Commentary

2019-10-08

This chapter offers a conceptual framework to compare the use of rules and incentives to manage physicians’ clinical decisions, and discusses the challenges for health policy. Clinical rules have assumed various names as managed care has evolved: treatment protocols or algorithms, regulations, administrative constraints, practice guidelines or parameters, prospective utilization review, utilization management, “cookbook” medicine, and simply “controls.” specific rules or rulings can be contested, appealed, and changed. Physicians contribute to the development of valid rules by helping managers to understand clinical realities and uncertainties. Rules also help preserve physicians’ ability to act as patients’ advocates by allowing—perhaps encouraging—physicians to challenge management overtly in certain clinical circumstances. Managed care systems need to balance the use of rules and incentives to meet the goals of providing high-quality, cost-effective care. Policymakers also need to clarify the legal issues surrounding the use of clinical rules and incentives.

A Comparison of International Health Outcomes and Health Care Spending

2019-10-08 · 4 citations

Does increased spending improve health outcomes? We analyzed 1988 data from OECD countries to determine how key health care indexes correlate with health care outcomes. Total health care spending per capita and outpatient and inpatient utilization are not related to health outcomes. How our resources are allocated seems to be more important than how much money is actually spent

Does income influence demand for medical services despite Japan's “Health Care for All” policy?

International Journal of Technology Assessment in Health Care · 2008-01-01 · 17 citations

OBJECTIVES: We examined the impact of household income on the use of medical services in Japan, where there is a "health care for all" policy, with important, centralized influence by the national government designed to ensure universal access. METHODS AND SUBJECTS: All healthcare societies operating in 2003 were included in the study, representing 14,776,193 insured adults and 15,496,752 insured dependents. The mean case rate (the average number of monthly bills per patient), the mean number of service days per person, and the mean medical cost per person served as indicators of medical service use. Multiple regression analysis was performed by the forced entry method using case rate, the number of service days, and medical cost as outcome variables, and average monthly salary, dependent ratio, average age, and premium rate as the explanatory variables. RESULTS: In the multiple regression analyses, average monthly salary showed a high positive correlation of outpatient and dental indicators, including case rate, the number of service days, and medical cost. If the average monthly salary were reduced 20 percent lower than the mean, the estimated changes (95 percent CI) in case rate for the insured were -7.49 (-8.14 approximately -6.84) percent for outpatient visits and -8.16 (-8.77 approximately -7.56) percent for dental services. CONCLUSIONS: Average monthly salary intensifies the effects of copayments on the case rate, the number of service days, and medical cost in the "Employees Health Insurance" in Japan. Thus, a low salary appears to discourage patients from seeking medical and dental services.

Patient-Motivated Prevention of Lifestyle-Related Disease in Japan

Disease Management & Health Outcomes · 2007-01-01 · 18 citations

Understanding the Impact of Health Policy : 10% Co-payments for Medical Services Reduce Compliance with Necessary Care Among Elderly Patients with Chronic Disease in Japan

Kyushu University Institutional Repository (QIR) (Kyushu University) · 2006-03-25

Co-payments help determine how expensive an individual health service is both to payers and to enrollees. The Japanese government had provided its elderly with first dollar coverage, including pharmaceuticals, until January 2001 when it introduced 10% co-payments in an effort to contain costs. We evaluated whether the Japanese increase in co-payments reduced compliance with necessary care, including prescription pharmaceuticals, in elderly patients with chronic illness. Subjects were members of the Health Care System for the Aged (persons age 70 or older) who belonged to a health insurance society located in Fukuoka Prefecture continuously from January 2000 to December 2001. We defined 234 highly compliant patients with hypertension and 35 with diabetes mellitus who visited physicians at least once per month during every month of the 6-month period from January to June 2000. We used time series analyses to compare medical service use during 6 months before and 12 months after the 10% co-payments were introduced. During this study, medical visits were necessary to obtain prescriptions for pharmaceuticals in Japan. Compliance decreased significantly for both hypertension and diabetes mellitus patients after the introduction of 10% co-payments, controlling for the possible impact of secular trends. The impact on necessary pharmaceutical use was likewise affected. However, the impact on costs was not as marked. Co-payments have a major impact on patient compliance and recommended medical service use (but perhaps not on costs), especially in the elderly with chronic diseases.

Does Seropositivity for Helicobacter pylori Antibodies Increase Outpatient Costs for Gastric and Duodenal Ulcer or Inflammation?

PharmacoEconomics · 2004-01-01 · 1 citations

EFFECTS OF AN INCREASE IN PATIENT COPAYMENTS ON MEDICAL SERVICE DEMANDS OF THE INSURED IN JAPAN

International Journal of Technology Assessment in Health Care · 2003-08-01 · 16 citations

OBJECTIVES: To examine quantitatively the effects of an increase in patient copayments from 10% to 20% on the demand for medical services in Japan. METHODS: The subjects of the study were the employees insured by the 1,797 health insurance societies, belonging to the National Federation of Health Insurance Societies, in 1996 and 1998. Indicators of medical service demands analyzed include the inpatient, outpatient, and dental case rates, the number of serviced days per case, the medical cost per day and the medical cost per insured. RESULTS: When the effects of an increase in patient copayments from 10% to 20% were evaluated, taking into account the average age, the average monthly salary, the total number, the gender (male-to-female) ratio and the dependent ratio of the insured, the estimated change in the case rate was -6.96% for inpatient, -4.79% for outpatient, and -5.77% for dental care. The estimated change in the number of serviced day per case was -4.66% for inpatient, -5.67% for outpatient, and -1.82% for dental care. The estimated change in the medical cost per day was -3.15% for inpatient, -13.00% for outpatient, and -11.48% for dental care. The estimated change in the medical cost per insured was -14.08% for inpatient, -21.54% for outpatient, and -18.11% for dental care. CONCLUSIONS: The increase in patient copayments from 10% to 20% enabled insurers to substantially reduce medical costs by cost shifting from the insurer to the insured, with resultant changes in the case rate and the number of service days per case.

Competitive Behavior In The HMO Marketplace

Health Affairs · 2002-01-01 · 31 citations

Are health maintenance organizations (HMOs) less profitable in more competitive markets, and does competition erode unusually high profits over time? To answer these questions, we examined profit rates (as a proportion of revenues) in 1994 and 1997 for all HMOs in 259 metropolitan areas. We found that profits were significantly lower on average in 1994 in markets with more competition, measured alternatively by the number of HMOs or their market concentration. We also found that there was no relationship between a market's relative profit ranking in 1994 and its ranking in 1997; highly profitable markets were not able to preserve their relative standing. Neither the proportion of HMO enrollees in for-profit HMOs nor HMO market penetration was significantly related to profit rates.

The Future Catches Up: A Medical School Curriculum in Health Economics

The American Journal of the Medical Sciences · 2000-05-01 · 6 citations

Financial Incentives And Drug Spending In Managed Care

Health Affairs · 1999-03-01 · 137 citations

Pharmaceutical costs have been rising dramatically since 1995, growing 16.6% in 1998 alone. This rate of increase is more than four times that of all health care spending. Employers, managed care organizations and consumers are looking anew for ways to stem these rising costs, without denying patients effective care. Therefore, this Issue Brief is especially timely because it investigates how patient copayments and financial incentives for physicians affect drug spending in managed care.