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1.
Plast Reconstr Surg ; 145(2): 545-554, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985657

RESUMO

BACKGROUND: Following bariatric surgery, patients develop problems related to lax abdominal skin that may be addressed by contouring procedures. Third-party insurers have subjective requirements for coverage of these procedures that can limit patient access. The authors sought to determine how well third-party payers cover abdominal contouring procedures in this population. METHODS: The authors conducted a cross-sectional analysis of insurance policies for coverage of panniculectomy, lower back excision, and circumferential lipectomy. Abdominoplasty was evaluated as an alternative to panniculectomy. Insurance companies were selected based on their market share and state enrolment. A list of medical necessity criteria was abstracted from the policies that offered coverage. RESULTS: Of the 55 companies evaluated, 98 percent had a policy that covered panniculectomy versus 36 percent who would cover lower back excision (p < 0.0001), and one-third provided coverage for circumferential lipectomy. Of the insurers who covered panniculectomy, only 30 percent would also cover abdominoplasty. Documentation of secondary skin conditions was the most prevalent criterion in panniculectomy policies (100 percent), whereas impaired function and secondary skin conditions were most common for coverage of lower back excision (73 percent and 73 percent, respectively). Frequency of criteria for panniculectomy versus lower back excision differed most notably for (1) secondary skin conditions (100 percent versus 73 percent; p = 0.0030), (2) weight loss (45 percent versus 7 percent; p = 0.0106), and (3) duration of weight stability (82 percent versus 53 percent; p = 0.0415). CONCLUSIONS: For the postbariatric population, panniculectomy was covered more often and had more standardized criteria than lower back excision or circumferential lipectomy. However, all have vast intracompany and interpolicy variations in coverage criteria that may reduce access to procedures, even among patients with established indications.


Assuntos
Abdominoplastia/economia , Cirurgia Bariátrica/economia , Contorno Corporal/economia , Cobertura do Seguro/economia , Seguro Saúde/estatística & dados numéricos , Abdominoplastia/estatística & dados numéricos , Dorso/cirurgia , Estudos Transversais , Humanos , Seguradoras/economia , Seguradoras/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Lipectomia/economia , Lipectomia/estatística & dados numéricos , Cuidados Pós-Operatórios/economia , Estados Unidos
3.
Medicine (Baltimore) ; 98(39): e17376, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31574887

RESUMO

This study aimed to compare the catastrophic health expenditure (CHE) and impoverishment of type 2 diabetes mellitus (T2DM) patients between 2 ethnic groups and explore the contribution of associated factors to ethnic differences in CHE and impoverishment in Ningxia Hui Autonomous Region, China.A cross-sectional study was conducted in 2 public hospitals from October 2016 to June 2017. Data were collected by interviewing eligible Hui and Han T2DM inpatients and reviewing the hospital electronic records. Both CHE and impoverishment were measured by headcount and gap. The contributions of associated factors to ethnic differences were analyzed by the Blinder-Oaxaca decomposition technique.Both the CHE and impoverishment of Hui patients before and after reimbursement were significantly higher than those of Han patients. The ethnic differences in CHE and impoverishment headcount after reimbursement were 11.9% and 9.8%, respectively. The different distributions of associated factors between Hui and Han patients contributed to 60.5% and 35.7% of ethnic differences in CHE and impoverishment, respectively. Household income, occupation, and region were significant contributing factors.Hui T2DM patients suffered greater CHE and impoverishment than Han patients regardless of reimbursements from health insurance. Differences in socioeconomic status between Hui and Han patients were the main factors behind the ethnic differences.


