Patient cost sharing - reforms without evidence: theoretical considerations and empirical findings from industrialized countries

"International health service research reveals a uniform tendency in practically all industrialised countries: an increasing shift of costs from solidarity-based financing to private households. Legislators and advisors usually justify this policy through the need to encourage cost-consciousness and especially 'individual responsibility'. Economists consider cost-sharing in health care to be necessary to prevent abuse of the welfare state. They expect user charges and co-payments to motivate a more 'rational' utilisation of health care and, thus, the financial stabilisation of health systems. Many politicians and economists base their assumptions about the 'health market' on the theorem of demand-side moral hazard. This model transforms patients into rational 'utility maximisers' consuming services beyond their needs thereby causing welfare losses to society as a whole. Moral hazard in health insurance belongs to the standard repertoires of economic textbooks. The present study analyses the extensive theoretical and empirical literature on patient cost-sharing published during the last forty years. The results show that persuasive evidence for demand-side moral hazard is still lacking. Furthermore, the claimed empiricism turns out to be inappropriate for providing evidence. Science health service research and clinical studies instead suggest that health insurance beneficiaries are not aiming to abuse the health system. In fact, introducing patient cost-sharing seems to endanger proper health care since it deters the sick from claiming benefits. The idea of 'rational' use transpires to be out of touch with reality. After a systematic in-depth review of current research on the topic, the author concludes that moral hazard in health insurance is a bogey of academic economic theory. Adequate reality-based evidence for implementing patient user fees and co-payments is lacking. In view of the detrimental effects on health service utilisation, he advises cancelling existing co-payment arrangements and abandoning cost-sharing policies." (author's abstract)"Die internationale Gesundheitssystemforschung zeigt in praktisch allen Industrieländern einen einheitlichen Trend auf: die zunehmende Verlagerung der Kosten von der solidarischen Finanzierung auf die privaten Haushalte. Gesetzgeber wie Berater begründen dies üblicherweise mit der Stärkung von Kostenbewusstsein und vor allem der 'Eigenverantwortung'. Wirtschaftswissenschaftler betrachten Selbstbeteiligungen in der Gesundheitsversorgung als notwendig, um dem Missbrauch der Solidargemeinschaft entgegenzuwirken. Von Gebühren und Zuzahlungen erwarten sie eine 'vernünftigere' Inanspruchnahme der Gesundheitsleistungen und eine finanzielle Stabilisierung der Systeme. Die Sicht vieler Politiker und Wirtschaftsexperten auf den 'Gesundheitsmarkt' ist durch das Theorem des versichertenseitigen Moral Hazard geprägt. Dieses Modell macht Krankenversicherte zu rationalen 'Nutzenmaximierern', die zum eigenen Vorteil über den Bedarf hinaus Leistungen in Anspruch nähmen und dadurch gesamtgesellschaftliche Wohlfahrtsverluste verursachten. Moral Hazard in der Krankenversicherung gehört zum Standard-Repertoire ökonomischer Lehrbücher. Die vorliegende Arbeit wertet die umfangreiche Literatur über Ansätze und Versuche der Kostenbeteiligung von Patienten aus, die in den letzten vier Jahrzehnten erschienen ist. Dabei stellt sich heraus, dass belastbare Belege für das Moral-Hazard-Verhalten von Versicherten bzw. Patienten bisher fehlen und die üblicherweise angeführte Empirie für den Nachweis ungeeignet ist. Gesundheitswissenschaftliche, versorgungsbezogene und klinische Studien legen vielmehr nahe, dass die Versicherten das System nicht ausnutzen wollen oder können. Die Einführung von Kostenbeteiligungen für Patienten scheint eher die bedarfsgerechte Versorgung zu gefährden, weil sie Kranke von der Inanspruchnahme abhalten. Die Vorstellung von der 'rationalen' Nutzung des Gesundheitswesens entpuppt sich als realitätsfremd. Nach gründlicher Auswertung des Forschungsstandes kommt der Autor zum Schluss, dass Moral Hazard in der Krankenversicherung ein Popanz der akademischen Wirtschaftstheorie geblieben ist. Für die Einführung von Kostenbeteiligungen für Patienten fehlt es an hinreichender realitätsbasierter Evidenz. In Anbetracht der schädlichen versorgungspolitischen Effekte erscheinen die Rücknahme aller Patientenzuzahlungen und der Verzicht auf Selbstbeteiligungen geboten." (Autorenreferat

