Financial protection of households against health shocks in Greece during the economic crisis.

BACKGROUND: Harsh funding cutbacks along with measures shifting cost to patients have been implemented in the Greek health system in recent years. Our objective was to investigate the evolution of financial protection of Greek households against out-of-pocket payments (OOPP) during the economic crisis. METHODS: National representative data of 33,091 households were derived from the Household Budget Surveys for the period 2008-2015. Financial protection was assessed by applying the approaches of catastrophic (CHE) and impoverishing OOPP. The determinants of CHE and impoverishment were examined using binary logistic regressions. RESULTS: OOPP dropped by 23.5% in real values between 2008 and 2015, though their share in households' budget rose from 6.9% to 7.8%, with an increasing trend since 2012. These outcomes were driven by significant increases in medical products (20.2%) and inpatient (63%) OOPP, while outpatient expenses decreased considerably (-62%). Both incidence and overshoot of CHE were significantly exacerbated. The additional burden was distributed progressively, hence, financial risk inequalities decreased. Food poverty increased, but its incidence still remains at very low levels. Both incidence and intensity of relative poverty increased considerably in real terms. The poverty impact of OOPP is aggravating following 2012, and 1.9% of individuals were impoverished due to OOPP in 2015. Households of higher size, lower expenditure quintile, in urban areas, without disabled, elderly or young children members, and with younger or retired, better-educated breadwinners were significantly less vulnerable to CHE. Households in the lower-middle expenditure quintile, in rural regions, and with elderly members were facing higher risk, while wealthier families exhibited a considerable lower likelihood of impoverishment. CONCLUSIONS: The expansion of reliance of healthcare funding on OOPP has increased the financial risk and hardship of Greek households, which may disrupt their living conditions and create barriers to healthcare access. Cost-sharing policies should recognise the different social protection needs of households.

Integrated Medicare and Medicaid managed care and rehospitalization of dual eligibles.

OBJECTIVES: Healthcare expenditures for dually eligible individuals covered by both Medicare and Medicaid constitute a disproportionate share of spending for the 2 programs. Fragmentation, inefficiency, and low-quality care have been long standing issues for this population. The objective of this study was to conduct an early evaluation of an innovative program that coordinates benefits for elderly dual eligibles. STUDY DESIGN: Longitudinal cohort study. METHODS: Comparable sources of administrative claims from 2007 to 2009 were used to examine differences in 30-day rehospitalization between dual eligibles in Massachusetts participating in Senior Care Options (SCO), an integrated managed care program, and dual eligibles in Medicare fee-for-service. Multivariable logistic regression models with county and time fixed effects were used for estimation. RESULTS: We found no statistically significant effect of SCO on rehospitalization, an area where coordinated care would be expected to make a substantial difference. CONCLUSIONS: Our results suggest that coordinating the financing and delivery of services through an integrated managed program may not sufficiently address the problems of inefficiency and fragmentation in care for hospitalized dual eligible enrollees.

Teaching money literacy in a positive youth development program: the project P.A.T.H.S. in Hong Kong.

In view of the high impact of materialistic orientation among children and adolescents, financial educational programs are provided as preventive measures. Without a clear framework, it is impossible to evaluate these programs. The goals of this paper are threefold. Firstly, the phenomena related to adolescent materialistic orientation and its associated problems in Hong Kong are examined. Secondly, the concept of financial education as a preventive measure is reviewed. Both board and narrow definitions of money literacy are examined. A framework on money literacy for children and adolescents as a founding stone for financial education is proposed. The framework finds its support from a typology proposed by the authors and results from an integration of research findings on dimensions of the concepts of money and success. Finally, curriculum units for Grades 7 to 9 students in a positive youth development program (the Project P.A.T.H.S.) are developed using the framework.

What are children's trusts? Early findings from a national survey.

BACKGROUND: The Children Act 2004 and National Service Framework for Children, Young People and Maternity Services require fuller integration of health, education and social services for children and young people in England and Wales. The UK government supported the establishment of 35 experimental children's trust pathfinders (henceforth called children's trusts) in England. METHODS: A questionnaire was completed by managers in all 35 children's trusts a year after their start. Children's trust documents were examined. Census and performance indicators were compared between children's trust areas and the rest of England. RESULTS: Children's trust areas had demographic and social characteristics typical of England. All children's trusts aimed to improve health, education and social services by greater managerial and service integration. All had boards representing the three sectors; other agencies' representation varied. Two-thirds of children's trusts had moved towards pooling budgets in at least some service areas. At this stage in their development, some had prioritized joint procurement or provision of services, with formal managerial structures, while others favoured an informal strategic planning, co-ordination and information sharing approach. The commonest priorities for services development were for disabled children (16 children's trusts), followed by early intervention (11) and mental health services (8). CONCLUSIONS: The diverse strategies adopted by these 35 children's trusts during their first year is due to their own characteristics and to the way government strategy developed during this period. Whilst some prioritized organizational development, joint financing and commissioning, and information sharing, others laid more emphasis on mechanisms for bringing front-line professionals closer together. Their experiences are of value to others deciding how best to integrate children's services.

Financial success under PPS: how to beat the odds.

Whether you are a publicly held company or a small mom and pop agency, you have to maximize both efficiency and productivity while maintaining patient satisfaction and staff morale. In the new world of home care, this is a tall order. In this first installment of a two part series, the author reviews the dimensions of financial success, issues of length of stay and episode of care, resource utilization planning, and reducing overhead. The second part will cover overall productivity, clinical productivity, and management strategies to synergize financial success under the prospective payment system.

Improving IDS performance through group practice expense management.

