Equity in healthcare financing: a case of Iran.

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

Evaluating and Valuing Drugs for Rare Conditions: No Easy Answers.

We find ourselves in an era of unprecedented growth in the development and use of so-called "orphan" drugs to treat rare diseases, which are poised to represent more than one-fifth of pharmaceutical expenditures by 2022. This widespread use has been facilitated by legislative and regulatory incentives in both the United States and abroad, yet US payers and health systems have not yet made a concerted effort to understand whether and how rare diseases require special considerations on their part and how to adapt traditional methods of health technology assessment and economic evaluation to accommodate these situations. In this article, we explore the general ethical dilemmas that rare diseases present, steps taken by health technology assessment bodies worldwide to define the level of rarity that would necessitate special measures and the modifications to their assessment and valuation processes needed, and the contextual components for rare-disease evaluation that lie outside of the assessment framework as a guide to US decision makers on constructing a formal and relevant process stateside.

Ethical Implications of Case-Based Payment in China: A Systematic Analysis.

How health care providers are paid affects how medicine is practiced. It is thus important to assess provider payment models not only from the economic perspective but also from the ethical perspective. China recently started to reform the provider payment model in the health care system from fee-for-service to case-based payment. This paper aims to examine this transition from an ethical perspective. We collected empirical studies on the impact of case-based payment in the Chinese health care system and applied a systematic ethical matrix that integrates clinical ethics and public health ethics to analyze the empirical findings. We identified eleven prominent ethical issues related to case-based payment. Some ethical problems of case-based payment in China are comparable to ethical problems of managed care and diagnosis related groups in high-income countries. However, in this paper we discuss in greater detail four specific ethical issues in the Chinese context: professionalism, the patient-physician relationship, access to care and patient autonomy. Based on the analysis, we cautiously infer that case-based payment is currently more ethically acceptable than fee-for-service in the context of China, mainly because it seems to lower financial barriers to access care. Nonetheless, it will be difficult to justify the implementation of case-based payment if no additional measures are taken to monitor and minimize its existing negative ethical implications.

Wish-fulfilling medicine in practice: the opinions and arguments of lay people.

BACKGROUND: Wish-fulfilling medicine appears to be on the rise. It can be defined as 'doctors and other health professionals using medical means (medical technology, drugs, and so on) in a medical setting to fulfil the explicitly stated, prima facie non-medical wish of a patient'. Some instances of wish fulfilling medicine can be understood as 'human enhancements'. AIM: The aim of this study is to map the normative opinions and arguments of lay people about wish-fulfilling medicine. METHODS: We conducted a qualitative study with lay people (five focus groups). We asked their opinions about five cases and the arguments for these opinions. Furthermore, we enquired about the role of the medical profession and the treating physician, and whether the participants saw a role for the government. RESULTS: The opinions and arguments used varied according to the example discussed. For instance, increased familiarity with a procedure like breast enhancement seems to garner more acceptance for that procedure, whereas completely new examples were considered less acceptable. Various different arguments were raised in focus groups; these included: people should be allowed to make up their own minds about this (autonomy); payment of the treatment; and concerns about risks. DISCUSSION: An ethical analysis of the emerging practice of wish-fulfilling medicine should take the normative views of all parties involved into account. Thus, it is important to establish what lay people think about wish-fulfilling medicine and in particular their arguments.

Ethical issues raised by the introduction of payment for performance in France.

