The Increasing Adoption of Out-of-Pocket Cost Caps: Benefits, Unintended Consequences, and Policy Opportunities.

This Viewpoint discusses potential benefits and unintended consequences of out-of-pocket cost caps in Medicare and the employer-sponsored health insurance market and provides suggested policy opportunities to address shortcomings.

Bariatric and Metabolic Surgery and Medical Insurance Payment in China.

PURPOSE OF REVIEW: This paper briefly introduces the status quo of bariatric and metabolic surgery and medical insurance payment in China. RECENT FINDINGS: Along with China's rapid economic growth, the prevalence of obesity and diabetes is increasing quickly. Because of their high body fat percentage and predominance of abdominal obesity, Chinese people experience metabolic disorders more frequently than Caucasians with the same BMI. Treatments are not medical because there is a lack of social understanding of obesity. Furthermore, obesity has not been accepted as a disease in China and so has not been included in the medical insurance payment system. Therefore, weight-loss medications are not covered by medical insurance. In China, bariatric and metabolic surgery have advanced for almost 20 years, and corresponding guidelines have been developed. However, there are regional and cognitive variations in whether medical insurance covers bariatric surgery or not. Recent research on the financial advantages of medical insurance coverage for weight-loss surgery showed that it conserves healthcare system resources. It will be important to raise public awareness regarding obesity in the future, present more evidence of the clinical efficacy of surgery, and work towards a higher percentage of medical insurance reimbursement for obesity treatment and bariatric surgery.

338ª Reunião Ordinária - 26 jan. 2023

Na parte da manhã. das 9h às 12h30, na Sala João Neves da Fontoura (Plenarinho) - Assembleia Legislativa do Estado do Rio Grande do Sul, Praça Marechal Deodoro, nº 101, Centro Histórico - Porto Alegre/RS. E no período da tarde, no 26 de janeiro de 2023, das 13h30 às 15h30, no Teatro Dante Barone - Assembleia Legislativa do Estado do Rio Grande do Sul, Praça Marechal Deodoro, nº 101, Centro Histórico - Porto Alegre/RS

Challenges for Medicare and universal health care in Australia since 2000.

OBJECTIVES: To identify the financing and policy challenges for Medicare and universal health care in Australia, as well as opportunities for whole-of-system strengthening. STUDY DESIGN: Review of publications on Medicare, the Pharmaceutical Benefits Scheme, and the universal health care system in Australia published 1 January 2000 - 14 August 2021 that reported quantitative or qualitative research or data analyses, and of opinion articles, debates, commentaries, editorials, perspectives, and news reports on the Australian health care system published 1 January 2015 - 14 August 2021. Program-, intervention- or provider-specific articles, and publications regarding groups not fully covered by Medicare (eg, asylum seekers, prisoners) were excluded. DATA SOURCES: MEDLINE Complete, the Health Policy Reference Centre, and Global Health databases (all via EBSCO); the Analysis & Policy Observatory, the Australian Indigenous HealthInfoNet, the Australian Public Affairs Information Service, Google, Google Scholar, and the Organisation for Economic Co-operation and Development (OECD) websites. RESULTS: The problems covered by the 76 articles included in our review could be grouped under seven major themes: fragmentation of health care and lack of integrated health financing, access of Aboriginal and Torres Strait Islander people to health services and essential medications, reform proposals for the Pharmaceutical Benefits Scheme, the burden of out-of-pocket costs, inequity, public subsidies for private health insurance, and other challenges for the Australian universal health care system. CONCLUSIONS: A number of challenges threaten the sustainability and equity of the universal health care system in Australia. As the piecemeal reforms of the past twenty years have been inadequate for meeting these challenges, more effective, coordinated approaches are needed to improve and secure the universality of public health care in Australia.

Addressing Racial Capitalism's Impact on Black Essential Workers During the COVID-19 Pandemic: Policy Recommendations.

Black Americans are more likely to be essential workers due to racial capitalism. Because of the COVID-19 pandemic, essential workers are less able to adhere to social distancing and stay-at-home guidelines due to the nature of their work, because they are more likely to occupy crowded households, and are more likely to possess pre-existing health conditions. To assist Black essential workers in preventing infection or reducing the intensity of symptoms if contracted, vaccination against the virus is essential. Unfortunately, Black essential workers face considerable barriers to accessing vaccinations and are hesitant to receive the vaccine due to widespread misinformation and justified historical mistrust of the American medical system. The purpose of this work is to (1) describe the disproportionate impact of COVID-19 on Black essential workers due to racial capitalism, (2) outline the socioeconomic and racial barriers related to vaccination within this population, and (3) to suggest policy-related approaches to facilitate vaccination such as access to on-site vaccination opportunities, the funding of community outreach efforts, and the mandating of increased employee benefits.