Assuntos
Doença Catastrófica/economia , Diabetes Mellitus Tipo 2/economia , Gastos em Saúde/estatística & dados numéricos , Seguro Saúde/economia , Pobreza/economia , Idoso , China , Estudos Transversais , Diabetes Mellitus Tipo 2/etnologia , Grupos Étnicos/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Socioeconômicos
5.
Schmerz ; 33(5): 437-442, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31531729

RESUMO

BACKGROUND: On March 10th 2017, the law amending narcotic and other regulations was expanded, thereby allowing physicians, irrespective of their specialization, to prescribe cannabis-derived medicines as magistral formulas or proprietary medicinal products at the expense of the German statutory health insurance (GKV). First prescription requires approval from the respective health insurance, which in turn commissions the Medical Advisory Board of the Statutory Health Insurance Funds (MDK) to prepare a medico-legal report. OBJECTIVES: Since § 31 Para. 6 of the German Social Code, Book V (SGB V) came into effect, a multitude of imponderables have been reported regarding reimbursement. Based on the experience of the MDK Nord, problems within the fields of patients, physicians and cannabis-derived medicines are illustrated. MATERIAL AND METHODS: Considering current literature, a retrospective review was conducted including approximately 2200 applications for reimbursement received in 2018 from patients residing in Hamburg and Schleswig-Holstein. RESULTS: A relevant problem within the field of patients resulted from the lack of a specific definition of the term "severe (chronic) disease". Although this term is mentioned several times in SGB V, it is not put into concrete terms. Circumstances like multimorbidity are not taken into account. Another problem consisted in an irreproducible anticipation of treatment with cannabis-derived medicines. Within the field of physicians, a major problem was caused by missing, fragmentary or inconsistent information regarding disease and/or therapy. Hence, initially, almost one-third of all applications could not be appraised. Amongst various cannabis-derived medicines, dried flowers were found to be the most problematic regarding doses and effective levels. Notably, a marked increase in numbers of applications for reimbursement of therapy with pure cannabidiol was noted. DISCUSSION: Numerous problems reported elsewhere and relating to prescription of cannabis-derived medicines were also observed by the MDK Nord. Many prescriptions reflected an uncertainty regarding therapeutic use of cannabis-derived medicines. Thus, one should consider restricting the prescription of cannabis-derived medicines to selected specialists. It should be noted that, in individual cases, e.g., patients suffering from neuropathic pain, treatment with cannabis-derived medicines seems to be a reasonable therapeutic option taking into account the risks and benefits.


Assuntos
Cannabis , Dor Crônica , Administração Financeira , Reembolso de Seguro de Saúde , Dor Crônica/tratamento farmacológico , Administração Financeira/normas , Administração Financeira/estatística & dados numéricos , Alemanha , Humanos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Reembolso de Seguro de Saúde/estatística & dados numéricos , Maconha Medicinal/economia , Maconha Medicinal/uso terapêutico , Estudos Retrospectivos
6.
BMC Health Serv Res ; 19(1): 661, 2019 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-31519181

RESUMO

BACKGROUND: Various attempts to examine health financing mechanisms in Nigeria highlight the fact that there is no single mechanism that fits all contexts and people. This paper sets out findings of an in-depth assessment of different health financing mechanisms in Nigeria. METHODS: The study was undertaken in the Federal Capital territory of Nigeria and two States (Niger and Kaduna). Data were collected through review of government documents, and in-depth interviews of purposively selected respondents. Data analysis was guided by a conceptual framework which draws from various approaches for assessing health financing mechanisms. Data was examined for current practices, what needs to change and how the change can happen. RESULTS: Health financing mechanisms in Nigeria do not operate optimally. Allocation and use of resources are neither evidence-based nor results-driven. Resources are not allocated equitably or in a manner that minimizes wastage and improves efficiency. None of the mechanisms effectively protects individuals/households from catastrophic health expenditure. Issues with social health insurance cut across legal frameworks and use of Health Maintenance Organisations (HMOs) as purchasers. The concomitant effect is that attainment of Universal Health Coverage is greatly compromised. In order to improve efficiency of health financing mechanisms, government needs to allocate more funds for purchasing health services; this spending must be based on evidence (strategic), and appropriately tracked. The legislation that established National Health Insurance Scheme should be amended such that social health insurance becomes mandatory for all citizens. Implementation of the latter should be complemented by revision of benefit package, strict oversight and regulation of HMOs. CONCLUSION: In order to improve health financing in the country, legal and regulatory frameworks need to be revised. Efficient utilization of resources could be improved through strategic purchasing arrangements and strict oversight.


