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2.
Clin Orthop Relat Res ; 480(9): 1636-1645, 2022 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-35543485

RESUMO

BACKGROUND: Income-based differences in the use of and outcomes in TKA have been studied; however, it is not known if different healthcare systems affect this relationship. Although Canada's single-payer healthcare system is assumed to attenuate the wealth-based differences in TKA use observed in the United States, empirical cross-border comparisons are lacking. QUESTIONS/PURPOSES: (1) Does TKA use differ between Pennsylvania, USA, and Ontario, Canada? (2) Are income-based disparities in TKA use larger in Pennsylvania or Ontario? (3) Are TKA outcomes (90-day mortality, 90-day readmission, and 1-year revision rates) different between Pennsylvania and Ontario? (4) Are income-based disparities in TKA outcomes larger in Pennsylvania or Ontario? METHODS: We identified all patients hospitalized for primary TKA in this cross-border retrospective analysis, using administrative data for 2012 to 2018, and we found a total of 161,244 primary TKAs in Ontario and 208,016 TKAs in Pennsylvania. We used data from the Pennsylvania Health Care Cost Containment Council, Harrisburg, PA, USA, and the ICES (formally the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada. We linked patient-level data to the respective census data to determine community-level income using ZIP Code or postal code of residence and stratified patients into neighborhood income quintiles. We compared TKA use (age and gender, standardized per 10,000 population per year) for patients residing in the highest-income versus the lowest-income quintile neighborhoods. Similarly secondary outcomes 90-day mortality, 90-day readmission, and 1-year revision rates were compared between the two regions and analyzed by income groups. RESULTS: TKA use was higher in Pennsylvania than in Ontario overall and for all income quintiles (lowest income quartile: 31 versus 18 procedures per 10,000 population per year; p < 0.001; highest income quartile: 38 versus 23 procedures per 10,000 population per year; p < 0.001). The relative difference in use between the highest-income and lowest-income quintile was larger in Ontario (28% higher) than in Pennsylvania (23% higher); p < 0.001. Patients receiving TKA in Pennsylvania were more likely to be readmitted within 90 days and were more likely to undergo revision within the first year than patients in Ontario, but there was no difference in mortality at 1 year. When comparing income groups, there were no differences between the countries in 90-day mortality, readmission, or 1-year revision rates (p > 0.05). CONCLUSION: These results suggest that universal health insurance through a single-payer may not reduce the income-based differences in TKA access that are known to exist in the United States. Future studies are needed determine if our results are consistent across other geographic regions and other surgical procedures. LEVEL OF EVIDENCE: Level III, therapeutic study.


Assuntos
Artroplastia do Joelho , Humanos , Ontário/epidemiologia , Readmissão do Paciente , Estudos Retrospectivos , Sistema de Fonte Pagadora Única , Estados Unidos
3.
Med Care ; 60(6): 397-401, 2022 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-35471488

RESUMO

Health care is a human right. Achieving universal health insurance coverage for all US residents requires significant system-wide reform. The most equitable and cost-effective health care system is a public, single-payer (SP) system. The rapid growth in national health expenditures can be addressed through a system that yields net savings over projected trends by eliminating profit and waste. With universal health insurance coverage through SP financing, providers can focus on optimizing delivery of services, rather than working within a system covered by payers who have incentives to limit costs regardless of benefit. Rather, with a SP, the people act as their own insurer through a partnership with provider organizations where tax dollars work for everyone. Consumer choice is then based on the best care to meet need with no out-of-pocket payments. SP financing is the best option to ensure equity, fairness, and public health priorities align with medical needs, providing incentives for wellness. Consumer choice will drive market forces, not provider network profits or insurer restrictions. This approach benefits public health, as everyone will have universal access to needed care, with treatment plans developed by providers based on what works best for the patient. In 2021, the American Public Health Association adopted a policy statement calling for comprehensive reforms to implement a SP system. The proposed action steps in this policy will help build a healthier nation, saving lives and reducing wasted health care expenditures while addressing inequities rooted in social, demographic, mental health, economic, and political determinants.