Evaluating pharmaceutical policy in South Korea

EThOS - Electronic Theses Online ServiceGBUnited Kingdo

The Cost of Confusion: The Paradox of Trademarked Pharmaceuticals

The United States spends nearly $1,000 per person annually on drugs—forty percent more than the next highest spender, Canada, and more than twice the amount France and Germany spend. Although myriad factors contribute to high drug spending in the United States, intellectual property law plays a crucial and well-documented role in inhibiting access to cheaper, generic medications. Yet, for the most part, the discussion of the relationship between intellectual property law and drug spending has centered on patent protection. Recently, however, a few researchers have turned their attention to a different avenue of exclusivity—trademark law. New studies suggest that pharmaceutical trademarks are diminishing the ability of physicians and consumers to accurately understand the relationship between generic and brand name medications. This Article synthesizes and relies on that research to demonstrate that trademarks in the pharmaceutical industry are at odds with the theoretical foundations of trademark law. The conventional justification for trademark protection is two pronged: trademarks not only minimize consumer confusion but also ensure manufacturers maintain consistent product quality. Relying on pharmaceutical case studies and behavioral research, this Article contends that pharmaceutical trademarks and trade dress are performing the opposite functions. Instead of reducing consumer confusion and enhancing market efficiency, pharmaceutical trademarks are actually confusing patients into believing that trademarked and generic drugs are distinct medications, leading to wasteful spending and even substantial morbidity. Accordingly, this Article encourages policymakers to reexamine the utility of trademarks in the pharmaceutical industry and ultimately suggests that such trademarked names should be replaced with a different type of mark—one that serves to distinguish a drug’s manufacturer without differentiating the drug itself from identical generics. Such an approach has the potential to not only save millions of dollars, but also improve patient outcomes

Supply chain thinking in healthcare: lessons and outlooks

Problem definition: The lessons learned over decades of supply chain management provide an opportunity for stakeholders in complex systems, such as healthcare, to understand, evaluate, and improve their complicated and often inefficient ecosystems. Methodology: We provide a primer on supply chain thinking in healthcare, with a focus on healthcare delivery, by following a framework that is customer-focused, systems-based, and strategically orientated, and that simultaneously considers clinical, operational, and financial dimensions. Our goal is to offer an understanding of how concepts and strategies in supply chain management can be applied and tailored to healthcare by considering the sector's unique challenges and opportunities. Results: After identifying key healthcare stakeholders and their interactions, we discuss the main challenges facing healthcare services from a supply chain perspective and provide examples of how various supply chain strategies are being and can be used in healthcare. Academic/practical relevance: The complexity in managing healthcare supply chains offers opportunities for important and impactful research avenues in key supply chain management areas such as coordination and integration (e.g., new care models), mass customization (e.g., the rise in precision medicine), and incentives (e.g., emerging reimbursement schemes), which might, in turn, provide insights relevant to traditional supply chains. We also put forward new perspectives for practice and possible research directions for the supply chain management community. Managerial implications: By using supply chain thinking, healthcare organizations can decrease costs and improve the quality of care by uncovering, quantifying, and addressing inefficiencies

Kostenbeteiligungen für Patienten - Reformansatz ohne Evidenz! Theoretische Betrachtungen und empirische Befunde aus Industrieländern