CONTEXT: In France, a new payment for performance (P4P) scheme for primary care physicians was introduced in 2009 through the 'Contract for Improving Individual Practice' programme. Its objective was to reduce healthcare expenditures while enhancing improvement in guidelines' observance. Nevertheless, in all countries where the scheme was implemented, it raised several concerns in the domain of professional ethics. OBJECTIVE: To draw out in France the ethical tensions arising in the general practitioner's (GP) profession linked to the introduction of P4P. METHOD: Qualitative research using two focus groups: first one with a sample of GPs who joined P4P and second one with those who did not. All collective interviews were recorded and fully transcribed. An inductive analysis of thematic content with construction of categories was conducted. All the data were triangulated. RESULTS: All participants agreed that conflicts of interest were a real issue, leading to the resurgence of doctor's dirigisme, which could be detrimental for patient's autonomy. GPs who did not join P4P believed that the scheme would lead to patient's selection while those who joined P4P did not. The level of the maximal bonus of the P4P was considered low by all GPs. This was considered as an offense by non-participating GPs, whereas for participating ones, this low level minimised the risk of patient's selection. CONCLUSION: This work identified several areas of ethical tension, some being different from those previously described in other countries. The authors discuss the potential impact of institutional contexts and variability of implementation processes on shaping these differences.

Estimating the economic burden of racial health inequalities in the United States.

The primary hypothesis of this study is that racial/ethnic disparities in health and health care impose costs on numerous aspects of society, both direct health care costs and indirect costs such as loss of productivity. The authors conducted three sets of analysis, assessing: (1) direct medical costs and (2) indirect costs, using data from the Medical Expenditure Panel Survey (2002-2006) to estimate the potential cost savings of eliminating health disparities for racial/ethnic minorities and the productivity loss associated with health inequalities for racial/ethnic minorities, respectively; and (3) costs of premature death, using data from the National Vital Statistics Reports (2003-2006). They estimate that eliminating health disparities for minorities would have reduced direct medical care expenditures by about $230 billion and indirect costs associated with illness and premature death by more than $1 trillion for the years 2003-2006 (in 2008 inflation-adjusted dollars). We should address health disparities because such inequities are inconsistent with the values of our society and addressing them is the right thing to do, but this analysis shows that social justice can also be cost effective.

The role of government and competing priorities in minority populations and developing nations.

OBJECTIVE: The purpose of this article is to analyze the role of governments in relation to the burden of chronic diseases and the potential response within the framework of competing priorities that determine resource allocation. METHODS: The following variables were analyzed both in retrospect and prospectively: the epidemiologic transition and the current effect of degenerative chronic diseases, the epidemic of diabetes and kidney disease in minority populations and developing countries, the potential response from healthcare systems, the relationship of chronic kidney disease vs quality of life and costs, and the differences between developed and developing countries. RESULTS: In Latin America, as in many other regions, cardiovascular diseases (ie, heart diseases and stroke) kill many people at early stages of renal disease. Only some survivors have access to renal replacement therapy. Those deaths can be attributed to the lack of systematized prevention and control programs to encompass chronic diseases and relate to poor engineering of adequate financial support. The Latin American Society of Nephrology and Hypertension is fostering a cardiovascular, cerebral, renal, and endocrine-metabolic health program in which 12 countries in the Latin American region implement different strategies, including allocation of national funds and strengthening of transplant programs. The focus of these strategies is on promotion, prevention, rehabilitation, research, and teaching. CONCLUSION: Developing countries should implement cardiovascular, cerebral, renal, and endocrine-metabolic health programs to improve efficiency of sanitary regulations and retrieve the huge amount of money that is spent on illnesses associated with the absence of systematized kidney disease control and follow-up programs.

Diagnosis-related group (DRG)-based case-mix funding system, a promising alternative for fee for service payment in China.

Fee for services (FFS) is the prevailing method of payment in most Chinese public hospitals. Under this retrospective payment system, medical care providers are paid based on medical services and tend to over-treat to maximize their income, thereby contributing to rising medical costs and uncontrollable health expenditures to a large extent. Payment reform needs to be promptly implemented to move to a prospective payment plan. The diagnosis-related group (DRG)-based case-mix payment system, with its superior efficiency and containment of costs, has garnered increased attention and it represents a promising alternative. This article briefly describes the DRG-based case-mix payment system, it comparatively analyzes differences between FFS and case-mix funding systems, and it describes the implementation of DRGs in China. China's social and economic conditions differ across regions, so establishment of a national payment standard will take time and involve difficulties. No single method of provider payment is perfect. Measures to monitor and minimize the negative ethical implications and unintended effects of a DRG-based case-mix payment system are essential to ensuring the lasting social benefits of payment reform in Chinese public hospitals.

