Comorbidity Assessment Is Uneven Across Veterans Health Administration and Medicare for the Same Patient: Implications for Risk Adjustment.

OBJECTIVE: Compare comorbidity identification in Medicare and Veterans Health Administration (VA) data for the purposes of risk adjustment. DATA SOURCES: Analysis of Medicare and VA datasets for dually-enrolled Veterans receiving care in both settings, fiscal years 2010-2014. STUDY DESIGN: A retrospective analysis of administrative data for a national sample of cancer decedents. DATA EXTRACTION METHODS: Comorbidities were evaluated using Elixhauser and Charlson coding algorithms. PRINCIPAL FINDINGS: Clinical comorbidities were more likely to be recorded in Medicare than in VA datasets. Of 42 comorbidities, 36 (86%) were recorded at a different frequency. For example, congestive heart failure was recorded for 22.0% of patients in Medicare data and for 11.3% of patients in VA data (P<0.001). CONCLUSION: There are large differences in comorbidity assessment across VA and Medicare administrative data for the same patient, posing challenges for risk adjustment.

Exploring the consequences of decentralization: has privatization of health services been the perceived effect of decentralization in Khartoum locality, Sudan?

BACKGROUND: The health system of Sudan has experienced several forms of decentralization, as well as, a radical reform. Authority and governance of secondary and tertiary health facilities have been shifted from federal to state levels. Moreover, the provision of health care services have been moved from large federal tertiary level hospitals such as Khartoum Teaching Hospital (KTH) and Jafaar Ibnoaf Hospital (JIH), located in the center of Khartoum, to smaller district secondary hospitals like Ibrahim Malik (IBMH), which is located in the southern part of Khartoum. Exploring stakeholders' perceptions on this decentralisation implementation and its relevant consequences is vital in building an empirical benchmark for the improvement of health systems. METHODS: This study utilised a qualitative design which is comprised of in-depth interviews and qualitative content analysis with an inductive approach. The study was conducted between July and December 2015, and aimed at understanding the personal experiences and perceptions of stakeholders towards decentralisation enforcement and the implications on public health services, with a particular focus on the Khartoum locality. It involved community members residing in the Khartoum Locality, specifically in catchments area where hospital decentralisation was implemented, as well as, affiliated health workers and policymakers. RESULTS: The major finding suggested that privatisation of health services occurred after decentralisation. The study participants also highlighted that scrutiny and reduction of budgets allocated to health services led to an instantaneous enforcement of cost recovery user fee. Devolving KTH Khartoum Teaching and Jafar Ibnoaf Hospitals into peripherals with less. Capacity, was considered to be a plan to weaken public health services and outsource services to private sector. Another theme that was highlighted in hospitals included the profit-making aspect of the governmental sector in the form of drug supplying and profit-making retail. CONCLUSIONS: A change in health services after the enforcement of decentralisation was illustrated. Moreover, the incapacitation of public health systems and empowerment of the privatisation concept was the prevailing perception among stakeholders. Having contextualised in-depth studies and policy analysis in line with the global liberalisation and adjustment programmes is crucial for any health sector reform in Sudan.

Private vs public child welfare systems: A comparative analysis of national safety outcome performance.

BACKGROUND: Ensuring the safety of American children is one of the chief mandates of the U.S. Child Welfare System. Yet system differences, including privatization remain an area of concern for whether safety of children is achieved. OBJECTIVE: This study examined the effect of privatization policy on the performance of state child welfare systems in terms of achieving national safety outcome standards. PARTICIPANTS AND SETTING: N1 = 10 states systems (5 privatized and 5 public systems) with N2 = 118,761 foster care cases located throughout the U.S. METHOD: Using data from the Adoption and Foster Care Analysis and Reporting System (AFCARS), safety outcome performance measures were assessed, as were child-/case factors to predict the likelihood of the system types meeting the national safety outcome standards. RESULTS: Logistic regression models of child, case, and system factors predicting the likelihood state systems met national safety outcome performance standards were statistically significant. Private systems, compared to non-private systems, were found to have lower odds of meeting the safety outcome 1 standard (OR = 0.41, 95% CI = 0.40-0.42), but greater odds of meeting the safety outcome 2 standard (OR = 6.79, 95% CI = 6.56-7.02). CONCLUSIONS: The implementation of privatization policy in state child welfare/foster care service delivery was found to have mixed results in terms of the national safety outcome standards.

