Achieving universal health coverage in South Africa through a district health system approach: conflicting ideologies of health care provision.

BACKGROUND: Universal Health Coverage (UHC) has emerged as a major goal for health care delivery in the post-2015 development agenda. It is viewed as a solution to health care needs in low and middle countries with growing enthusiasm at both national and global levels. Throughout the world, however, the paths of countries to UHC have differed. South Africa is currently reforming its health system with UHC through developing a national health insurance (NHI) program. This will be practically achieved through a decentralized approach, the district health system, the main vehicle for delivering services since democracy. METHODS: We utilize a review of relevant documents, conducted between September 2014 and December 2015 of district health systems (DHS) and UHC and their ideological underpinnings, to explore the opportunities and challenges, of the district health system in achieving UHC in South Africa. RESULTS: Review of data from the NHI pilot districts suggests that as South Africa embarks on reforms toward UHC, there is a need for a minimal universal coverage and emphasis on district particularity and positive discrimination so as to bridge health inequities. The disparities across districts in relation to health profiles/demographics, health delivery performance, management of health institutions or district management capacity, income levels/socio-economic status and social determinants of health, compliance with quality standards and above all the burden of disease can only be minimised through positive discrimination by paying more attention to underserved and disadavantaged communities. CONCLUSIONS: We conclude that in South Africa the DHS is pivotal to health reform and UHC may be best achieved through minimal universal coverage with positive discrimination to ensure disparities across districts in relation to disease burden, human resources, financing and investment, administration and management capacity, service readiness and availability and the health access inequalities are consciously implicated. Yet ideological and practical issues make its achievement problematic.

The 8 basic payment methods in health care.

Eight basic payment methods are applicable across all types of health care. Each method is defined by the unit of payment (per time period, beneficiary, recipient, episode, day, service, dollar of cost, or dollar of charges). These methods are more specific than common terms, such as capitation, fee for service, global payment, and cost reimbursement. They also correspond to the division of financial risk between payer and provider, with each method reflecting a risk factor within the health care spending identity. Financial risk gradually shifts from being primarily on providers when payment is per time period to being primarily on payers when payment is per dollar of charges. Method 4 (per episode) marks the line between epidemiologic and treatment risk. The 8 methods are typically combined to balance risk and thus balance incentives between payers and providers. This taxonomy makes it easier to understand trends in payment reform-especially the shifting division of financial risk and the movement toward value-based purchasing-and types of payment reform, such as bundling, accountable care organizations, medical homes, and cost sharing. The taxonomy also enables prediction of conflicts between payers and providers. For each unit of payment, providers are rewarded for increasing units while decreasing their own cost per unit. No payment method is neutral on quality because each encourages and discourages the provision of care overall and in particular situations. Many professional norms and business practices have been established to mitigate undesirable incentives. Health care differs from many other industries in that the unit of payment remains variable and unsettled.

Economic benefits of less restrictive regulation of advanced practice nurses in North Carolina.

BACKGROUND: With looming provider shortages and increased demand for health care, many states are looking for low-cost ways to alleviate the shortages. PURPOSE: The purpose of this study was to assess the economic impact of less restrictive regulations for advanced practice registered nurses (APRNs) in North Carolina. METHOD: We use economic impact analysis to demonstrate the economic impacts of making state scope-of-practice regulations on APRNs less restrictive in North Carolina. Outcomes include economic output, value-added, payroll compensation, employment, and tax revenue for North Carolina and for various subregions. DISCUSSION: If North Carolina adopted the same approach to APRN regulation as the least restrictive states, its economy will benefit from substantial increases in economic output and employment. The state will also see increases in tax revenue. CONCLUSIONS: In addition to substantially shrinking the size of projected physician shortages, allowing full scope-of-practice for APRNs will bring significant economic benefits to the state of North Carolina. Our analysis should be helpful to policy makers considering ways to deal with provider shortages.

State trends in the cost of employer health insurance coverage, 2003-2013.

From 2010 to 2013--the years following the implementation of the Affordable Care Act--there has been a marked slowdown in premium growth in 31 states and the District of Columbia. Yet, the costs employees and their families pay out-of-pocket for deductibles and their share of premiums continued to rise, consuming a greater share of incomes across the country. In all but a handful of states, average deductibles more than doubled over the past decade for employees working in large and small firms. Workers are paying more but getting less protective benefits. Costs are particularly high, compared with median income, in Southern and South Central states, where incomes are below the national average. Based on recent forecasts that predict an uptick in private insurance growth rates starting in 2015, securing slow cost growth for workers, families, and employers will likely require action to address rising costs of medical care services.

The Impact of the Affordable Care Act on Large Employers: A Retrospective.