Assuntos
American Public Health Association , Sistema de Fonte Pagadora Única , Atenção à Saúde , Reforma dos Serviços de Saúde , Humanos , Seguradoras , Cobertura Universal do Seguro de Saúde
4.
J Surg Oncol ; 125(5): 824-830, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34989410

RESUMO

BACKGROUND AND OBJECTIVES: Neoadjuvant chemotherapy (NAC) requires coordination of various services to ensure timely and accurate delivery of care. This can result in multiple hospital visits and extend time to treatment (TTT). The primary purpose of our study was to evaluate time to NAC for patients at a regional cancer centre. Healthcare resource use in the form of hospital visits before NAC was also evaluated. METHODS: A retrospective chart analysis of patients with invasive breast cancer who underwent NAC between 1 January 2012 and 31 December 2018 was performed. RESULTS: Overall, 286 patients underwent NAC. Median TTT was 22 days (range: 2-105). Median number of visits between first consultation and NAC was 5 (range: 0-12). Majority of additional visits were for diagnostic imaging/interventions, with a median number of 4 visits (range: 0-10). Each additional hospital visit increased time to NAC treatment by 14%. CONCLUSIONS: Women undergoing NAC require multiple visits before initiating treatment-the majority of these visits are for diagnostic imaging. These results support the need for the coordination of multidisciplinary care and diagnostic imaging for breast cancer patients undergoing NAC to reduce hospital visits, improve the patient experience, and reduce TTT.


Assuntos
Neoplasias da Mama , Terapia Neoadjuvante , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Quimioterapia Adjuvante , Feminino , Hospitais , Humanos , Terapia Neoadjuvante/métodos , Estudos Retrospectivos , Sistema de Fonte Pagadora Única , Tempo para o Tratamento
5.
Curr Oncol ; 28(6): 4748-4755, 2021 11 16.
Artigo em Inglês | MEDLINE | ID: mdl-34898584

RESUMO

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.


Assuntos
Antineoplásicos , Atitude do Pessoal de Saúde , Neoplasias , Oncologistas , Antineoplásicos/economia , Antineoplásicos/uso terapêutico , Atitude , Canadá , Pesquisas sobre Atenção à Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Internet , Neoplasias/tratamento farmacológico , Sistema de Fonte Pagadora Única/economia , Terapias em Estudo/economia
6.
Artigo em Inglês | MEDLINE | ID: mdl-34682728

RESUMO

Since 1995, a national health insurance (NHI) program has been in operation in Taiwan, which provides uniform comprehensive coverage. Forced by severe financial deficit, global budgeting reimbursement was adopted in the healthcare sector to control healthcare expenditures in 2002. A two-stage data envelopment analysis (DEA) approach was used to measure the efficiency of hospital resource allocation among stakeholders in Taiwan's NHI system, and to further explore the changes in resource allocation after the introduction of a global budgeting payment scheme. The dataset was collected from the annual statistical reports of Taiwan's Ministry of Health and Welfare (MOHW) and was used to estimate the efficiency of resource allocation in hospital-based healthcare services under global budgeting. In terms of efficiency during the period from 2003 to 2009, one-third of decision-making units (DMUs) improved their productivity in stage I, and seven out of the total of eighteen DMUs saw falls in financial efficiency in stage II. After global budgeting was implemented, there were significant positive impacts on the efficiency of hospital resource allocation in Taiwan. The two-stage DEA model for analyzing the effects of the global budgeting reimbursement system on productivity and financial efficiency represents a key decision-making tool for hospital administrators and policymakers.


Assuntos
Orçamentos , Sistema de Fonte Pagadora Única , Atenção à Saúde , Programas Nacionais de Saúde , Taiwan
8.
J Plast Reconstr Aesthet Surg ; 74(10): 2737-2743, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33896742

RESUMO

BACKGROUND: Rising health care costs and the high number of uninsured Americans has led to the increasing popularity of a single payer alternative. While opinions of physicians at large have been studied, we present the first data examining the views of United States (U.S.) board-certified plastic surgeons on a single payer health care system and its implications for patients and practice. METHODS: A total of 3,431 US plastic and reconstructive surgeons were sent a 25-item Qualtrics survey and responses collected from September 1 to November 1, 2019. Independent variables included surgeon sociodemographic characteristics. The association between these and a preference for a single payer was evaluated using the logistic regression. RESULTS: There was a 11% response rate (n = 383). The majority of respondents were in private practice (64.5%). Forty-four percent believed that it is the government's responsibility to ensure care is provided for all; 34% were willing to give up income in exchange for reduced paperwork and administrative burden. Sixty-three percent would not work the same number of hours under single payer. Private practice plastic surgeons were significantly less likely to favor single payer (95% CI: 0.19 and 0.76). Among academic plastic surgeons, 24% would consider leaving if single payer were enacted and 60% would decrease the reconstructive portion of their practice. CONCLUSIONS: Most U.S. plastic and reconstructive surgeons do not support a single payer health care system. Its enactment could have sweeping implications for plastic surgeons nationwide, among the most significant being a shift from academic to private practice with a potential reduction in patient access to complex reconstructive procedures.


