17 research outputs found

    Healthcare financing in OECD countries beyond the public-private split

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    Background: Studies of long-term trends in the healthcare financing mix generally focus on a dichotomous concept discerning public from private funding sources. More detailed analyses of the funding mix tend to be restricted to a small number of cases or do rarely examine time trends. Aim: This paper enhances the existing body of literature by developing and applying a trichotomous concept for healthcare funding, distinguishing taxes, contributions, and private sources. This includes a new aggregated indicator for the mix of three financing sources and its graphical representation. Methods: The study mainly builds upon OECD Health Data 2011. We measure changes in the funding mix since 1972 as its distance from a funding mix that equally draws upon taxes, contributions and private sources. Results: Up to 1980, the OECD healthcare systems move toward ideal-typical financing schemes. Between 1980 and 2000, the funding mix hybridizes mainly driven by privatization processes in NHS and social insurance countries and ongoing switch-over-processes between these two healthcare system types. Since 2000, OECD countries again tend toward ideal-typical funding schemes. Discussion: We use the framework for institutional change developed by Streeck and Thelen. The quantitative approach highlights changes in terms of displacement, layering, and drift but fails to fully reveal conversion processes. Therefore, further qualitative research is needed to capture not only shifts between the funding sources but also more gradual changes within them. Conclusion: The back-and-forth development of the trichotomous funding mix challenges assumptions of a universal trend toward hybrid financing structures. -- Rahmen: Arbeiten, die langfristige Trends des Finanzierungsmix von Gesundheitsausga-ben untersuchen, basieren in der Regel auf einem dichotomen Konzept, das öffentliche und private Quellen unterscheidet. Detailliertere Studien zum disaggregierten Finanzierungsmix sind zumeist auf kleine Fallzahlen beschrĂ€nkt oder betrachten keine Entwicklungen ĂŒber Zeit. Ziel: Das Arbeitspapier entwickelt ein trichotomes Finanzierungskonzept, das zwischen Steuern, BeitrĂ€gen und privaten Quellen unterscheidet und wendet dieses auf OECD-Gesundheitssysteme an. HierfĂŒr wird ein neuer HybriditĂ€tsindex gebildet, der den Finanzierungsmix eines Landes beschreibt und graphisch verortet. Methoden: Wir messen die VerĂ€nderungen im Finanzierungsmix seit 1972 als Distanz von einem hypothetischen Finanzierungsmix, der sich jeweils zu einem Drittel auf Steuern, BeitrĂ€ge und privaten Ausgaben stĂŒtzt. Als Quelle dienen die OECD Health Data 2011 und ergĂ€nzende nationale Statistiken. Ergebnisse: Bis etwa 1980 steuern die OECD-Gesundheitssysteme auf unterschiedliche idealtypische Finanzierungsmodelle zu. Zwischen 1980 und 2000 beobachten wir eine Hybridisierung der Finanzierung von Gesundheitsausgaben, die vorwiegend auf Privatisierungsprozesse in den NHS- und SozialversicherungslĂ€ndern zurĂŒckgefĂŒhrt werden kann. Überdies tragen einzelne LĂ€nder durch einen inkrementellen Übergang vom Sozialversicherungssystem zum NHS zunĂ€chst zur Hybridisierung bei. Seit 2000 neigen die OECD-LĂ€nder wieder idealtypischen Finanzierungsstrukturen zu. Diskussion: Wir analysieren die Befunde anhand der von Streeck und Thelen entwickelten Formen institutionellen Wandels. Der Hybridisierungsindex verdeutlicht Wandel in Form von Displacement, Layering und Drift, wĂ€hrend Conversion-Prozesse nicht vollstĂ€ndig abgebildet werden können. HierfĂŒr bedarf es qualitativer Analysen, die nicht nur Verschiebungen zwischen Finanzierungsarten sondern graduelle VerĂ€nderungen innerhalb einer Finanzierungsart erfassen. Fazit: Der Wandel zwischen Hybridisierungsphasen und Phasen der StĂ€rkung idealtypischer Finanzierung deutet darauf hin, dass funktionale Annahmen eines langfristigen Trends zu hybriden Finanzierungsstrukturen zu kurz greifen.

