Ethical Implications of Case‐Based Payment in China: A Systematic Analysis

How health care providers are paid affects how medicine is practiced. It is thus important to assess provider payment models not only from the economic perspective but also from the ethical perspective. China recently started to reform the provider payment model in the health care system from fee‐for‐service to case‐based payment. This paper aims to examine this transition from an ethical perspective. We collected empirical studies on the impact of case‐based payment in the Chinese health care system and applied a systematic ethical matrix that integrates clinical ethics and public health ethics to analyze the empirical findings. We identified eleven prominent ethical issues related to case‐based payment. Some ethical problems of case‐based payment in China are comparable to ethical problems of managed care and diagnosis related groups in high‐income countries. However, in this paper we discuss in greater detail four specific ethical issues in the Chinese context: professionalism, the patient‐physician relationship, access to care and patient autonomy. Based on the analysis, we cautiously infer that case‐based payment is currently more ethically acceptable than fee‐for‐service in the context of China, mainly because it seems to lower financial barriers to access care. Nonetheless, it will be difficult to justify the implementation of case‐based payment if no additional measures are taken to monitor and minimize its existing negative ethical implications.     

The Cost-Effectiveness Analysis of Teleglaucoma Screening Device

Glaucoma is the leading cause of irreversible vision loss and costs the American economy $2.9 billion. Teleglaucoma remotely detects glaucoma improving access to ophthalmic care in rural areas. It helps manage glaucoma more efficiently to preserve vision and reduce healthcare costs. A cost-effectiveness analysis was conducted using healthcare provider or third-party payer perspective within rural Canada. The study population were patients at-risk of glaucoma which includes those with diabetes and/or hypertension, family history of glaucoma, adults older than 50 years, and concurrent ocular conditions in rural Alberta. Markov modelling was used to model glaucoma health states. Effectiveness was measured in Quality-Adjusted Life Years (QALYs) and costs were used in Canadian dollars. Using TreeAge Pro 2009, incremental cost-effectiveness ratios (ICER) were developed in dollars per QALYs. Deterministic and probabilistic sensitivity analyses were performed to assess the factors affecting cost-effectiveness. Teleglaucoma had a 20% increase in ophthalmologist-referral rate; it reduced patient travel times by 61 hours and physician wait times by 30% in comparison to in-person examination (standard of care). Teleglaucoma costs $872 per patient screened which was 80% less than in-person examination. Teleglaucoma had a greater incremental effectiveness providing an additional 0.12 QALY per patient examination. It was more sensitive (86.5%) and less specific (78.6%) than in-person examination. Teleglaucoma was more cost-effective than in-person examination with an ICER of-$27,460/QALY. This indicated that teleglaucoma will save $27, 460 for each additional QALY gained. Long term benefits showed teleglaucoma prevents 24% cases of glaucoma blindness after 30 years. Teleglaucoma demonstrated improved health outcomes, as well as, cost benefits. It increases access to ophthalmic care and improves healthcare service efficiency, specifically in rural areas. Teleglaucoma is more cost-effective than current in-person examination and can improve the quality of life in glaucoma patients.     

Role of Endocrinologists In Eliminating Health Care Disparities

ObjectiveTo review some of the persistent disparities in health and health care in the United States related to race, ethnicity, and socioeconomic status, with a focus on diabetes mellitus and obesity, and to discuss the role of endocrinologists in preventing these disparities.MethodsSome of the efforts made by the US government, such as public health strategies, to address health disparities are outlined, and statistics about diabetes and obesity are presented.ResultsThe elimination of health disparities, recognized as a national challenge for decades, is a national priority as defined in the national goals for Healthy People 2010. Health disparities refer to the differences in the quality of health and health care access and outcomes across racial, ethnic, and socioeconomic groups. Such disparities may be related to the patient (education, socioeconomic status, environment, language), the health care system (location, structural barriers, financial resources), or the provider, including a lack of diversity in the health care workforce. Endocrinologists are responsible for the care of many patients with chronic diseases, including obesity and diabetes mellitus. Both of these chronic diseases are diagnosed with increased frequency in minority populations and are preventable, difficult to manage, and associated with many complications and high health care costs.ConclusionThe role of endocrinologists is to provide equitable, affordable, accessible, high-quality, timely, cost-effective, and culturally sensitive health care. They must be involved in population health decisions and development of optimal health care policy so that endocrine disorders can ultimately be prevented. In addition, they must educate themselves, their patients, and the community regarding maintenance of healthy lifestyles to prevent complications. (Endocr Pract. 2009;15:612-623)     

