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Medicine and democracy: The importance of institutional quality in the relationship between health expenditure and health outcomes in the MENA region

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Publication date: Available online 16 June 2016
Source:Health Policy
Author(s): Marwân-al-Qays Bousmah, Bruno Ventelou, Mohammad Abu-Zaineh
Evidence suggests that the effect of health expenditure on health outcomes is highly context-specific and may be driven by other factors. We construct a panel dataset of 18 countries from the Middle East and North Africa region for the period 1995–2012. Panel data models are used to estimate the macro-level determinants of health outcomes. The core finding of the paper is that increasing health expenditure leads to health outcomes improvements only to the extent that the quality of institutions within a country is sufficiently high. The sensitivity of the results is assessed using various measures of health outcomes as well as institutional variables. Overall, it appears that increasing health care expenditure in the MENA region is a necessary but not sufficient condition for health outcomes improvements.


Health policy and the policymaking system: A case study of primary care in Ireland

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Publication date: Available online 16 June 2016
Source:Health Policy
Author(s): Niall Kelly, John Garvey, Dónal Palcic
In 2001 the Irish government published a reforming policy intended to modernise and expand the delivery of primary care in Ireland. Fifteen years later, the Irish health system remains beset by problems indicative of a fragmented and underdeveloped primary care system. This case study examines the formation and implementation of the 2001 primary care policy and identifies key risk categories within the policymaking process itself that inhibited the timely achievement of policy objectives. Our methodology includes a directed content analysis of the policy formation and implementation documents and the influencing academic literature, as well as semi-structured interviews with key personnel involved in the process. We identify three broad risk categories – power, resources and capability – within the policymaking process that strongly influenced policy formation and implementation. We additionally show that the disjoint between policy formation and policy implementation was a contested issue among those involved in the policy process and provided space for these risks to critically undermine Ireland's primary care policy.

Factors influencing the difference between forecasted and actual drug sales volumes under the price–volume agreement in South Korea

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Publication date: Available online 16 June 2016
Source:Health Policy
Author(s): Sun-Young Park, Euna Han, Jini Kim, Eui-Kyung Lee
This study analyzed factors contributing to increases in the actual sales volumes relative to forecasted volumes of drugs under price–volume agreement (PVA) policy in South Korea. Sales volumes of newly listed drugs on the national formulary are monitored under PVA policy. When actual sales volume exceeds the pre-agreed forecasted volume by 30% or more, the drug is subject to price-reduction. Logistic regression assessed the factors related to whether drugs were the PVA price-reduction drugs. A generalized linear model with gamma distribution and log-link assessed the factors influencing the increase in actual volumes compared to forecasted volume in the PVA price-reduction drugs. Of 186 PVA monitored drugs, 34.9% were price-reduction drugs. Drugs marketed by pharmaceutical companies with previous-occupation in the therapeutic markets were more likely to be PVA price-reduction drugs than drugs marketed by firms with no previous-occupation. Drugs of multinational pharmaceutical companies were more likely to be PVA price-reduction drugs than those of domestic companies. Having more alternative existing drugs was significantly associated with higher odds of being PVA price-reduction drugs. Among the PVA price-reduction drugs, the increasing rate of actual volume compared to forecasted volume was significantly higher in drugs with clinical usefulness. By focusing the negotiation efforts on those target drugs, PVA policy can be administered more efficiently with the improved predictability of the drug sales volumes.

Factors influencing coverage decisions on medical devices: A retrospective analysis of 78 medical device appraisals for the Austrian hospital benefit catalogue 2008–2015

