The Rise and Rise of Evidence in Health Care

Health care practitioners (especially doctors) have always given assurances that what they do is efficacious. But in the past 50 years justification of the effectiveness of health care interventions has attained a new prominence. Evidence, at least notionally, now lies at the heart of health care policy and practice. This article provides an overview of the generation and use of evidence on effectiveness in health care. It explains why rigorous methodologies have taken hold and describes the major preoccupation with trying to ensure that research evidence has an impact on clinical practice. The strengths and weaknesses of evidence-based health care are explored to identify the opportunities for profitable transfer of experience across the public sector.     

Regulating health insurance: the challenges of managed networks

The role of the regulator in health insurance is examined in the context of the change in nature of regulatory oversight necessary to monitor the activities of the regulated parties. Health insurance to this point has been largely regulated by insurance departments that have historically focused on monitoring the solvency and meeting the contractually required reimbursements for indemnity carriers. Now as the indemnity carrier has either migrated to managed care or faced a declining book of business, the historic role of regulation must change to match the new environment. This article examines the role of the health insurance/managed care regulator department under this new paradigm and identifies where and how the regulator can exert influence in such a system.     

论商业保险基础风险原理对建立基本医疗保障制度的适用价值

2009年新医改重大举措不断,它对于我国相对薄弱的医疗保障体系无疑是必需和及时的。本文从理论上初步论述了商业保险基础风险原理对完善建立我国全民基本医疗保障制度的适用价值。通过总结国际医疗保障制度改革及其研究的趋势,论证以医疗保险的基础风险为依据,是实现社会医疗保险预期绩效的基本保证。同时指出定性定量分析我国全民医保的基础风险,才能从根本上找到完善建立相关制度的措施和方法,促进我国医疗保障体系的进一步科学发展。     

Employee contributions: a primer on their use, historical trends and overall fit within benefits strategy

This article focuses on the use of employee contributions as a strategic tool within employee health plans. While most employers require some form of employee contributions for health care, there is no clear "one-size-fits-all" solution. A myriad of strategies are in place, some active and some passive. This article reviews both common and emerging strategies and how they differ based on industry, employer size and region; discusses how employee contribution strategy fits within overall benefits strategy; and provides a strategic framework for approaching employee contributions in the future.     

Health risk management: well-being for the employee and the bottom line

For most employers, a small percent of the employee/participant population accounts for a large percent of health care costs. However, the population of this high-cost group changes from year to year. The fundamental problem is keeping employees out of the high-risk/high-cost segment, something plan design changes cannot address but that integrated health risk management (IHRM) can help achieve. This article explains how employers can implement an IHRM program to significantly lower health care costs to a degree unattainable through traditional cost-control strategies, while simultaneously raising workers' productivity and well-being.     

The Politics of Evidence-Based Health Policy-Making

Israel's National Health Insurance Law which came into effect in January 1995 required a substantial reform of the country's health-care system. Health care in Israel was decentralized, lightly regulated, dominated by politicised decisions, under-funded and inefficient. Health policy was poorly grounded in data and largely influenced by political considerations. The main thrusts of the reform were to universalize health insurance coverage, increase freedom of choice, depoliticize the system, stabilize the system financially, and decrease service provision by the state by transferring some responsibilities to 'sick funds' to be regulated by the Ministry of Health. Data were to play an important role in de-politicizing and making decision-making more rational. This article gives some encouragement to proponents of evidence-based policy-making but shows that, even where the intention is to use data, political motives are a strong force.     

Risk Communication and the Social Amplification of Public Sector Risk

Concerns exist within the public sector about the ability of organizations to communicate issues of risk. These concerns include: the nature and magnitude of risks; the vulnerability of those who may bear the consequences associated with an event; and the sense of helplessness felt by victim groups. Apart from the public sector's role as risk generator, regulator and communicator, it also has some responsibility for dealing with the consequences of a major catastrophic event through agencies such as health care and the emergency services. Under certain conditions, it is apparent that concerns over risk issues can escalate beyond a level expected by those charged with the management of that risk. Within this framework, the effective communication of risk and uncertainty is an integral, but often neglected, part of public sector activities. This article explores the process of risk communication and risk amplification and suggests a number of perspectives on policy development.     

