Risk Adjustment and Primary Health Care in Chile

Chile´s primary health care (PHC) payment system uses income of the municipalities and the geographic location of health centres (HCs) to adjust current capitation payments. Concerns over the ability of the formula to direct health resources where greater health needs are discussed. We uses a sample of 10,000 individuals was drawn and two years data was collected from a region in Chile. Three models were tested: i) age and gender, ii) age, gender and the presence of two key diagnoses and iii) age, gender and the presence of seven key diagnoses, to estimate how significant their effects were on utilization and per-capita expenditures. Regression analysis was performed to calculate the predictive values of the independent variables and two tests applied to select the best and next best model. The main results are the following. First, the use of services by age and gender confirmed international trends, where children under five, women and elderly were the main users of PHC services. Second, women consulted twice as much as men. Thrid, clear difference by SES were observed, indigents aged 65+ under-utilised PHC services. From the three models simulated, the major improvement in the predictive power took place from the demographic to the demographic plus two diagnoses model. Improvements were limited when five other diagnoses were added (Rsquare= 28%). The conclusion is that the current normative formula used by the MOH provides little incentives to care appropriately for indigents and people with chronic conditions such as diabetes and hypertension. A capitation payment that adjusts for age, gender, and presence of hypertension and diabetes will better guide resources to those with poorer health and lower SES. Keywords: Primary health care, Payment system, Risk adjustment

Capturing the value of vaccination within health technology assessment and health economics:Country analysis and priority value concepts

Background: A value of vaccination framework for economic evaluation (EE) identified unique value concepts for the broad benefits vaccination provides to individuals, society, healthcare systems and national economies. The objectives of this paper were to work with experts in developed countries to objectively identify three priority concepts to extend current EE. Methods: The previously developed classification of value concepts in vaccination distinguished 18 concepts, categorised as conventional payer and societal perspective concepts and novel broader societal concepts. Their inclusion in current EE guidelines was assessed. Experts identified eight criteria relevant to decision-making and measurement feasibility, which were weighted and used to score each concept. The relative ranking of concepts by importance and the gaps in guidelines were used to identify three priority concepts on which to focus immediate efforts to extend EE. Results: The EE guidelines review highlighted differences across countries and between guidelines and practice. Conventional payer perspective concepts (e.g., individual and societal health gains and medical costs) were generally included, while gaps were evident for conventional societal perspective concepts (e.g., family/caregiver health and economic gains). Few novel broader societal benefits were considered, and only in ad hoc cases. The top-three concepts for near-term consideration: macroeconomic gains (e.g., benefiting the economy, tourism), social equity and ethics (e.g., equal distribution of health outcomes, reduced health/financial equity gaps) and health systems strengthening, resilience and security (e.g., efficiency gains, reduced disruption, increased capacity). Conclusions: Gaps, inconsistencies and limited assessment of vaccination value in EE can lead to differences in policy and vaccination access. The three priority concepts identified provide a feasible approach for capturing VoV more broadly in the near-term. Robust methods for measuring and valuing these concepts in future assessments will help strengthen the evidence used to inform decisions, improving access to vaccines that are demonstrably good value for money from society's point of view. (C) 2022 GlaxoSmithKline Biologicals S.A. Published by Elsevier Ltd

Cost-effectiveness and budget effect of pre-exposure prophylaxis for HIV-1 prevention in Germany from 2018 to 2058

Background Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy for men-who-have-sex-with-men (MSM). The high cost of PrEP has until recently been a primary barrier to its use. In 2017, generic PrEP became available, reducing the costs by 90%. Aim Our objective was to assess cost-effectiveness and costs of introducing PrEP in Germany. Methods We calibrated a deterministic mathematical model to the human immunodeficiency virus (HIV) epidemic among MSM in Germany. PrEP was targeted to 30% of high-risk MSM. It was assumed that PrEP reduces the risk of HIV infection by 85%. Costs were calculated from a healthcare payer perspective using a 40-year time horizon starting in 2018. Results PrEP can avert 21,000 infections (interquartile range (IQR): 16,000–27,000) in the short run (after 2 years scale-up and 10 years full implementation). HIV care is predicted to cost EUR 36.2 billion (IQR: 32.4–40.4 billion) over the coming 40 years. PrEP can increase costs by at most EUR 150 million within the first decade after introduction. Ten years after introduction, PrEP can become cost-saving, accumulating to savings of HIV-related costs of EUR 5.1 billion (IQR: 3.5–6.9 billion) after 40 years. In a sensitivity analysis, PrEP remained cost-saving even at a 70% price reduction of antiretroviral drug treatment and a lower effectiveness of PrEP. Conclusion Introduction of PrEP in Germany is predicted to result in substantial health benefits because of reductions in HIV infections. Short-term financial investments in providing PrEP will result in substantial cost-savings in the long term