Changes in spirits purchasing behaviours after privatisation of government-controlled sales in Washington, USA.

INTRODUCTION AND AIMS: The privatisation of the Washington Liquor Monopoly in 2012 offered a unique opportunity to study spirits purchasing behaviour changes from a government to licensed system. DESIGN AND METHODS: Four representative cross-sectional surveys of adults aged 18 and older in Washington state were recruited between January 2014 and October 2015 (Wave 1, N = 1202; W2, N = 804; W3, N = 823; W4, N = 662). Analyses compared spirits purchasing behaviours before privatisation from retrospective reports to current reports in the areas of travel distance, spirits quality, purchase frequency and size of bottle. Respondents also directly reported on changes in convenience, selection and prices. RESULTS: No significant changes were found in these aspects of purchasing. However, subgroup analyses found that younger drinkers 18-29 reduced travel distance and increased purchase frequency while drinkers aged 50 and older travelled further. Reduced travel distances were associated with grocery and drug stores while increased travel distances were associated with liquor superstores, wholesale stores and government stores in bordering states. Respondents reported that liquor purchasing was more convenient after privatisation but that the selection of spirits was better and prices were lower in the government-controlled stores. DISCUSSION AND CONCLUSIONS: The government monopoly stores were viewed as offering a wider selection of products and as having lower prices than those in the privatised system. The variety of store types in the licensed system allowed drinkers to select stores based on convenience, selection or prices, so that travel times increased for some buyers, presumably those seeking lower prices or a wider selection.

Carbon Information Disclosure, Marketization, and Cost of Equity Financing.

Using listed enterprises in China's heavy pollution industry from 2009 to 2013, this study tests the relationship between marketization degree, carbon information disclosure, and the cost of equity financing. The results show that, regardless of marketization degree, the overall level of carbon information disclosure of listed enterprises in China's heavy pollution industry is low. The content of carbon information disclosure is mainly non-financial carbon information, and the financial carbon information disclosure is very low. The cost of equity financing is different in areas with different marketization degrees, specifically speaking, the cost of equity financing is lower in regions with a high marketization degree than that of a low marketization degree. Carbon information disclosure, non-financial carbon information disclosure, and financial carbon information disclosure are negatively correlated with the cost of equity financing. The marketization degree has strengthened the negative correlation between carbon information disclosure, non-financial carbon information disclosure, financial carbon information disclosure, and the cost of equity financing, respectively.

Out of Sight, Out of Mind? Measuring the Relationship between Privatization and Medicaid Self-Reporting.

Privatization has grown exponentially, both in salience and in form, over the past several decades. This shifting of administrative authority away from the state can make it difficult for program recipients to link their use of a federal program back to government, a disconnect known as "submerging" the state. However, privatization is a process that occurs in degrees, and not all privatization initiatives look alike. This study leverages variation in the implementation of Medicaid managed care, which is the most widespread form of Medicaid privatization, to examine how privatization maps onto state submersion and affects state visibility. This analysis shows that, although Medicaid managed care enrollment, at large, does not relate to recipients' self-reported Medicaid enrollment, when privatized Medicaid plans introduce administrative designs that obscure the role of government, Medicaid self-reporting declines. These findings demonstrate that policy recipients are less able to recognize both the personal relevance of a specific public program and the public nature of this interaction when privatized programs utilize design features that attenuate signals of government involvement. In highlighting this disconnect, this article shows how privatization makes it more difficult for policy recipients to engage in the civic sphere as informed advocates for their self-interest.

Privatization in the Irish hospital sector since 1980.

Background: Privatization has transformed health care systems over the last several decades. This article examines trends in bed supply in Ireland between 1980 and 2015 within the context of government policy on bed provision in a system of inequitable access to care. Ireland has not published bed data on private hospitals since the 1980s, even if they comprise about one-quarter of all hospitals. However, this article presents, for the first time, annual bed data since the 1980s collected from private hospitals and used to trace the evolution of bed supply over time. Methods: Bed data were collected for private Irish hospitals for the years 1980-2015, mainly through direct requests to hospitals. Additional sources included the Irish Medical Directory, private health insurance data, hospital company records and newspaper archives. Results: Subject to data caveats explained in the article, between 1980 and 2015, total inpatient beds decreased by 25.5% nationally. Inpatient bed numbers in private for-profit (PFP) hospitals rose from 0 to 1075 but decreased from 9601 to 5216 in private not-for-profit (PNFP) hospitals and from 7028 to 6092 in public hospitals (using the Irish hospital classification, beds in private hospitals increased from 1518 to 1910 but decreased from 15 111 to 10 473 in public hospitals). Also, by 2015, 24.1% of PFP hospital beds were day beds, compared to 17.7% for PNFP and 15.7% for public hospitals (using the Irish classification, by 2015, day beds accounted for 23.8% of beds in private hospitals and 16.1% in public hospitals). Conclusions: Trends in bed supply in Ireland between 1980 and 2015 are documented empirically for all Irish acute hospitals and contextualized within government policy on bed provision. The Irish acute hospital system has experienced privatization reforms supported by the government over the last several decades.

