Impact of Structural Adjustment Programs on Health Care Financing in Iran

In the 1980s, health sector reforms for improving the efficiency and quality of health systems began in many developing countries. Reforms initially were part of broader policies known as Structural Adjustment Programs (SAPs), whose main objective was to enhance economic growth mainly by elimination of market distortions. In Iran, the SAP began by the first Five Year Development Plan (FYDP) (1990–1995) and was intensified during the second FYDP (1995–1999). Iran's health sector was profoundly affected by these reforms. Applying the theoretical framework developed by the Commission on Microeconomics and Health (CMH) and health economics theories on willingness-to-pay to available data from Iran, these questions were investigated: (1) Did the SAP increase the risk of catastrophic health payments, defined here as payments 30% or more of the household's annual capacity to pay? (2) If so, what was the extent? (3) How did the risk vary among socio-economic strata? Additionally two questions focused on resource mobilization and supply-side efficiency goals of the policy: (4) How much revenue was raised by the government? Was there any sign of the fungibility of revenues? (5) Did the policy affect the efficiency of public services through reallocation of the government subsidies in favor of the primary and preventive care? To address questions 1 through 3 this study employed multivariate analysis regressions (probit), with the catastrophic payment event as a binary dependent variable, based on data from Iran's Household Income and Expenditures Survey (HIES) for 1995 (pre-SAP) and 2002 (post-SAP). The study's pooled cross-section dataset had 68,485 sample households (n1995= 36,399; n2002 =32,086). The study design used a series of probit models. It began with the naïve model (an uncontrolled pre-post comparison). The model was then controlled for confounding factors. The final approach entailed two variants of a difference-in-differences (DID) model. The DID approach included public sector workers as a pseudo-control group to control for history and maturity effects. The instrumental variables (IV) variant calculated marginal effect estimates for DID by correcting the probit estimates for the endogeneity of expenditure. The proxy variant addressed the endogeneity problem using the eigen vector corresponding to the largest eigen value of the covariance matrix of 31 of the households' assets as a proxy for wealth. For questions 4 and 5 the government financial statistics and public expenditures on health were examined. All monetary figures are in constant 1997 Rials, where the official exchange rate was 1,753 Rials for one US dollar. The study found that in the pre-SAP year the risk was on average 3.58%. The SAP increased the risk of catastrophic expenditures by 1.17 percentage points (p-value=0.046) under the IV approach, and by 1.23 percentage points under the proxy approach (p-value=0.013). Income was the most important predictor of the risk. Health insurance coverage decreased the risk for the hypothetical household at the poverty line by 1.16 percentage points. For an average household, an additional child below age three raised the risk by 0.85, while an additional senior (aged 60+) increased the risk by 0.53 percentage points (p-value=0.001). Also, urban households experienced 0.41 percentage points less risk than rural households. The SAP generated substantial revenue for the government. From 1994 to 2001, the fee revenues grew 12.7 fold, from 172 to 2,189 billion constant (1997) Rials in real terms. Iran's government allowed the health sector to retain revenues through decentralization of authorities. However, despite the huge increase in the fee revenues, the government health budget did not actually grow. The revenues were eventually fungible because the share of the general government budget allocated to health declined from 8.27% pre-SAP, to only 3.96% in 2001. The study's simulations found that for every 100 Rials of fee revenue generated in 2002, 132 Rials of the government budget left the health sector and was never reallocated. Furthermore, a "what if" simulated scenario estimated that in 2002, only 74% of the fungible revenues would have been sufficient to have entirely eliminated the risk of catastrophic payments. Regarding the supply-side efficiency goals, the SAP had a rather thoughtful approach: much of the consumer cost sharing was imposed in the services that are generally less cost-effective. The inpatient fee revenue accounted for 70% of the total. The public-private partnership was noteworthy, too. For the services not prone to market failure, e.g. imaging, pharmaceuticals, lab services and inpatient services, the private sector participated in service provision quite successfully. The government also carefully protected and expanded the primary and preventive services: in 2001, 16,281 community clinics called Rural Health Houses covered around 95 percent of the population free of charge. The major health indicators of the nation were also improved substantially over the SAP period. (Abstract shortened by UMI.

The impact of provider payment reforms and associated care delivery models on cost and quality in cancer care: A systematic literature review.