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Publication date: Available online 16 June 2016
Source:Health Policy
Author(s): Agnes Kisser, Heinz Tüchler, Judit Erdös, Claudia Wild
Background Health technology assessments of medical devices (MD) present a well-recognized challenge to evaluators: the evidence on safety and clinical effectiveness is often of lower quality than for pharmaceuticals making a reliable assessment of the risk-benefit ratio difficult. Thus other factors might gain importance in decision making. Objective To analyse which factors impact MD reimbursement decisions within the Austrian appraisal programme on “extra medical services” (procedures reimbursed in addition to case flat rates) for inpatient care over the past eight years. Methods We collected variables on evidence base and device characteristics from all MD appraisals and assessed their impact on the reimbursement decision by means of odds ratios. Separate analyses were carried out for subgroups based on the risk class of the medical device subject of the assessment or the number of randomised controlled trials (RCTs) available for the assessment. Results Of 59 devices, 23 (39%) were accepted for reimbursement (18 with restrictions) and 36 (61%) were rejected. Variables addressing the quality of the evidence base were positive predictors for risk class II devices only, whereas no significant association could be determined in devices of risk class III. Inversely, high risk device characteristics were positive predictors in the subgroup not supported by RCTs only. Conclusion Our data indicate that the combination of high risk characteristics and a low evidence base are factors favouring a positive reimbursement decision of MD, albeit with restrictions. Further research should analyse if these restrictions are appropriate to generate evidence development and to contain risks associated with early access to these MD.

Misuse of OTC drugs in Poland

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Publication date: Available online 18 June 2016
Source:Health Policy
Author(s): Tomasz Zaprutko, Dorota Koligat, Michał Michalak, Marta Wieczorek, Malwina Józiak, Monika Ratajczak, Kinga Szydłowska, Joanna Miazek, Krzysztof Kus, Elżbieta Nowakowska
Introduction The misuse of over-the-counter (OTC) drugs became a global public health concern. Although abuse with dextrometorphan (DXM), pseudoefedrine (PSD), codeine (COD) or benzydamine (BND) may lead even to psychosis, drugs containing these substances are relatively cheap and freely available. In Poland the Act on Counteracting Drug Addiction was amended in 2015, however it seems that there are still some points which could be improved. Methods Study was conducted between October 2014 and June 2015 using a specially designed questionnaire delivered to pharmacists from the Greater Poland region. Questionnaire consisting of 11 closed questions was distributed by direct contact and via the Internet. From over 2500 distributed questionnaires, we received 761 sheets and 680 were included. Results The misuse of OTC drugs is increasing in Poland from pharmacists point of view. The most popular substance was PSD followed by COD and DXM. The main reason of misuse of these drugs could be related to the use of Internet and free access to these medications. In respondents (58.2%) opinion OTC drugs containing analyzed substances should be moved into the prescription status. Conclusions The misuse of OTC drugs should be considered as a very dangerous phenomenon. Although the Act on Counteracting Drug Addiction was amended in Poland in 2015, there are some facets requiring improvement. Social education may play a key role in the limitation of misuse of OTC drugs.

Reframing tobacco dependency management in acute care: A case study

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Publication date: Available online 22 June 2016
Source:Health Policy
Author(s): Annette S.H. Schultz, Randolph Guzman, Jo-Ann V. Sawatzky, Rick Thurmeier, Anna Fedorowicz, Kaitlin Fulmore
Effective tobacco dependence treatment within acute care tends to be inadequate. The purpose of the Utilizing best practices to Manage Acute care patients Tobacco Dependency (UMAT) was to implement and evaluate an evidence-based intervention to support healthcare staff to effectively manage nicotine withdrawal symptoms of acute surgical patients. Data collection for this one-year longitudinal case study included: relevant patient experiences and staff reported practice, medication usage, and chart review. Over the year each data source suggested changes in tobacco dependence treatment. Key changes in patient survey responses (N =55) included a decrease in daily smoking and cigarette cravings. Of patients who used nicotine replacement therapy, they reported an increase in symptom relief. Staff (N =45) were surveyed at baseline, mid-point and end of study. Reported rates of assessing smoking status did not change over the year, but assessment of withdrawal symptoms emerged as daily practice and questions about cessation diminished. Also delivery of nicotine replacement therapy products increased over the year. Chart reviews showed a shift in content from documenting smoking behavior to withdrawal symptoms and administration of nicotine replacements; also frequency of comments increased. In summary, the evidence-based intervention influenced unit norms and reframed the culture related to tobacco dependence treatment.