Patient choice and private provision decreased public provision and increased inequalities in Scotland: a case study of elective hip arthroplasty.

Background: This is the first research to examine how the policy of patient choice and commercial contracting where NHS funds are given to private providers to tackle waiting times, impacted on direct NHS provision and treatment inequalities. Methods: An ecological study of NHS funded elective primary hip arthroplasties in Scotland using routinely collected inpatient data 1 April 1993-31 March 2013. Results: An increased use of private sector provision by NHS Boards was associated with a significant decrease in direct NHS provision in 2008/09 (P < 0.01) and with widening inequalities by age and socio-economic deprivation. National treatment rate fell from 143.8 (140.3, 147.3) per 100 000 in 2006/07 to 137.8 (134.4, 141.2) per 100 000 in 2007/08. By 2012/13, territorial NHS Boards had not recovered 2006/07 levels of provision; this was most marked for NHS Boards with the greatest use of private sector, namely Fife, Grampian and Lothian. Patients aged 85 years and over or living in the more deprived areas of Scotland appear to have been disadvantaged since the onset of patient choice in 2002. Conclusions: NHS funding of private sector provision for elective hip arthroplasty was associated with a decrease in public provision and may have contributed to an increase in age and socio-economic inequalities in treatment rates.

Austeridad y privatización sanitaria en época de crisis: ¿existen diferencias entre las comunidades autónomas? Respuesta / Differences in austerity and healthcare privatisation between autonomous communities in times of crisis in Spain. Replay

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[Austerity and healthcare privatization in times of crisis: are there any differences among autonomous communities?]. / Austeridad y privatización sanitaria en época de crisis: ¿existen diferencias entre las comunidades autónomas?

OBJECTIVE: To analyse the differences between autonomous communities in Spain according to their policies of austerity and healthcare privatization during the economic crisis. METHODS: Changes in the application of legal reforms, healthcare privatization and healthcare financing/resources in the autonomous communities were analysed, and a summary indicator of each dimension was constructed. RESULTS: The Basque Country showed the clearest behaviour towards a weak policy of austerity and privatization, as opposed to La Rioja, Madrid, and the Balearic Islands. CONCLUSIONS: The three classifications will enable analysis of the mediating effect of policies of austerity and privatization in the relationship between the economic crisis and health in the Spanish context.

Employment effects of hospital privatization in Germany.

The main argument for the ongoing privatization process is that privatization will lead to an increase in efficiency, which has been confirmed by a large number of studies. An important argument against privatization is that privatization may lead to employment reductions. In the hospital sector, potential employment reductions might also lead to a decrease in the quality of care. This is the first study to investigate the employment effects of different types of hospital privatization (i.e., for-profit vs non-profit privatization) on different categories of staff. A combination of propensity score matching and difference-in-difference methods was used to identify the causal effect. We found large employment reductions after for-profit privatization, while there were no permanent reductions after non-profit privatization. Moreover, even for-profit privatization does not affect all types of staff. While there are large reductions in non-clinical staff, we could not detect any reduction in the number of physicians. The consequences of the detected employment effects of privatization have to be addressed in greater detail in future research.

Alcohol outlet densities and alcohol price: the British Columbia experiment in the partial privatization of alcohol sales off-premise.

