Hospital use behaviors and associated costs in a health insurance organization, Japan

Physicians are known to play an important role in the rise of health care costs. But patients--the other side of the chain of health care systems--have been given little attention. The present study utilized the outpatient claims (in the belief that the outpatient hospital visits are mainly decided by the patients) from a health insurance organization in Japan (the Fukuoka Prefecture public service mutual aid association for government employees who serve in small cities, towns, and villages) to analyze the employee behaviors in the use of hospital care and the costs associated with these behaviors. Number of diseases diagnosed for an employee, number of claims an employee submitted for one disease, number of hospitals an employee visited, number of claims an employee had from one hospital, and the total number of claims an employee submitted were used to describe the hospital use behaviors. Results showed that some employees exhibited unusual behaviors, characterized by having an extremely large number of diseases diagnosed, visiting a large number of different hospitals, having a large number of claims, etc. Higher medical expenditures were associated with such behaviors. The findings of this study suggest that the patients' role in the rise of health care costs cannot be ignored, and cost-containment strategies targeting modification of patient behaviors in the use of hospital care may prove to be very useful.     

Predicting the Frequency and Amount of Health Care Expenditures

Abstract

This article extends the standard two-part model for predicting health care expenditures to the case where multiple events may occur within a one-year period. The first part of the extended model represents the frequency of events, such as the number of inpatient hospital stays or outpatient visits, and the second part models expenditure per event. Both component models also use independent variables that consist of an individual’s demographic and access characteristics, socioeconomic status, health status, health insurance coverage, employment status, and industry classification. The second part of the model also includes a variable representing the number of events to predict the expenditure per event, thus capturing dependencies between the first and second parts. This article introduces closed-form predictors of annual total expenditures and demonstrates how to create simulated predictive distributions for individuals and groups. The data for this study are from the Medical Expenditure Panel Survey (MEPS). MEPS panels 7 and 8 from 2003 were used for estimation; panels 8 and 9 from 2004 were used to validate predictions. This annual expenditures model provided a better fit to the data than standard two-part models. The count variable was significant in predicting outpatient expenditures. The aggregate expenditures model provided better point predictions of held-out total expenditures than competing models, including the standard two-part model. The predictive distribution for aggregate expenditures for small groups is long tailed, with both the variability and skewness decreasing as the group size increases, an important point for programs designed to manage expenditures.     

Community health care in developing countries

Health care systems in many developing countries have shared characteristics. Government expenditures in poor countries are low for health care. The majority of people cannot easily reach a modern health facility. Most spending is for high-cost curative medicine, e.g., hospitals. Programs are often inefficient in their use of funds. The tragedy of disease in developing countreis is that many of the most serious problems are either preventable or curable by simple, inexpensive, safe methods. About 16 million children under age 5 died in 1979 in developing countries; 5 million of these deaths could have been prevented by immunization against measles, polio, tetanus, diphtheria, whooping cough, and typhoid. Many countries are establishing community-level health care facilities that use community health workers instead of doctors. A 3-tiered program is being adopted in some areas: the community health center, the rural or urban polyclinic, and the referral hospital. The community health center seeks to provide two-thirds of the needed services, including supervision of pregnancy, midwifery, care of new-born children, treatment of endemic diseases, and emergency care for injuries. Early experience has taught that it is more important for the community health worker to have practical experience and the respect of the people he serves than formal education. Improvements in nutrition, hygiene, and sanitation are needed to reach the full health potential of most communities.     

