Regional variation in health care utilization and mortality

Geographic variation in health care utilization has raised concerns of possible inefficiencies in health care supply, as differences are often not reflected in health outcomes. Using comprehensive Norwegian microdata, we exploit cross-region migration to analyze regional variation in health care utilization. Our results indicate that place factors account for half of the difference in utilization between high and low utilization regions, while the rest reflects patient demand. We further document heterogeneous impacts of place across socioeconomic groups. Place factors account for 75% of the regional utilization difference for high school dropouts, and 40% for high school graduates; for patients with a college degree, the impact of place is negligible. We find no statistically significant association between the estimated place effects and overall mortality. However, we document a negative association between place effects and utilization-intensive causes of death such as cancer, suggesting high-supply regions may achieve modestly improved health outcomes.     

Rebalancing health systems toward community-based care: The role of subsectoral politics

There has been increased policy discourse urging a “rebalancing” of health systems from institutionally-based to community-based approaches. This paper offers an analysis of the subsectoral dynamics that condition opportunities to strengthen community-based care relative to acute care. We report on the results of a policy study in Ontario, Canada that explored factors impacting on the capacity to expand community-based care. In so doing, we highlight the challenges associated with the community subsector’s ability to develop ‘critical’ status and challenge the dominance of the acute subsector. We conclude that attempts to rebalance health systems toward community-based care should begin by understanding that health care is not a monolithic policy sector, but rather a collection of proximate policy sub-sectors, inclusive of community care, acute care, and institutional care, each with their own internal characteristics and dynamics that impact sectoral directions.     

《医疗卫生产业化范畴界定和策略研究》项目概述

该文简要介绍了<医疗卫生产业化范畴界定和策略研究>项目的背景、目标、研究内容和研究方法等,旨在研究医疗卫生产业化的适用范围、目标定位、障碍、障碍根源、约束条件、动力阻力、关键技术和可行性,研制和推荐可操作的卫生产业化宏观策略、管理模式和方案.     

关于卫生事业发展与费用控制的探讨

卫生系统面临着空前的全方位的改革,改革的总体目标是用比较低廉的费用提供比较优质的医疗服务,努力满足广大人民群众的基本医疗服务需求。费用控制是保证改革总体目标得以实现的关键环节。该分析了费用控制与卫生事业发展的关系,对医药费用控制的现状进行了评价,结合改革举措分析了医药费用控制的未来发展趋势。     

The contribution of primary care to health and health systems in low- and middle-income countries: A critical review of major primary care initiatives

It has been 30 years since the Declaration of Alma Ata. During that time, primary care has been the central strategy for expanding health services in many low- and middle-income countries. The recent global calls to redouble support for primary care highlighted it as a pathway to reaching the health Millennium Development Goals. In this systematic review we described and assessed the contributions of major primary care initiatives implemented in low- and middle-income countries in the past 30 years to a broad range of health system goals. The scope of the programs reviewed was substantial, with several interventions implemented on a national scale. We found that the majority of primary care programs had multiple components from health service delivery to financing reform to building community demand for health care. Although given this integration and the variable quality of the available research it was difficult to attribute effects to the primary care component alone, we found that primary care-focused health initiatives in low- and middle-income countries have improved access to health care, including among the poor, at reasonably low cost. There is also evidence that primary care programs have reduced child mortality and, in some cases, wealth-based disparities in mortality. Lastly, primary care has proven to be an effective platform for health system strengthening in several countries. Future research should focus on understanding how to optimize the delivery of primary care to improve health and achieve other health system objectives (e.g., responsiveness, efficiency) and to what extent models of care can be exported to different settings.     

发展中国家的医疗卫生服务体系

考察了发展中国家的卫生筹资和服务提供体系,并认为发展中国家需要扩大医疗保障覆盖面,需要重新关注初级卫生保健和公共卫生,只有这样才能不断完善其卫生体系。     

Equity and equality in health and health care

This paper explores four definitions of equity in health care: equality of utilization, distribution according to need, equality of access, and equality of health. We argue that the definitions of 'need' in the literature are inadequate and propose a new definition. We also argue that, irrespective of how need and access are defined, the four definitions of equity are, in general, mutually incompatible. In contrast to previous authors, we suggest that equality of health should be the dominant principle and that equity in health care should therefore entail distributing care in such a way as to get as close as is feasible to an equal distribution of health.     