BACKGROUND: Alcohol beverage prices or taxes have been shown to be related to alcohol sales and use and related problems. What is not clear are the mechanisms underlying these relationships. METHODS: This study examines the relationship between alcohol outlet density under conditions of the partial privatization of off-premise consumption in British Columbia (BC) occurring over the past decade. Two hypotheses are tested. First, reflecting basic supply-demand principles, greater geographic densities of alcohol outlets will be directly related to reductions in beverage prices in response to greater competition. Second, reflecting the effects of niche marketing and resulting market stratification, increased densities of private liquor stores will be especially related to reductions in beverage prices within this outlet category. Data were collected from: (i) a survey of BC private store prices and practices, (ii) alcohol outlet location information, and (iii) data on demographic characteristics. Multilevel models examine the relationships between prices at individual private liquor stores and the densities of government liquor stores, private liquor stores, bars, and restaurants, controlling for background demographics and geographic unit level effects. Spatial dependencies were also examined. RESULTS: Increased densities of private liquor stores were associated with lower mean prices of beer and all alcohol aggregated across brands at the store level. There appeared to be no outlet level effect on discounting patterns, however, with the mean price differences apparently reflecting differences in the quality of brands carried rather than unequal prices for any given brand. CONCLUSIONS: Increased densities of private off-sale alcohol outlets appear to result in lower prices charged at said establishments independently of other types of alcohol outlets suggesting that they represent an emerging marketing niche in the context of off-sale outlet privatization.

Changes in hospital efficiency after privatization.

We investigated the effects of privatization on hospital efficiency in Germany. To do so, we obtained boot-strapped data envelopment analysis (DEA) efficiency scores in the first stage of our analysis and subsequently employed a difference-in-difference matching approach within a panel regression framework. Our findings show that conversions from public to private for-profit status were associated with an increase in efficiency of between 2.9 and 4.9%. We defined four alternative post-privatization periods and found that the increase in efficiency after a conversion to private for-profit status appeared to be permanent. We also observed an increase in efficiency for the first three years after hospitals were converted to private non-profit status, but our estimations suggest that this effect was rather transitory. Our findings also show that the efficiency gains after a conversion to private for-profit status were achieved through substantial decreases in staffing ratios in all analyzed staff categories with the exception of physicians and administrative staff. It was also striking that the efficiency gains of hospitals converted to for-profit status were significantly lower in the diagnosis-related groups (DRG) era than in the pre-DRG era. Altogether, our results suggest that converting hospitals to private for-profit status may be an effective way to ensure the scarce resources in the hospital sector are used more efficiently.

Hematopoietic cell transplantation with autologous cord blood in patients with severe aplastic anemia: an opportunity to revisit the controversy regarding cord blood banking for private use.

The controversy surrounding private banking of umbilical cord blood units (CBU), as a safeguard against future malignancy or other life-threatening conditions, raises many questions in pediatric clinical practice. Recent favorable experiences with autologous transplantation for severe aplastic anemia using privately stored CBU, suggested a possible utility. While private banking is difficult to justify statistically or empirically, there may exist rare cases where autologous transplant of stored umbilical CBU could be beneficial. The reality of privately banked CBU and the possibility for future discovery of additional indications for autologous cord blood transplant, motivated us to re-examine our attitudes towards private cord blood banking.

Effect of privatization of the drug distribution system on drug prices in Malaysia.

BACKGROUND: Previous studies on anti-infective and cardiovascular drugs have shown extraordinary price increases following privatization of the Malaysian drug distribution system. Therefore, it was felt that there was a need to undertake a full-scale study to evaluate the effect of privatization of the Malaysian drug distribution system on drug prices. OBJECTIVES: To compare pre-privatization drug prices with post-privatization drug prices, and to compare the prices with international reference prices (IRPs). METHODS: Five hundred and sixty-four drugs were listed in price lists for 1994, 1995-1996, 1997-2000 and 2001-2003. The 1994 data were taken as the pre-privatization prices, and all other lists were considered to be post-privatization prices. The pre-privatization prices (1994) were compared with those in 1995-1996. The prices in 1995-1996 were compared with those in 1997-2000, and the 1997-2000 prices were compared with those in 2001-2003. Furthermore, the 2001-2003 prices were compared with the median IRPs taken from Management Sciences for Health. RESULTS: The prices increased by 10.42% in 1995-1996, decreased by 3.37% in 1997-2000, and increased by 64.04% in 2001-2003. The increase in prices does not follow any pricing formula but is influenced by free market principles. The commonly used generic drugs showed enormously higher prices compared with the IRPs. CONCLUSION: Some of the prices increased several hundred-fold compared with the previous year, showing that no pricing formula has been followed. Increasing prices over the years may lead to higher expenditures and a hurdle to drug accessibility. A rational pricing structure is needed for transparent pricing, and government involvement and the formation of a medicine pricing policy seems vital.

Availability of renal replacement therapy in Central and Eastern Europe.