Brasil investiu pelo menos R$ 128 milhões em ações da Política Nacional de Promoção à Saúde no ano de 2021

Governo Federal, por meio do Ministério da Saúde, investiu pelo menos R$ 128 milhões em ações da Política Nacional de Promoção à Saúde (PNPS) no ano de 2021. O investimento fortaleceu o Sistema Único de Saúde (SUS) no estímulo à amamentação, no combate à obesidade infantil e na execução das ações do Programa Saúde na Escola.

Estimating and Comparing Health and Financial Risk Protection Outcomes in Economic Evaluations.

OBJECTIVES: Improving health and financial risk protection (FRP, the prevention of medical impoverishment) and their distributions is a major objective of national health systems. Explicitly describing FRP and disaggregated (eg, across socioeconomic groups) impact of health interventions in economic evaluations can provide decision makers with a broader set of health and financial outcomes to compare and prioritize interventions against each other. METHODS: We propose methods to synthesize such a broader set of outcomes by estimating and comparing the distributions in both health and FRP benefits procured by health interventions. We build on benefit-cost analysis frameworks and utility-based models, and we illustrate our methods with the case study of universal public finance (financing by government regardless of whom an intervention is targeting) of disease treatment in a low- and middle-income country setting. RESULTS: Two key findings seem to emerge: FRP is critical when diseases are less lethal (eg, case fatality rates <1% or so), and quantitative valuation of inequality aversion across income groups matters greatly. We recommend the use of numerous sensitivity analyses and that all distributional health and financial outcomes be first presented in a disaggregated form (before potential subsequent aggregation). CONCLUSIONS: Estimation approaches such as the one we propose provide explicit disaggregated considerations of equity, FRP, and poverty impact for the development of health sector policies, with high relevance for population-based preventive measures.

Epidemics and local governments in struggling nations: COVID-19 in Lebanon.

Municipalities in Lebanon represent local governments at the basic community level. The proximity of the municipality to the local community and its knowledge of available resources, can be crucial in easing the impact of any disaster. This study aimed to document the range of preparedness/reactivity of municipalities as COVID-19 swept through Lebanon. A qualitative case study was implemented to explore municipal response to control the epidemic, using in-depth semi-structured interviews with twenty-seven stakeholders from nine municipalities across all governorates in Lebanon. In each municipality, participants included mayors/deputy mayors, available members of municipal councils, prominent community leaders, health care professionals, and managers of local NGOs. The collected data were analyzed using the comparative thematic analysis. The socioecological model was adopted to illustrate the dynamic interplay between the barriers and facilitators at all ecological levels. The response to the pandemic differed significantly in volume and nature among different municipalities across regions, with rural areas clearly disadvantaged in terms of adequacy and completeness of response. Barriers consistently mentioned by most municipalities included economic collapse and poverty, shortage in resources, lack of support from the central government, stigma, lack of awareness, underreporting, flaws in the MOPH surveillance system, impeded accessibility to healthcare services, limited number and weak role of municipal police, increased mental illnesses, and political patronage, favoritism, and interference. On the other hand, increased donations, community engagement, social support and empathy, sufficient human resources, the effective role of healthcare systems, and good governance were identified as key facilitators. The socioecological model identified several multi-level facilitators and loopholes which can be addressed through a suggested strategic "roadmap" providing evidence-based interventions for future epidemics. It is crucial meanwhile that the central government strengthens the administrative and financial resources of municipalities in preparing and rapidly deploying the expected optimal response.

We're all in this together: Focus on community attenuates effects of pandemic-related financial hardship on reactance to COVID-19 public health regulations.

There has been resistance to COVID-19 public health restrictions partly due to changes and reductions in work, resulting in financial stress. Psychological reactance theory posits that such restrictions to personal freedoms result in anger, defiance, and motivation to restore freedom. In an online study (N = 301), we manipulated the target of COVID-19 restrictions as impacting self or community. We hypothesized that (a) greater pandemic-related financial stress would predict greater reactance, (b) the self-focused restriction condition would elicit greater reactance than the community-focused restriction condition, (c) reactance would be greatest for financially-stressed individuals in the self-focused condition, and (d) greater reactance would predict lower adherence to social distancing guidelines. Independent of political orientation and sense of community, greater financial stress predicted greater reactance only in the self-focused condition; the community-focused condition attenuated this association. Additionally, greater reactance was associated with lower social distancing behavior. These findings suggest that economic hardship exacerbates negative responses to continued personal freedom loss. Community-focused COVID-19 health messaging may be better received during continued pandemic conditions.