Implementing Evidence-Based Practice in Health Care

This article summarizes recent research on the effectiveness of efforts to implement evidence-based health care. The authors conclude that the evidence in support of single interventions being effective in bringing about practitioner change is weak at best. The authors give examples and evaluative comments on more complex organizational and systemic interventions that are aimed at changing clinical practice, and discuss some of the barriers to their application.     

The Effects of Uncertainty on the Demand for Health Insurance

This article analyzes the effects of uncertainty and increases in risk aversion on the demand for health insurance using a theoretical model that highlights the interdependence between insurance and health care demand decisions. Two types of uncertainty faced by the individuals are examined. The first one is the uncertainty in the consumer's pretreatment health and the second is the uncertainty surrounding the productivity of health care. Comparative statics results are reported indicating the impact on the demand for insurance of shifts in the distributions of pretreatment health and productivity of health care in the form of first‐order stochastic dominance, Rothschild–Stiglitz mean‐preserving spreads, and second‐order stochastic dominance. The demand for insurance increases in response to a Rothschild–Stiglitz increase in risk in the distribution of the pretreatment health provided that the health production function is in a special class and the price elasticity of health care is nondecreasing in the pretreatment health. Provided also that the demand for health care is own‐price inelastic, the same conclusion is obtained when the uncertainty is about the productivity of health care.     

How universal health care would influence decisions about work and retirement

The current U.S. health care system distorts individual decisions about work and retirement. After a brief explanation of how the current health care system works, this article reviews those distortions and considers how individuals would respond to the implementation of a universal health care system. The author argues that the likely adverse impacts of an employer health insurance mandate on low-skilled workers could be more than offset by a well-designed system of government subsidies.     

Chancen und Herausforderungen der Rückversicherung in der gesetzlichen Krankenversicherung

In 2009 a so-called morbidity orientated risk structure equalization scheme was installed for the German statutory health insurance in order to minimize structural differences between different providers with respect to revenue and expenditures. Even with this mechanism some risks to the individual health insurance providers remain. Reinsurance could be a way to mitigate these risks, but so far only very few contracts have been signed. Moreover the existing reinsurance contracts only focus on the periphery of the statutory health insurance system such as travel health insurance. In this article we therefore analyse existing risks for individual health insurance providers and evaluate their (re-)insurability. Hereafter the potential for reinsurance solutions in the German statutory health insurance itself as well as in newer forms of healthcare provision (e.g. integrated health care and managed care) is discussed. We find that reinsurance may be a reasonable solution for many of the risks in the statutory health insurance scheme. But as research in this area is very young further analysis of the nature of risks is necessary.     

Consumer-driven health plans: design features to promote quality improvement

The most prevalent form of consumer-driven health plans (CDHPs) presents risks in terms of the cost, quality and appropriate use of health care. This article identifies those risks and shows employers how they can reduce them without compromising the overall cost-control potential of CDHPs. A good CDHP strategy should work on both the demand and supply sides of the market.     

A Gentle Introduction to Risk Aversion and Utility Theory

While the topics of risk aversion and utility theory have been discussed extensively in the academic literature on risk and insurance, this literature does not include a pedagogical discussion that is widely accessible for classroom use. This article provides a practical introduction to risk aversion that is designed for readers with little prerequisite course work in economics or statistics. We describe a simple model of insurance demand that can be applied to the property, liability, life, and health insurance markets. We also demonstrate how risk aversion affects a variety of real-life insurance decisions made under conditions of uncertainty, including how much the market will bear to pay for insurance administrative expenses and how demand varies for different types of auto insurance coverage. Exercises and practice problems are provided so that readers can test their mastery of the concepts presented in the article. An instructional note on using this article to teach risk aversion in the classroom is also provided.     