    The changing role of the state in the Dutch healthcare system

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    This paper deals with the changing role of the state in the Dutch healthcare system. At the eve of the first oil crisis the Netherlands had a relatively compound healthcare system combining several characteristics of the three Western healthcare system types: National Health Service, social health insurance system, and private health insurance system. Comparative case-studies on OECD countries indicate a hybridization trend from relatively pure to mixed healthcare systems during the era of ‘permanent austerity’. The adequate question is therefore, how and why the role of the state has changed in the relatively mixed Dutch social health insurance system. In order to approach this research question in a systematic way, we distinguish between three dimensions of the healthcare system: regulation, financing, and service provision. In the regulation dimension we observe an increasing state influence on coverage by an incremental socialization of the private sector. This progress culminated in 2006 in the merger of sickness funds and private health insurances into a functional social health insurance under private law. Since the early 1980s the state also directly intervened in the corporatist bargaining of providers and insurers in order to contain costs and regain global competiveness. At the beginning of the new millennium tight budgets resulting in long waiting lists were no longer accepted against the background of a booming economy. Instead, the role of competition increased through new opportunities and incentives for selective contracting between insurers and providers. Therefore, we observe a shift from corporatist self-regulation towards state-regulated market competition within the institutional framework of a social health insurance system. This ongoing reform process towards a welfare market for medical goods was supported by the main political parties on the left and right in order to enhance efficiency and safeguard solidarity

    The changing role of the state in the Italian healthcare system

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    The present study describes and explains the changing role of the state in the Italian healthcare system since the beginning of the 1970s, with a particular focus on developments following 1978 when the healthcare system was transformed from a social insurance system into a national health service. In order to address these changes in a systematic way, we track healthcare system development along three dimensions: regulation, financing, and service provision. With regard to regulation, we observe a relative retreat of the state due to decentralization processes and internal market mechanisms. Quantitative measures for the financing and service provision dimension also indicate a modest relative retreat of the state. Taking regional data into account, we identify a clear North-South-divide in the public/private mix of financing and service provision. Although the focus of the paper is to describe the changing role of the state in the Italian healthcare system, we also offer preliminary explanations. We seek to identify the role of exogenous shocks such as economic crises versus endogenous stressors specific to the healthcare system itself (i.e. inherent inefficiencies) on healthcare system change. Therefore, the paper aims to provide a tentative, yet dynamic account of healthcare system change that is both descriptive and explanatory. -- Dieses Papier behandelt die verĂ€nderte Rolle des Staates im italienischen Gesundheitssystem seit den 1970er Jahren. Italien vollzog zum Beginn des Untersuchungszeitraums einen Systemwechsel von einem Sozialversicherungssystem zu einem Nationalen Gesundheitsdienst. Um die anschließenden Wandlungsprozesse in systematischer Form zu erfassen, unterscheiden wir zwischen drei Dimensionen von StaatstĂ€tigkeit im Gesundheitswesen: Regulierung, Finanzierung und Leistungserbringung. In der Regulierung beobachten wir einen relativen RĂŒckzug des Staates durch Dezentralisierungsprozesse und die partielle EinfĂŒhrung interner MĂ€rkte. Dieser Befund deckt sich auch mit den quantitativen Analysen zur Finanzierung und Leistungserbringung. Durch die Einbeziehung regionaler Daten zeigt sich zudem ein klares Nord-SĂŒd-GefĂ€lle, das sich sowohl im öffentlichen Anteil an der Finanzierung als auch an der Leistungserbringung widerspiegelt. Das Papier beschrĂ€nkt sich nicht auf die Beschreibung des Staatswandels, sondern bietet auch erste ErklĂ€rungen fĂŒr diese Beobachtungen. Dazu werden sowohl exogene Faktoren wie wirtschaftliche Krisen oder EuropĂ€isierung als auch endogene Stressoren wie systeminhĂ€rente Defizite betrachtet.