An Analytical Framework for Contrasting Patient and Provider Views of the Process of Chronic Disease Management

Medical anthropologists involved in clinical research are often asked to help explain patients' "noncompliance" with treatment recommendations. The clinical literature on "noncompliance" tends to problematize only the patient's perspective, treating the provider's perspective as an uncontroversial point of departure. Explicating the articulation between provider and patient assumptions, expectations, and perceptions in managing chronic illness is an area well suited to the unique perspective of medical anthropologists. In this article we present an analytical framework for contrasting patient and provider goals, strategies, and evaluation criteria in chronic illness management, using examples from research on type 2 diabetes care in South Texas. This approach goes beyond contrasting patient and provider concepts and explanations of the illness itself and examines their contrasting views within the dynamic process of long-term care. This approach may prove especially useful for research aimed at a clinical audience, since it maintains a clinically relevant focus while giving serious consideration to the patient's perspective.     

Identifying predictors of high quality care in English general practice: observational study

ObjectivesTo assess variation in the quality of care in general practice and identify factors associated with high quality care.Design Observational study.Setting Stratified random sample of 60 general practices in six areas of England.Results Quality of clinical care varied substantially, and access to care, continuity of care, and interpersonal care varied moderately. Scores for asthma, diabetes, and angina were 67%, 21%, and 17% higher in practices with 10 minute booking intervals for consultations compared with practices with five minute booking intervals. Diabetes care was better in larger practices and in practices where staff reported better team climate. Access to care was better in small practices. Preventive care was worse in practices located in socioeconomically deprived areas. Scores for satisfaction, continuity of care, and access to care were higher in practices where staff reported better team climate.Conclusions Longer consultation times are essential for providing high quality clinical care. Good teamworking is a key part of providing high quality care across a range of areas and may need specific support if quality of care is to be improved. Additional support is needed to provide preventive care to deprived populations. No single type of practice has a monopoly on high quality care: different types of practice may have different strengths.

What is already known on this topic

Quality of care varies in virtually all aspects of medicine that have been studiedMost studies look at quality of care from a single perspective or for a single condition

What this study adds

Quality of care varies for both clinical care and assessments by patients of access and interpersonal carePractices with longer booking intervals provide better management of chronic disease; preventive care is less good in practices in deprived areasNo single type of practice has a monopoly on high quality care—small practices provide better access but poorer diabetes careGood team climate reported by staff is associated with a range of aspects of high quality care     

Measuring and improving the quality of mental health care: a global perspective

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology‐based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient‐centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement‐based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.     

Access to medical care for documented and undocumented Latinos in a southern California county.

To determine local access to medical care among Latinos, we conducted telephone interviews with residents of Orange County, California. The survey replicated on a local level the national access surveys sponsored by the Robert Wood Johnson Foundation. We compared access among Latino citizens of the United States (including permanent legal residents), undocumented Latinos, and Anglos, and analyzed predictors of access. Among the sample of 958 respondents were 137 Latino citizens, 54 undocumented Latinos, and 680 Anglos. Compared with Anglos, Latino citizens and undocumented immigrants had less access to medical care by all measures used in the survey. Although undocumented Latinos were less likely than Latino citizens to have health insurance, by most other measures their access did not differ significantly. By multivariate analysis, health insurance status and not ethnicity was the most important predictor of access. Because access to medical care is limited for both Latino citizens and undocumented immigrants, policy proposals to improve access for Latinos should consider current barriers faced by these groups and local differences in access to medical care.     