Assuntos
Atitude do Pessoal de Saúde , Médicos , Procedimentos Cirúrgicos Reconstrutivos/economia , Sistema de Fonte Pagadora Única , Cirurgia Plástica/economia , Adulto , Idoso , Feminino , Acesso aos Serviços de Saúde/economia , Humanos , Prática Institucional/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Prática Privada/estatística & dados numéricos , Inquéritos e Questionários , Estados Unidos
9.
Health Serv Res ; 56(4): 615-625, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33788283

RESUMO

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.


Assuntos
Redução de Custos/economia , Reembolso de Seguro de Saúde/economia , Sistema de Fonte Pagadora Única/economia , Simulação por Computador , Planos de Pagamento por Serviço Prestado/economia , Gastos em Saúde/estatística & dados numéricos , Humanos , Modelos Econômicos , Estados Unidos
11.
J Health Polit Policy Law ; 46(4): 563-575, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-33503243

RESUMO

Structural racism is a fundamental cause of racial inequities in health in the United States. Structural racism is manifested in inequality in the criminal justice system; de facto segregation in education, health care, and housing; and ineffective and disproportionately violent policing and economic disenfranchisement in communities of color. The inequality that Black people and communities of color face is the direct result of centuries of public policy that made Black and Brown skin a liability. The United States is now in an unprecedented moment in its history with a new administration that explicitly states, "The moment has come for our nation to deal with systemic racism . . . and to deal with the denial of the promise of this nation-to so many." The opportunities for creating innovative and bold policy must reflect the urgency of the moment and seek to dismantle the systems of oppression that have for far too long left the American promise unfulfilled. The policy suggestions made by the authors of this article speak to the structural targets needed for dismantling some of the many manifestations of structural racism so as to achieve health equity.


Assuntos
Afro-Americanos , Política de Saúde , Disparidades em Assistência à Saúde/etnologia , Política Pública , Racismo , COVID-19/etnologia , Governo Federal , Humanos , Remuneração , Sistema de Fonte Pagadora Única , Determinantes Sociais da Saúde , Justiça Social , Estados Unidos , Cobertura Universal do Seguro de Saúde
12.
Ann Otol Rhinol Laryngol ; 130(8): 868-872, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32698602

RESUMO

INTRODUCTION: In a publicly funded health care system, fiscally responsible management of any program is required. This is especially pertinent as evolving technology and associated incremental costs, places pressure on device availability within a fixed funding envelope. The application of rotational magnet technology and associated escalating surgical wait times must be justified to patients and the single-payer system. We present a single cochlear implant center's attempt at a rationing schema for magnetic resonance compatible cochlear implantation. Contrasting approaches to rationing care are evaluated and deliberated. METHODS: Based on a comparison of magnetic resonance imaging (MRI) rates within the general population to our cochlear implant (CI) cohort, we attempt the development of a decision-making schema that maximizes the number of patients to receive a CI while rationing the distribution of a rotational magnet technology to similarly situated individuals most likely to benefit. RESULTS: We elect to provide rotational magnet technology to select patient cohorts. This is based on the dominant imaging needs of these populations and the probability of requiring recurrent imaging studies. We consider this an ethical approach grounded in the egalitarian principle of equality of opportunity within cohorts of patients. CONCLUSION: Given finite resources, increasing per unit cost will unavoidably extend wait times for adult patients. Our approach does not afford similar implant devices for all patients, but rather all similarly situated individuals. Therefore, access to a scare medical resource requires program rigor and a formalized policy around candidacy for emergent technology.


Assuntos
Tomada de Decisão Clínica , Implante Coclear , Implantes Cocleares , Imageamento por Ressonância Magnética , Seleção de Pacientes , Sistema de Fonte Pagadora Única , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Canadá , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Imãs , Masculino , Pessoa de Meia-Idade , Adulto Jovem
13.
Ann Surg ; 274(6): e522-e528, 2021 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31904598

RESUMO

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.


Assuntos
Serviço Hospitalar de Emergência/economia , Custos Hospitalares , Tempo de Internação/economia , Sistema de Fonte Pagadora Única/economia , Procedimentos Cirúrgicos Operatórios/economia , Adolescente , Adulto , Idoso , Humanos , Pessoa de Meia-Idade , Escócia , Adulto Jovem
14.
Soc Sci Med ; 265: 113454, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33190928

RESUMO

A growing literature in comparative political economy and health economics has argued several cost-saving effects of a single-payer healthcare system. Despite this growing evidence, there has been no large-scale empirical examination of whether such an effect exists cross-nationally over time. This paper serves as the first attempt to find and calculate the extent to which healthcare spending is affected by the utilization of a single-payer scheme. I introduce an original dataset for OECD countries that measures when and where systems that qualify as single-payer exist, and employ it to test whether significant differences exist in health expenditures. Results demonstrate a significant difference between single- and multi-payer system expenditures. I estimate the utilization of a single-payer system is associated with decreased expenditure equal to 0.750 percentage-points of a nation's GDP. This would equate to the United States saving well over $1.5 trillion over ten years.