ObjectivesTo investigate the impact of provider payment reforms and associated care delivery models on cost and quality in cancer care.MethodsData sources/study setting: Review of English-language literature published in PubMed, Embase and Cochrane library (2007-2019). Study design: We performed a systematic literature review (SLR) to identify the impact of cancer care reforms. Primary endpoints were resource use, cost, quality of care, and clinical outcomes. Data collection/extraction methods: For each study, we extracted and categorized comparative data on the impact of policy reforms. Given the heterogeneity in patients, interventions and outcome measures, we did a qualitative synthesis rather than a meta-analysis.ResultsOf the 26 included studies, seven evaluations were in fact qualified as quasi experimental designs in retrospect. Alternative payment models were significantly associated with reduction in resource use and cost in cancer care. Across the seventeen studies reporting data on the implicit payment reforms through care coordination, the adoption of clinical pathways was found effective in reduction of unnecessary use of low value services and associated costs. The estimates of all measures in ACO models varied considerably across participating providers, and our review found a rather mixed impact on cancer care outcomes.ConclusionThe findings suggest promising improvement in resource utilization and cost control after transition to prospective payment models, but, further primary research is needed to apply robust measures of performance and quality to better ensure that providers are delivering high-value care to their patients, while reducing the cost of care

Use of Transnational Services to Prevent Treatment Interruption in Tuberculosis-Infected Persons Who Leave the United States

A major problem resulting from interrupted tuberculosis (TB) treatment is the development of drug-resistant TB, including multidrug-resistant TB (MDR TB), a more deadly and costly-to-treat form of the disease. Global health systems are not equipped to diagnose and treat the current burden of MDR TB. TB-infected foreign visitors and temporary US residents who leave the country during treatment can experience treatment interruption and, thus, are at greater risk for drug-resistant TB. Using epidemiologic and demographic data, we estimated TB incidence among this group, as well as the proportion of patients referred to transnational care–continuity and management services during relocation; each year, ≈2,827 visitors and temporary residents are at risk for TB treatment interruption, 222 (8%) of whom are referred for transnational services. Scale up of transnational services for persons at high risk for treatment interruption is possible and encouraged because of potential health gains and reductions in healthcare costs for the United States and receiving countries

Postoperative <i>Staphylococcus aureus</i> Infections in Medicare Beneficiaries

<div><p><i>Staphylococcus aureus (S. aureus)</i> infections are important because of their increasing frequency, resistance to antibiotics, and high associated rates of disabilities and deaths. We examined the incidence and correlates of <i>S. aureus</i> infections following 219,958 major surgical procedures in a 5% random sample of fee-for-service Medicare beneficiaries from 2004–2007. Of these surgical patients, 0.3% had <i>S. aureus</i> infections during the hospitalizations when index surgical procedures were performed; and 1.7% and 2.3%, respectively, were hospitalized with infections within 60 days or 180 days following admissions for index surgeries. <i>S. aureus</i> infections occurred within 180 days in 1.9% of patients following coronary artery bypass graft surgery, 2.3% following hip surgery, and 5.9% following gastric or esophageal surgery. Of patients first hospitalized with any major infection reported during the first 180 days after index surgery, 15% of infections were due to <i>S. aureus</i>, 18% to other documented organisms, and no specific organism was reported on claim forms in 67%. Patient-level predictors of <i>S. aureus</i> infections included transfer from skilled nursing facilities or chronic hospitals and comorbid conditions (e.g., diabetes, congestive heart failure, chronic obstructive pulmonary disease, and chronic renal disease). In a logarithmic regression, elective index admissions with <i>S. aureus</i> infection stayed 130% longer than comparable patients without that infection. Within 180 days of the index surgery, 23.9% of patients with <i>S. aureus</i> infection and 10.6% of patients without this infection had died. In a multivariate logistic regression of death within 180 days of admission for the index surgery with adjustment for demographics, co-morbidities, and other risks, <i>S. aureus</i> was associated with a 42% excess risk of death. Due to incomplete documentation of organisms in Medicare claims, these statistics may underestimate the magnitude of <i>S. aureus</i> infection. Nevertheless, this study generated a higher rate of <i>S. aureus</i> infections than previous studies.</p></div

Descriptive characteristics and outcomes of study population of Medicare beneficiaries with selected index surgeries.

<p>Note: SA denotes <i>Staphylococcus aureus</i>, SNF denotes skilled nursing facility, ERSD denotes end stage renal disease, COPD denotes chronic obstructive pulmonary disease, Pts. denotes patients.</p>+<p>Note that the co-morbodities are not mutually exclusive dummy variables. A patient can have multiple comorbities so the sums of the groups exceed the total population.</p><p>Descriptive characteristics and outcomes of study population of Medicare beneficiaries with selected index surgeries.</p

Adjusted predictors of <i>S. aureus</i> infection within 180-days following surgery by type of index surgery based on incidence rate ratio (IRR).