Inequality in the face of death? Public expenditure on health care for different socioeconomic groups in the last year of life.

OBJECTIVE: To investigate the association between public expenditure on health care in the last year of life and individual socioeconomic status in Sweden. METHODS: Population-based study of public expenditure using linked registers for all 16,617 deaths among Stockholm County Council residents in 2002 (population 1.8 million). Age-standardized, total and per capita spend were calculated by income categories, age and specialty. Multivariate analysis examined the association between socioeconomic status and public expenditure. RESULTS: County council expenditure on health care in the last year of life rose with increasing income of the deceased person. Median per capita expenditure increased from 55,417 Swedish Kronor (SEK) (US$ 7542) in the lowest income group to SEK 94,678 (US$ 12,887) in the highest. Total age-standardized spend increased by 60% across the same interval (80,227 [95% confidence interval (CI) 79,946-80,497] to SEK 127,344 [95% CI 126,969-127,719]). Expenditure decreased with increasing age over 65 years in all income groups. Higher income was independently associated with greater total public health spend in multivariate analysis, adjusting for age, sex, health-care utilization and major diagnostic groups. CONCLUSIONS: There is inequality in public expenditure on health care at the end of life across socioeconomic groups in Stockholm. This phenomenon merits attention within Sweden, and beyond, in countries with less comprehensive welfare systems.

No free bed with ventilator: experience of a public health specialist.

While the author was dealing with a poor elderly father struggling to shift his gravely injured young son to a government hospital due to the high cost of intensive care, her friends across the globe were discussing euthanasia in the social media. While marginalised groups of people are struggling to access care in India, friends who have moved to developed parts of the world were discussing one's choice to live or die! The poor father, after battling to save his son and reaching out to many people for help, could not save him. Early treatment might have helped the young boy. The incident left the author thinking about how the poor are denied care simply because they cannot afford it. Others debate when to pull the plug on the patient. … How many families can afford such care in India? When nearly 71% of the people are paying out of pocket for healthcare and 16% are pushed below the poverty line every year, can we even think of universal health coverage? It just sounds like a fancy term to be used at conferences and meetings because the ground reality is completely different.

Assessing income redistributive effect of health financing in Zambia.

Ensuring an equitable health financing system is a major concern particularly in many developing countries. Internationally, there is a strong debate to move away from excessive reliance on direct out-of-pocket (OOP) spending towards a system that incorporates a greater element of risk pooling and thus affords greater protection for the poor. This is a major focus of the move towards universal health coverage (UHC). Currently, Zambia with high levels of poverty and income inequality is implementing health sector reforms for UHC through a social health insurance scheme. However, the way to identify the health financing mechanisms that are best suited to achieving this goal is to conduct empirical analysis and consider international evidence on funding universal health systems. This study assesses, for the first time, the progressivity of health financing and how it impacts on income inequality in Zambia. Three broad health financing mechanisms (general tax, a health levy and OOP spending) were considered. Data come from the 2010 nationally representative Zambian Living Conditions and Monitoring Survey with a sample size of 19,397 households. Applying standard methodologies, the findings show that total health financing in Zambia is progressive. It also leads to a statistically significant reduction in income inequality (i.e. a pro-poor redistributive effect estimated at 0.0110 (p < 0.01)). Similar significant pro-poor redistribution was reported for general taxes (0.0101 (p < 0.01)) and a health levy (0.0002 (p < 0.01)). However, the redistributive effect was not significant for OOP spending (0.0006). These results further imply that health financing redistributes income from the rich to the poor with a greater potential via general taxes. This points to areas where government policy may focus in attempting to reduce the high level of income inequality and to improve equity in health financing towards UHC in Zambia.

Ethics of the Physician's Role in Health-Care Cost Control: AOA Critical Issues.