IDSs can turn around an owned group practice's poor financial performance by taking steps to more effectively manage the practice's expenses. The primary areas on which an IDS should focus its expense-management efforts are physician compensation, nonprovider staffing, and facility planning. The physician compensation system, for example, should include incentives for physicians to improve performance and increase productivity, and the size of the nonprovider staff should be adjusted according to patient volumes. Other areas in which changes in strategy may be required include information system investments; budgeting, accounts-payable, and purchasing processes; and corporate allocations of practice revenues to recover practice acquisition costs.

Consumer focus can spur group practice turnaround.

Many healthcare organizations have lost money on their employed group practices. The solution to this dilemma is not necessarily divestment of the group practices. Instead, some healthcare organizations should view their physicians as an asset. Healthcare organizations and physicians need to develop a new framework for their relationship to optimize their competitive advantage. Three guiding principles that will help accomplish this objective are to recast the healthcare organization-physician relationship to focus on the consumer, reconfigure the economic model to exceed consumer demands, and restructure the group practice to encourage fiscal and service excellence. In developing a new relationship framework, the stakeholders need to define the group practice's mission, strategic direction, composition, infrastructure, compensation model, and structure.

Assessing an IDS's readiness to operate profitably under a risk contract.

An IDS that wishes to assume risk should understand first the factors that have caused IDSs to experience poor financial performance under risk contracts. Then, the IDS should clarify its goals for managed care contracting, assess its operational strengths and weaknesses, evaluate potential managed care payer partners, and understand the amount of risk associated with various contract options. Implementation issues that need to be addressed include aligning the financial incentives of physicians and the IDS, establishing systemwide policies and procedures for monitoring performance, and developing information systems capabilities.

The right strategy and perseverance can make an IDS profitable.

Results of a recent study of 11 leading integrated delivery systems (IDSs) belie the common perception that IDSs are incapable of turning a profit. The study determined that the primary factors driving the poor financial performance of IDSs are organizational complexity, payment reductions mandated by the Balanced Budget Act of 1997, and a general lack of foresight regarding financial problems when embarking on an integration strategy. By implementing a wide range of initiatives to stem losses and improve financial performance, several of the case-study IDSs have accomplished dramatic financial turnarounds over the past three years, and all have achieved consistently stronger financial performance.

Off-balance-sheet financing can generate capital for strategic development.

To manage their real estate portfolios effectively and obtain funding for strategic development, IDSs should consider adopting off-balance-sheet financing strategies, such as sale-and-leaseback transactions, synthetic leases, and joint-venture arrangements. Under these approaches, real estate assets are moved off of the organization's balance sheet via a partial or complete transfer of ownership to a third-party entity. The organization typically retains a satisfactory degree of control over the assets as lessee in sale-and-leaseback and synthetic-lease arrangements, or limited or minority partner in a joint venture, while freeing up cash to use for other strategic purposes.

Measuring and managing risk improves strategic financial planning.

Strategic financial risk assessment is a practical technique that can enable healthcare strategic decision makers to perform quantitative analyses of the financial risks associated with a given strategic initiative. The technique comprises six steps: (1) list risk factors that might significantly influence the outcomes, (2) establish best-guess estimates for assumptions regarding how each risk factor will affect its financial outcomes, (3) identify risk factors that are likely to have the greatest impact, (4) assign probabilities to assumptions, (5) determine potential scenarios associated with combined assumptions, and (6) determine the probability-weighted average of the potential scenarios.

How IDSs can make their risk contracts more profitable.

To understand the causes of financial losses associated with risk arrangements, and eliminate those deficits, integrated delivery systems (IDSs) need to be able to perform detailed analyses on all aspects of their utilization data. Evaluations of utilization should begin with a traditional variance analysis to pinpoint areas where costs are higher than anticipated. Then, a series of increasingly specific analyses should be performed on utilization data within those areas. Often, losses may be attributable to the inability of primary care physicians to serve as effective patient care managers. IDSs, therefore, should compare the practices of their primary care physicians and share results in a way that highlights each physician's performance while ensuring physician anonymity. IDSs should take steps to reduce future losses by providing physicians and utilization management staff with information that will help them control costs, developing a performance-improvement plan for primary care physicians, and implementing payment incentives for physicians.

Kaiser's turnaround: hope for other nonprofits?

After the heady mid-1990's rush of lower premiums, most managed care systems tumbled into a well of red ink. Those hit especially hard were nonprofit MCOs, which have a limited ability to raise capital compared with their nonprofit competitors. However, Kaiser Permanente has reported its first quarterly surplus since 1997, and this has given hope to other nonprofits that they too will soon return to the black. Is this hope justified? Is Kaiser's medicine the right treatment for other integrated systems?

Applying risk management strategies to strengthen an IDS's investment policy.

The increased financial risk that not-for-profit integrated delivery systems have assumed to function under managed care has required them to become increasingly reliant on income and gains from their investment portfolios. This reliance underscores the need for these organizations to take steps to effectively manage their investment risk. Not-for-profit IDSs should establish a systematic approach to investment risk management that is based on maintaining a sound fiduciary infrastructure and having a clear understanding of risk exposures, the most important of which are policy and market risk. Applying reasonable and common-sense risk management strategies to investment policy will enhance an IDS's overall financial and competitive strength.

Improving the financial performance of IDS-owned physician practices.

Although physician practices acquired by integrated delivery systems (IDSs) have tended to show financial losses, these practices still offer IDSs considerable overall benefits, such as expanded market share and greater coordination of care. IDSs should not necessarily avoid acquiring practices. However, it is essential that IDSs take steps to improve the financial performance of acquired practices.