香港医疗融资方案之探讨

如同其他国家一样,香港正面对人口增长及老化、市民对医疗服务期望高、新医疗科技成本较高的问题,由此而生的问题是香港沿用多年的医疗体制能否长期得以维持?香港的公立医疗服务能否以有限的财政资源应付无尽的需求?香港政府聘用了哈佛顾问小组,就香港的医疗体制和融资方式作出检讨。该文将就香港的医疗体制及融资方案问题作出探讨。     

新时代下的健康需要、卫生服务需求与利用：一个新的分析框架

健康需要、卫生服务需求与利用是卫生服务研究中的核心主题,因为其与卫生服务筹资、分配、提供、治理等卫生服务体系发展的核心问题紧密相关,一定程度上也会影响卫生政策的价值取向和权衡。在实际研究中,出现了三者概念混用和滥用现象。因此,正确界定三者的概念内涵、厘清概念间关系,对丰富健康需要理论研究、推动卫生服务体系可持续发展具有重要意义。     

Emerging issues in public health: a perspective on China's healthcare system

China's expenditure on healthcare has increased dramatically over the last 20 years, and three broad trends are seen in the associated health outcomes. First, limited improvements have been achieved to aggregate high-level health outcomes, e.g. infant mortality. Second, development of large and widening health inequalities associated with disparate wealth between provinces and a rural-urban divide. Finally, the burden of disease is shifting from predominantly communicable diseases to chronic diseases. Reasons for the limited gains from investment in healthcare are identified as: (1) increased out-of-pocket expenditure including a high proportion of catastrophic expenditure; (2) a geographical imbalance in healthcare spending, focusing on secondary and tertiary hospital care and greater expenditure on urban centres compared with rural centres; and (3) the commercialization of healthcare without adequate attention to cost control, which has led to escalation of prices and decreased efficiency. Recently, the Chinese Government has initiated widespread reform. Three key policy responses are to establish rural health insurance, partly funded by the Government (the New Rural Co-operative Medical Care System); to develop community health centres; and to aspire to universal basic healthcare coverage by 2020 (Healthy China 2020).     

Pricing and reimbursement of drugs and medical devices in Hungary

Similarly to other countries of Central and Eastern Europe, Hungary has witnessed massive diffusion of healthcare technology such as drugs and medical devices since 1990. While substantial new pharmaceuticals, medical devices, and procedures have been liberalized, there has been no proper evaluation or training in their use. Healthcare providers have come to find themselves as entrepreneurs in private practice, while patients are acquiring an increasing awareness as customers of healthcare,demanding services in return for their taxes and contributions. This has led to extremely irrational patterns of investment in technology, with most an obvious waste of resources, while leaving basic needs unmet. Both the National Health Insurance Fund and the Ministry of Finance believe that the current pharmaceutical and medical device bill is too high. However, introducing a more transparent and flexible pricing and reimbursement framework may enable a more efficient allocation of the limited resources to be achieved. Laszlo Gulacsi Head,Unit of Health Economics and Technology, Assessment in Health Care,Department of Public Policy and Management, Budapest University of Economic Sciences and Public Administration, Fovam ter 8, 1125 Budapest,Hungary, e-mail: lgulacsi@mail.datanet.hu     

运用财务管理 解析医保问题

随着我国医疗体制改革的不断深入和现代医院管理制度的逐步完善,医保款项的核算在整个医院财务会计的循环中起着重要的作用。在此基础之上,财务人员进行相应的财务分析,就能找出医保财务的问题所在,从而采取有效的应对措施。     