The black box of health care expenditure growth determinants

In this paper, the determinants of growth of aggregate health expenditures are investigated. The study departs from previous literature in that it looks at differences across countries in growth (and not levels) of health care expenditures. Estimation is made for 24 OECD countries. Health system characteristics usually believed to influence health expenditures growth, like population ageing, the type of health system (public reimbursement, public contract or integrate) and existence of gatekeepers, are found to be non-significant. Nevertheless, there is evidence that health expenditures experienced a clear slower growth in the last decade. The explanation for this slowdown could not be found in the proposed model and should stimulate further research. © 1998 John Wiley & Sons, Ltd.     

Institutional arrangements and efficiency of health care delivery systems

This study examined the efficiency of health care delivery systems in 24 OECD countries. Practicing physicians, practicing nurses, inpatient beds, and pharmaceuticals were considered as inputs to treat populations of various age groups. Data envelopment analysis (DEA) was utilized to calculate efficiency. We also calculated input efficiency that should be helpful in determining excess number of physicians, nurses, inpatient beds, and pharmaceuticals consumed. Institutional arrangements affect efficiency: public-contract and public-integrated countries are more efficient than public-reimbursement countries. Countries in which physicians are paid in wages and salaries and countries with capitation have higher efficiency than fee-for-service countries. Countries in which a primary care physician acts as a gatekeeper are also more efficient than countries without gatekeepers.     

Informal care and health care use of older adults

Informal care by adult children is a common form of long-term care for older adults and can reduce medical expenditures if it substitutes for formal care. We address how informal care by all children affects formal care, which is critically important given demographic trends and the many policies proposed to promote informal care. We examine the 1998 Health and Retirement Survey (HRS) and 1995 Asset and Health Dynamics Among the Oldest-Old Panel Survey (AHEAD) using two-part utilization models. Instrumental variables (IV) estimation controls for the simultaneity of informal and formal care. Informal care reduces home health care use and delays nursing home entry.     

Health insurance and imperfect competition in the health care market

We show that when health care providers have market power and engage in Cournot competition, a competitive upstream health insurance market results in over-insurance and over-priced health care. Even though consumers and firms anticipate the price interactions between these two markets - the price set in one market affects the demand expressed in the other - Pareto improvements are possible. The results suggest a beneficial role for Government intervention, either in the insurance or the health care market.     

中部四省女性农民工医疗保健服务利用及影响因素分析

目的:分析经济因素对女性农民工医疗保健服务利用的影响作用,为建立女性农民工医疗保健服务对策提供科学依据。方法:采用问卷调查中部4省1 142例女性农民工的人口学特征、医疗保健服务需求和利用情况及影响因素,运用EPI Data 3.0建立数据库,SPSS 17.0进行统计分析。结果:女性农民工最近两周患病率为29.4%,高于2008年第四次国家卫生服务调查;未就诊的女性农民工为38.1%,与第四次国家卫生服务调查接近;慢性病患病率为17.8%,略低于第四次国家卫生服务调查。有22.3%的女性农民工未接受过产前检查,产前检查达到5次的占36.9%。结论:女性农民工的疾病经济风险比较高,经济状况是农村居民卫生服务利用的主要影响因素,建议结合女性农民工的务工特点建立适宜的医疗保险和服务方式。     

用科学发展观统领卫生事业

该文认为把科学发展观贯彻到卫生工作的各个方面，贯穿于卫生事业改革与发展的全过程，是推进卫生事业全面、协调、可持续发展的战略选择，并提出“两个适应”、“三个统筹”和“三个坚持”的观点。     

日本预防保健体系对我国构建家庭保健体系的启示

日本的医疗卫生保健体系从广义上讲以预防保健、医疗和照护为三大支柱,并针对儿童、残疾人、老年人等弱势群体通过社会福利政策给予支持,从而打造了全方位的预防保健、医疗、照护、福利网络。随着医疗费用在国民收入中所占比例的不断增加和人口老龄化的不断加剧,日本逐步深化预防保健的重要性,积极促进以治疗为重点的医疗体制向重视疾病预防、健康促进的预防保健医疗体制转变。同时,加强保健、医疗、照护、福利在社区层面的联合。本文重点分析日本预防保健体系的构成及特点,总结其经验,以期为中国强化预防保健意识,促进人口计生系统转型,构建全面深入的家庭预防保健体系提供借鉴和参考。     

