Current Attitudes toward Unfunded Cancer Therapies among Canadian Medical Oncologists.

BACKGROUND: Despite successes in the development of innovative anticancer therapies, the fiscal and capacity restraints of the Canadian public healthcare system result in challenges with drug access. A meaningful proportion of systemic therapies ultimately do not receive public funding despite supporting clinical evidence. In this study, we assessed Canadian medical oncologists' current attitudes toward discussing publicly unfunded cancer treatments with patients and predictors of different practices. METHODS: A web-based survey consisting of multiple choice and case-based scenarios was distributed to medical oncologists identified through the Royal College of Physicians and Surgeons of Canada directory. RESULTS: A total of 116 responses were received. Almost all respondents reported discussing publicly unfunded treatments, including those who did so for Health Canada (HC) approved treatments (50%) and those who discussed off-label treatments (i.e., not HC approved) as guided by national guidelines (48%). Respondents in practice for over 15 years versus less than 5 years (OR 0.14, 95% CI 0.04-0.50, p = 0.002) and those who worked in a community practice versus comprehensive cancer center (OR 0.17, 95% CI 0.03-0.91, p = 0.04) were significantly less likely to discuss off-label treatment options with their patients. Almost half of respondents (47%) indicated that their institution did not permit the administration of unfunded treatments. CONCLUSIONS: There is variability in medical oncologists' practices when it comes to discussing unfunded therapies. Given the limitations within Canada's publicly funded healthcare system, physicians are faced with the challenge of navigating an increasingly complex balance between patient care and available resources. Engagement of relevant stakeholders and policy makers is crucial in the continued evaluation of Canada's drug funding process.

Reducing administrative costs in US health care: Assessing single payer and its alternatives.

OBJECTIVE: Excess administrative costs in the US health care system are routinely referenced as a justification for comprehensive reform. While there is agreement that these costs are too high, there is little understanding of what generates administrative costs and what policy options might mitigate them. DATA SOURCES: Literature review and national utilization and expenditure data. STUDY DESIGN: We developed a simulation model of physician billing and insurance-related (BIR) costs to estimate how certain policy reforms would generate savings. Our model is based on structural elements of the payment process in the United States and considers each provider's number of health plan contracts, the number of features in each health plan, the clinical and nonclinical processes required to submit a bill for payment, and the compliance costs associated with medical billing. DATA EXTRACTION: For several types of visits, we estimated fixed and variable costs of the billing process. We used the model to estimate the BIR costs at a national level under a variety of policy scenarios, including variations of a single payer "Medicare-for-All" model that extends fee-for-service Medicare to the entire population and policy efforts to reduce administrative costs in a multi-payer model. We conducted sensitivity analyses of a wide variety of model parameters. PRINCIPAL FINDINGS: Our model estimates that national BIR costs are reduced between 33% and 53% in Medicare-for-All style single-payer models and between 27% and 63% in various multi-payer models. Under a wide range of assumptions and sensitivity analyses, standardizing contracts generates larger savings with less variance than savings from single-payer strategies. CONCLUSION: Although moving toward a single-payer system will reduce BIR costs, certain reforms to payer-provider contracts could generate at least as many administrative cost savings without radically reforming the entire health system. BIR costs can be meaningfully reduced without abandoning a multi-payer system.

Current and Projected Financial Burden of Emergency General Surgery for Adults in Scotland's Single Payer Healthcare System: A Cost Analysis of Hospital Admissions.

OBJECTIVE: To calculate the current and projected financial burden of EGS hospital admissions in a single-payer healthcare system. SUMMARY OF BACKGROUND DATA: EGS is an important acute care service, which demands significant healthcare resources. EGS admissions and associated costs have increased over time, associated with an aging demographic. The National Health Service is the sole provider of emergency care in Scotland. METHODS: Principal, high and low Scottish population projections were obtained for 2016 until 2041. EGS admission data were projected using an ordinary least squares linear regression model. An exponential function, fitted to historical length of hospital stay (LOS) data, was used to project future LOS. Historical hospital unit cost per bed day was projected using a linear regression model. EGS cost was calculated to 2041 by multiplying annual projections of population, admission rates, LOS, and cost per bed day. RESULTS: The adult (age >15) Scottish population is projected to increase from 4.5 million to 4.8 million between 2016 and 2041. During this time, EGS admissions are expected to increase from 83,132 to 101,090 per year, cost per bed day from £786 to £1534, and overall EGS cost from £187.3 million to £202.5 million. CONCLUSIONS: The future financial burden of EGS in Scotland is projected to increase moderately between 2016 and 2041. This is in sharp contrast to previous studies from settings such as the United States. However, if no further reductions in LOS or cost per bed day are made, especially for elderly patients, the cost of EGS will rise dramatically.

