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Context: Approaches to priority‐setting for scarce resources have shifted to public deliberation as trade‐offs become more difficult. We report results of a qualitative analysis of public deliberation in Switzerland, a country with high health‐care costs, an individual health insurance mandate and a strong tradition of direct democracy with frequent votes related to health care. Methods: We adapted the Choosing Healthplans All Together (CHAT) tool, an exercise developed to transform complex health‐care allocation decisions into easily understandable choices, for use in Switzerland. We conducted focus groups in twelve Swiss cities, recruiting from a range of socio‐economic backgrounds in the three language regions. Findings: Participants developed strategic arguments based on the importance of basic coverage for all, and of cost‐benefit evaluation. They also expressed arguments relying on a principle of solidarity, in particular the importance of protection for vulnerable groups, and on the importance of medical care. They struggled with the place of personal responsibility in coverage decisions. In commenting on the exercise, participants found the degree of consensus despite differing opinions surprising and valuable. Conclusion: The Swiss population is particularly attentive to the costs of health care and means of reducing these costs. Swiss citizens are capable of making trade‐offs and setting priorities for complex health issues. [ABSTRACT FROM AUTHOR]

This article examines how nations split decision-making about health services between federal and sub-federal levels, creating variation between states or provinces. When is this variation ethically acceptable? We identify three sources of ethical acceptability—procedural fairness, value pluralism, and substantive fairness—and examine these sources with respect to a case study: the fact that only 30 out of 51 US states or territories passed mandates requiring private insurers to offer extensive coverage of autism behavioral therapies, creating variation for privately insured children living in different US states. Is this variation ethically acceptable? To address this question, we need to analyze whether mandates go to more or less needy states and whether the mandates reflect value pluralism between states regarding government’s role in health care. Using time-series logistic regressions and data from National Survey of Children with Special Health Care Needs, Individual with Disabilities Education Act, legislature political composition, and American Board of Pediatrics workforce data, we find that the states in which mandates are passed are less needy than states in which mandates have not been passed, what we call a cumulative advantage outcome that increases between-state disparities rather than a compensatory outcome that decreases between-state disparities. Concluding, we discuss the implications of our analysis for broader discussions of variation in health services provision. [ABSTRACT FROM PUBLISHER]

The article discusses the socio-economic determinants of health (SEDH), as well as the public provision of a wide array of health-promoting socio-economic interventions. It also presents the socio-economic determinants of health, including the non-medical factors such as education, income, employment and housing. It also cites the opinion of Alan Derickson concerning the universal health insurance in the U.S., which he said was based in three major components, namely, needs, efficiencies and rights.

Objective To demonstrate that employees can gain understanding of the financial constraints involved in designing health insurance benefits. Background While employees who receive their health insurance through the workplace have much at stake as the cost of health insurance rises, they are not necessarily prepared to constructively participate in prioritizing their health insurance benefits in order to limit cost. Design Structured group exercises. Setting and participants Employees of 41 public and private organizations in Northern California. Intervention Administration of the CHAT (Choosing Healthplans All Together) exercise in which participants engage in deliberation to design health insurance benefits under financial constraints. Main outcome measures Change in priorities and attitudes about the need to exercise insurance cost constraints. Results Participants ( N = 744) became significantly more cognizant of the need to limit insurance benefits for the sake of affordability and capable of prioritizing benefit options. Those agreeing that it is reasonable to limit health insurance coverage given the cost increased from 47% to 72%. Conclusion It is both possible and valuable to involve employees in priority setting regarding health insurance benefits through the use of structured decision tools. [ABSTRACT FROM AUTHOR]

This article reports on a study that sought to identify what employment benefit packages were desired by low-income populations in the U.S. which would also be affordable for most companies. A group of low-income people were asked to choose the employee benefits they most desired and health care topped the list followed by retirement, vacation, disability pay and other factors. Although low-income status with or without health insurance is a source of poorer health, the authors say employee benefits might at least improve the health of the risk population.