Informal out-of-pocket payments for healthcare services in Greece

BackgroundInformal out-of-pocket (OOP) payments for healthcare services are not unusual in Greece.AimThis study estimates the association between respondent and incident-level characteristics and informal payments.MethodsA survey of 4218 households was conducted from November 2016 to February 2017. We analyzed healthcare incidents by all household members within the past four months. Multivariate negative binomial regression analysis was used to estimate the association between respondents and incident-level characteristics and informal OOP payments to providers.ResultsA total of 3494 healthcare incidents were reported by 3183 household-representatives. More-than-half (63 %) of all incidents involved informal activity (median=€150). About 30 % of those were related to provider requested payments. Using hospital, dental, diagnostic/screening, and emergency department services compared to primary care services and having oncological and surgical conditions were among the strongest predictors of higher rates for informal payments. The use of specific providers for reasons related to trust, reputation, referral, and lack of alternatives was also associated with higher rates of informal payments. Provider requested and skip the line payments were associated with larger OOP amounts compared to gratitude payments.ConclusionThis survey reveals that informal payments occur for higher-need and less cost-responsive healthcare services particularly in areas where patients lack alternatives. Health policy and regulatory interventions, including stricter control of the financial reporting system are essential to limit informal payments.     

Health care costs and financial consequences of epidemiological changes in chronic diseases in Latin America: evidence from Mexico

OBJECTIVE: To determine the costs of health services and the financial consequences of changes in the epidemiological profile of chronic diseases in Latin America. STUDY DESIGN: We conducted longitudinal analyses of costs and of the economic impact of the epidemiological transition in healthcare services for diabetes and hypertension in the Mexican health system. The study population included both the insured and uninsured populations. METHODS: The cost-evaluation method was based on the instrumentation and consensus techniques. To estimate the epidemiological changes and financial consequences for 2004-2006, six models were constructed according to the Box-Jenkins technique, using confidence intervals of 95% and the Box-Pierce test. FINDINGS: Costs ranged from US$613 to US$887 for diabetes, and from US$485 to US$622 for hypertension. Regarding epidemiological changes for 2004 compared with 2006, an increase is expected in both cases, although results predict a greater increase for diabetes, 10-15% in all three institutions (P<0.05). Comparing the financial consequences of health services required by insured and uninsured populations, the greater increase (17%) will be for the insured population (P<0.05). The financial requirements for both diseases will amount to 9.5% of the total budget for the uninsured population and 13.5% for the insured population. CONCLUSIONS: If the risk factors and the different healthcare models remain as they are at present, the economic impact of expected epidemiological changes on the social security system will be particularly strong. Another relevant financial factor is the appearance of internal competition in the use and allocation of financial resources among the main providers in the health services; this factor becomes even more complicated within each provider. In effect, within each institution, hypertension and diabetes programmes must compete for resources with other programmes for chronic and infectious diseases.     

Update on immunizations for healthcare personnel in the United States

Healthcare personnel (HCP) play a pivotal role in the transmission of contagious pathogens in the healthcare setting, and HCP are themselves at risk for infection with such pathogens due to the nature of their occupation. Many practices are important in order to reduce infection transmission, including HCP immunization. Unfortunately, HCP immunization rates in the United States (U.S.) have not reached recommended levels, so new strategies are being used to improve HCP coverage, including mandatory immunization and the use of immunization rates as measures of quality and safety. This article will review current practices, policies, and issues surrounding HCP immunization in the U.S.     

The recent health reform in Croatia: True reforms or just a fundraising exercise?

Croatia's most recent reform of the healthcare system was implemented in 2008. The aim of the reform was to enhance financial stability of the system by introducing additional sources of financing, as well as increase the efficiency of the system by reducing sick pay transfers to households, rationalising spending on pharmaceuticals, restructuring hospitals etc. This paper attempts to assess the success of the 2008 healthcare system reform in reaching financial stability and sustainability, and to evaluate the effects of the reform on equity in funding the system. It takes into account the fact that the reform coincided with a severe economic crisis and decline in the overall living standard of Croatian citizens. The paper shows that the reform ended up being expansionary and thus impaired the necessary fiscal adjustment. Finally, it is argued that in circumstances of declining disposable incomes, increased co-payments aimed at the financial stabilisation of the health system made health services less affordable and could have had detrimental effects on equity in the utilisation of health care.     