Out of pocket payments and social health insurance for private hospital care: Evidence from Greece

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Publication date: Available online 25 June 2016
Source:Health Policy
Author(s): Nikolaos Grigorakis, Christos Floros, Haritini Tsangari, Evangelos Tsoukatos
The Greek state has reduced their funding on health as part of broader efforts to limit the large fiscal deficits and rising debt ratios to GDP. Benefits cuts and limitations of Social Health Insurance (SHI) reimbursements result in substantial Out of Pocket (OOP) payments in the Greek population. In this paper, we examine social health insurance's risk pooling mechanisms and the catastrophic impact that OOP payments may have on insured's income and well-being. Using data collected from a cross sectional survey in Greece, we find that the OOP payments for inpatient care in private hospitals have a positive relationship with SHI funding. Moreover, we show that the SHI funding is inadequate to total inpatient financing. We argue that the Greek health policy makers have to give serious consideration to the perspective of a SHI system which should be supplemented by the Private Health Insurance (PHI) sector.

Off-label drug use and temporary recommendations for use: Rearranging the deckchairs on the Titanic?

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Publication date: Available online 1 July 2016
Source:Health Policy
Author(s): Alain Braillon, Joel Lexchin



Response to the letter: The long-term reform in the Netherlands: What is the scientific rational for the WMO?

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Publication date: July 2016
Source:Health Policy, Volume 120, Issue 7
Author(s): Hans Maarse, Patrick Jeurissen


The long-term reform in the Netherlands: what is the scientific rational for the WMO?

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Publication date: July 2016
Source:Health Policy, Volume 120, Issue 7
Author(s): Inge F.A. Broeckaert, Wenda van Loenen, Tjerk Overduin, Marc J. Vincent, Nardo J.M. van der Meer, Peter H.J. van der Voort


Evidence is missing to diagnose a public health tragedy

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Publication date: July 2016
Source:Health Policy, Volume 120, Issue 7
Author(s): José A. Tapia Granados, Javier Rodriguez


Long term impact of the economic crisis on health care in the Greek setting: The Pandora box?

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Publication date: July 2016
Source:Health Policy, Volume 120, Issue 7
Author(s): Foteini Anastasiou, Maria Antonopoulou, Ioanna Tsiligianni, Christos Lionis


Government, politics and health policy: Ways forward from Mackenbach and McKee's study

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Publication date: July 2016
Source:Health Policy, Volume 120, Issue 7
Author(s): Lauri Kokkinen, Carles Muntaner


Re-insurance in the Swiss health insurance market: Fit, power, and balance

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Publication date: July 2016
Source:Health Policy, Volume 120, Issue 7
Author(s): Christian P.R. Schmid, Konstantin Beck
Risk equalization mechanisms mitigate insurers’ incentives to practice risk selection. On the other hand, incentives to limit healthcare spending can be distorted by risk equalization, particularly when risk equalization payments depend on realized costs instead of expected costs. In addition, cost based risk equalization mechanisms may incentivize health insurers to distort the allocation of resources among different services. The incentives to practice risk selection, to limit healthcare spending, and to distort the allocation of resources can be measured by fit, power, and balance, respectively. We apply these three measures to evaluate the risk adjustment mechanism in Switzerland. Our results suggest that it performs very well in terms of power but rather poorly in terms of fit. The latter indicates that risk selection might be a severe problem. We show that re-insurance can reduce this problem while power remains on a high level. In addition, we provide evidence that the Swiss risk equalization mechanism does not lead to imbalances across different services.