The United States health-care expenditure is rising precipitously. The Congressional Budget Office has estimated that, in 2025, at our current rate of increased spending, 25% of the gross domestic product will be allocated to health care. Our per-capita spending on health care also far exceeds that of any other industrialized country. Health-care costs must be addressed if our country is to remain competitive in the global marketplace and to maintain its financial solvency. If unchecked, the uncontrolled rise in health-care expenditures will not only affect our capacity to provide our patients with high-quality care but also threaten the ability of our nation to compete economically on the global stage. This is not hyperbole but fiscal reality.As physicians, we are becoming increasingly familiar with the economics impacting health-care policy. Thus, we are in a unique position to control the cost of health care. This includes an increased reliance on creating and adhering to evidence-based guidelines. We can do this and still continue to respect the primacy of patient welfare and the right of patients to act in their own self-interest. However, as evidenced by the use of high-volume centers of excellence, each strategy adapted to control costs must be vetted and must be monitored for its unintended ethical consequences.The solution to this complex problem must involve the input of all of the health-care stakeholders, including the patients, payers, and providers. Physicians ought to play a role in designing and executing a remedy. After all, we are the ones who best understand medicine and whose moral obligation is to the welfare of our patients.

Study Of Physician And Patient Communication Identifies Missed Opportunities To Help Reduce Patients' Out-Of-Pocket Spending.

Some experts contend that requiring patients to pay out of pocket for a portion of their care will bring consumer discipline to health care markets. But are physicians prepared to help patients factor out-of-pocket expenses into medical decisions? In this qualitative study of audiorecorded clinical encounters, we identified physician behaviors that stand in the way of helping patients navigate out-of-pocket spending. Some behaviors reflected a failure to fully engage with patients' financial concerns, from never acknowledging such concerns to dismissing them too quickly. Other behaviors reflected a failure to resolve uncertainty about out-of-pocket expenses or reliance on temporary solutions without making long-term plans to reduce spending. Many of these failures resulted from systemic barriers to health care spending conversations, such as a lack of price transparency. For consumer health care markets to work as intended, physicians need to be prepared to help patients navigate out-of-pocket expenses when financial concerns arise during clinical encounters.

Financial "risk-sharing" or refund programs in assisted reproduction: an Ethics Committee opinion.

Financial "risk-sharing" fee structures in assisted reproduction programs charge patients a higher initial fee but provide reduced fees for subsequent cycles and often a partial or complete refund if treatment fails. This opinion of the ASRM Ethics Committee analyzes the ethical issues raised by these fee structures, including patient selection criteria, conflicts of interest, success rate transparency, and patient informed consent. This document replaces the document of the same name, last published in 2013 (Fertil Steril 2013;100:334-6).

Out-of-pocket expenditure and its determinants in the context of private healthcare sector expansion in sub-Saharan Africa urban cities: evidence from household survey in Ouagadougou, Burkina Faso.

BACKGROUND: Conventional wisdom suggests that out-of-pocket (OOP) expenditure reduces healthcare utilization. However, little is known about the expenditure borne in urban settings with the current development of the private health sector in sub-Saharan Africa. In an effort to update knowledge on medical expenditure, this study investigated the level and determinants of OOP among individuals reporting illness or injury in Ouagadougou, Burkina Faso and who either self-treated or received healthcare in either a private or public facility. METHODS: A cross-sectional study was conducted with a representative sample of 1017 households (5638 individuals) between August and November 2011. Descriptive statistics and multivariate techniques including generalized estimating equations were used to analyze the data. RESULTS: Among the surveyed sample, 29.6% (n = 1666) persons reported a sickness or injury. Public providers were the single most important providers of care (36.3%), whereas private and informal providers (i.e.: self-treatment, traditional healers) accounted for 29.8 and 34.0%, respectively. Almost universally (96%), households paid directly for care OOP. The average expenditure per episode of illness was 8404XOF (17.4USD) (median 3750XOF (7.8USD). The total expenditure was higher for those receiving care in private facilities compared to public ones [14,613.3XOF (30.3USD) vs. 8544.1XOF (17.7USD); p < 0.001], and the insured patients' bill almost tripled uninsured (p < 0.001). Finally, medication was the most expensive component of expenditure in both public and private facilities with a mean of 8022.1XOF (16.7USD) and 12,270.5 (25.5USD), respectively. CONCLUSION: OOP was the principal payment mechanism of households. A significant difference in OOP was found between public and private provider users. Considering the importance of private healthcare in Burkina Faso, regulatory oversight is necessary. Furthermore, an extensive protection policy to shield households from catastrophic health expenditure is required.