"Die internationale Gesundheitssystemforschung zeigt in praktisch allen Industrieländern einen einheitlichen Trend auf: die zunehmende Verlagerung der Kosten von der solidarischen Finanzierung auf die privaten Haushalte. Gesetzgeber wie Berater begründen dies üblicherweise mit der Stärkung von Kostenbewusstsein und vor allem der 'Eigenverantwortung'. Wirtschaftswissenschaftler betrachten Selbstbeteiligungen in der Gesundheitsversorgung als notwendig, um dem Missbrauch der Solidargemeinschaft entgegenzuwirken. Von Gebühren und Zuzahlungen erwarten sie eine 'vernünftigere' Inanspruchnahme der Gesundheitsleistungen und eine finanzielle Stabilisierung der Systeme. Die Sicht vieler Politiker und Wirtschaftsexperten auf den 'Gesundheitsmarkt' ist durch das Theorem des versichertenseitigen Moral Hazard geprägt. Dieses Modell macht Krankenversicherte zu rationalen 'Nutzenmaximierern', die zum eigenen Vorteil über den Bedarf hinaus Leistungen in Anspruch nähmen und dadurch gesamtgesellschaftliche Wohlfahrtsverluste verursachten. Moral Hazard in der Krankenversicherung gehört zum Standard-Repertoire ökonomischer Lehrbücher. Die vorliegende Arbeit wertet die umfangreiche Literatur über Ansätze und Versuche der Kostenbeteiligung von Patienten aus, die in den letzten vier Jahrzehnten erschienen ist. Dabei stellt sich heraus, dass belastbare Belege für das Moral-Hazard-Verhalten von Versicherten bzw. Patienten bisher fehlen und die üblicherweise angeführte Empirie für den Nachweis ungeeignet ist. Gesundheitswissenschaftliche, versorgungsbezogene und klinische Studien legen vielmehr nahe, dass die Versicherten das System nicht ausnutzen wollen oder können. Die Einführung von Kostenbeteiligungen für Patienten scheint eher die bedarfsgerechte Versorgung zu gefährden, weil sie Kranke von der Inanspruchnahme abhalten. Die Vorstellung von der 'rationalen' Nutzung des Gesundheitswesens entpuppt sich als realitätsfremd. Nach gründlicher Auswertung des Forschungsstandes kommt der Autor zum Schluss, dass Moral Hazard in der Krankenversicherung ein Popanz der akademischen Wirtschaftstheorie geblieben ist. Für die Einführung von Kostenbeteiligungen für Patienten fehlt es an hinreichender realitätsbasierter Evidenz. In Anbetracht der schädlichen versorgungspolitischen Effekte erscheinen die Rücknahme aller Patientenzuzahlungen und der Verzicht auf Selbstbeteiligungen geboten." (Autorenreferat)"International health service research highlights a uniform tendency in practically all industrialised countries: the increasing shift of costs from solidarity-based financing to private households. Legislators and advisors usually justify this policy through the need to encourage cost-consciousness and mainly 'self-responsibility'. Economists consider cost-sharing in health care to be necessary for preventing abuse of the caring society. They expect user charges and co-payments to motivate a more 'rational' utilisation of health care and, thus, the financial stabilisation of health systems. Many politicians and economists base their assumptions on the 'health market' on the theorem of demand-side moral hazard. This model transforms enrollees into rational 'utility maximisers' who are consuming services beyond their needs thereby causing welfare losses to the society as a whole. Moral hazard in health insurance belongs to the standard repertoires of economic textbooks. The present study analyses the extensive literature on approaches and experiments to introduce patient cost-sharing published during the last 40 years. Results show that persuasive evidence for demand-side moral hazard is still lacking. Furthermore, the usually quoted empiricism turns out to be inappropriate for proving evidence. Health science, service research and clinical studies rather suggest that health insurance beneficiaries are not aiming at or willing to abuse the health system. In fact, introducing patient cost-sharing seems to endanger adequate health care since they deter the ill from claiming benefits. The idea of 'rational' use emerges as out of touch with reality. After a systematic in-depth review of current research on the topic, the author concludes that moral hazard in health insurance is a bogey of academic economic theory. Adequate reality-based evidence for implementing patient user fees and co-payments is lacking. In view of the detrimental effects on health service utilisation, it is advised to cancel existing co-payments and to abandon costsharing policies." (author's abstract

Economic costs, impacts and financing strategies for mental health in South Africa