Public–private sector interactions and the demand for supplementary health insurance in the United Kingdom

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Publication date: July 2016
Source:Health Policy, Volume 120, Issue 7
Author(s): Anikó Bíró, Mark Hellowell
We examine the demand for private health insurance (PHI) in the United Kingdom and relate this to changes in the supply of public and private healthcare. Using a novel collection of administrative, private sector and survey data, we re-assess the relationships between the quality and availability of public and private sector inpatient care, and the demand for PHI. We find that PHI coverage in the United Kingdom is positively related to the median of the region- and year-specific public sector waiting times. We find that PHI prevalence ceteris paribus increases with being self-employed and employed, while it decreases with having financial difficulties. In addition, we highlight the complexities of inter-sectoral relations and their impact on PHI demand. Within a region, we find that an increase in private healthcare supply is associated with a decrease in public sector waiting times, implying lower PHI demand. This may be explained by the usage of private facilities by NHS commissioners. These results have important implications for policymakers interested in the role of private healthcare supply in enhancing the availability of and equitable access to acute inpatient care.


Effects of the financial crisis and Troika austerity measures on health and health care access in Portugal

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Publication date: July 2016
Source:Health Policy, Volume 120, Issue 7
Author(s): Helena Legido-Quigley, Marina Karanikolos, Sonia Hernandez-Plaza, Cláudia de Freitas, Luís Bernardo, Beatriz Padilla, Rita Sá Machado, Karla Diaz-Ordaz, David Stuckler, Martin McKee
Although Portugal has been deeply affected by the global financial crisis, the impact of the recession and subsequent austerity on health and to health care has attracted relatively little attention. We used several sources of data including the European Union Statistics for Income and Living Conditions (EU-SILC) which tracks unmet medical need during the recession and before and after the Troika's austerity package. Our results show that the odds of respondents reporting having an unmet medical need more than doubled between 2010 and 2012 (OR=2.41, 95% CI 2.01–2.89), with the greatest impact on those in employment, followed by the unemployed, retired, and other economically inactive groups. The reasons for not seeking care involved a combination of factors, with a 68% higher odds of citing financial barriers (OR=1.68, 95% CI 1.32–2.12), more than twice the odds of citing waiting times and inability to take time off work or family responsibilities (OR 2.18, 95% CI 1.20–3.98), and a large increase of reporting delaying care in the hope that the problem would resolve on its own (OR=13.98, 95% CI 6.51–30.02). Individual-level studies from Portugal also suggest that co-payments at primary and hospital level are having a negative effect on the most vulnerable living in disadvantaged areas, and that health care professionals have concerns about the impact of recession and subsequent austerity measures on the quality of care provided. The Portuguese government no longer needs external assistance, but these findings suggest that measures are now needed to mitigate the damage incurred by the crisis and austerity.

Effectiveness of comprehensive care programs for patients with multiple chronic conditions or frailty: A systematic literature review

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Publication date: July 2016
Source:Health Policy, Volume 120, Issue 7
Author(s): Petra Hopman, Simone R. de Bruin, Maria João Forjaz, Carmen Rodriguez-Blazquez, Giuseppe Tonnara, Lidwien C. Lemmens, Graziano Onder, Caroline A. Baan, Mieke Rijken
Objective To describe comprehensive care programs targeting multimorbid and/or frail patients and to estimate their effectiveness regarding improvement of patient and caregiver related outcomes, healthcare utilization and costs. Methods Systematic search in six electronic databases for scientific papers published between January 2011 and March 2014, supplemented by reference tracking. Wagner's Chronic Care Model (CCM) was used to operationalize comprehensive care. The quality of the included studies was assessed, and a best-evidence synthesis was applied. Results Nineteen publications were included describing effects of eighteen comprehensive care programs for multimorbid or frail patients, of which only one was implemented in a European country. Programs varied in target groups, settings, interventions and number of CCM components addressed. Providing comprehensive care might result in more patient satisfaction, less depressive symptoms, a better health-related quality of life or functioning of multimorbid or frail patients, but the evidence is insufficient. There is no evidence that comprehensive care reduces the number of primary care or GP visits or healthcare costs. Regarding the use of inpatient care, the evidence was insufficient. No evidence was found for a beneficial effect of comprehensive care on caregiver-related outcomes. Conclusion Despite the fact that over the years several (good-quality) studies have been performed to estimate the value of comprehensive care for multimorbid and/or frail patients, evidence for their effectiveness remains insufficient. More good-quality studies and/or studies allowing meta-analysis are needed to determine which specific target groups at what moment will benefit from comprehensive care. Moreover, evaluation studies could improve by using more appropriate outcome measures, e.g. measures that relate to patient-defined (personal) goals of care.