The power of local autonomy: expanding health care to unauthorized immigrants in San Francisco

Abstract

I analyse the mechanisms through which an inclusive local policy environment in the integrated city-county of San Francisco operates to improve unauthorized immigrants’ access to and utilization of health care. Within – but not outside – the bounds of this inclusive local context, committed providers reported being able to provide attention to unauthorized immigrants without worrying about the direct costs of doing so; to buffer, marshal resources, and advocate for individual unauthorized patients; and to exert substantial autonomy in deciding how to approach lack of legal status in their patient–provider interactions. These results highlight the potential and limitation of sub-national policies seeking to ameliorate unauthorized immigrants’ health vulnerability in a hostile US federal context.     

Health System Challenges in Organizing Quality Diabetes Care for Urban Poor in South India

Background

Weak health systems in low- and middle-income countries are recognized as the major constraint in responding to the rising burden of chronic conditions. Despite recognition by global actors for the need for research on health systems, little attention has been given to the role played by local health systems. We aim to analyze a mixed local health system to identify the main challenges in delivering quality care for diabetes mellitus type 2.

Methods

We used the health system dynamics framework to analyze a health system in KG Halli, a poor urban neighborhood in South India. We conducted semi-structured interviews with healthcare providers located in and around the neighborhood who provide care to diabetes patients: three specialist and 13 non-specialist doctors, two pharmacists, and one laboratory technician. Observations at the health facilities were recorded in a field diary. Data were analyzed through thematic analysis.

Result

There is a lack of functional referral systems and a considerable overlap in provision of outpatient care for diabetes across the different levels of healthcare services in KG Halli. Inadequate use of patients’ medical records and lack of standard treatment protocols affect clinical decision-making. The poor regulation of the private sector, poor systemic coordination across healthcare providers and healthcare delivery platforms, widespread practice of bribery and absence of formal grievance redress platforms affect effective leadership and governance. There appears to be a trust deficit among patients and healthcare providers. The private sector, with a majority of healthcare providers lacking adequate training, operates to maximize profit, and healthcare for the poor is at best seen as charity.

Conclusions

Systemic impediments in local health systems hinder the delivery of quality diabetes care to the urban poor. There is an urgent need to address these weaknesses in order to improve care for diabetes and other chronic conditions.     

Effect of management on natural capital stocks underlying ecosystem service provision: a ‘provider group’ approach

Land management practices directly impact on the occurrence and condition of natural capital stocks, which can be measured using species diversity and abundance metrics. Species identity and abundance drive ecosystem service supply, either through effects of local diversity and/or through the presence of service providing species. However, the influence of management practices on the provision of ecosystem services is not adequately understood. We grouped grassland plant species into six groups according to desirable attributes (palatability and nutritional value to livestock; medicinal or aromatic compounds; nectar production; pollen production; nitrogen fixation; and endemic and red listed species), which we recognise as ecosystem service ‘provider groups’, and tested the influence of three land management practices (abandonment of mowing, grazing, and mowing) on diversity and abundance within these groups in upland temperate grasslands of Transylvania (Romania). All three management practices favoured at least one provider group, but hay making in upland grasslands favoured more provider groups than abandonment of mowing or grazing. The effects of management on diversity and abundance within several provider groups diverged from the effects on overall species diversity and abundance. Management, through changes in species composition, favours certain provider groups, and hence ecosystem services, over others. The provider group approach is more useful than overall species diversity metrics for assessing the provision of ecosystem services from landscapes and can be used to inform the development of agri-environment schemes and conservation policies aimed at meeting priorities for ecosystem service provision.     

No magic bullets: a systematic review of 102 trials of interventions to improve professional practice.