    Exceptional Multi Stage Mineralization of Secondary Minerals in Cavities of Flood Basalts from the Deccan Volcanic Province, India

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    Flood basalts of the Deccan Volcanic Province erupted between about 67.5 to 60.5 Ma ago and reached a thickness of up to 3500 m. The main part consists of compound and simple lava flows with a tholeiitic composition erupted within 500,000 years at about 65 Ma. Within the compound lava flows, vesicles and cavities are frequent. They are filled by secondary minerals partly of well development and large size. This study presents data on the secondary mineralization including detailed field descriptions, optical, cathodoluminescence and SEM microscopy, X-ray diïżœractometry, fluid inclusions, C and O isotope analyses, and Rb-Sr and K-Ar geochronology. The investigations indicate a multistage precipitation sequence with three main stages. During stage I clay minerals and subsurface filamentous fabrics (SFFs), of probably biogenic origin, formed after the lava flows cooled down near to the Earth’s surface. In stage II, first an assemblage of calcite (I) and zeolite (I) (including mordenite, heulandite, and stilbite) as well as plagioclase was overgrown by chalcedony, and finally a second calcite (II) and zeolite (II) generation developed by burial metamorphism by subsequent lava flows. Stage III is characterized by precipitation of a third calcite (III) generation together with powellite and apophyllite from late hydrothermal fluids. Rb-Sr and K-Ar ages of apophyllite indicate a large time span for stage III. Apophyllite formed within diïżœerent time intervals from the Paleogene to the early Miocene even within individual lava flows at certain localities. From the Savda/Jalgaon quarry complex, ages cluster at 44–48 Ma and 25–28 Ma, whereas those from the Nashik area are 55–58 Ma and 21–23 Ma, respectively

    Comprehensive biomarker analysis of long-term response to trastuzumab in patients with HER2-positive advanced gastric or gastroesophageal adenocarcinoma

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    Background A subgroup of patients with HER2-positive metastatic gastric and gastroesophageal junction cancers shows long-term response under trastuzumab maintenance monotherapy. Obviously, HER2 status alone is not able to identify these patients. We performed this study to identify potential new prognostic biomarkers for this long-term responding patient group. Patients and methods Tumor samples of 19 patients with HER2-positive metastatic gastric and gastroesophageal junction cancer who underwent trastuzumab treatment were retrospectively collected from multiple centers. Patients were divided into long-term responding (n=7) or short-term responding group (n=12) according to progression-free survival (PFS≄12 months vs. PFS<12 months). Next generation sequencing and microarray-based gene expression analysis were performed along with HER2 and PD-L1 immunohistochemistry. Results Long-term responding patients had significantly higher PD-L1 combined positive scores (CPS) and CPS correlated with longer progression-free survival. PD-L1 positivity (CPS≄1) was further associated with an increased CD4+ memory T-cell score. The ERBB2 copy number as well as the tumor mutational burden could not discriminate between short-term and long-term responding patients. Genetic alterations and co-amplifications in HER2 pathway associated genes such as EGFR, which were connected to trastuzumab resistance, were present in 10% of the patients and equally distributed between the groups. Conclusion The study highlights the clinical relevance of PD-L1 testing also in the context of trastuzumab treatment and offers a biological rational by demonstrating elevated CD4+ memory T-cells scores in the PD-L1-positive group

    Herleitung waldbaulicher Empfehlungen im Zeichen des Klimawandels in der OstthĂŒringer Trias-Schichtstufenlandschaft

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    Die OstthĂŒringische Trias-Schichtstufenlandschaft wurde als Untersuchungsgebiet ausgewĂ€hlt, weil hier auf engstem Raum eine hohe geologische und bodenkundliche Vielfalt vorhanden ist. Die negativen EinflĂŒsse auf das Ökosystem Wald und die Waldleistungen durch die extremen Trockenperioden der letzten Jahre sind Thema dieser Arbeit und aktueller denn je. Es sind an fĂŒnf Beprobungspunkten (BP) die Vegetation (innerhalb einer Vegetationsperiode zweimal), der Humus und der Boden (mittels Bodenprofil) aufgenommen. Dabei sind Gemeinsamkeiten und WidersprĂŒche festgestellt und herausgearbeitet. Wasserhaushalt, pH-Wert und Carbonatgehalt wurden mit verschiedenen Verfahren (ökologische Artengruppen, Zeigerpflanzen nach Ellenberg und Bodenprofil) am BP verglichen und die Beprobungspunkte einander gegenĂŒberge-stellt. Die Aufnahmen und Ergebnisse sind mit der Literatur zum Thema Wald im Klimawandel besprochen. Die Konsequenzen fĂŒr die Beprobungspunkte sind herausgearbeitet und LösungsvorschlĂ€ge in Form von waldbaulichen Empfehlungen gegeben. Ziel dieser Arbeit ist, auf den verschiedenen bearbeiteten Standorten auch in Zukunft Wald möglichst klimastabil als wichtiges Landschaftselement wachsen zu lassen
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