Defining care products to finance health care in the Netherlands

A case-mix project started in the Netherlands with the primary goal to define a complete set of health care products for hospitals. The definition of the product structure was completed 4 years later. The results are currently being used for billing purposes. This paper focuses on the methodology and techniques that were developed and applied in order to define the casemix product structure. The central research question was how to develop a manageable product structure, i.e., a limited set of hospital products, with acceptable cost homogeneity. For this purpose, a data warehouse with approximately 1.5 million patient records from 27 hospitals was build up over a period of 3 years. The data associated with each patient consist of a large number of a priori independent parameters describing the resource utilization in different stages of the treatment process, e.g., activities in the operating theatre, the lab and the radiology department. Because of the complexity of the database, it was necessary to apply advanced data analysis techniques. The full analyses process that starts from the database and ends up with a product definition consists of four basic analyses steps. Each of these steps has revealed interesting insights. This paper describes each step in some detail and presents the major results of each step. The result consists of 687 product groups for 24 medical specialties used for billing purposes

Market structure and hospital–insurer bargaining in the Netherlands

In 2005, competition was introduced in part of the hospital market in the Netherlands. Using a unique dataset of transactions and list prices between hospitals and insurers in the years 2005 and 2006, we estimate the influence of buyer and seller concentration on the negotiated prices. First, we use a traditional structure–conduct–performance model (SCP-model) along the lines of Melnick et al. (J Health Econ 11(3): 217–233, 1992) to estimate the effects of buyer and seller concentration on price–cost margins. Second, we model the interaction between hospitals and insurers in the context of a generalized bargaining model similar to Brooks et al. (J Health Econ 16: 417–434, 1997). In the SCP-model, we find that the market shares of hospitals (insurers) have a significantly positive (negative) impact on the hospital price–cost margin. In the bargaining model, we find a significant negative effect of insurer concentration, but no significant effect of hospital concentration. In both models, we find a significant impact of idiosyncratic effects on the market outcomes. This is consistent with the fact that the Dutch hospital sector is not yet in a long-run equilibrium

Disparities in the use of ambulatory surgical centers: a cross sectional study

<p>Abstract</p> <p>Background</p> <p>Ambulatory surgical centers (ASCs) provide outpatient surgical services more efficiently than hospital outpatient departments, benefiting patients through lower co-payments and other expenses. We studied the influence of socioeconomic status and race on use of ASCs.</p> <p>Methods</p> <p>From the 2005 State Ambulatory Surgery Database for Florida, a cohort of discharges for urologic, ophthalmologic, gastrointestinal, and orthopedic procedures was created. Socioeconomic status was established at the zip code level. Logistic regression models were fit to assess associations between socioeconomic status and ASC use.</p> <p>Results</p> <p>Compared to the lowest group, patients of higher socioeconomic status were more likely to have procedures performed in ASCs (OR 1.07 CI 1.05, 1.09). Overall, the middle socioeconomic status group was the most likely group to use the ASC (OR 1.23, CI 1.21 to 1.25). For whites and blacks, higher status is associated with increased ASC use, but for Hispanics this relationship was reversed (OR 0.84 CI 0.78, 0.91).</p> <p>Conclusion</p> <p>Patients of lower socioeconomic status treated with outpatient surgery are significantly less likely to have their procedures in ASCs, suggesting that less resourced patients are encountering higher cost burdens for care. Thus, the most economically vulnerable group is unnecessarily subject to higher charges for surgery.</p

A methodology to estimate the potential to move inpatient to one day surgery

BACKGROUND: The proportion of surgery performed as a day case varies greatly between countries. Low rates suggest a large growth potential in many countries. Measuring the potential development of one day surgery should be grounded on a comprehensive list of eligible procedures, based on a priori criteria, independent of local practices. We propose an algorithmic method, using only routinely available hospital data to identify surgical hospitalizations that could have been performed as one day treatment. METHODS: Moving inpatient surgery to one day surgery was considered feasible if at least one surgical intervention was eligible for one day surgery and if none of the following criteria were present: intervention or affection requiring an inpatient stay, patient transferred or died, and length of stay greater than four days. The eligibility of a procedure to be treated as a day case was mainly established on three a priori criteria: surgical access (endoscopic or not), the invasiveness of the procedure and the size of the operated organ. Few overrides of these criteria occurred when procedures were associated with risk of immediate complications, slow physiological recovery or pain treatment requiring hospital infrastructure. The algorithm was applied to a random sample of one million inpatient US stays and more than 600 thousand Swiss inpatient stays, in the year 2002. RESULTS: The validity of our method was demonstrated by the few discrepancies between the a priori criteria based list of eligible procedures, and a state list used for reimbursement purposes, the low proportion of hospitalizations eligible for one day care found in the US sample (4.9 versus 19.4% in the Swiss sample), and the distribution of the elective procedures found eligible in Swiss hospitals, well supported by the literature. There were large variations of the proportion of candidates for one day surgery among elective surgical hospitalizations between Swiss hospitals (3 to 45.3%). CONCLUSION: The proposed approach allows the monitoring of the proportion of inpatient stay candidates for one day surgery. It could be used for infrastructure planning, resources negotiation and the surveillance of appropriate resource utilization