Neonatal hearing screening: modelling cost and effectiveness of hospital- and community-based screening

BACKGROUND: Children with congenital hearing impairment benefit from early detection and management of their hearing loss. These and related considerations led to the recommendation of universal newborn hearing screening. In 2001 the first phase of a national Newborn Hearing Screening Programme (NHSP) was implemented in England. Objective of this study was to assess costs and effectiveness for hospital and community-based newborn hearing screening systems in England based on data from this first phase with regard to the effects of alterations to parameter values. METHODS: Design: Clinical effectiveness analysis using a Markov Model. Outcome measure: quality weighted detected child months (QCM). RESULTS: Both hospital and community programmes yielded 794 QCM at the age of 6 months with total costs of £3,690,000 per 100,000 screened children in hospital and £3,340,000 in community. Simulated costs would be lower in hospital in 48% of the trials. Any statistically significant difference between hospital and community in prevalence, test sensitivity, test specificity and costs would result in significant differences in cost-effectiveness between hospital and community. CONCLUSION: This modelling exercise informs decision makers by a quantitative projection of available data and the explicit and transparent statements about assumptions and the degree of uncertainty. Further evaluation of the cost-effectiveness should focus on the potential differences in test parameters and prevalence in these two settings

Risk Adjustment and Primary Health Care in Chile

Aim: To offer a capitation formula with greater capacity for guiding resource spending on population with poorer health and lower socioeconomic status in the context of financing and equity in primary health care. Methods: We collected two years of data on a sample of 10000 individuals from a region in Chile, Valdivia and Temuco and evaluated three models to estimate utilization and expenditures per capita. The first model included age and sex; the second one included age, sex, and the presence of two key diagnoses; and the third model included age, sex, and the presence of seven key diagnoses. Regression results were evaluated by R2 and predictive ratios to select the best specifications. Results: Per-capita expenditures by age and sex confirmed international trends, where children under five, women, and the elderly were the main users of primary health care services. Women sought health advice twice as much as men. Clear differences by socioeconomic status were observed for the indigent population aged 65 years who under-utilized primary health care services. From the three models, major improvement in the predictive power occurred from the demographic (adjusted R2, 9%) to the demographic plus two diagnoses model (adjusted R2, 27%). Improvements were modest when five other diagnoses were added (adjusted R2, 28%). Conclusion: The current formula that uses municipality’s financial power and geographic location of health centers to adjust capitation payments provides little incentive to appropriate care for the indigent and people with chronic conditions. A capitation payment that adjusts for age, sex, and the presence of diabetes and hypertension will better guide resource allocation to those with poorer health and lower socioeconomic status

Umverteilungseffekte in der Finanzierung von Gesundheitsleistungen

Health care systems are financed through a mixture of different components: taxes, contributions to social health insurance, premiums to private health insurance, out of pocket payments by patients. These components can be combined differently leading to specific effects of interpersonal redistribution. This can be compared between different countries. In such a comparison the redistributional impact of the German health care systems is rather regressive – which is basically caused by the opportunity for people with high income to leave social health insurance. In comparison to a health insurance system with risk rated premiums, financing of the German social health insurance leads to interpersonal redistribution from higher to lower income, from the young to the elderly, form healthy to sick and from singles to families with children. The pay-as-you-go character of the system leads especially in combination with an aging population and technological change to burden for future generations. In comparison to a system in which each region finances its own health care expenditures, there also considerable interregional redistributions. The financing system in Germany is not conceptually consistent. Reform proposals (unified health insurance for all; flat rate premiums) tackle these inconsistencies.Redistribution, health care financing, premiums, contributions, aging population, technological change

Von der 'Poliklinik' in die Kassenarztpraxis Versuch einer Rekonstruktion der Entscheidungssituation ambulant taetiger Aerzte in Ostdeutschland

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