Impacto económico del dengue en pacientes y familiares / Economic impact of dengue on patients and families

Introducción: En Cuba no se han estudiado suficientemente los gastos de bolsillo y la pérdida de calidad de vida relacionada con la salud (de pacientes con dengue y sus familiares. Objetivo: Describir la afectación de la calidad de vida, los costos no médicos directos (gastos de bolsillo) e indirectos de pacientes hospitalizados con dengue y sus familiares. Método: Estudio de descripción de costos desde la perspectiva de pacientes y familiares, para los hospitalizados con dengue en el Clínico Quirúrgico Salvador Allende, en noviembre de 2013. En enero-febrero de 2014 se aplicó un cuestionario cerrado de 173 preguntas. Se calcularon la pérdida promedio de calidad de vida relacionada con la salud, los costos no médicos directos y los costos indirectos. Resultados: Durante el episodio de dengue el grupo de edad más afectado fue el de 30-44 años. Predominaron las mujeres (63,3 por ciento). La calidad de vida relacionada con la salud se afectó sensiblemente pasando como promedio de 86,9 el día antes de la enfermedad a 27,8 el día que las personas se sintieron más enfermas. En el momento de la entrevista, el 51 por ciento de los pacientes percibían que no se habían recuperado de la enfermedad. Los pacientes estuvieron hospitalizados como promedio 5 días. Los gastos de bolsillo de pacientes y familiares ascendieron a 61,24 CUC (IC95 por ciento 43,23-79,25 CUC), en que el 66,2 por ciento fue en alimentación y el 13,6 por ciento en transporte. Las pérdidas promedio de ingreso fueron de 25,30 CUC para los pacientes y 4,50 CUC para los familiares. Los costos totales promedio por paciente fueron de 89,25 CUC (IC95 por ciento 67,33-110,29 CUC). Conclusiones: Se evidenció la pérdida de calidad de vida como consecuencia del dengue. Los gastos de bolsillo fueron altos y representan tres veces el valor del salario medio de la Provincia La Habana(AU)

Introduction: Health-related loss of quality of life among dengue patients and their relatives, and unforeseen family expenses incurred for this reason, have not been sufficiently studied in Cuba. Objective: Describe the impact on quality of life, as well as the non-medical direct and indirect unforeseen expenses incurred by patients hospitalized with dengue and their relatives. Method: A cost analysis study was conducted based on data provided by patients hospitalized with dengue in Salvador Allende Clinical Surgical Hospital and their relatives in November 2013. A closed-ended questionnaire of 173 questions was applied in January-February 2014. Estimation was made of average health-related loss of quality of life, direct non-medical costs and indirect costs. Results: The 30-44 years age group was the most harshly affected during the episode. There was a predominance of the female sex (63.3 percent). Health-related quality of life decreased dramatically from an average 86.9 the day before the disease to 27.8 on the day when patients felt the worst. At the time of the interview, 51 percent of the patients perceived that they had not recovered from the disease. Mean hospital stay was 5 days. Unforeseen patient and family expenses rose to 61.24 CUC (CI 95 percent; 43.23-79.25 CUC), of which 66.2 percent was spent on food and 13.6 percent on transport. Average income loss was 25.30 CUC for patients and 4.50 CUC for relatives. Total average cost per patient was 89.25 CUC (CI 95 percent 67.33-110.29 CUC). Conclusions: Evidence was found of loss of quality of life as a result of dengue. Unforeseen expenses were high, representing three times the mean salary in the province of Havana(AU)