During the past 15 years, deep political and economic changes have occurred in Central and Eastern Europe (CEE). New, independent countries have appeared on the map because of the partition of the former Soviet Union and the former Yugoslavia and Czechoslovakia. One significant area of change in the CEE region has been intensive reform of the healthcare systems in each country. In particular, renal replacement therapy (RRT) in most of these countries was underdeveloped during the so-called "real" socialism era. But enormous effort on the part of the nephrology communities, supported by the economic help of local, regional, and central authorities, has resulted in gradual progress in this matter. Both main RRT modalities (dialysis and renal transplantation) have evolved simultaneously in most of these countries but not always equally. In most CEE countries, RRT is available for all patients with end-stage renal disease. Still, an unsatisfactory level of RRT availability, despite the efforts of the nephrology community, continues to be a concern in Belorussia and Russia, where additional support from the healthcare system is required. The lowest rates of RRT are found in Albania, Moldova, and Ukraine, but reliable data from these countries are lacking.

Mechanisms behind privatization: a case study of private growth in Swedish elderly care.

For many years the Swedish Welfare State has been associated with a welfare model in which the public sector dominates both the provision and financing of the elderly care system. However, influenced by the ongoing trend of New Public Management, the past 15 years have been characterized by governmental regimes encouraging competition and as a result there has been a substantial increase in private providers. This case study on elderly care in Sweden provides new insights into the mechanisms behind the spread and growth of privatization. Our results show that in 1990 only 1% of the labour force in the elderly care sector was employed by private organizations, in comparison to 2003 when the private share had increased to 13%. The accompanying organizational changes have been controversial and are often criticized. In general, left-wing politicians have frequently defended the traditional welfare model dominated by public providers, whereas right-wing politicians have urged for a larger share of alternative providers. In this study, statistics between the years 1990 and 2003 were used to model the relationship between privatization and a number of economic, political and social/demographic variables. The results from regression and diffusion analysis imply that privately managed elderly care has established itself mainly in metropolitan areas dominated by right-wing regimes. Surprisingly, neighbouring municipalities tend to follow these pioneers irrespective of their political colour or economic situation. In fact, after shifting political power many of those neighbouring municipalities dominated by left-wing regimes not only maintain an abundance of private contractors but also encourage a continued process of contracting out publicly managed elderly care units. As a result, clusters of municipalities with an increasing degree of privatization arise despite political and economic differences. In conclusion, geographical proximity seems to be an important variable in addition to population density, ideology and financial situation when privatization reforms are implemented in the Swedish elderly care system.

Mass privatisation and the post-communist mortality crisis: a cross-national analysis.

BACKGROUND: During the early-1990s, adult mortality rates rose in most post-communist European countries. Substantial differences across countries and over time remain unexplained. Although previous studies have suggested that the pace of economic transition was a key driver of increased mortality rates, to our knowledge no study has empirically assessed the role of specific components of transition policies. We investigated whether mass privatisation can account for differences in adult mortality rates in such countries. METHODS: We used multivariate longitudinal regression to analyse age-standardised mortality rates in working-age men (15-59 years) in post-communist countries of eastern Europe and the former Soviet Union from 1989 to 2002. We defined mass privatisation programmes as transferring at least 25% of large state-owned enterprises to the private sector within 2 years with the use of vouchers and give-aways to firm insiders. To isolate the effect of mass privatisation, we used models to control for price and trade liberalisation, income change, initial country conditions, structural predispositions to higher mortality, and other potential confounders. FINDINGS: Mass privatisation programmes were associated with an increase in short-term adult male mortality rates of 12.8% (95% CI 7.9-17.7; p<0.0001), with similar results for the alternative privatisation indices from the European Bank for Reconstruction and Development (7.8% [95% CI 2.8-13.0]). One mediating factor could be male unemployment rates, which were increased substantially by mass privatisation (56.3% [28.3-84.3]; p<0.0001). Each 1% increase in the percentage of population who were members of at least one social organisation decreased the association of privatisation with mortality by 0.27%; when more than 45% of a population was a member of at least one social organisation, privatisation was no longer significantly associated with increased mortality rates (3.4% [95% CI -5.4 to 12.3]; p=0.44). INTERPRETATION: Rapid mass privatisation as an economic transition strategy was a crucial determinant of differences in adult mortality trends in post-communist countries; the effect of privatisation was reduced if social capital was high. These findings might be relevant to other countries in which similar policies are being considered.