The Patient Protection and Affordable Care Act (ACA) has created a new environment for employer health benefit plan management that is influencing costs, benefit design, delivery, administration, financing and compliance as well as the positioning of health care within the benefits portfolio and the broader total rewards strategy. This article will examine the key pragmatic effects of health reform for larger employers to date, quantifying its direct costs and discussing the new dimensions of management that reform has introduced. The discussion will focus on nongrandfathered self-funded plans and will address only major influences. It is not intended to be all-encompassing and is, of necessity, general in nature. Each employer will have somewhat differing experiences and results but should find the discussion to be helpful both in understanding what has evolved as well as what is to come.

Total Transformation: How ACA Is Driving Changes in the Provider Landscape.

Motivated by Affordable Care Act provisions designed to put the brakes on rapidly increasing health care costs, employers are adopting numerous strategies for creating greater efficiency in how they purchase health care. The strategies are centered on holding providers more accountable for improving patient outcomes and reducing unnecessary expenses. In conjunction with the federal agency for health care, Centers for Medicare and Medicaid Services (CMS), they will drastically transform the provider landscape. This article discusses those strategies, along with their potential impact on providers.

National trends in the cost of employer health insurance coverage, 2003-2013.

Looking at trends in private employer-based health insurance from 2003 to 2013, this issue brief finds that premiums for family coverage increased 73 percent over the past decade--faster than median family income. Employees' contributions to their premiums climbed by 93 percent over that time frame. At the same time, deductibles more than doubled in both large and small firms. Workers are thus paying more but getting less protective benefits. However, the study also finds that while premiums continued to rise through 2013, the rate of growth slowed between 2010 and 2013, following implementation of the Affordable Care Act. While families experienced slower growth in premium contributions and deductibles over this period, sluggish growth in median family income means families are paying more in premiums and deductibles as a share of their income than ever before.

What will be the impact of the employer mandate on the U.S. workforce?

The Affordable Care Act's employer mandate requires large firms to pay penalties unless they offer affordable health insurance coverage to full-time employees, raising concerns that employers might lay off workers or reduce hours. In this brief, we estimate the number of workers potentially at risk of losing their jobs or having hours reduced. Most workers near the thresholds--those in firms with around 50 full-time-equivalent employees or those working near 30 hours per week--are already insured or have been offered coverage. There are 100,000 full-time workers at the firm-size threshold and 296,000 at the hourly threshold who are unin­sured. Fewer than 10 percent, less than 0.03 percent of the U.S. labor force, might see reduc­tions in employment or hours in the short run. Over time, employment patterns might change, leading to fewer firm sizes and work schedules near the thresholds, potentially affecting up to 0.5 percent of the workforce.

Medicaid and Children's Health Insurance Programs: essential health benefits in alternative benefit plans, eligibility notices, fair hearing and appeal processes, and premiums and cost sharing; exchanges: eligibility and enrollment. Final rule.

This final rule implements provisions of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act. This final rule finalizes new Medicaid eligibility provisions; finalizes changes related to electronic Medicaid and the Children's Health Insurance Program (CHIP) eligibility notices and delegation of appeals; modernizes and streamlines existing Medicaid eligibility rules; revises CHIP rules relating to the substitution of coverage to improve the coordination of CHIP coverage with other coverage; and amends requirements for benchmark and benchmark-equivalent benefit packages consistent with sections 1937 of the Social Security Act (which we refer to as ``alternative benefit plans'') to ensure that these benefit packages include essential health benefits and meet certain other minimum standards. This rule also implements specific provisions including those related to authorized representatives, notices, and verification of eligibility for qualifying coverage in an eligible employer-sponsored plan for Affordable Insurance Exchanges. This rule also updates and simplifies the complex Medicaid premium and cost sharing requirements, to promote the most effective use of services, and to assist states in identifying cost sharing flexibilities. It includes transition policies for 2014 as applicable.

Bending the Medicare cost curve for physicians' services: lessons learned from Canada.

In 1997 Congress created the Sustainable Growth Rate (SGR) formula for the payment of physicians under Part B of Medicare. SGR established a target rate of growth for aggregate costs of physician services under Part B, linked to growth in overall GDP. If growth in aggregate Part B costs exceeds the target, the rate at which physicians are paid in the following year is to be reduced by a corresponding amount. In SGR, Congress and the U.S. medical profession jointly confront a policy dilemma with no clear solution. For several years running, Congress has elected to postpone cuts in payment to physicians required under SGR. Absent further Congressional action, in 2013 physicians' fees under Part B of Medicare will be reduced by more than 30 %. The historical roots of SGR suggest that a potential solution lies in shifting to regional expenditure targets-an approach applied successfully in Canada in the 1970s when Canadian Medicare confronted rising physician fees. The commission that created what was to become SGR was aware of the lessons learned in Canada, and recommended that they also be applied to U.S. Medicare.

The Health and Social Care Bill: value for money or service improvement?

Over the past couple of weeks, I have found myself yet again examining the proposed new Health and Social Care Bill. Although the Bill has cleared the House of Commons for now, it is being scrutinized in the House of Lords, who have had plenty of critical and uncomplimentary things to say. My concern regarding the progress of the Bill and the negative response surrounding it prompted me to revisit the legislation.