Assuntos
Assistência à Saúde/organização & administração , Financiamento da Assistência à Saúde , Seguro Saúde/organização & administração , Assistência à Saúde/economia , Sistemas Pré-Pagos de Saúde , Serviços de Saúde/economia , Humanos , Seguro Saúde/economia , Nigéria , Cobertura Universal do Seguro de Saúde
7.
Rev Med Suisse ; 15(660): 1532, 2019 Aug 28.
Artigo em Francês | MEDLINE | ID: mdl-31496184
8.
BMC Health Serv Res ; 19(1): 633, 2019 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-31488152

RESUMO

BACKGROUND: Faced with growing budget pressure, policymakers worldwide recognize the necessity of strategic disinvestment from ineffective, inefficient or harmful medical practices. However, disinvestment programs face substantial social, political and cultural challenges: mistrust, struggles for clinical autonomy or stakeholders' reluctance to engage in what can be perceived as 'rationing'. Academic literature says little about effective strategies to address these challenges. This paper provides insights on this matter. We analyzed the epistemic work of a group of policymakers at the National Health Care Institute on what was initially a disinvestment initiative within the context of the Dutch basic benefits package: the 'Appropriate Care' program. The Institute developed a strategy using national administrative data to identify and tackle low-value care covered from public funds as well as potential underuse, and achieve savings through improved organization of efficiency and quality in health care delivery. How did the Institute deal with the socio-political sensitivities associated with disinvestment by means of their epistemic work? METHOD: We conducted ethnographic research into the National Health Care Institute's epistemic practices. Research entailed document analysis, non-participant observation, in-depth conversations, and interviews with key-informants. RESULTS: The Institute dealt with the socio-political sensitivities associated with disinvestment by democratizing the epistemic practices to identify low-value care, by warranting data analysis by clinical experts, by creating an epistemic safe space for health care professionals who were the object of research into low-value care, and by de-emphasizing the economization measure. Ultimately, this epistemic work facilitated a collaborative construction of problems relating to low-value care practices and their solutions. CONCLUSIONS: This case shows that - apart from the right data and adequate expertise - disinvestment requires clinical leadership and political will on the part of stakeholders. Our analysis of the Institute's Appropriate Care program shows how the epistemic effort to identify low-value care became a co-construction between policymakers, care providers, patients and insurers of problems of 'waste' in Dutch social health insurance. This collective epistemic work gave cognitive, moral and political standing to the idea of 'waste' in public health expenditure.


Assuntos
Assistência à Saúde/economia , Seguro Saúde/economia , Avaliação de Programas e Projetos de Saúde/economia , Antropologia Cultural , Orçamentos , Humanos , Países Baixos , Previdência Social/economia
9.
Schmerz ; 33(5): 443-448, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31478141

RESUMO

BACKGROUND: Since March 2017 the law amending narcotics and other legal regulations has made it possible for doctors to prescribe cannabis and cannabis-derived medicines. The introduction of § 31 para 6 of the Social Code Book V (SGB V) allows that patients can be treated with cannabis-derived medicines at the expense of the statutory health insurance if they have a severe illness. COURT DECISIONS: The law requires the approval of a prescription of cannabis for medical purposes by the health insurance before the granting of benefits. Due to denied permission, numerous cases are pending before the social tribunals. The article presents which legal issues are decided and why there is still no case law from the Federal Social Court on the essential questions. OUTLOOK: The possibility of prescribing cannabis as medicine at the expense of the health insurance is an important advance in social law. The § 31 para 6 SGB V should be evaluated as soon as possible. The provisions of SGB V for the reimbursement of off-label treatment should be harmonized with § 31 para 6 SGB V.