Analysis of Contraceptive Use Among Immigrant Women Following Expansion of Medicaid Coverage for Postpartum Care.

Importance: Access to postpartum care is restricted for low-income women who are recent or undocumented immigrants enrolled in Emergency Medicaid. Objective: To examine the association of a policy extending postpartum coverage to Emergency Medicaid recipients with attendance at postpartum visits and use of postpartum contraception. Design, Setting, and Participants: This cohort study linked Medicaid claims and birth certificate data from 2010 to 2019 to examine changes in postpartum care coverage on postpartum care and contraception use. A difference-in-difference design was used to compare the rollout of postpartum coverage in Oregon with a comparison state, South Carolina, which did not cover postpartum care. The study used 2 distinct assumptions to conduct the analyses: first, preintervention differences in postpartum visit attendance and contraceptive use would have remained constant if the policy expanding coverage had not been passed (parallel trends assumption), and second, differences in preintervention trends would have continued without the policy change (differential trend assumption). Data analysis was performed from September 2020 to October 2021. Exposures: Medicaid coverage of postpartum care. Main Outcomes and Measures: Attendance at postpartum visits and postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery. Results: The study population consisted of 27 667 live births among 23 971 women (mean [SD] age, 29.4 [6.0] years) enrolled in Emergency Medicaid. The majority of all births were to multiparous women (21 289 women [76.9%]; standardized mean difference [SMD] = 0.08) and were delivered vaginally (20 042 births [72.4%]; SMD = 0.03) and at term (25 502 births [92.2%]; SMD = 0.01). Following Oregon's expansion of postpartum coverage to women in Emergency Medicaid, there was a large and significant increase in postpartum care visits and contraceptive use. Assuming parallel trends, postpartum care attendance increased by 40.6 percentage points (95% CI, 34.1-47.1 percentage points; P < .001) following the policy change. Under the differential trends assumption, postpartum visits increased by 47.9 percentage points (95% CI, 41.3-54.6 percentage points; P < .001). Postpartum contraception use increased similarly. Under the parallel trends assumption, postpartum contraception within 60 days increased by 33.2 percentage points (95% CI, 31.1-35.4 percentage points; P < .001). Assuming differential trends, postpartum contraception increased by 28.2 percentage points (95% CI, 25.8-30.6 percentage points; P < .001). Conclusions and Relevance: These findings suggest that expanding Emergency Medicaid benefits to include postpartum care is associated with significant improvements in receipt of postpartum care and contraceptive use.

Cost-Effectiveness of COVID-19 Policy Measures: A Systematic Review.

OBJECTIVES: The COVID-19 pandemic has had a major impact on our society, with drastic policy restrictions being implemented to contain the spread of the severe acute respiratory syndrome coronavirus 2. This study aimed to provide an overview of the available evidence on the cost-effectiveness of various coronavirus disease 2019 policy measures. METHODS: A systematic literature search was conducted in PubMed, Embase, and Web of Science. Health economic evaluations considering both costs and outcomes were included. Their quality was comprehensively assessed using the Consensus Health Economic Criteria checklist. Next, the quality of the epidemiological models was evaluated. RESULTS: A total of 3688 articles were identified (March 2021), of which 23 were included. The studies were heterogeneous with regard to methodological quality, contextual factors, strategies' content, adopted perspective, applied models, and outcomes used. Overall, testing/screening, social distancing, personal protective equipment, quarantine/isolation, and hygienic measures were found to be cost-effective. Furthermore, the most optimal choice and combination of strategies depended on the reproduction number and context. With a rising reproduction number, extending the testing strategy and early implementation of combined multiple restriction measures are most efficient. CONCLUSIONS: The quality assessment highlighted numerous flaws and limitations in the study approaches; hence, their results should be interpreted with caution because the specific context (country, target group, etc) is a key driver for cost-effectiveness. Finally, including a societal perspective in future evaluations is key because this pandemic has an indirect impact on the onset and treatment of other conditions and on our global economy.