Assuntos
Gastos em Saúde , Organização para a Cooperação e Desenvolvimento Econômico , Atenção à Saúde , Humanos , Seguro Saúde , Sistema de Fonte Pagadora Única , Estados Unidos
16.
BMJ Open ; 10(5): e033833, 2020 05 11.
Artigo em Inglês | MEDLINE | ID: mdl-32398332

RESUMO

OBJECTIVE: The objectives of this study are to refine the measurement of appropriate emergency department (ED) use and to provide a natural observation of appropriate ED use rates based on professional versus patient perspectives. SETTING: Taiwan has a population of 23 million, with one single-payer universal health insurance scheme. Taiwan has no limitations on ED use, and a low barrier to ED use may be a surrogate for natural observation of users' perspectives in ED use. PARTICIPANTS: In 7 years, there were 1 835 860 ED visits from one million random samples of the National Health Insurance Database. MEASURES: Appropriate ED use was determined according to professional standards, measured by the modified Billings New York University Emergency Department (NYU-ED) algorithm, and further analysed after the addition of prudent patient standards, measured by explicit process-based and outcome-based criteria. STATISTICAL ANALYSES: The area under the receiver operating characteristic curve (AUC) was used to reflect the performance of appropriate ED use measures, and sensitivity analyses were conducted using different thresholds to determine the appropriateness of ED use. The generalised estimating equation model was used to measure the associations between appropriate ED use based on process and outcome criteria and covariates including sex, age, occupation, health status, place of residence, medical resources area, date and income level. RESULTS: Appropriate ED use based on professional criteria was 33.5%, which increased to 63.1% when patient criteria were added. The AUC, which combines both professional and patient criteria, was high (0.85). CONCLUSIONS: The appropriate ED use rate nearly doubled when patient criteria were added to professional criteria. Explicit process-based and outcome-based criteria may be used as a supplementary measure to the implicit modified Billings NYU-ED algorithm when determining appropriate ED use.


Assuntos
Algoritmos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adolescente , Adulto , Idoso , Área Sob a Curva , Atitude do Pessoal de Saúde , Criança , Tratamento de Emergência/classificação , Tratamento de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Curva ROC , Estudos Retrospectivos , Sistema de Fonte Pagadora Única/estatística & dados numéricos , Taiwan , Adulto Jovem
17.
J Ambul Care Manage ; 43(3): 199-204, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32467433

RESUMO

One of the most controversial areas in discussions of single-payer approaches for the United States, such as "Medicare for All," concerns its implications for costs. Confusion over differences between federal and total spending and effects of lower patient cost sharing gets in the way of "apples-to-apples" comparisons. Key areas with potential to lower costs are lower administrative costs and lower provider prices. But cost reduction would likely be smaller than some envision, especially in the price area because of the need for a long process to gradually allow providers to adjust to lower prices and Americans' unique attitudes toward regulation.


Assuntos
Gastos em Saúde , Medicare/economia , Sistema de Fonte Pagadora Única , Cobertura Universal do Seguro de Saúde , Custo Compartilhado de Seguro , Custos e Análise de Custo , Humanos , Estados Unidos
18.
Plast Reconstr Surg ; 145(6): 1089e-1096e, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32459785

RESUMO

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.


Assuntos
Reforma dos Serviços de Saúde , Gastos em Saúde/legislação & jurisprudência , Sistema de Fonte Pagadora Única/economia , Cirurgia Plástica/economia , Humanos , Estados Unidos
19.
AJNR Am J Neuroradiol ; 41(5): 772-776, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32299804

RESUMO

The year 2019 featured extensive debates on transforming the United States multipayer health care system into a single-payer system. At a time when reimbursement structures are in flux and potential changes in government may affect health care, it is important for neuroradiologists to remain informed on how emerging policies may impact their practices. The purpose of this article is to examine potential ramifications for neuroradiologist reimbursement with the Medicare for All legislative proposals. An institution-specific analysis is presented to illustrate general Medicare for All principles in discussing issues applicable to practices nationwide.


Assuntos
Medicare , Neurologia , Radiologia , Sistema de Fonte Pagadora Única , Cobertura Universal do Seguro de Saúde , Humanos , Medicare/legislação & jurisprudência , Sistema de Fonte Pagadora Única/legislação & jurisprudência , Estados Unidos , Cobertura Universal do Seguro de Saúde/legislação & jurisprudência
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