试析医疗卫生事业发展的特殊矛盾和我国医改的路径选择

市场经济条件下医疗卫生事业发展面临五大特殊矛盾。现行医疗卫生体制要解决的首要问题是体制、机制创新问题。公立医院改革和医疗保险体制改革相结合,建立以公益性医院为主题的医疗保险职能和公共医疗服务职能相结合的制度统一、全民覆盖、统筹城乡的新型公共医疗服务保险制度,构建政事分开、管办分开、医保基金管用分开的医疗卫生管理体制,是化解现行医药卫生体制蕴藏的内在矛盾,破解我国医改难题的可行的路径选择。     

农村社区居家养老服务需求强度的实证分析——基于辽宁省S镇农村老年人的问卷调查

基于辽宁省S镇农村社区老年人居家养老服务需求调查发现,农村社区居家养老更加符合农村老年人的养老意愿。依据克雷顿·奥尔德弗"ERG"需求层次理论,将农村老年人需求分为生活照料、医疗保健、精神赡养三个层次。通过李克特量表法衡量居家养老服务需求强度得出,农村老年人所需的医疗保健和精神赡养与生活照料相比需求强度较高。运用spearman相关系数模型测算了年龄、性别、生活自理能力、婚姻状况、健康自评等因素对居家养老服务需求强度的影响程度。为此,我国发展农村居家养老服务需要尊重老年人的养老意愿,以居家养老服务需求强度为依据实施精准供给,积极完善农村社会化养老服务政策支持体系,逐步满足农村社区老年人的养老需求。     

中国城镇居民医疗保险和新型农村合作医疗衔接路径探讨——基于湖北省武汉市的实证分析

中国城镇职工医疗保险、新型农村合作医疗和城镇居民医疗保险的建立标志着全民医保体系的确立,但是基本医疗卫生服务仍然表现出明显的城乡二元化特征。湖北省武汉市作为中部经济发展水平较高的大城市,在城市化和人口流动加快的背景下,迫切需要实现城乡医疗卫生资源的整合和基本医疗保险制度的衔接。首先实现城镇居民医疗保险和新农合衔接,进而探索城乡居民医疗保险和城镇职工医疗保险衔接,分两步走实现城乡三大医疗保险制度衔接。     

Did the Health Card Program Ensure Access to Medical Care for the Poor during Indonesia's Economic Crisis?

The Indonesian Social Safety Net health card program was implementedin response to the economic crisis that hit Indonesia in 1997,to preserve access to health care services for the poor. Healthcards were allocated to poor households, entitling them to subsidizedcare from public health care providers. The providers receivedbudgetary support to compensate for the extra demand. This articlefocuses on the effect of the program on primary outpatient healthcare use, disentangling the direct effect of allocating healthcards from the indirect effect of government transfers to healthcare facilities. For poor health card owners the program resultedin a net increase in use of outpatient care, while for nonpoorhealth card owners the program resulted mainly in a substitutionfrom private to public health care. The largest effect of theprogram seems to have come from a general increase in the supplyof public services resulting from the budgetary support to publicproviders. These benefits seem to have been captured mainlyby the nonpoor. As a result, most of the benefits of the healthcard program went to the nonpoor, even though distribution ofthe health cards was propoor. The results suggest that had theprogram, in addition to targeting the poor, established a closerlink between provision of services to the target groups andfunding, the overall results would have been more propoor.     

Comparing the Impact of News: A Tale of Three Health Care Sectors

Abstract:   This paper examines the impact of news on the volatility of equity returns in three sectors of the health care industry – health care service providers, producers of drugs and supplies, and third‐party payors. The news impact is found to be asymmetric in that bad news (i.e., a negative shock) has a significantly greater effect on volatility than good news. Intra‐industry differences in health care equity market performance are documented and are consistent with the fundamental attributes of these sectors including the degree of price and cost pressures facing firms, the physical capital requirements of firms, the search behavior of health care customers, and the presence of alternative market opportunities.     