Integrating benefits decision making

Integrated employee benefit decision making helps employees use their benefits more wisely and identify opportunities to balance their immediate benefits needs (such as health care) and future benefits needs (such as retirement). This article discusses how employers can overcome employees' behavioral barriers to making integrated employee benefit decisions by changing the ways benefits are communicated and employees are presented with action decisions. Undertaking these steps allows employers to not only improve their employees' overall financial perspectives, but also furthers plan sponsors' goals of actively promoting personal responsibility with respect to retirement funding and changing employee behavior with respect to controlling health care costs.     

The next big thing in health benefits: consumer choice

Consumers are the only ones who can affect all decision points that drive health care cost and quality. As a result, consumers' health and financial security depend on their taking more responsibility for their health care decisions and having the tools and information needed to do so successfully. This article explains the five key decision points that drive health care cost and quality, how technology aids marketplace innovations, and how employers can help advance consumer choice in order to push the health care system to deliver better care and keep inflation in check.     

Health and finance: exploring the parallels between health care delivery and professional financial planning

This article compares the role of risk and uncertainty discourse across two rather disparate areas of expertise: personal financial planning and health care delivery. On the basis of 42 semi-structured interviews and eight recorded meetings between planners and their clients, as well as a comprehensive review of extant health literature, it is argued that three points of convergence – the discursive management of uncertainty, the temporalization of risk, and the use of images – offer a modicum of certainty which functions ultimately to legitimize expertise and facilitate courses of remedial action while simultaneously assuaging laypeople’s existential anxieties. The article concludes with a number of reflections on the importance of agency and trust.     

Dis-Ag-reement: the construction and negotiation of risk in the Swedish controversy over antibacterial silver

What constitutes a potentially hazardous object is often debated. This article analyses the polemic construction and negotiation of risk in the Swedish controversy over the use of antibacterial silver in health care and consumer products. This debate engages the media, government agencies, parliament and government, non-governmental organizations and companies. Texts and websites from these actors were studied using content analysis. Antibacterial silver is construed by some actors as a risk object with harmful effects on a series of objects at risk: the environment, public health, organisms and sewage treatment. In contrast, other actors deny that antibacterial silver is a risk object, instead construing it as mitigating risk. In such a schema, antibacterial silver is conceived of as managing the risk objects of bacteria and micro-organisms, in turn managing the risk objects of infection, bad smell and washing, and in turn helping the environment and public health (objects at risk). The structure of the debate suggests two basic modes of risk communication. First, antibacterial silver is construed as a risk object, endangering a variety of objects at risk, such as organisms, public health, the environment and sewage treatment. Second, this association between antibacterial silver and objects at risk is obstructed, by denying that antibacterial silver is a risk object or by associating silver with the benefit of mitigating risk.     

United we stand,divided we fall: the failure of an accounting information system in a major radiology provider

This article explores the way in which a major Australian radiology organization implemented a complex accounting information system and how workers in the 72 radiology practices that had to use it resisted the change. The study reports on the issues that led to the circumvention of the system by individuals and, after only three years, complete withdrawal of the accounting information system by the parent organization. This article has implications for firms in the health care and other sectors considering implementing new accounting information systems. Organizations need to incorporate change management techniques and provide open communication to all stakeholders to minimize disruption and potential problems.     

The role of the PBM in total health management strategies for individuals with chronic conditions

In this article, we examine the multiple data sources and outcomes surrounding the management of both pharmacy and medical cost spending for chronic health care in one pharmacy benefit manager (PBM). We offer examples of how the complex relationship between interventions and spending is utilized in order to bring value to PBMs' clients above and beyond the scope of traditional pharmacy trend analytics. Additionally, we demonstrate how the implementation of disease management programs can effectively impact the largest component of total health care costs.