整合医疗：中国医改的战略选择

本文从理论、国际经验和趋势,以及中国现状,阐述整合医疗在医疗卫生改革中的重要性和作用。建议将整合医疗作为中国医改的战略选择,大力整合医疗卫生体系,建立公立医院之间、公立医院与城乡基层医疗卫生机构的分工协作机制,恢复三级医疗卫生网络,实行分级医疗、双向转诊的医疗服务模式,从根本上改变目前医疗卫生体系分割的局面,提高医疗卫生资源的利用效率,切实缓解群众＂看病难、看病贵＂的问题。     

医疗高需求患者卫生保健策略研究

在中国医改进程中,社会公众"看病贵"的呼声从未间断。但大数据分析表明:只占较少比例(5%)的医疗需求较高的患者,医疗费用占居民医疗总支出的较大比例(约50%)。"看病贵"问题显然并非普遍存在。本文在引入医疗高需求患者概念的基础上,归纳分析医疗高需求患者特征,借鉴国际上医疗高需求患者卫生保健组织及项目的做法经验,分析未来中国医疗高需求患者的保健策略,以期为医改和卫生政策制定提供指导。     

The impact of home hospitalization on healthcare costs of exacerbations in COPD patients

Home-hospitalization (HH) improves clinical outcomes in selected patients with chronic obstructive pulmonary disease (COPD) admitted at the emergency room due to an exacerbation, but its effects on healthcare costs are poorly known. The current analysis examines the impact of HH on direct healthcare costs, compared to conventional hospitalizations (CH). A randomized controlled trial was performed in two tertiary hospitals in Barcelona (Spain). A total of 180 exacerbated COPD patients (HH 103 and CH 77) admitted at the emergency room were studied. In the HH group, a specialized respiratory nurse delivered integrated care at home. The average direct cost per patient was significantly lower for HH than for CH, with a difference of 810€ (95% CI, 418–1,169€) in the mean cost per patient. The magnitude of monetary savings attributed to HH increased with the severity of the patients considered eligible for the intervention. This study was funded by Grants AATM 8/02/99 from the Agencia d’Avaluació de Tecnología Mèdica (Barcelona, Spain); FIS 98/0052-01 from the Fondo de Investigaciones Sanitarias (Spain); SEPAR 1998 (Spain); CHRONIC project (IST-1999/12158) from the European Union (DG XIII); Comissionat per a Universitats i Recerca de la Generalitat de Catalunya (1999-SGR-00228); Fundación Mapfre Medicina (Spain); Red Respira—ISCIII—RTIC-03/11 and Red Telemedicina ISCIII—RTIC—03/117. Alejandro Casas was pre-doctoral research fellow supported by CHRONIC (IST-1999/12158) from the European Union (DG XIII).     

试论建立我国医疗机构评审制度

建立我国的医疗机构评审制度是医疗机构宏观管理的一项重要措施。本文回顾了我国医院评审活动的历史经验,讨论了建立我国医疗机构评审制度的必要性和可行性,介绍了现行医疗机构评审制度的组成与特点,提出了下一阶段医疗机构评审工作的对策。     

医疗卫生领域安德森模型的发展、应用及启示

安德森模型自1968年创建以来,在倾向特征、促进资源和需要三个初始组成部分基础上,通过增加模型测量指标、调整结构、扩充路径关系、转变分析路径等方式历经5次修正和完善,实现了其作为理论模型的完整性及实证研究的可行性,最终获得了国际学术界的广泛认可。在欧美各国广泛应用于医疗卫生服务研究领域,作为分析影响个体就医选择、医疗花费、疾病筛查、药物使用等医疗卫生服务利用行为主要因素的理论模型。梳理并借鉴安德森模型的发展演变、国外应用研究进展,不但有助于我国医疗卫生服务领域的学术研究,亦对优化我国医疗卫生政策、国家卫生服务调查中问卷的指标设计具有现实指导意义。     

Vaccinal status of healthcare students in Lille

Introduction

Vaccine recommendations are the same for healthcare students than for other health care workers. The aim of this study was to describe mandatory and recommended vaccinal coverage and evaluate the benefit of systematic monitoring by a medical team in the Lille Medical School.