发达国家的农村医疗卫生制度及其对我国的启示

深化我国农村医疗卫生体制改革离不开对发达国家有益经验的借鉴。本文选取了一些有代表性的发达国家，即美国、日本和澳大利亚，对其农村医疗卫生制度进行系统考察。针对农村健康状况劣于城市的现状，美国制定出各项政策措施及立法措施，在很大程度上改善了农村医疗卫生状况，并促进了卫生公平。澳大利亚将初级卫生保健作为农村卫生发展的重要方向和目标，在保障农村居民卫生可及性和公平性等方面做出了重大努力。依托国民健康保险制度，日本针对农村地区进行积极干预和政策倾斜，达到了城乡之间医疗卫生服务的均等化。上述经验对我国农村医疗卫生体制改革具有重要的借鉴意义。     

Improving the delivery of clinic care

There has been an increasingly widespread movement toward the delivery of health care in outpatient settings. Hospitals must start to prepare for the shift from inpatient to outpatient services. Reductions in reimbursement and increasing costs will force hospitals to collect and obtain more data on outpatient services. Projecting future demands and assessing current utilization rates are two of the key factors in maintaining stability. This article is a case study of a major urban medical center's outpatient clinic. It includes a summary of observations on the clinic's daily operations and several recommendations for improvement. While the original analysis was highly specific to the actual facility observed, this article has been structured so that it may be applied to other institutions.     

医保支付之限额付费方式——基于湖南蓝山、桑植两县的调查

医疗保险支付方式是医疗保险机构对医、患(参保人)的付费方式。支付方式改革是当今世界很多国家医改的核心与难题。湖南蓝山县和桑植县推行了限额付费方式改革,参合农民在乡镇卫生院看病就医,门诊、住院费用付费限额内如实自付,超额部分由新农合基金全额报销,同时,对卫生院实行诊疗人次费用、住院床日费用以及总费用控制,对医生实行绩效工资制。创造了有别于"全民免费医疗"的"全民限费医疗"新模式。推广这种新模式的路径是:明确医疗服务的享受主体、服务主体及范围,科学制定总额预付标准,完善监管机制,建立医疗服务与社会医疗保险二位一体的新体制等。     

The impact of the managed care backlash on health care spending

The health spending slowdown associated with the managed care revolution in the 1990s suggests that managed care may have been successful in controlling health care spending. I exploit the passage of state regulation during the “managed care backlash” as well as geographic variation in managed care intensity to measure the impact of managed care on spending. I find that restricting managed care causes a large and significant increase in hospital spending, which cannot be explained by changes in hospital market concentration, other regulatory activity, and multiple other possible explanations. I also do not find effects of the backlash on mortality.     

地方政府财政支出的民生化进程与农村居民消费——基于总量和分类支出视角下的理论分析与实证检验

基于总量和分类支出的视角,从宏观层面对地方政府民生财政支出与农村居民消费进行理论分析,并采用1998~2011年中国大陆31个省市面板数据加以实证检验,研究结果表明：地方政府民生财政支出确实有效地促进了农村居民消费,尤其是对以教育文化娱乐、医疗保健等为主的发展享受性消费的挤入程度要大于以衣食住为主的基本生存性消费;但在民生财政具体分类支出方面影响却存在着差异,即教育和医疗卫生支出对农村居民消费产生显著的挤入效应,而文化和社会保障等支出影响微弱。因此,在稳步扩大民生财政支出比重的同时,应注重优化民生财政支出结构,增加农村居民收入等,全面提高农村居民消费水平。     

城乡居民医保逆选择的破解——一个基于不同人口年龄需求的设计

逆选择困扰了我国城乡居民医保事业的可持续发展.在原有的大病和重病保障之外,基于不同人口年龄需求设计一个有条件、有限度和有年龄差别的特殊医保待遇方案,让参保者在没有享受到大病重病医保待遇的情况下,也可获得一些与年龄相称的医保待遇.这一设计除了能增加参保的弹性,让各年龄群体都自愿积极参保,还可增强居民的健康意识,提高居民的健康水平,减少居民和医保的医药开支.此外,它还能促进基层医疗服务业的发展.     