Teaching quality and cost in the tumultuous era of health-care reform.

The passage of the 2010 Affordable Care Act has not ended bitter debates around the policies and practice patterns required to appropriately balance access, quality, and cost in the U.S. health-care system. While many physicians have asked simply "to be left alone" to continue practicing as they see fit, this is an increasingly untenable position, given the notably high costs and very mixed clinical outcomes in the United States relative to other developed nations. A new multi-author text on Medical Quality Management stresses physician involvement in health-care quality, safety, and efficiency and lays out key concepts to help readers better understand many of the national challenges and opportunities that lie ahead. This essay extends lessons from this book and the national debate on health-care reform and suggests promising areas for clinician engagement in the ongoing evolution of the U.S. health-care system.

Commissioning reform in the NHS: will he who pays the piper ever really call the tune?

Since the purchaser/provider split was first introduced in the early 1990s, there have been successive attempts to enhance and strengthen the role of commissioners in the English NHS. Their role is to ensure that health services are planned and delivered in a way that meets the interests of patients and taxpayers rather than healthcare providers. The new coalition government has recently set out its proposals to transfer commissioning responsibilities from primary care trusts to a national NHS Commissioning Board and a set of general practice-led commissioning consortia. It is too early to say whether these reforms are likely to transform commissioning and finally place payers, rather than providers, in the driving seat of the NHS. However they unfold they are likely to have a significant impact on healthcare professionals in commissioning, primary care and specialist roles.

The welfare gain from replacing the health insurance tax exclusion with lump-sum tax credits.

This paper analyzes the welfare gain from replacing the tax exclusion of employer-provided health insurance with a lump-sum tax credit. It differs from earlier studies in that we look at the welfare cost of health insurance tax exclusion as coming directly from excessive health insurance rather than from overconsumption of medical care and that we account for the labor market effect of the tax exclusion on welfare. Both differences work to produce a smaller tax reform welfare gain. For a set of mid-range parameter values, the welfare gain is about 21% of current health insurance tax expenditures. In addition, government tax expenditures would fall by 38%, and health insurance spending would fall by 77% after the reform.

State trends in premiums and deductibles, 2003-2010: the need for action to address rising costs.

Rapidly rising health insurance costs continue to strain the budgets of U.S. families and employers. This issue brief analyzes changes in private employer-based health premiums and deductibles for all states from 2003 to 2010, and finds total premiums for family coverage increased 50 percent across states and employee annual share of premiums increased by 63 percent over these seven years. At the same time, per-person deductibles doubled in large, as well as small, firms. If premium trends continue at the rate prior to enactment of the Affordable Care Act, the average premium for family coverage will rise 72 percent by 2020, to nearly $24,000. Health reform offers the potential to reduce insurance cost growth while improving financial protections. If efforts succeed in slowing annual premium growth by 1 percentage point, by 2020 employers and families together would save $2,161 annually for family coverage, compared with projected premiums at historical rates of increase.

Feeling pinched. Hospitals, docs anxious as 'provider payment cuts are pretty easy to do'.

In the aftermath of the debt-ceiling battle, providers are feeling nervous since lawmakers need to come up with another $1.5 trillion in cuts by the end of the year. "Provider payment cuts are pretty easy to do, relatively speaking. And there doesn't seem to be a clear connection in the minds of policymakers that equates payment cuts with access problems," says Michael Regier, left, of provider alliance VHA.

Health-care reform's great expectations and physician reality.

The Patient Protection and Affordable Care Act will not prove to be the reform for which physicians were long hoping. Private insurance rates will climb sharply, forcing people onto government programs; physician reimbursement will plummet; the physician shortage will worsen; rationing in the form of waiting lists is certain; health care as a whole will worsen; and once fully engaged, nationalization of health care will be irreversible.

Health-care reform 2010: how will it impact you and your practice?

There are several transformative features of the 2 landmark health-care reform laws passed by the Congress and signed into law by the President in March. The most critical elements that will impact pharmacists and patients are categorized into 6 key areas in this commentary: health insurance reform; improvements in Medicare and Medicaid; pharmacy practice expansion; health professions education and workforce initiatives; prevention and wellness; and enhanced access to affordable medications. The relevant features of these new opportunities are presented and the implications for pharmacists and their patients are discussed.

Small businesses and the Affordable Care Act of 2010.

The Patient Protection and Affordable Care Act (ACA) includes several short- and long-term provisions designed to help small businesses pay for and maintain health insurance for their workers, and to allow workers without employer coverage to gain access to affordable, comprehensive health insurance. Provisions include a small business tax credit to offset premium costs for firms that offer coverage starting this taxable year, establishment of state-based insurance exchanges that promise to lower administrative costs and pool risk more broadly, and creation of new market rules and an essential benefit standard to protect small firms and their workers. Analysis shows that up to 16.6 million workers are in firms that would be eligible for the tax credit in 2010 to 2013. Over the next 10 years, small businesses and organizations could receive an estimated $40 billion in federal support through the premium credit program.