Population and methods

A survey was performed from June 2011 to August 2011 on all students in the first year of Health Care Studies. The personal immunization record was considered as evidence of vaccination. The reference vaccinal schedule was the one recommended by the French High Council for Public Health in 2011.

Results

We analyzed the personal immunization records of 553 students. The vaccination coverage was 96.7% (535) for DTP, 74.7% (413) for hepatitis B, and 92.2% (510) of the students had a tuberculin test result. Concerning the recommended vaccinations, 78% (431) were covered for measles, and 78.9% (436) had a history of either chickenpox or its immunization. About 72.7% (402) of students were vaccinated for Haemophilus influenzae and Bordetella pertussis. Respectively, 24.2% (134) and 81% (448) had previously been vaccinated for Neisseria meningitis and tuberculosis. The monitoring of students allowed improving hepatitis B vaccination coverage by 22.28% (123). The student's vaccinal coverage was still inadequate for hepatitis B and measles. The systematic monitoring allowed significantly improving vaccinal coverage for hepatitis B.     

Healthcare Preferences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth

BackgroundThroughout the developing world, children living on urban streets is a byproduct of economic deprivation. In Lahore, Pakistan, there are an estimated 5,000–7,000 street children.PurposeThe study examined HIV risk behaviors and factors associated with exchanging sex among male street children in Lahore, Pakistan.MethodsThe survey was conducted from August 2003 to March 2004 among 565 registrants, ages 5–19, of Project Smile, a program that aimed to enhance the lives of street children in Lahore. We analyzed the frequency of and correlates of recent (past 3 months) sex exchange for money, drugs, or goods. Multivariate log–binomial regression was used to evaluate the independent effect of covariates on exchange sex.ResultsApproximately 40% of participants reported having exchanged sex during the past 3 months. In multivariate analysis, the factors associated with exchanging sex were living on the street for longer than 48 months (Prevalence Ratio [PR]=1.36, 95% Confidence Interval [CI]: 0.99–1.85), reporting ever having used drugs (PR=1.87, 1.10–3.16), cutting one's self (PR=1.66, 95% CI: 1.26–2.19), and having heard of HIV/AIDS (PR=1.36, 95% CI: 1.03–1.80) after adjusting for demographic and street life variables.ConclusionsWe found high rates of sex exchange among a sample of street children in Lahore, Pakistan. The finding that children who have heard about HIV/AIDS are more likely to exchange sex suggests that children at HIV risk talk about HIV, but accuracy of their conversations is unclear. Street children in Pakistan are in great need of HIV education and safe alternatives for generating income.     

The Armenian healthcare system: recent changes and challenges

Background  Armenian healthcare reforms have been carried out since independence in 1991, but achieved their full scale starting in 1995–1996. Although the healthcare system has already been modified and changed for 10 years, there is a lack of research in this regard. Objectives  This paper aims to present the organization of the healthcare system in Armenia, its changes and challenges throughout the reform process. Methods  This paper is mainly based on a review of the relevant professional literature, a review and interpretation of legal acts in the healthcare field, and a review of research and assessment works done by several international and local organizations. Results  There are still large numbers of elements typical for the Soviet Semashko model in Armenian healthcare structures. Implemented reforms have separated the institutions of the public payer and the providers, but did not manage to change the model of financing to be based on compulsory insurance. The level of financing is similar to the average in Central and Eastern Europe, but is based mainly on out-of-pocket payments contributing to about 80% of all system resources. The informal payments reach even 45% of expenditures. The structure of hospital beds remains ineffective, and there are still no mechanisms of increasing the quality of services. Privatization has been applied, but the role of private providers is still limited. Conclusions  The reforms have not caused satisfactory improvement in healthcare performance, although the health indicators are better than at the beginning of the transformation period. The stability of the reforming processes in previous years as well as the engagement of international institutions is a chance for positive changes in the near future.