Over the past decade, calls to address the increasing burden of mental, neurological and substance-use (MNS) disorders and to include mental health care as an essential component of universal health coverage (UHC) have attracted mounting interest from governments. With the inclusion of mental health in the 2015 Sustainable Development Goals (SDGs) there is now a global policy commitment to invest in mental health as a health, humanitarian and development priority. Low and middle-income countries (LMICs) such as South Africa, contemplating mental health system scale-up embedded into wider SDG- and UHC-related health-sector transformations, must address a number of key mental health financing policy considerations for attaining population-based improvements in mental health. Despite ongoing transformations in the South African health sector, there has been an implicit neglect of the integration of mental health services into general health service development. This has been driven in part by a lack of locally-derived evidence in several areas, including: the economic basis for investing in mental health, the current resourcing of the mental health system, opportunities for improved efficiency and equity, and how reforms may be structured and paid for in light of the country's ongoing efforts to implement a National Health Insurance (NHI) scheme. This thesis therefore attempts to address these gaps and aims to generate new knowledge on the economic costs, impacts and financing strategies for mental health in South Africa. This aim is achieved by fulfilling the following research objectives: 1. To examine the impact of social, national and community-based health insurance on health care utilization for MNS disorders in low- and middle-income countries. 2. To examine the policy context, strategic needs, barriers and opportunities for sustainable financing for mental health in South Africa. 3. To quantify public health system expenditure on mental health services, by service level and province, and to document and evaluate the resources and constraints of the mental health system in South Africa. 4. To examine the household economic costs and levels of financial risk protection associated with depression symptoms in South Africa. In the first part, the systematic review reports on the impact of social, national and community based health insurance on health care utilization for MNS disorders in LMICs, published until October 2018. As a secondary goal, the systematic review identifies whether there are any specific lessons that can be learnt from existing approaches to integrate mental health care into financing reforms towards universal health coverage. In the second part, a qualitative examination of the policy context, strategic needs, barriers and opportunities for sustainable financing for mental health in South Africa was conducted through a situational analysis that was complimented with a synthesis of key stakeholder consultations. The findings provide recommendations for how scaled-up mental health services can best be paid for in a way that is feasible, fair and appropriate within the fiscal constraints and structures of the country. In the third part, the thesis then empirically quantified public health system expenditure on mental health services, by service-level and province for the 2016/17 financial year, and documented and evaluated the resources and constraints of existing mental health investments in South Africa through a national survey; achieving one of the highest sample sizes of any costing study conducted for mental health in LMICs. In the fourth and final part, a household survey study was conducted to determine the level of financial protection for persons living with depression symptoms in the Dr. Kenneth Kaunda health district of South Africa, which is serving as a pilot site for the NHI. The household economic factors associated with increased depression symptom severity on a continuum are reported; and demonstrate that financial risk protection efforts are needed across this continuum. The thesis concludes by synthesizing findings towards an improved understanding of the key lessons that can be learned from other LMICs toward sustainable financing for mental health; the economic burden of inadequate mental health care to households in South Africa; and the efficiency of existing mental health investments and inequities in resourcing and access. Through this lens, and borrowing from the experiences of other LMICs, recommendations for key priorities for health service and financing reforms towards the scaled-up delivery of mental health services in South Africa are generated. The thesis is presented as papers embedded in a narrative that includes an introduction and synthesis discussion. Four papers (3 published and 1 under review) form the basis of the results chapters

Kostenbeteiligung für Patienten - Reformansatz ohne Evidenz! Theoretische Betrachtungen und empirische Befunde aus Industrieländern