<p>Note: <i>S. aureus</i> denotes <i>Staphylococcus aureus</i>. <i>S. aureus</i> infection refers to first hospitalization coinciding or following surgery of interest with discharge diagnoses including any ICD-9 code specific for infection due to <i>S. aureus</i>. Rehab denotes rehabilitation; SNF denotes skilled nursing facility; ESRD denotes end-stage renal disease; NEast denotes northeast; MidAtlan denotes mid-Atlantic; COPD denotes chronic obstructive pulmonary disease; n.a. denotes not applicable, vs. denotes versus. IRR>1 denotes factor associated with higher risk; IRR<1 denotes lower risk. Each IRR regression was based on all cross-tabulated non-zero cells. Based on log likelihood ratio Chi-squared, the overall regression tests for all six procedures plus the pooled group were highly significant (p<0.0001). *denotes p<0.05.</p><p>Adjusted predictors of <i>S. aureus</i> infection within 180-days following surgery by type of index surgery based on incidence rate ratio (IRR).</p

Average Changes in Cardiac Risk Factor Levels from Baseline Values by Program and Time Point.

<p>Statistical significance: N denotes not significant, *p<0.05, †p<0.01, ‡p<0.001.</p><p>MBMI is the Benson-Henry Mind/Body Medical Institute. Ornish is The Dean Ornish Program for Reversing Heart Disease. BMI is body mass index; SBP is systolic blood pressure; DBP is diastolic blood pressure; mmHg is millimeters mercury; HDL is high density lipoprotein; LDL is low density lipoprotein; METs are metabolic equivalents; mos. denotes months of follow-up; ANY denotes all participants at the follow-up time; FULL denotes participants with final (24 month) data; n denotes the number of participants in that column. Data are not shown for 24 mos. ANY, but the patients and results are very similar to those for 24 mos. FULL.</p><p>Average Changes in Cardiac Risk Factor Levels from Baseline Values by Program and Time Point.</p

Risk Factor Changes in the Two Lifestyle Modification Programs Based on Multivariable Regressions with Quadratic Terms for Time.

<p>Notes: MBMI denotes the Cardiac Wellness Program of the Benson-Henry Mind Body Institute; Ornish is The Dean Ornish Program for Reversing Heart Disease. BMI denotes body mass index; LDL denotes low density lipoprotein; HDL denotes high density lipoprotein; SBP denotes systolic blood pressure; DBP denotes diastolic blood pressure.</p

Multivariable Relationships between Patient Characteristics, Type of Lifestyle Modification Program, and Changes in Cardiac Risk Factors over Two Years^a.

a<p>Statistical significance (Sig.): *p<0.05, †p<0.01, ‡p<0.001.</p>b<p>Reference group is the (MBMI) program.</p>c<p>Quarter denotes quarter year (3-month period).</p>d<p>Reference group is stable angina.</p><p>MBMI is the Benson-Henry Mind/Body Medical Institute. Ornish is The Dean Ornish Program for Reversing Heart Disease. BMI denotes body mass index; HDL denotes high density lipoprotein; LDL denotes low density lipoprotein; METS denotes metabolic equivalents; PCI is percutaneous coronary intervention; CABG is coronary artery bypass graft surgery; AMI is acute myocardial infarction.</p><p>Multivariable Relationships between Patient Characteristics, Type of Lifestyle Modification Program, and Changes in Cardiac Risk Factors over Two Years^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0114772#nt107" target="_blank">a</a>}.</p

Proportions of Participants in Each Lifestyle Modification Program at Targeted Risk Factor Levels at Each Time Point.

<p>Notes: Targets defined as body mass index (BMI) < = 25; systolic blood pressure (SBP) <140 mm Hg; low density lipoprotein (LDL) <100 mg/dl; high density lipoprotein (HDL)>40 mg/dl (male) or>50 mg/dl (female). Mon denotes months. Statistical significance: * p<0.05, ** p<0.01, *** p<0.001, N denotes not significant. McNemar’s chi-square test was used for hypothesis testing. MBMI denotes the Cardiac Wellness Program of the Benson-Henry Mind Body Institute, Ornish is The Dean Ornish Program for Reversing Heart Disease.</p