Health system efficiency and democracy: A public choice perspective.

Due to increasing demand and scarce financial resources for healthcare, health system efficiency has become a major topic in political and scientific debates. While previous studies investigating determinants of health system efficiency focused primarily on economic and social influence factors, the role of the political regime has been neglected. In addition, there is a lack of formal theoretical work on this specific topic, which ensures transparency and logical consistency of arguments and implications. Using a public choice approach, this paper provides a rigorous theoretical and empirical investigation of the relationships between health system efficiency and political institutions. We develop a simple principal-agent model describing the behavior of a government with respect to investments in population health under different political regimes. The main implication of the theoretical model is that governments under more democratic regimes put more effort in reducing embezzlement of health expenditure than non-democratic regimes. Accordingly, democratic countries are predicted to have more efficient health systems than non-democratic countries. We test this hypothesis based on a broad dataset including 158 countries over the period 1995-2015. The empirical results clearly support the implications of the theoretical model and withstand several robustness checks, including the use of alternative indicators for population health and democracy and estimations accounting for endogeneity. The empirical results also indicate that the effect of democracy on health system efficiency is more pronounced in countries with higher income levels. From a policy perspective, we discuss the implications of our findings in the context of health development assistance.

Cost Analysis of Liver Acquisition Fees Before and After Acuity Circle Policy Implementation.

Importance: Acuity circles (AC) liver allocation policy was implemented to eliminate donor service area geographic boundaries from liver allocation and to decrease variability in median Model of End-stage Liver Disease (MELD) score at transplant and wait list mortality. However, the broader sharing of organs was also associated with more flights for organ procurements and higher costs associated with the increase in flights. Objective: To determine whether the costs associated with liver acquisition changed after the implementation of AC allocation. Design, Setting, and Participants: This single-center cost comparison study analyzed fees associated with organ acquisition before and after AC allocation implementation. The cost data were collected from a single transplant institute with 2 liver transplant centers, located 30 miles apart, in different donation service areas. Cost, recipient, and transportation data for all cases that included fees associated with liver acquisition from July 1, 2019, to October 31, 2020, were collected. Exposures: Primary liver offer acceptance with associated organ procurement organization or charter flight fees. Main Outcomes and Measures: Specific fees (organ acquisition, surgeon, import, and charter flight fees) and total fees per donor were collected for all accepted liver donors with at least 1 associated fee during the study period. Results: Of 213 included donors, 171 were used for transplant; 90 of 171 (52.6%) were male, and the median (interquartile range) age of donors was 41.0 (30.0-52.8) years in the pre-AC period and 36.9 (24.0-48.8) years in the post-AC period. There was no significant difference in the post-AC compared with pre-AC period in median (range) MELD score (24 [8-40] vs 25 [6-40]; P = .27) or median (range) match run sequence (15 [1-3951] vs 10 [1-1138]; P = .31), nor in mean (SD) distance traveled (155.83 [157.00] vs 140.54 [144.33] nautical miles; P = .32) or percentage of donors requiring flights (58.5% [69 of 118] vs 56.8% [54 of 95]; P = .82). However, costs increased significantly in the post-AC period: total cost increased 16% per accepted donor (mean [SD] of $52 966 [13 278] vs $45 725 [9300]; P < .001) and 55% per declined donor (mean [SD] of $15 865 [3942] vs $10 217 [4853]; P < .001). Contributing factors included more than 2-fold increases in the proportions of donors incurring import fees (31.4% [37 of 118] vs 12.6% [12 of 95]; P = .002) and surgeon fees (19.5% [23 of 118] vs 9.5% [9 of 95]; P = .05), increased acquisition fees (10% increase; mean [SD] of $43 860 [3266] vs $39 980 [2236]; P < .001), and increased flight expenses (43% increase; mean [SD] of $12 904 [6066] vs $9049 [5140]; P = .002). Conclusions and Relevance: The unintended consequences of implementing broader sharing without addressing organ acquisition fees to account for increased importation between organ procurement organizations must be remedied to contain costs and ensure viability of transplant programs.

Evaluation of Clinical and Economic Outcomes Following Implementation of a Medicare Pay-for-Performance Program for Surgical Procedures.