Assuntos
Cannabis , Seguro Saúde , Médicos , Prescrições , Assistência à Saúde/legislação & jurisprudência , Alemanha , Humanos , Seguro Saúde/economia , Seguro Saúde/legislação & jurisprudência , Médicos/legislação & jurisprudência , Prescrições/estatística & dados numéricos
10.
BMC Health Serv Res ; 19(1): 610, 2019 Aug 30.
Artigo em Inglês | MEDLINE | ID: mdl-31470846

RESUMO

BACKGROUND: Even though China launched a series of measures to alleviate several financial burdens (including health insurance scheme, increased government investment, and so on), the economic burden of health expenditure has still not been alleviated. Out-of-pocket payments (OPPs) show not only a time correlation but also some degree of spatial correlation. The aims of the current study were thus to identify the spatial cluster of OPPs, to investigate the main factors affecting variation, and to explore the spatial spillover sources of China's OPP. METHODS: Global and local spatial autocorrelation tests were validated to identify the spatial cluster of OPPs using the panel data of 31 provinces in China from 2005 to 2016. The Spatial Durbin Model, established in this paper, measured the spatial spillover effect of OPPs and analyzed the possible spillover sources (demand, supply, and socio-economic factors. RESULTS: OPPs were found to have a significant and positive spatial correlation. The results of the Spatial Durbin Model showed the direct and indirect effects of demand, supply, and socio- economic factors on China's OPPs. Among the demand factors, the direct and indirect correlation (elasticity) coefficients were positive. Among the supply factors, the direct and indirect effects of the share of primary health beds on residents' OPPs were negative. The ratio of health technicians in hospitals to those in primary health institutions on per capital OPPs had a significant indirect effect. Among the socio-economic factors, the direct effects of GDP, government health expenditure, and urbanization on OPPs were found to be positive. There were no significant indirect effects of socio-economic factors on OPPs. CONCLUSION: This paper finds that China's OPPs are not randomly distributed but, overall, present a positive spatial cluster, even though a series of measures have been launched to promote health equity. Socio-economic factors and those associated with demand were found to be the main influences of variation in OPPs, while demand was seen to be the driver of the positive spatial spillover of OPPs, whereby effective supply could inhibit these positive spillover effects.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , China , Equidade em Saúde/economia , Equidade em Saúde/estatística & dados numéricos , Humanos , Seguro Saúde/economia , Investimentos em Saúde , Análise Espaço-Temporal , Urbanização
11.
Schmerz ; 33(5): 392-398, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31444574

RESUMO

This article reports a case of pronounced, chronic lumboischialgia, which was not satisfactorily controlled by conventional analgesic treatment. The level of pain under high-dose dronabinol treatment with oral and inhalative administration as well as the way to reimburse the cost of medicinal cannabis flowers, the treatment success and criteria of the economic prescription procedure are presented.


Assuntos
Dronabinol , Dor Lombar , Maconha Medicinal , Adulto , Doença Crônica , Dronabinol/economia , Dronabinol/uso terapêutico , Flores , Humanos , Seguro Saúde/economia , Dor Lombar/tratamento farmacológico , Maconha Medicinal/economia , Maconha Medicinal/uso terapêutico , Dor/tratamento farmacológico , Resultado do Tratamento
12.
BMC Health Serv Res ; 19(1): 544, 2019 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-31375108