OBJECTIVE: To determine the effectiveness of different types of interventions in improving health professional performance and health outcomes. DATA SOURCES: MEDLINE, SCISEARCH, CINAHL and the Research and Development Resource Base in CME were searched for trials of educational interventions in the health care professions published between 1970 and 1993 inclusive. STUDY SELECTION: Studies were selected if they provided objective measurements of health professional performance or health outcomes and employed random or quasi-random allocation methods in their study designs to assign individual subjects or groups. Interventions included such activities as conferences, outreach visits, the use of local opinion leaders, audit and feedback, and reminder systems. DATA EXTRACTION: Details extracted from the studies included the study design; the unit of allocation (e.g., patient, provider, practice, hospital); the characteristics of the targeted health care professionals, educational interventions and patients (when appropriate); and the main outcome measure. DATA SYNTHESIS: The inclusion criteria were met by 102 trials. Areas of behaviour change included general patient management, preventive services, prescribing practices, treatment of specific conditions such as hypertension or diabetes, and diagnostic service or hospital utilization. Dissemination-only strategies, such as conferences or the mailing of unsolicited materials, demonstrated little or no changes in health professional behaviour or health outcome when used alone. More complex interventions, such as the use of outreach visits or local opinion leaders, ranged from ineffective to highly effective but were most often moderately effective (resulting in reductions of 20% to 50% in the incidence of inappropriate performance). CONCLUSION: There are no "magic bullets" for improving the quality of health care, but there are a wide range of interventions available that, if used appropriately, could lead to important improvements in professional practice and patient outcomes.     

Using and joining a franchised private sector provider network in Myanmar

BACKGROUND: Quality is central to understanding provider motivations to join and remain within a social franchising network. Quality also appears as a key issue from the client's perspective, and may influence why a client chooses to use a franchised provider over another type of provider. The dynamic relationships between providers of social franchising clinics and clients who use these services have not been thoroughly investigated in the context of Myanmar, which has an established social franchising network. This study examines client motivations to use a Sun Quality Health network provider and provider motivations to join and remain in the Sun Quality Health network. Taken together, these two aims provide an opportunity to explore the symbiotic relationship between client satisfaction and provider incentives to increase the utilization of reproductive health care services. METHODS AND FINDINGS: Results from a series of focus group discussions with clients of reproductive health services and franchised providers shows that women chose health services provided by franchised private sector general practitioners because of its perceived higher quality, associated with the availability of effective, affordable, drugs. A key finding of the study is associated with providers. Provider focus group discussions indicate that a principle determinate for joining and remaining in the Sun Quality Health Network was serving the poor.     

Improving Maternal Care through a State-Wide Health Insurance Program: A Cost and Cost-Effectiveness Study in Rural Nigeria

Background

While the Nigerian government has made progress towards the Millennium Development Goals, further investments are needed to achieve the targets of post-2015 Sustainable Development Goals, including Universal Health Coverage. Economic evaluations of innovative interventions can help inform investment decisions in resource-constrained settings. We aim to assess the cost and cost-effectiveness of maternal care provided within the new Kwara State Health Insurance program (KSHI) in rural Nigeria.

Methods and Findings

We used a decision analytic model to simulate a cohort of pregnant women. The primary outcome is the incremental cost effectiveness ratio (ICER) of the KSHI scenario compared to the current standard of care. Intervention cost from a healthcare provider perspective included service delivery costs and above-service level costs; these were evaluated in a participating hospital and using financial records from the managing organisations, respectively. Standard of care costs from a provider perspective were derived from the literature using an ingredient approach. We generated 95% credibility intervals around the primary outcome through probabilistic sensitivity analysis (PSA) based on a Monte Carlo simulation. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the base case separately through a scenario analysis. Finally, we assessed the sustainability and feasibility of this program’s scale up within the State’s healthcare financing structure through a budget impact analysis. The KSHI scenario results in a health benefit to patients at a higher cost compared to the base case. The mean ICER (US$46.4/disability-adjusted life year averted) is considered very cost-effective compared to a willingness-to-pay threshold of one gross domestic product per capita (Nigeria, US$ 2012, 2,730). Our conclusion was robust to uncertainty in parameters estimates (PSA: median US$49.1, 95% credible interval 21.9–152.3), during one-way sensitivity analyses, and when cost, quality, cost and utilization parameters of the base case scenario were changed. The sustainability of this program’s scale up by the State is dependent on further investments in healthcare.