Purpose: The purpose of this study was to demonstrate the feasibility and results of ascertaining Medicare enrollees' priorities for insured medical benefits. Design and Methods: Structured group exercises were conducted with Medicare enrollees from clinical and community settings in central North Carolina. By participating in a decision exercise, CHAT: Choosing Healthplans All Together, individuals and groups chose medical benefits within the constraints of a monthly Medicare + Choice premium. The acceptability of the exercise and the resulting benefit package were assessed. Results: Ten groups (121 individuals) made trade-oils that involved the selection of more tightly managed care in order to add pharmacy, dental, and long-term care benefits. All were willing to forgo experimental therapy; 7 groups gave priority to insuring the uninsured. Participants found the exercise overwhelmingly acceptable and were willing to abide by their groups' choices. Implications: Medicare enrollees are able to come to consensus about financially constrained benefit packages that may be useful in reform of the Medicare program. [ABSTRACT FROM AUTHOR]

Objective: A frequently cited obstacle to universal insurance is the lack of consensus about what benefits to offer in an affordable insurance package. This study was conducted to assess the feasibility of providing uninsured patients the opportunity to define their own benefit package within cost constraints.Design: Structured group exercises.Setting: Community setting.Participants: Uninsured individuals recruited from clinical and community settings in central North Carolina.Measurements: Insurance choices were measured using a simulation exercise, CHAT (Choosing Healthplans All Together). Participants designed managed care plans, individually and as groups, by selecting from 15 service categories having varied levels of restriction (e.g., formulary, copayments) within the constraints of a fixed monthly premium comparable to the typical per member/per month managed care premium paid by U.S. employers.Main Results: Two hundred thirty-four individuals who were predominantly male (70%), African American (55%), and socioeconomically disadvantaged (53% earned <$15,000 annually) participated in 22 groups and were able to design health benefit packages individually and in groups. All 22 groups chose to cover hospitalization, pharmacy, dental, and specialty care, and 21 groups chose primary care and mental health. Although individuals' choices differed from their groups' selections, 86% of participants were willing to abide by group choices.Conclusions: Groups of low-income uninsured individuals are able to identify acceptable benefit packages that are comparable in cost but differ in benefit design from managed care contracts offered to many U.S. employees today. [ABSTRACT FROM AUTHOR]

Many initiatives for covering the uninsured call for ‘basic’ health care coverage, yet few define that term. The Just Coverage project used a computer-based simulation exercise to learn how nearly 800 community members in northern California identified the inclusions and exclusions that would constitute basic coverage, Working with a limited budget, participants distinguished essential from nonessential health care needs, resisted high patient cost sharing, and tolerated tight restrictions on provider choice. They also supported practice guidelines and standards of effectiveness, and they excluded nigh-cost, low-value interventions. These results reinforce the importance of community input to policymakers. [ABSTRACT FROM AUTHOR]

IMPORTANCE Physicians' views about health care costs are germane to pending policy reforms. OBJECTIVE To assess physicians' attitudes toward and perceived role in addressing health care costs. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional survey mailed in 2012 to 3897 US physicians randomly selected from the AMA Masterfile. MAIN OUTCOMES AND MEASURES Enthusiasm for 17 cost-containment strategies and agreement with an 11-measure cost-consciousness scale. RESULTS A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a "major responsibility" for reducing health care costs, whereas only 36% reported that practicing physicians have "major responsibility." Most were "very enthusiastic" for "promoting continuity of care" (75%), "expanding access to quality and safety data" (51%), and "limiting access to expensive treatments with little net benefit" (51%) as a means of reducing health care costs. Few expressed enthusiasm for "eliminating fee-for-service payment models" (7%). Most physicians reported being "aware of the costs of the tests/treatments [they] recommend" (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they "should be solely devoted to individual patients' best interests, even if that is expensive" (78%) and that "doctors need to take a more prominent role in limiting use of unnecessary tests" (89%). Most (85%) disagreed that they "should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more." In multivariable logistic regression models testing associations with enthusiasm for key cost-containment strategies, having a salary plus bonus or salary-only compensation type was independently associated with enthusiasm for "eliminating fee for service" (salary plus bonus; odds ratio [OR], 3.3,99% CI, 1.8-6.1; salary only: OR, 4.3,99% CI, 2.2-8.5). In multivariable linear regression models, group or government practice setting (β = 0.87, 95% CI, 0.29 to 1.45, P = .004; and β = 0.99, 95% CI, 0.20 to 1.79, P = .01, respectively) and having a salary plus bonus compensation type (P = 0.82; 95% CI, 0.32 to 1.33; P = .002) were positively associated with cost-consciousness. Finding the "uncertainty involved in patient care disconcerting" was negatively associated with cost-consciousness (β = -1.95; 95% CI, -2.71 to -1.18; P < .001). CONCLUSION AND RELEVANCE In this survey about health care cost containment, US physicians reported having some responsibility to address health care costs in their practice and expressed general agreement about several quality initiatives to reduce cost but reported less enthusiasm for cost containment involving changes in payment models. [ABSTRACT FROM AUTHOR]