The new Australian after-hours general practice incentive payment mechanism: equity for rural general practice?

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Publication date: July 2016
Source:Health Policy, Volume 120, Issue 7
Author(s): Amanda L. Neil, Mark Nelson, Andrew J. Palmer
In July 2015, a national scheme for after-hours incentive funding for general practices was re-introduced in Australia, 2-years after funding was transferred to regional primary health care organisations (Medicare Locals). The re-introduction was recommended in a 2014 review of after-hours primary care reflecting the “overwhelming desire” among general practice. Given the centrality of after-hours care provision in rural and remote practices identified in the review, we compare and contrast the current and historical after-hours incentive funding mechanisms focussing on fairness towards rural general practices. While there are similarities between the current and historical mechanisms, significant differences exist. The comparison is not straightforward. The major consistency is utilisation of practice standardised whole patient equivalents (SWPE) as the basis of funding, inherently favouring large urban general practices. This bias is expected to increase given a shift in focus from practices with no option but to provide 24/7 care to any practice providing 24/7 care; and an associated increased funding per SWPE. Differences primarily pertain to classification processes, in which the realities of rural service provision and recognition of regional support mechanisms are given minimal consideration. Rapid introduction of the new general practice after-hours incentive funding mechanism has led to inconsistencies and has exacerbated inherent biases, particularly inequity towards rural providers. Impact on morale and service provision in non-urban areas should be monitored.

The 2013 cholesterol guideline controversy: Would better evidence prevent pharmaceuticalization?

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Publication date: July 2016
Source:Health Policy, Volume 120, Issue 7
Author(s): Lynn Unruh, Thomas Rice, Pauline Vaillancourt Rosenau, Andrew J. Barnes
Cardiovascular disease (CVD) remains the leading cause of death globally. A class of medications, known as statins, lowers low-density lipoprotein cholesterol levels, which are associated with CVD. The newest 2013 U.S. cholesterol guideline contains an assessment of risk that greatly expands the number of individuals without CVD for whom statins are recommended. Other countries are also moving in this direction. This article examines the controversy surrounding these guidelines using the 2013 cholesterol guidelines as a case study of broader trends in clinical guidelines to use a narrow evidence base, expand the boundaries of disease and overemphasize pharmaceutical treatment. We find that the recommendation in the 2013 cholesterol guidelines to initiate statins in individuals with a lower risk of CVD is controversial and there is much disagreement on whether there is evidence for the guideline change. We note that, in general, clinical guidelines may use evidence that has a number of biases, are subject to conflicts of interest at multiple levels, and often do not include unpublished research. Further, guidelines may contribute to the “medicalization” or “pharmaceuticalization” of healthcare. Specific policy recommendations to improve clinical guidelines are indicated: these include improving the evidence base, establishing a public registry of all results, including unpublished ones, and freeing the research process from pharmaceutical sector control.

The 2011 proposal for Universal Health Insurance in Ireland: Potential implications for healthcare expenditure

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Publication date: July 2016
Source:Health Policy, Volume 120, Issue 7
Author(s): Sheelah Connolly, Maev-Ann Wren
The Irish healthcare system has long been criticised for a number of perceived weaknesses, including access to healthcare based on ability-to-pay rather than need. Consequently, in 2011, a newly elected government committed to the development of a universal, single-tier system based on need and financed through Universal Health Insurance (UHI). This article draws on the national and international evidence to identify the potential impact of the proposed model on healthcare expenditure in Ireland. Despite a pledge that health spending under UHI would be no greater than in the current predominantly tax-funded model, the available evidence is suggestive that the proposed model involving competing insurers would increase healthcare expenditure, in part due to an increase in administrative costs and profits. As a result the proposed model of UHI appears to be no longer on the political agenda. Although the Government has been criticised for abandoning its model of UHI, it has done so based on national and international evidence about the relatively high additional costs associated with this particular model.

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