Single-Payer Health Care in the United States: Implications for Plastic Surgery.

Health care reform continues to be a topic of debate among lawmakers, politicians, physicians, and citizens of the United States. In recent years, proposed changes to the health care industry have grown in both granularity and popularity, with the possibility of adapting a single-payer health insurance system reaching an all-time high. The implications of such a policy are far-reaching and can be challenging to conceptualize, especially in isolation. The purpose of this article is to review some of the anticipated changes under this new system, specifically as they pertain to the field of plastic surgery.

Projected costs of single-payer healthcare financing in the United States: A systematic review of economic analyses.

BACKGROUND: The United States is the only high-income nation without universal, government-funded or -mandated health insurance employing a unified payment system. The US multi-payer system leaves residents uninsured or underinsured, despite overall healthcare costs far above other nations. Single-payer (often referred to as Medicare for All), a proposed policy solution since 1990, is receiving renewed press attention and popular support. Our review seeks to assess the projected cost impact of a single-payer approach. METHODS AND FINDINGS: We conducted our literature search between June 1 and December 31, 2018, without start date restriction for included studies. We surveyed an expert panel and searched PubMed, Google, Google Scholar, and preexisting lists for formal economic studies of the projected costs of single-payer plans for the US or for individual states. Reviewer pairs extracted data on methods and findings using a template. We quantified changes in total costs standardized to percentage of contemporaneous healthcare spending. Additionally, we quantified cost changes by subtype, such as costs due to increased healthcare utilization and savings due to simplified payment administration, lower drug costs, and other factors. We further examined how modeling assumptions affected results. Our search yielded economic analyses of the cost of 22 single-payer plans over the past 30 years. Exclusions were due to inadequate technical data or assuming a substantial ongoing role for private insurers. We found that 19 (86%) of the analyses predicted net savings (median net result was a savings of 3.46% of total costs) in the first year of program operation and 20 (91%) predicted savings over several years; anticipated growth rates would result in long-term net savings for all plans. The largest source of savings was simplified payment administration (median 8.8%), and the best predictors of net savings were the magnitude of utilization increase, and savings on administration and drug costs (R2 of 0.035, 0.43, and 0.62, respectively). Only drug cost savings remained significant in multivariate analysis. Included studies were heterogeneous in methods, which precluded us from conducting a formal meta-analysis. CONCLUSIONS: In this systematic review, we found a high degree of analytic consensus for the fiscal feasibility of a single-payer approach in the US. Actual costs will depend on plan features and implementation. Future research should refine estimates of the effects of coverage expansion on utilization, evaluate provider administrative costs in varied existing single-payer systems, analyze implementation options, and evaluate US-based single-payer programs, as available.

Tax-funded social health insurance: an analysis of revenue sources, Hungary.

Health financing is a complex health system function, which cannot be analysed accurately without tracking each step of the flow of funds separately. We analysed the revenue mix of the Hungarian health insurance fund from 1994 to 2015 and discuss the policy implications of our findings. We used the System of Health Accounts published in 2000 and the revised version of 2011, which introduced separate classifications for the sources of health expenditure. Based on the 2000 version, health insurance contributions were the main source of public funding in Hungary. According to the 2011 version, nearly 70% of health insurance fund revenues came from government tax transfers in 2015, illustrating the striking difference in how revenues and expenditures are reported using this version. Use of the 2011 version will better inform national policy-making and international comparisons and facilitate documentation and analysis of how countries have adapted their revenue mix to changing macroeconomic circumstances. The finding that Hungary has a predominantly tax-funded social health insurance system suggests that traditional understanding and description of health-financing models are no longer adequate and may limit consideration of potential resource-generation options. Hungary is also a good example of how separating revenue generation and pooling broadens policy options to tackle gaps in social health insurance coverage, although the government did not act on these due to the lack of a consistent health-financing strategy. The findings may be particularly relevant for low- and middle-income countries that are trying to expand social health insurance coverage despite limited formal employment.

