medical care , and sicker persons are more likely to use it, the solidarity principle-cross subsidization from the rich to the sick, which is a fundamental principle of national health insurance systems, is clearly violated.

Managed care in four managed competition OECD health systems.

Managed care emerged in the American health system in the 1980s as a way to manage suppliers' induced demand and to contain insurers' costs. While in Israel the health insurers have always been managed care organizations, owning health care facilities, employing medical personnel or contracting selectively with independent providers, European insurers have been much more passive, submitting themselves to collective agreements between insurers' and providers' associations, accompanied by extensive government regulation of prices, quantities, and budgets. With the 1990s reforms, and the introduction of risk-adjusted "managed competition", a growing pressure to allow the European insurers to manage their own care - including selective contracting with providers - has emerged, with varying speed of the introduction of policy changes across the individual countries. This paper compares experiences with managed care in Israel, The Netherlands, Germany and Switzerland since the 1990s. After a brief description of the health insurance markets in the four countries, we focus comparatively on the emergence of managed care in the markets for ambulatory care and inpatient market care. We conclude with an evaluation of the current situation and a discussion of selected health policy issues.

On the calculation of the Israeli risk adjustment rates.

OBJECTIVE: The Israeli risk adjustment formula, introduced in 1995 and which serves for the allocation of the health budget to the sickness funds, is unique compared to countries with a similar national health insurance system in that it is not calculated on the basis of actual cost data of the sickness funds but on the basis of quantities retrieved from surveys. The current article aims to analyze the implications of the Israeli methodology. METHODS: The article examines the validity of the Israeli methodology used to set the 2004 risk adjustment rates and compare these rates with the "correct" ones, which are derived from the 2004 internal relative cost scales of the sickness funds. RESULTS: The Israeli methodology ignores services provided by the sickness funds and assumes constant unit cost across the sickness funds, an assumption which is implausible. Comparing the actual and the "correct" rates, it turns out that the actual rates over-compensate all the sickness funds for members in age 0-14, and under-compensate them for insurees aged 55+. In age 0-4, the over-compensation per capita is about NIS 1,500 while the under-compensation in age group 75+ reaches NIS 1,600. CONCLUSIONS: The current risk adjustment formula distorts the intended competition on good quality care among the sickness funds, and turns it into a competition on profitable members. After 18 years of using incorrect rates, the Israeli risk adjustment rates should be calculated, as is common in other systems, based on individual cost data from the sickness funds.

Private and public patients in public hospitals in Australia.

INTRODUCTION: The nature of the private-public mix in health insurance and in health care is a major issue in most health systems. OBJECTIVE: To compare the hospitalization characteristics of private and public patients hospitalized in public hospitals. METHODS: We focused on planned, overnight and same-day admissions, discharged during 2004-2005 from the public New South Wales hospitals, and run fixed-effects regressions in order to identify the effect of accommodation status (private/public) on the hospitalization characteristics. RESULTS: Private patients have one third less waiting days than public patients, and they are assigned higher urgency of admission. Length of stay and length of visit are both unrelated to the accommodation status, however, private patients tend to have more hours in ICU and more procedures performed during the hospitalization. In-hospital mortality and the number of transfers (wards) are not affected by the accommodation status. CONCLUSIONS: Private patients are treated differently than public patients in public hospitals, reinforcing the private health insurance-related inequity in inpatient care identified by others. Two health policy issues emerge from the findings: the role of private health insurance in the Australian socialized medicine system, and in particular, in the public hospitals; and the way public hospitals are reimbursed for private patients.

Income-related inequalities in health and health services use in Israel.

BACKGROUND: Income-related inequalities in health and in health services use pose a disturbing and challenging issue in health systems, which are based on social health insurance such as Israel. OBJECTIVE: To explore income-related inequalities in health and in health services use in Israel in 2009-2010. METHODS: We used the Central Bureau of Statistics file, which linked information on 7,175 households (24,595 persons) from the 2009 Health Survey and the 2010 Incomes Survey. Raw and adjusted concentration curves and indices were calculated for ten chronic conditions (adjusting for age), visits to physicians and hospitalizations (adjusting for health and location). RESULTS: There is no income-related inequality in asthma and in cancer. The income-related inequality in the remaining eight conditions is 'pro-poor', namely, they are more prevalent among poor households. The order of the level of inequality is (from the least unequally distributed): any condition, hypertension, heart diseases, diabetes, depression, respiratory diseases, digestive diseases, and the condition with the highest income-related inequality is activities of daily living (ADL) limitations. The income-related inequality in secondary physicians' services is 'pro-rich'. The income-related inequality in primary care is 'pro- poor'. Hospitalization days are significantly more unequally - 'pro-poor' - distributed in the population. DISCUSSION: International findings are basically similar to the ones found in this paper. Three reasons are believed to have caused these income-related inequalities: the use of preventive services, health behavior and compliance with the doctors' directions; they might constitute a useful framework for strategizing interventions. The efforts of the Ministry of Health and of the sickness funds launched in 2010 to reduce inequalities should be evaluated by repeating the present analysis with newer data.