Abstract: We applied a decision tool for rationing choices, with a predetermined budget of about US$11 per household per year, to identify priorities of poor people regarding health insurance benefits in India in late 2005. A total of 302 individuals, organized in 24 groups, participated from a number of villages and neighborhoods of towns in Karnataka and Maharashtra. Many individuals were illiterate, innumerate and without insurance experience. Involving clients in insurance package design is based on an implied assumption that people can make judicious rationing decisions. Judiciousness was assessed by examining the association between the frequency of choosing a package and its perceived effectiveness. Perceived effectiveness was evaluated by comparing respondents’ choices to the costs registered in 2049 illness episodes among a comparable cohort, using three criteria: ‘reimbursement’ (reimbursement regardless of the absolute level of expenditure), ‘fairness’ (higher reimbursement rate for higher expenses) and ‘catastrophic coverage’ (insurance for catastrophic exposure). The most frequently chosen packages scored highly on all three criteria; thus, rationing choices were confirmed as judicious. Fully 88.4% of the respondents selected at least three of the following benefits: outpatient, inpatient, drugs and tests, with a clear preference to cover high aggregate costs regardless of their probability. The results show that involving prospective clients in benefit package design can be done without compromising the judiciousness of rationing choices, even with people who have low education, low-income and no previous experience in similar exercises. [Copyright &y& Elsevier]

CHAT (Choosing Healthplans All Together) is an exercise in participatory decision making designed to engage the public in health care priority setting. Participants work individually and then in groups to distribute a limited number of pegs on a board as they select from a wide range of insurance options. Randomly distributed health events illustrate the consequences of insurance choices. In 1999- 2000, the authors conducted fifty sessions of CHAT involving 592 residents of North Carolina. The exercise was rated highly regarding ease of use, informativeness, and enjoyment. Participants found the information believable and complete, thought the group decision-making process was fair, and were willing to abide by group decisions. CHAT holds promise as a tool to foster group deliberation, generate collective choices, and incorporate the preferences and values of consumers into allocation decisions. It can serve to inform and stimulate public dialogue about limited health care resources. [ABSTRACT FROM AUTHOR]

To describe the willingness of insured citizens to trade off their own health benefits to cover the uninsured. Descriptive study of individual and group decisions and decision making using quantitative and qualitative methods. Twenty-nine groups of citizens ( N= 282) residing throughout Minnesota. Groups participated in Choosing Healthplans All Together (CHAT), a simulation exercise in which participants choose whether and how extensively to cover health services in a hypothetical health plan constrained by limited resources. We describe individual and group decisions, and group dialogue concerning whether to allocate 2% of their premium to cover uninsured children in Minnesota, or 4% of their premium to cover uninsured children and adults. While discussing coverage for the uninsured, groups presented arguments about personal responsibility, community benefit, caring for the vulnerable, social impact, and perceptions of personal risk. All groups chose to insure children; 22 of 29 groups also insured adults. More individuals chose to cover the uninsured at the end of the exercise, after group deliberation, than before (66% vs 54%; P < .001). Individual selections differed from group selections more often for the uninsured category than any other. Nevertheless, 89% of participants were willing to abide by the health plan developed by their group. In the context of tradeoffs with their own health insurance benefits, groups of Minnesotans presented value-based arguments about covering the uninsured. All 29 groups and two thirds of individuals chose to contribute a portion of their premium to insure all children and most groups chose also to insure uninsured adults. J GEN INTERN MED 2004;19:868–874. [ABSTRACT FROM AUTHOR]

Focuses on the Short Portable Mental Status Scale, a measure used in a study to test health insurance benefits. Description of methodology used in the study; How the selection for health insurance operates; Statistics on the cost of Medicare packages; What packages cover; Details on estimated premium costs.