Litigation funding: status and issues

Litigation funding is new and topical. It has the capacity to significantly alter the litigation scene. It gives rise to particular issues that need understanding and attention. It is relevant only in certain situations, and while it is not a possible solution to all types of claims it has the potential to significantly increase opportunities to pursue certain claims. The basic model of litigation funding is an investment business based on securing an appropriate return on investment. It is not a banking loan as no interest is charged, and not insurance as no premium is charged. Investment is made in any case that has a sufficient prospect of success on its merits, and has a strong legal team with a convincing case strategy. In some types of offering, however, the model of litigation funding can appear to be more like the provision of legal services. This is where a funder, sometimes from a legal services background, conducts a detailed assessment of the legal merits of a case (including obtaining or providing specialist legal advice on the case) prior to agreeing to funding. Funders determine the risk, and ultimately the extent of the investment, based on an assessment of the merits of the case, the solvency of the defendant (or, in the case of a funded defendant, the resources of the claimant) and the size of the claim and likely return. However, during this research the contrary view that litigation funding is part of the legal services market has been raised. Arguably the nature of the funding being offered and background of the funder (i.e. whether legal services or insurance/financial sector) can be factor. This research examines the current structure of the litigation funding market and the types of product on offer. Litigation funding can apply advanced banking techniques to a legal claim, treating it like any other valuable asset and applying the same risk assessment techniques in determining the level of finance offered. The initial phase of 3rd party litigation funding is an exploratory affair where both the funder and the client are seeking partners in spreading risk and distributing reward. The funder cannot make such a decision without detailed assessment of the legal and factual matrix of the case and its prospects of success (and would perhaps be foolish to proceed without such an exercise) and although the funder might share such insights with the prospective client, they are essentially the funder's work product. The development of the litigation funding market has thus merely recognised an expanded use for a new asset class (claims or defences) and opened up a new market for associated finance. Litigation funding is currently a bespoke product tailored to the needs of the specific market and legal jurisdiction. There are thus, difference conceptions of litigation funding in the UK, mainland Europe, Australia, Canada, the US and South Africa. Within the UK there are examples of co-funding or risk spreading so that some funders may jointly fund a large case, and some arrangements may involve various companies providing different packets of finance or insurance. The principal constraint on the development of litigation funding is traditional public policy against funding others’ litigation or intermeddling in the conduct of litigation (the concepts of maintenance and champerty discussed later in this report). However, such rules are being reformed in some jurisdictions, although no consistency has 2 emerged over what the emerging policy and principles should be, and different jurisdictions are making different reforms at different speeds (or not doing so). This research examines the status of litigation third party funding, the different funding models currently in use and assesses the historical development of third party funding and the legislative and policy considerations that inform the current market. In doing so, it draws conclusions on the potential of litigation funding to increase access to justice in light of current policy changes in the provision of legal services

Disruptive Prescription for the German Health Care System? Feasibility and Impact of Disruptive Innovations in the German Context

As with many health care systems of developed countries, the German system is in dire need of reforms in order to be able to ensure the provision of health care in the future. In this paper, we examine the potential feasibility and impact of the theory of disruptive innovation in the context of the German health care system. For this purpose, we conduct a review based on the concept for the disruption of the American health care system by Christensen et al. (The innovator’s prescription—a disruptive solution for health care. McGraw-Hill, 2009) and then analyze the German context accordingly. Our results indicate that the disruption of the German health care system could present considerable opportunities as well as diverse risks. Furthermore, its implementation would face some significant barriers due to the divergent structure and the prevailing culture and values of key stakeholders in the German system