Le financement de la santé est une fonction complexe du système de santé, qui ne peut pas être précisément analysée sans étudier séparément chaque étape du flux de fonds. Dans cet article, nous analysons le mix de recettes du fonds d'assurance maladie hongrois de 1994 à 2015 et nous évoquons les implications de nos constatations sur la définition des politiques. Nous avons utilisé le Système des Comptes de la Santé publié en 2000 ainsi que sa version révisée de 2011, qui a introduit des classifications différentes pour les sources des dépenses de santé. En se fondant sur la version de 2000, ce sont les cotisations d'assurance maladie qui ont constitué la principale source de financement public en Hongrie. Mais d'après la version de 2011, près de 70% des recettes constitutives des fonds de l'assurance maladie sont provenues de transferts fiscaux gouvernementaux en 2015, ce qui illustre la différence flagrante dans la manière d'enregistrer les recettes et les dépenses proposée par cette version révisée. L'utilisation de la version de 2011 permettra de mieux informer le processus d'élaboration des politiques nationales, de faciliter les comparaisons internationales ainsi que de mieux documenter et analyser la manière dont les pays adaptent leur mix de recettes face à l'évolution des circonstances macroéconomiques. Le fait que le système d'assurance maladie sociale de Hongrie s'avère principalement financé par l'impôt montre que la compréhension et la description habituelles des modèles de financement de la santé ne sont plus adaptées et que cela peut même entraver la considération d'autres options envisageables pour générer des recettes. La Hongrie est également un bon exemple illustrant comment le fait de séparer la génération des recettes et la mise en commun des fonds élargit les options politiques pour réduire les déficiences dans la couverture de l'assurance maladie sociale, même si le gouvernement n'a pas agi sur ce point, faute de stratégie de financement de la santé cohérente en la matière. Ces constatations peuvent être particulièrement utiles pour les pays à revenu faible et intermédiaire qui essayent d'étendre la couverture de leur assurance maladie sociale malgré un niveau d'emploi limité dans le secteur formel.

La financiación de la salud es una función compleja del sistema sanitario que no puede analizarse con precisión si no se hace un seguimiento independiente de cada paso del flujo de fondos. Se ha analizado la combinación de ingresos de la caja húngara de seguros médicos de 1994 a 2015 y se han discutido las implicaciones políticas de los resultados. Se ha usado el Sistema de Cuentas de Salud publicado en 2000 y la versión revisada de 2011, que introdujo las clasificaciones separadas para las fuentes de gasto en salud. Según la versión de 2000, las cotizaciones al seguro de enfermedad eran la principal fuente de financiación pública en Hungría. Según la versión de 2011, casi el 70 % de los ingresos de la caja de seguros médicos procedían de las transferencias de impuestos del gobierno en 2015, lo que ilustra la sorprendente diferencia en la forma en que se informan los ingresos y los gastos utilizando esta versión. El uso de la versión de 2011 servirá de base para la formulación de políticas nacionales y comparaciones internacionales y facilitará la documentación y el análisis de cómo los países han adaptado su combinación de ingresos a las cambiantes circunstancias macroeconómicas. La conclusión de que Hungría tiene un sistema de seguridad social financiada principalmente por los impuestos sugiere que la comprensión y la descripción tradicionales de los modelos de financiación sanitaria ya no son adecuados y limitan la consideración de las posibles opciones de generación de recursos. Hungría es también un buen ejemplo de cómo la separación entre la generación de ingresos y la puesta en común amplía las opciones políticas para abordar las brechas en la cobertura de la seguridad social, aunque el gobierno no haya actuado al respecto debido a la falta de una estrategia coherente de financiación sanitaria. Las conclusiones pueden ser particularmente pertinentes para los países de ingresos bajos y medianos que estén tratando de ampliar la cobertura de la seguridad social a pesar de la limitación del empleo formal.