Importance: Surgical complications increase hospital costs by approximately $20 000 per admission and extend hospital stays by 9.7 days. Improving surgical care quality and reducing costs is needed for patients undergoing surgery, health care professionals, hospitals, and payers. Objective: To evaluate the association of the Hospital-Acquired Conditions Present on Admission (HAC-POA) program, a mandated national pay-for-performance program by the Centers for Medicare & Medicaid Services, with surgical care quality and costs. Design, Setting, and Participants: A cross-sectional study of Medicare inpatient surgical care stays from October 2004 through September 2017 in the US was conducted. The National Inpatient Sample and a propensity score-weighted difference-in-differences analysis of hospital stays with associated primary surgical procedures was used to compare changes in outcomes for the intervention and control procedures before and after HAC-POA program implementation. The sample consisted of 1 317 262 inpatient surgical episodes representing 1 198 665 stays for targeted procedures and 118 597 stays for nontargeted procedures. Analyses were performed between November 1, 2020, and May 7, 2021. Exposures: Implementation of the HAC-POA program for the intervention procedures included in this study (fiscal year 2009). Main Outcomes and Measures: Incidence of surgical site infections and deep vein thrombosis, length of stay, in-hospital mortality, and hospital costs. Analyses were adjusted for patient and hospital characteristics and indicators for procedure type, hospital, and year. Results: In our propensity score-weighted sample, the intervention procedures group comprised 1 047 351 (88.5%) individuals who were White and 742 734 (60.6%) women; mean (SD) age was 75 (6.9) years. The control procedures group included 94 715 (88.0%) individuals who were White, and 65 436 (60.6%) women; mean (SD) age was 75 (7.1) years. After HAC-POA implementation, the incidence of surgical site infections in targeted procedures decreased by 0.3 percentage points (95% CI, -0.5 to -0.1 percentage points; P = .02) compared with nontargeted procedures. The program was associated with a reduction in length of stay by 0.5 days (95% CI, -0.6 to -0.4 days; P < .001) and hospital costs by 8.1% (95% CI, -10.2% to -6.1%; P < .001). No significant changes in deep vein thrombosis incidence and mortality were noted. Conclusions and Relevance: The findings of this study suggest that the HAC-POA program is associated with small decreases in surgical site infection and length of stay and moderate decreases in hospital costs for patients enrolled in Medicare. Policy makers may consider these findings when evaluating the continuation and expansion of this program for other surgical procedures, and payers may want to consider adopting a similar policy.

Availability, affordability and price components of insulin products in different-level hospital pharmacies: Evidence from two cross-sectional surveys in Nanjing, China.

The essential medicine--insulin cannot be easily accessed and afforded in many countries. To help address this issue, we evaluated the availability, affordability and price of insulin products in Nanjing, eastern China. Two cross-sectional studies were conducted in 2016 and 2018. A total of 56 hospital pharmacies were sampled, using a simplified and adapted World Health Organization/Health Action International (WHO/HAI) methodology. Prices were expressed as Median Price Ratios (MPRs) to Australian Pharmaceutical Benefit Scheme (PBS) prices. In addition, we investigated the price components of seven selected insulin products as a case study before and after the Online Centralized Procurement Policy for Hospital Drugs in May, 2018. Affordability was presented as the number of daily wages of the lowest paid unskilled government worker (LPGW) required to purchase 1000IU of insulin based on the average courses of treatment, approximately 30 days' treatment. The availability of insulin products was very high in secondary hospitals and tertiary hospitals both in 2016 and 2018, but in community hospitals was very low. In 2018, the availability of prandial insulin products showed fluctuation compared to 2016. The availability of pre-mixed human insulin products was over 95% overall, and also very high (80%) in community hospitals in 2018. The prices of insulin products were much lower than PBS prices of Australian in this study, with the MPRs less than 1 (0.32 to 0.71 in 2016 vs. 0.30 to 0.68 in 2018) for all insulin types. But insulin products in Nanjing in 2016 and 2018 were considered unaffordable, because the number of daily wages of the LPGW needed to purchase for the 30 days treatment of insulin products ranged from 2.26 to 8.49 in 2016 and 1.88 to 7.09 in 2018. The manufacturers' selling price contributed the main part (74.15% to 77.70% before and 74.86% to 91.51% after the implementation of the bidding policy) of the price components of target insulin brands. The availability of insulin products was high in secondary hospitals and tertiary hospitals, but lower in community hospitals. However, the affordability in community hospitals was better than other hospitals, but the insulin products were still unaffordable for patients on low incomes. Further improvements of the availability accessibility and affordability of medicines in advancing health insurance policies and lowering drug prices should be put forward.