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

When the world depends on effective public health intervention – and public health does not deliver

The COVID-19 crisis offers both special opportunities and challenges for Public Health. The initial management of the pandemic was dominated by virologists, supported by epidemiologists who did not always meet indispensable scientific requirements. Interdisciplinary and complex Public Health concerns and expertise, however, did not have tangible impact in the COVID-19 debate. Public Health is universal and goes beyond health security as social and other upstream determinants of health play a central role. As an explicitly political concept Public Health must safeguard its broad socio-political approach and obviate all tendency towards biomedical reductionism. &nbsp

When the world depends on effective public health intervention – and public health does not deliver

The COVID-19 crisis offers both special opportunities and challenges for Public Health. The initial management of the pandemic was dominated by virologists, supported by epidemiologists who did not always meet indispensable scientific requirements. Interdisciplinary and complex Public Health concerns and expertise, however, did not have tangible impact in the COVID-19 debate. Public Health is universal and goes beyond health security as social and other upstream determinants of health play a central role. As an explicitly political concept Public Health must safeguard its broad socio-political approach and obviate all tendency towards biomedical reductionism.   Conflicts of interest: None declared

Hindrer Nordhordlandsbroen smoltens utvandring?

Den dramatiske nedgangen av laksebestanden i Vosso har brakt flere institusjoner sammen for å undersøke betydningen av menneskeskapte forhold for denne utviklingen. De siste årene har søkelyset i hovedsak vært rettet mot lakselus og andre faktorer som kan påvirke smoltutvandringen. Havforskningsinstituttet har undersøkt hvilken betydning Norhordlandsbroen kan ha

Use of anesthesia dramatically alters the oral glucose tolerance and insulin secretion in C57Bl/6 mice

Evaluation of the impact of anesthesia on oral glucose tolerance in mice. Anesthesia is often used when performing OGTT in mice to avoid the stress of gavage and blood sampling, although anesthesia may influence gastrointestinal motility, blood glucose, and plasma insulin dynamics. C57Bl/6 mice were anesthetized using the following commonly used regimens: (1) hypnorm/midazolam repetitive or single injection; (2) ketamine/xylazine; (3) isoflurane; (4) pentobarbital; and (5) A saline injected, nonanesthetized group. Oral glucose was administered at time 0 min and blood glucose measured in the time frame −15 to +150 min. Plasma insulin concentration was measured at time 0 and 20 min. All four anesthetic regimens resulted in impaired glucose tolerance compared to saline/no anesthesia. (1) hypnorm/midazolam increased insulin concentrations and caused an altered glucose tolerance; (2) ketamine/xylazine lowered insulin responses and resulted in severe hyperglycemia throughout the experiment; (3) isoflurane did not only alter the insulin secretion but also resulted in severe hyperglycemia; (4) pentobarbital resulted in both increased insulin secretion and impaired glucose tolerance. All four anesthetic regimens altered the oral glucose tolerance, and we conclude that anesthesia should not be used when performing metabolic studies in mice

Spectral metrics on quantum projective spaces

We show that the noncommutative differential geometry of quantum projective spaces is compatible with Rieffel's theory of compact quantum metric spaces. This amounts to a detailed investigation of the Connes metric coming from the unital spectral triple introduced by D'Andrea and Dabrowski. In particular, we establish that the Connes metric metrizes the weak-* topology on the state space of quantum projective space. This generalizes previous work by the second author and Aguilar regarding spectral metrics on the standard Podles spheres.Comment: 32 page