RESUMO

BACKGROUND: In most developing countries, healthcare cost is mainly paid at the time of sickness and out-of-pocket at the point of service delivery which potentially could inhibit access. The total economic cost of illness for households is also estimated to be frequently above 10% of household income which is categorized as catastrophic. The purpose of this study was to assess factors that determine decisions to join the community based health insurance in West Gojjam zone. METHODS: A community based cross sectional survey was conducted to collect data from 690 household heads using a multistage sampling technique. A binary logistic regression was used to identify the determinants of household decisions for CBHI enrollment. RESULTS: Out of the participants, 58% were CBHI members. Besides, family size (AOR = 1.17; CI = 1.02-1.35), average health status (AOR = .380; CI = .179-.805), chronic disease (AOR = 3.42; CI = 1.89-6.19); scheme benefit package adequacy (AOR = 2.17; CI = 1.20-3.93), perceived health service quality (AOR = 3.69; CI = 1.77-7.69), CBHI awareness (AOR = 4.90; CI = 1.65-14.4); community solidarity (AOR = 3.77; CI = 2.05-6.92) and wealth (AOR = 3.62; CI = 1.67-7.83) were significant determinant factors for enrolment in the community based health insurance scheme. CONCLUSION: CBHI awareness, family health status, community solidarity, quality of service of health institutions, and wealth were major factors that most determine the household decisions to enroll in the system. Therefore, in-depth and sustainable awareness creation programs on the scheme; stratified premium- based on economic status of households; incorporation of social capital factors, particularly building community solidarity in the scheme implementation are vital to enhance sustainable enrollment. As perceived family health status and the existence of chronic disease were also found significant determinants of enrollment, the Government might have to look for options to make the scheme mandatory.


Assuntos
Seguro Saúde/estatística & dados numéricos , Saúde Pública , Adulto , Comportamento do Consumidor/estatística & dados numéricos , Estudos Transversais , Assistência à Saúde/economia , Etiópia , Feminino , Humanos , Seguro Saúde/economia , Masculino , Pessoa de Meia-Idade , Fatores Socioeconômicos , Adulto Jovem
13.
Cien Saude Colet ; 24(7): 2727-2736, 2019 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-31340289

RESUMO

To describe the last place of medical and dental health service used in relation to private health plans, and examine the effect of being registered in the primary healthcare system through the Family Health Strategy (FHS). This was a cross-sectional study using data from Brazil's 2008 National Household Survey. Multinomial logistic regression was performed to analyze how a private health plan and enrollment in the FHS influenced the use of health services. Results showed that individuals with a private health plan tend to use medical and dental services more than individuals without such a plan. However, many individuals with a private health plan used public services or paid out-of-pocket services, mainly for dental care. Among individuals without a private plan, being enrolled in the FHS reduced the use of out-of-pocket private services, regardless of age, income or educational level. Enrollment in the FHS increased the chances of using public services, and the effect of this enrollment is greater among those who have a private plan. Policies to strengthen public primary healthcare and to expand the FHS should be encouraged within the universal health system.


Assuntos
Serviços de Saúde Bucal/estatística & dados numéricos , Saúde da Família , Programas Nacionais de Saúde/organização & administração , Atenção Primária à Saúde/estatística & dados numéricos , Brasil , Estudos Transversais , Serviços de Saúde Bucal/economia , Política de Saúde , Humanos , Seguro Saúde/economia , Programas Nacionais de Saúde/economia , Atenção Primária à Saúde/economia , Inquéritos e Questionários
14.
Artigo em Inglês | MEDLINE | ID: mdl-31330995

RESUMO

Access to health care and financial protection for migrants can be promoted through diverse health insurance schemes, designed to suit migrants' needs within a specific context. The Migrant Fund (M-Fund) is a voluntary, non-profit health insurance scheme operating along the Thai-Myanmar border in Thailand since 2017 and aims to protect the health of migrants uncovered by existing government insurance schemes. A qualitative evaluation was conducted between December 2018 and March 2019 to determine M-Fund's operational impacts, provide recommendations for improvement, and draw suggestions about its role in protecting migrant health. In-depth interviews with 20 individuals and 5 groups were conducted in three categories: (1) International, national, and local partners; (2) M-Fund clients; and (3) M-Fund staff. Interview information was triangulated with findings from other informants, a document review, and researchers' observations. Despite covering a small number of 9131 migrants, the M-Fund has contributed to improving access to care for migrants, raised awareness about migrant health protection, and reduced the financial burden for public hospitals. The M-Fund acts as a safety-net initiative for those left behind due to unclear government policy to protect the health of undocumented/illegal migrants. Despite clear merits, the issue of adverse selection to the scheme is a critical challenge. Evidence from this evaluation is useful to inform the future design of government insurance schemes for migrants.