实施科教兴医战略实现江西卫生事业可持续发展

该文通过回顾近十几年来江西省卫生改革与发展的历程，阐述了实施科教兴医战略是实现江西卫生事业可持续发展的必要性，并提出了实施科教兴医战略的具体措施。     

Financing of health care services in Hungary

In this paper we give a practical overview of the changes in the financing of health care in Hungary. We describe the financing system of general practitioners, home care (nursing), out-patient care and the acute and chronic care of hospitals. We show how the financial system has changed after the political changes of 1990. The global budget approach of the 1980s was replaced by performance-related financing methods including the ICPM (International Classification of Procedures in Medicine) code system of the WHO (World Health Organization) in out-patient care and the introduction of HBCS (Homogén Betegségcsoportok, Homogeneous Disease Groups) in in-patient care. We underline that the efforts made towards reforming health care financing resulted in an activity-related financing system.     

Fairness and feasibility in national health care systems.

The issue of National Health Care reform has been discussed from many different perspectives. One of the most fundamental justifications for such reform is based on the notion of horizontal equity. The motivation for equity in medical services use contrasts with the seeming lack of concern for equity in financing. Proposed policy remedies often involve transfers through taxation, though the effects of government taxation often reduce the efficiency of publicly financed health insurance. Further, the effects of heterogeneous preferences complicate the assessment of optimal medical service consumption levels. Ethical justification aside, this paper addresses the notion of fairness in the provision of medical care from an economic perspective. It suggests policies which might be most suitable in achieving such a goal. A paradoxical result of these considerations of fairness is that unequal insurance coverage is requisite to ensure more equal utilization of medical services by the population. The concept of fairness is then developed into a bottom up system of equity in the medical market.     

谈卫生事业的发展

该文阐述了新时期卫生事业的发展不能只停留在生产要素量的增长上，而着重要看生产能力质的提高，更要把“服务人群健康水平的提高”作为卫生事业发展的试金石和最终归结点。在确立发展的目标定位时应以卫生事业的服务主体为参照系，而在选择发展的载体时，应从“东一榔头西一锤”、“拆东墙补西墙”、“鹤立鸡群”、“拚设备”等发展的误区里走出来，并从宏观和微观两个层面论述了该怎样发展。     

Contextual effects on health care access among immigrants: Lessons from three ethnic communities in Hawaii

Immigrant health care is the product of the dynamic interaction between societal factors and the individual's socio-economic and cultural characteristics. Our knowledge about immigrant health care, however, has been limited to individual characteristics, without paying attention to the social context in which immigrants reside. This paper explores the effects of social contexts on access to health care among recent immigrants. As a natural experiment, it compares health care experiences of three immigrant groups in Hawaii – Filipinos, Koreans, and Marshallese – who are situated in different social contexts including immigrant health policy, ethnic community, and individual networks. Through household surveys conducted between October 2005 and January 2006, information of 378 recent immigrant adults on health care access, health insurance status, socio-demographic characteristics, linguistic and cultural factors, health status, ethnic community social capital, and social networks was obtained. The results of analyses show that Marshallese respondents have better access to health care than the other two groups, in spite of their lowest socioeconomic status. The high insurance rate of the Marshallese, mainly associated with a state health policy that provides health insurance assistance for the Marshallese, is the major contributor of their greater health care access. While Filipino immigrants do not benefit from state insurance assistance, high levels of health care resources and social capital within the Filipino community enable them to have significantly better health care access than Koreans, who have higher income and educational attainment. Interestingly, the advanced family/kinship networks are associated with better levels of immigrant health care access, while the increase of co-ethnic friend networks is related to lower access to health care. This study implies that restoration of immigrants' eligibility for public health insurance assistance, development of health care resources and social capital within ethnic communities, and mobilization of immigrant networks would be effective starting points to improve health care access among immigrants.