Patient willingness to contribute to the cost of novel implants in total joint arthroplasty: the Canadian experience

Background: In Canada, health care is covered by provincial health insurance programs; patients do not directly participate in paying for their acute care expenses. The aim of this study is to assess the willingness of Canadian patients to contribute to the costs of novel total joint arthroplasty implants. Methods: We administered a questionnaire to patients attending an outpatient arthroplasty clinic in Ontario. In the questionnaire, the longevity and risk of complications of a "standard" implant were described. We asked if participants would be willing to contribute to the cost of 3 novel implants that had differing longevities and risks of complications compared with the standard implant. Results: One hundred and fifteen patients completed our questionnaire. Up to 62% of patients were willing to contribute a copayment to get an implant with greater longevity. Willingness to pay decreased to 40% for an implant with greater longevity but an increased risk of complications. Forty percent of participants were willing to pay for an implant with the same longevity as the standard implant but a decreased risk of complications. Participants with a higher income were more willing than other participants to contribute to the cost of a novel implant with greater longevity or lower complication rates. Conclusion: This study demonstrated that up to 62% of our sample of patients in Ontario were willing to share the costs of a novel total joint replacement implant. Willingness to pay was associated with the proposed benefits of the implant and certain patient characteristics. Our study shows that a high proportion of Canadian patients may be willing to copay to have access to new technologies.

Contexte: Au Canada, les soins de santé sont assurés par les régimes provinciaux d'assurance maladie; les patients ne participent pas directement au paiement des soins de santé actifs. Le but de cette étude était de vérifier si les patients canadiens sont prêts à contribuer au paiement de prothèses d'un type nouveau pour les arthroplasties totales. Méthodes: Nous avons administré un questionnaire à des patients d'une clinique externe d'arthroplastie en Ontario. Dans le questionnaire, on décrivait la durée de vie et les risques de complications associés à une prothèse « standard ¼. Nous avons demandé aux participants s'ils étaient ouverts à l'idée de contribuer au paiement de 3 prothèses d'un nouveau type, comportant une durée de vie et des risques de complications différents de ceux de la prothèse standard. Résultats: Cent quinze patients ont répondu à notre questionnaire. Jusqu'à 62 % des patients se sont dits prêts à contribuer à une forme de copaiement pour obtenir une prothèse plus durable. La volonté de payer diminuait à 40 % pour une prothèse plus durable mais comportant plus de risques de complications. Quarante pour cent des participants se sont dits prêts à payer pour une prothèse de même durée de vie que la prothèse standard, mais comportant moins de risques de complications. Les participants ayant un revenu plus élevé étaient davantage disposés à contribuer au paiement d'une prothèse d'un nouveau type plus durable et comportant moins de risques de complications comparativement aux autres participants. Conclusion: Cette étude a démontré que jusqu'à 62 % de notre échantillon de patients ontariens étaient prêts à partager les coûts d'une nouvelle prothèse pour arthroplastie totale. La volonté de payer était associée aux avantages présumés de la prothèse et à certaines caractéristiques des patients. Notre étude montre qu'une forte proportion de patients canadiens seraient prêts à s'engager dans un copaiement pour avoir accès à de nouvelles technologies.

Healthcare System-Funded Preventive Genomic Screening: Challenges for Australia and Other Single-Payer Systems.

The prospect of healthcare systems offering population-based preventive genomic testing to all adults is becoming feasible. Some single-payer or state-funded healthcare systems are already considering offering universal testing as part of routine care. In countries with public healthcare systems, there is a unique opportunity to provide such testing in the form of a national screening program, following existing national population health-screening frameworks. This paradigm, if achievable, could help deliver a degree of testing quality and equity-of-access that may not be possible in private-payer or direct-to-consumer models, to maximize prevention and health benefits. Here, we outline some of the major challenges ahead in considering this prospect and discuss the research that is helping shape the future direction in Australia and elsewhere.

Determining preventable acute care spending among high-cost patients in a single-payer public health care system.