Conclusions

This study provides evidence that the investment made by the KSHI program in rural Nigeria is likely to have been cost-effective; however, further healthcare investments are needed for this program to be successfully expanded within Kwara State. Policy makers should consider supporting financial initiatives to reduce maternal mortality tackling both supply and demand issues in the access to care.     

Changes in perceptions of quality of, and access to, services among clients of a fractional franchise network in Nepal

With declining levels of international donor funding for financing reproductive health programmes, developing country governments and international donors are looking towards private sector strategies to expand the supply of quality reproductive health services. One of the challenges of a health franchise is to improve the quality of services provided by independent private practitioners. Private providers are more likely to abide by the quality standards set by a franchiser if they see a financial benefit resulting from franchise participation. This study was conducted to measure whether (a) there were improvements in perceived quality of care and perceived access to health facilities once these facilities became part of a franchise and (b) improvements in perceived quality and perceived access were associated with increased client loyalty to franchised clinics. Franchisees were given basic reproductive health training for seven days and services marketing training for two days. Exit interviews were conducted with male and female clients at health facilities. A pre-test measurement was taken in April 2001, prior to the start of project activities. A post-test measurement was taken in February/March 2002, about 9 months after the pre-test. Multilevel regression analysis, which takes the hierarchical structure of the data into account, was used for the analysis. After taking provider-level variation into account and controlling for client characteristics, the analyses showed significant improvements in perceived quality of care and perceived access to services. Private provider participation in a franchise network helps improve client perceptions of quality of, and access to, services. Improvements in client perceptions of quality and access contribute to increased client loyalty to franchised clinics. Once increased client loyalty translates into higher client volumes, providers are likely to see the benefits of franchise participation. In turn, this should lead to increased provider willingness to remain part of the franchise and to abide by the standards of quality set by the franchiser.     

Impact of Rural Residence and Health System Structure on Quality of Liver Care

Background

Specialist physician concentration in urban areas can affect access and quality of care for rural patients. As effective drug treatment for hepatitis C (HCV) becomes increasingly available, the extent to which rural patients needing HCV specialists face access or quality deficits is unknown. We sought to determine the influence of rural residency on access to HCV specialists and quality of liver care.

Methods

The study used a national cohort of 151,965 Veterans Health Administration (VHA) patients with HCV starting in 2005 and followed to 2009. The VHA’s constant national benefit structure reduces the impact of insurance as an explanation for observed disparities. Multivariate cox proportion regression models for each quality indicator were performed.

Results

Thirty percent of VHA patients with HCV reside in rural and highly rural areas. Compared to urban residents, highly rural (HR 0.70, CI 0.65-0.75) and rural (HR 0.96, CI 0.94-0.97) residents were significantly less likely to access HCV specialty care. The quality indicators were more mixed. While rural residents were less likely to receive HIV screening, there were no significant differences in hepatitis vaccinations, endoscopic variceal and hepatocellular carcinoma screening between the geographic subgroups. Of note, highly rural (HR 1.31, CI 1.14-1.50) and rural residents (HR 1.06, CI 1.02-1.10) were more likely to receive HCV therapy. Of those treated for HCV, a third received therapy from a non-specialist provider.

Conclusion

Rural patients have less access to HCV specialists, but this does not necessarily translate to quality deficits. The VHA''s efforts to improve specialty care access, rural patient behavior and decentralization of HCV therapy beyond specialty providers may explain this contradiction. Lessons learned within the VHA are critical for US healthcare systems restructuring into accountable care organizations that acquire features of integrated systems.     