Assuntos
Acesso aos Serviços de Saúde/economia , Seguro Saúde/economia , Migrantes , Administração Financeira , Humanos , Mianmar , Tailândia
15.
Value Health ; 22(7): 762-767, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31277821

RESUMO

OBJECTIVES: To evaluate the relationship between cancer history and cost-related medication nonadherence (CRN) as well as cost-coping strategies, by health insurance coverage. METHODS: We used the 2013 to 2016 National Health Interview Survey to identify adults aged 18 to 64 years with (n = 3599) and without (n = 56 909) a cancer history. Cost-related changes in medication use included (1) CRN, measured as skipping, taking less, or delaying medication because of cost, and (2) cost-coping strategies, measured as requesting lower cost medication or using alternative therapies to save money. Separate multivariable logistic regressions were used to calculate the adjusted odds ratios (AORs) of CRN and cost-coping strategies associated with cancer history, stratified by insurance. RESULTS: Cancer survivors were more likely than adults without a cancer history to report CRN (AOR 1.26; 95% confidence interval [CI] 1.10-1.43) and cost-coping strategies (AOR 1.10; 95% CI 0.99-1.19). Among the privately insured, the difference in CRN by cancer history was the greatest among those enrolled in high-deductible health plans (HDHPs) without health savings accounts (HSAs) (AOR 1.78; 95% CI 1.30-2.44). Among adults with HDHP and HSA, cancer survivors were less likely to report cost-coping strategies (AOR 0.62; 95% CI 0.42-0.90). Regardless of cancer history, CRN and cost-coping strategies were the highest for those uninsured, enrolled in HDHP without HSA, and without prescription drug coverage under their health plan (all P<.001). CONCLUSIONS: Cancer survivors are prone to CRN and more likely to use cost-coping strategies. Expanding options for health insurance coverage, use of HSAs for those with HDHP, and enhanced prescription drug coverage may effectively address CRN.


Assuntos
Antineoplásicos/economia , Antineoplásicos/uso terapêutico , Sobreviventes de Câncer/psicologia , Gastos em Saúde , Cobertura do Seguro/economia , Seguro Saúde/economia , Adesão à Medicação , Neoplasias/tratamento farmacológico , Neoplasias/economia , Adolescente , Adulto , Redução de Custos , Dedutíveis e Cosseguros/economia , Substituição de Medicamentos/economia , Medicamentos Genéricos/economia , Medicamentos Genéricos/uso terapêutico , Feminino , Pesquisas sobre Serviços de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Poupança para Cobertura de Despesas Médicas , Pessoa de Meia-Idade , Neoplasias/epidemiologia , Neoplasias/psicologia , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
16.
Value Health ; 22(7): 792-798, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31277826