BACKGROUND: Research has shown that a small proportion of patients account for the majority of health care spending. The objective of this analysis was to determine the amount and proportion of preventable acute care spending among high-cost patients. METHODS: We examined a population-based sample of all adult high-cost patients using linked administrative health care data housed at ICES in Toronto, Ontario. High-cost patients were defined as those in and above the 90th percentile of the cost distribution. Preventable acute care (emergency department visits and hospitalisations) was defined using validated algorithms. We estimated costs of preventable and non-preventable acute care for high- and non-high-cost patients by category of visit/condition. We replicated our analysis for persistent high-cost patients and high-cost patients under 65 years and those 65 years and older. RESULTS: We found that 10% of all acute care spending among high-cost patients was considered preventable; this figure was higher for non-high-cost patients (25%). The proportion of preventable acute care spending was higher for persistent high-cost patients (14%) and those 65 years and older (12%). Among ED visits, the largest portion of preventable care spending was for primary care treatable conditions; for hospitalisations, the highest proportions of preventable care spending were for COPD, bacterial pneumonia and urinary tract infections. CONCLUSIONS: Although high-cost patients account for a substantial proportion of health care costs, there seems to be limited scope to prevent acute care spending among this patient population. Nonetheless, care coordination and improved access to primary care, and disease prevention may prevent some acute care.

Can single disease payment system based on clinical pathway reduce hospitalization costs in rural area? A case study of uterine leiomyoma in Anhui, China.

BACKGROUND: Single disease payment program based on clinical pathway (CP-based SDP) plays an increasingly important role in reducing health expenditure in china and there is a clear need to explore the scheme from different perspectives. This study aimed at evaluating the effect of the scheme in rural county public hospitals within Anhui, a typical province of China,using uterine leiomyoma as an example. METHODS: The study data were extracted from the data platform of the New Rural Cooperative Medical Office of Anhui Province using stratified-random sampling. Means, constituent ratios and coefficients of variations were calculated and/or compared between control versus experiment groups and between different years. RESULTS: The total hospitalization expenditure (per-time) dropped from 919.08 ± 274.92 USD to 834.91 ± 225.29 USD and length of hospital stay reduced from 9.96 ± 2.39 days to 8.83 ± 1.95 days(P < 0.01), after CP-based SDP had implemented. The yearly total hospitalization expenditure manifested an atypical U-shaped trend. Medicine expense, nursing expense, assay cost and treatment cost reduced; while the fee of operation and examination increased (P < 0.05). The expense constituent ratios of medicine, assay and treatment decreased with the medicine expense dropped the most (by 4.4%). The expense constituent ratios of materials, ward, operation, examination and anesthetic increased,with the examination fee elevated the most (by 3.9%).The coefficient of variation(CVs) of treatment cost declined the most (- 0.360); while the CV of materials expense increased the most (0.186). CONCLUSION: There existed huge discrepancies in inpatient care for uterine leiomyoma patients. Implementation of CP-based SDP can help not only in controlling hospitalization costs of uterine leiomyoma in county-level hospitals but also in standardizing the diagnosis and treatment procedures.

How Single-payer Stacks Up: Evaluating Different Models of Universal Health Coverage on Cost, Access, and Quality.

Described as "universal prepayment," the national health insurance (or single-payer) model of universal health coverage is increasingly promoted by international actors as a means of raising revenue for health care and improving social risk protection in low- and middle-income countries. Likewise, in the United States, the recent failed efforts to repeal and replace the Affordable Care Act have renewed debate about where to go next with health reform and arguably opened the door for a single-payer, Medicare-for-All plan, an alternative once considered politically infeasible. Policy debates about single-payer or national health insurance in the United States and abroad have relied heavily on Canada's system as an ideal-typical single-payer system but have not systematically examined health system performance indicators across different universal coverage models. Using available cross-national data, we categorize countries with universal coverage into those best exemplifying national health insurance (single-payer), national health service, and social health insurance models and compare them to the United States in terms of cost, access, and quality. Through this comparison, we find that many critiques of single-payer are based on misconceptions or are factually incorrect, but also that single-payer is not the only option for achieving universal coverage in the United States and internationally.