医疗服务体系的满意度评价——基于2557个城乡不同收入家庭的调查

目的：了解我国城乡居民对目前医疗服务体系的评价。方法：对城乡不同收入家庭进行了问题调查,共计发放问卷2610份,收回有效问卷为2557份,采用SPSS18.0、Excel软件建立数据库并进行数据分析。结论：城乡家庭对目前医疗服务的评价不高;不同收入、年龄、城乡群体的评价有所差别。建议：加强医疗机构尤其是基层医疗机构的能力建设;提高医护人员的技术水平和职业道德;加强医疗卫生领域的监督管理;加强医疗服务模式创新。     

Frequent-user patients: reducing costs while making appropriate discharges

Homeless patients who lack access to the health resources they need to maintain their health on their own pose a challenge for hospitals: Premature discharge of such patients can result in their being readmitted to the hospital in a short time, leading to higher costs for the hospital. Hospitals can address this problem by developing clear, effective homeless discharge policies and by developing ongoing relationships with appropriate medical respite care providers. A hospital also can benefit from spearheading an initiative to develop a medical respite program, enlisting the assistance of other community stakeholders.     

The Effects of Consumer-Directed Health Plans on Health Care Spending

We use unique data from an insurer that exclusively offers high-deductible, "consumer-directed" health plans to identify the effect of plan features, notably employer contributions to the spending account, on health care spending. Our results show that the marginal dollar contributed by the employer to the spending account is entirely spent on outpatient and pharmacy services. In contrast, out-of-pocket spending was not responsive to the amount the employer contributes to the spending account. Our results represent the first plausibly causal estimates of the components of consumer-driven health plans on health spending. The magnitudes of the effects suggest important health care spending consequences to higher employer contributions to spending accounts. Our findings are most directly relevant to health reimbursement arrangement plan designs, though our results are still of value to health savings account plan designs.     

Capped hospital budgets,risk-influencing activities and financial consequences

It has long been recognized in the health economics literature that increased financial incentives for better-informed health care providers not only lead to desirable efficiency gains and cost savings but may have unintended consequences. Accounting-based cost containment instruments like capped budgets or prospective payment may induce physicians and hospitals to systematically avoid high-cost patients. Our paper uses an empirical approach backed by theoretical arguments to study a small German hospital’s reactions to a major increase in financial incentives. We first describe essential features of the German hospital sector and developments that led to the introduction of capped budgets for hospital care in 1993. Next, incentives to treat high-cost patients before and after the reform are analyzed in more detail. Using an anesthesia-related patient severity score (ASA score) as a proxy for financial patient risk, we empirically address the question of how the distribution of ASA scores has changed over time at the hospital for the 1989–2002 period. Our analysis of detailed operating room data reveals that the number of high-risk patients (high-ASA score) showed a systematic and significant decrease after the introduction of capped budgets. Using data from the new German DRG-reimbursement system, we also gain some preliminary evidence of the possible financial consequences of such practices.     

Health care reform and reform for health: creating a health system for communities in the 21st century

If we are to improve the health of the population and reduce the inequalities in health that plague our communities and our planet, we will have to give greater attention to the determinants of health. The reform of the health care system, necessary though it is, will never be sufficient; we need to reform our whole society and in particular to focus on human rather than economic development. At the community level we need to create healthy communities that are “health-creating systems” of environmental, social and human development, as well as health care systems that focus first on improving and maintaining health. Such a “bottom-down” health care system would see the hospital become once again the place of last resort (but still a potentially important partner in creating healthier communities) and would focus instead on how to provide health promotion and health care from the household level up.     

城镇职工退休人员缴纳医疗保险费的可行性及其相关问题探讨——社会保障学者专题讨论综述

2016年初有政府官员提出要建立合理分担、可持续的医保筹资机制,合理强化医保个人缴费责任,研究实行职工医保退休人员缴费政策。部分社会保障学者在微信平台上进行了"退休人员缴纳医疗保险费是否缓解医疗基金支付压力的良方"专题讨论。讨论从退休人员缴纳医保费问题的可行性开始,逐渐深入到医疗控费、公立医院改革、政府角色定位和长期护理保险等医疗领域重难点问题。