Quality of Care Provided to Patients with Diabetes Mellitus in Puerto Rico: Managed Care Versus Fee-for-Service Experience

ObjectiveTo evaluate and compare the quality of diabetes care in a large managed care system and fee-for-service payment system in Puerto Rico.MethodsThis retrospective cross-sectional study assessed the adherence to standards of diabetes care in 1,687,202 subjects—226,210 from a fee-for-service population and 1,460,992 from a managed care group. Patients with diabetes mellitus were identified from insurance claims reports. Type of health-care provider, service location, number of visits, and laboratory utilization were also assessed.ResultsFrom the analysis, we identified 90,616 patients with diabetes (5.4% of the overall study group). Of these, 66,587 (73.5%) were found to have at least one encounter with a physician in a medical visit. Of the 66,586 patients with diabetes who visited a physician, only 4% were treated by an endocrinologist. General laboratory utilization was 34% for the entire population of patients with diabetes studied. In the group of patients with documented laboratory tests, 93% had a documented fasting blood glucose test; in contrast, hemoglobin A1c testing was performed in only 9% of the patients. The fee-for-service group had a higher rate of visits to medical specialists and general laboratory utilization, whereas the managed care group had a higher rate of hospital admissions and emergency department visits.ConclusionThe quality of diabetes management and the subsequent outcomes are related to patient and healthcare provider adherence to standards of care. In this analysis, we found that patients and physicians are responsible for low compliance with recognized standards of diabetes care in Puerto Rico. The lack of adequate management will lead to increased mortality, development and severity of chronic complications, and increased emergency department utilization. Therefore, health-care providers and payers should find ways to achieve more effective promotion of adherence to accepted standards of care for patients with diabetes. (Endocr Pract. 2005;11:376-381)     

The politics of recognition in culturally appropriate care

Over the last 20 years, the concept of culturally appropriate health care has been gradually gaining popularity in medicine and public health. In calling for health care that is culturally appropriate, minority groups seek political recognition of often racialized constructions of cultural difference as they intervene in health care planning and organization. Based on interview narratives from people involved in community organizing to establish a federally funded community health center in a mid-size New England city, I chart the emergence of a language of "culturally appropriate health care" in language used to justify the need for a health center. An identity model of recognition underlies the call for ethnic resemblance between patient and provider seen in many culturally appropriate care programs. I contrast this model of health care with earlier calls for community access and control by activists in the 1970s and explore the practical and theoretical implications of each approach.     

A randomized controlled trial of interventions to enhance patient-physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045

Background

Disparities in health and healthcare are extensively documented across clinical conditions, settings, and dimensions of healthcare quality. In particular, studies show that ethnic minorities and persons with low socioeconomic status receive poorer quality of interpersonal or patient-centered care than whites and persons with higher socioeconomic status. Strong evidence links patient-centered care to improvements in patient adherence and health outcomes; therefore, interventions that enhance this dimension of care are promising strategies to improve adherence and overcome disparities in outcomes for ethnic minorities and poor persons.

Objective

This paper describes the design of the Patient-Physician Partnership (Triple P) Study. The goal of the study is to compare the relative effectiveness of the patient and physician intensive interventions, separately, and in combination with one another, with the effectiveness of minimal interventions. The main hypothesis is that patients in the intensive intervention groups will have better adherence to appointments, medication, and lifestyle recommendations at three and twelve months than patients in minimal intervention groups. The study also examines other process and outcome measures, including patient-physician communication behaviors, patient ratings of care, health service utilization, and blood pressure control.

Methods

A total of 50 primary care physicians and 279 of their ethnic minority or poor patients with hypertension were recruited into a randomized controlled trial with a two by two factorial design. The study used a patient-centered, culturally tailored, education and activation intervention for patients with active follow-up delivered by a community health worker in the clinic. It also included a computerized, self-study communication skills training program for physicians, delivered via an interactive CD-ROM, with tailored feedback to address their individual communication skills needs.

Conclusion

The Triple P study will provide new knowledge about how to improve patient adherence, quality of care, and cardiovascular outcomes, as well as how to reduce disparities in care and outcomes of ethnic minority and poor persons with hypertension.