RESUMO

BACKGROUND: Estimates of drug spending are often central to the public policy debate on how to manage healthcare spending in the United States. Nevertheless, common estimates of prescription drug spending vary substantially by source, which can inhibit productive policy dialogue. OBJECTIVES: To review publicly reported estimates of drug spending and uncover the underlying methodological inputs that drive the substantial variation in estimates of prescription drug spending. METHODS: We systematically evaluated 5 estimates of drug spending to identify differences in the underlying methodological inputs and approaches. To uniformly assess and compare estimates, we developed a model to identify the inputs of 3 primary components associated with each estimate: numerator (How is drug cost measured?), denominator (How is healthcare cost measured?), and population (What group of individuals is included in the measurement?). We then applied standardized methodological inputs to each estimate to assess whether variation among estimates could be reconciled. We then conducted a sensitivity analysis to address important limitations. RESULTS: We found that the 18.8 percentage point range in the publicly reported estimates is predominately attributed to methodological differences. Reconciling estimates using a standardized methodological approach reduces this range to 4.0 percentage points. CONCLUSIONS: Because variation in estimates of drug spending is primarily driven by methodological differences, stakeholders should seek to establish a mutually agreed upon methodological approach that is appropriate for the policy question at hand to provide a sound basis for health spending policy discussions.


Assuntos
Custos de Medicamentos , Gastos em Saúde , Seguro Saúde/economia , Medicamentos sob Prescrição/economia , Redução de Custos , Análise Custo-Benefício , Custos de Medicamentos/tendências , Gastos em Saúde/tendências , Humanos , Seguro Saúde/tendências , Modelos Econômicos , Medicamentos sob Prescrição/uso terapêutico , Fatores de Tempo , Estados Unidos
17.
Value Health ; 22(7): 799-807, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31277827

RESUMO

OBJECTIVES: In theory, a successful coverage with evidence development (CED) scheme is one that addresses the most important uncertainties in a given assessment. We investigated the following: (1) which uncertainties were present during the initial assessment of 3 Dutch CED cases, (2) how these uncertainties were integrated in the initial assessments, (3) whether CED research plans included the identified uncertainties, and (4) issues with managing uncertainty in CED research and ways forward from these issues. METHODS: Three CED initial assessment dossiers were analyzed and 16 stakeholders were interviewed. Uncertainties were identified in interviews and dossiers and were categorized in different causes: unavailability, indirectness, and imprecision of evidence. Identified uncertainties could be mentioned, described, and explored. Issues and ways forward to address uncertainty in CED schemes were discussed during the interviews. RESULTS: Forty-two uncertainties were identified. Thirteen (31%) were caused by unavailability, 17 (40%) by indirectness, and 12 (29%) by imprecision. Thirty-four uncertainties (81%) were only mentioned, 19 (45%) were described, and the impact of 3 (7%) uncertainties on the results was explored in the assessment dossiers. Seventeen uncertainties (40%) were included in the CED research plans. According to stakeholders, research did not address the identified uncertainty, but CED research should be designed to focus on these. CONCLUSIONS: In practice, uncertainties were neither systematically nor completely identified in the analyzed CED schemes. A framework would help to systematically identify uncertainty, and this process should involve all stakeholders. Value of information analysis, and the uncertainties that are not included in this analysis should inform CED research design.


Assuntos
Custos de Medicamentos , Medicina Baseada em Evidências/economia , Cobertura do Seguro/economia , Seguro Saúde/economia , Mecanismo de Reembolso/economia , Incerteza , Tomada de Decisão Clínica , Análise Custo-Benefício , Humanos , Modelos Econômicos , Modelos Estatísticos , Países Baixos , Seleção de Pacientes , Rituximab/economia , Rituximab/uso terapêutico , Participação dos Interessados , Trastuzumab/economia , Trastuzumab/uso terapêutico , alfa-Glucosidases/economia , alfa-Glucosidases/uso terapêutico
18.
S Afr Med J ; 109(7): 498-502, 2019 Jun 28.
Artigo em Inglês | MEDLINE | ID: mdl-31266576