Die internationale Gesundheitssystemforschung zeigt in praktisch allen Industrieländern einen einheitlichen Trend auf: die zunehmende Verlagerung der Kosten von der solidarischen Finanzierung auf die privaten Haushalte. Gesetzgeber wie Berater begründen dies üblicherweise mit der Stärkung von Kostenbewusstsein und vor allem der Eigenverantwortung. Wirtschaftswissenschaftler betrachten Selbstbeteiligungen in der Gesundheitsversorgung als notwendig, um dem Missbrauch der Solidargemeinschaft entgegenzuwirken. Von Gebühren und Zuzahlungen erwarten sie eine vernünftigere Inanspruchnahme der Gesundheitsleistungen und eine finanzielle Stabilisierung der Systeme. Die Sicht vieler Politiker und Wirtschaftsexperten auf den Gesundheitsmarkt ist durch das Theorem des versichertenseitigen Moral Hazard geprägt. Dieses Modell macht Kran-kenversicherte zu rationalen Nutzenmaximierern, die zum eigenen Vorteil über den Bedarf hinaus Leistungen in Anspruch nähmen und dadurch gesamtgesellschaftliche Wohlfahrtsverluste verursachten. Moral Hazard in der Krankenversicherung gehört zum Standard-Repertoire ökonomischer Lehrbücher. Die vorliegende Arbeit wertet die umfangreiche Literatur über Ansätze und Versuche der Kostenbeteiligung von Patienten aus, die in den letzten vier Jahrzehnten erschienen ist. Dabei stellt sich heraus, dass belastbare Belege für das Moral-Hazard-Verhalten von Versicherten bzw. Patienten bisher fehlen und die üblicherweise angeführte Empirie für den Nachweis ungeeignet ist. Gesundheitswissenschaftliche, versorgungsbezogene und klinische Studien legen vielmehr nahe, dass die Versicherten das System nicht ausnutzen wollen oder können. Die Einführung von Kostenbeteiligungen für Patienten scheint eher die bedarfsgerechte Versorgung zu gefährden, weil sie Kranke von der Inanspruchnahme abhalten. Die Vorstellung von der rationalen Nutzung des Gesundheitswesens entpuppt sich als realitätsfremd. Nach gründlicher Auswertung des Forschungsstandes kommt der Autor zum Schluss, dass Moral Hazard in der Krankenversicherung ein Popanz der akademischen Wirtschaftstheorie geblieben ist. Für die Einführung von Kostenbeteiligungen für Patienten fehlt es an hinrei-chender realitätsbasierter Evidenz. In Anbetracht der schädlichen versorgungspolitischen Effekte erscheinen die Rücknahme aller Patientenzuzahlungen und der Verzicht auf Selbstbeteiligungen geboten. -- International health service research highlights a uniform tendency in practically all industrialised countries: the increasing shift of costs from solidarity-based financing to private households. Legislators and advisors usually justify this policy through the need to encourage cost-consciousness and mainly self-responsibility. Economists consider cost-sharing in health care to be necessary for preventing abuse of the caring society. They expect user charges and co-payments to motivate a more rational utilisation of health care and, thus, the financial stabilisation of health systems. Many politicians and economists base their assumptions on the health market on the theorem of demand-side moral hazard. This model transforms enrollees into rational utility maximisers who are consuming services beyond their needs thereby causing welfare losses to the society as a whole. Moral hazard in health insurance belongs to the standard repertoires of economic textbooks. The present study analyses the extensive literature on approaches and experiments to introduce patient cost-sharing published during the last 40 years. Results show that persuasive evidence for demand- side moral hazard is still lacking. Furthermore, the usually quoted empiricism turns out to be inappropriate for proving evidence. Health science, service research and clinical studies rather suggest that health insurance beneficiaries are not aiming at or willing to abuse the health system. In fact, introducing patient cost-sharing seems to endanger adequate health care since they deter the ill from claiming benefits. The idea of rational use emerges as out of touch with reality. After a systematic in-depth review of current research on the topic, the author concludes that moral hazard in health insurance is a bogey of academic economic theory. Adequate reality-based evidence for implementing patient user fees and co-payments is lacking. In view of the detrimental effects on health service utilisation, it is advised to cancel existing co-payments and to abandon costsharing policies.

Economic Implications of Patient-Related Factors in Diabetes Care

Diabetes mellitus is a chronic disease characterized by high blood sugar levels with serious complications, particularly if it is not adequately treated. It is increasingly prevalent and burdensome from both a health and economic standpoint globally, amounting to hundreds of billions of dollars in expenditure each year [1,2]. Also increasing are the numbers and types of pharmaceutical interventions being introduced to treat this disease. Over the next decade, numerous diabetes compounds currently in development are expected to be commercialized, making it essential for the most robust and accurate evidence to be available to healthcare decision-makers [3]. Approximately 90% of people with diabetes are diagnosed as Type 2 (T2D), most often in adulthood [4]. In contrast, Type 1 diabetes (T1D) patients are commonly diagnosed as juveniles, but live well into adulthood with effective treatment [4]. Consequently, adult patients with diabetes, namely T2D, are responsible for most of the health and economic burden of this disease. Therefore, much of the effort to improve outcomes and reduce costs in diabetes concentrates on this population