RESUMO

BACKGROUND: Prescribed Minimum Benefits (PMBs) in South Africa (SA) are a set of minimum health services that all members of medical aid schemes have access to regardless of their benefit options or depleted funds. Medical aid schemes are liable to pay for these services. However, ~40% of all complaints received by the Council for Medical Schemes (CMS) are in relation to PMBs. Individuals/stakeholders who are unsatisfied with judgments on their complaints are allowed to appeal. OBJECTIVES: To determine and describe the pattern of PMB appeals from 1 January 2006 to 31 December 2016. METHODS: This was a descriptive cross-sectional study that utilised the CMS Judgments on Appeals database. Data for PMBs, levels of appeal, judgments, appellants, respondents and medical scheme types were extracted. The CMS's lists of chronic conditions, PMBs and registered schemes were used to confirm PMBs and to categorise schemes as either open (i.e. to all South Africans) or restricted (i.e. only open to members of specific organisations). Data were extracted and frequencies were calculated using Stata software, version 14. RESULTS: All eligible appeal reports (N=340) were retrieved and 123 PMB appeals were included in the study (36.2%). The median number of PMB appeals per year was 11 (interquartile range 9 - 27). Open schemes accounted for 82.1% of all the PMB appeals. Half of the total appeals (50.4%, 62/123) were by medical aid schemes appealing their liability to pay for PMBs, and of these 69.4% (43/62) were found in favour of members. The remaining half (49.6%, 61/123) were appeals by members appealing that schemes were liable to pay, and of these 80.3% (49/61) were found in favour of the medical aid schemes. Treatment options that were scheme exclusions constituted 34.4% (21/61) of reasons why schemes were found not liable to pay. Various types of cancers and emergency conditions constituted one-quarter of all PMB appeals. CONCLUSIONS: While the pattern is unclear and the extent of the problem is masked, this study shows that a quarter of the conflict resulting in PMB appeals was due to various types of cancers and emergency conditions. Medical schemes should revise their guidelines, policies and criteria for payment of these two services and improve their communication with healthcare providers and members.


Assuntos
Seguro Saúde/legislação & jurisprudência , Estudos Transversais , Humanos , Seguro Saúde/economia , África do Sul
20.
Anesthesiology ; 131(3): 534-542, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31283739

RESUMO

BACKGROUND: In addition to payments for services, anesthesia groups in the United States often receive revenue from direct hospital payments. Understanding the magnitude of these payments and their association with the hospitals' payer mixes has important policy implications. METHODS: Using a dataset of financial reports from 240 nonacademic California hospitals between 2002 and 2014, the authors characterized the prevalence and magnitude of direct hospital payments to anesthesia groups, and analyzed the association between these payments and the fraction of anesthesia revenue derived from public payers (e.g., Medicaid). RESULTS: Of hospitals analyzed, 69% (124 of 180) made direct payments to an anesthesia group in 2014, compared to 52% (76 of 147) in 2002; the median payment increased from $242,351 (mean, $578,322; interquartile range, $72,753 to $523,861; all dollar values in 2018 U.S. dollars) to $765,128 (mean, $1,295,369; interquartile range, $267,006 to $1,503,163) during this time period. After adjusting for relevant covariates, hospitals where public insurers accounted for a larger fraction of anesthesia revenues were more likely to make direct payments to anesthesia groups (ß = 0.45; 95% CI, 0.10 to 0.81; P = 0.013), so that a 10-percentage point increase in the fraction of anesthesia revenue derived from public payers would be associated with a 4.5-percentage point increase in the probability of receiving any payment. Among hospitals making payments, our results (ß = 2.10; 95% CI, 0.74 to 3.45; P = 0.003) suggest that a 1-percentage point increase in the fraction of anesthesia revenue derived from public payers would be associated with a 2% relative increase in the amount paid. CONCLUSIONS: Direct payments from hospitals are becoming a larger financial consideration for anesthesia groups in California serving nonacademic hospitals, and are larger for groups working at hospitals serving publicly insured patients.


Assuntos
Anestesiologia/economia , Economia Hospitalar/estatística & dados numéricos , Prática de Grupo/economia , Custos Hospitalares/estatística & dados numéricos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , California , Estudos de Coortes , Humanos , Prática Privada/economia , Estudos Retrospectivos , Estados Unidos
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