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Importance: Households have high burden of health care payments. Alternative financing approaches could reduce this burden for some households., Objective: To estimate the distribution of household health care payments across income under health care reform policies., Design, Setting, and Participants: Cross-sectional study with microsimulation used nationally representative data of the US population in 2030. Civilian, noninstitutionalized population from the 2022 Current Population Survey linked to expenditures from the 2018 and 2019 Medical Expenditure Panel Survey and 2022 National Health Expenditure Accounts were included., Exposure: Rate regulation of hospital, physician, and other health care professional payments equal to the all-payer mean in the status quo, spending growth target at 4% annual per capita growth, and single-payer health care financed through taxes., Main Outcomes and Measures: Household health care payments (out-of-pocket expenses, premiums, and taxes) as a share of compensation., Results: The synthetic population contained 154 456 records representing 339.5 million individuals, with 51% female, 7% Asian, 14% Black, 18% Hispanic White, 56% non-Hispanic White, and 5% other races and ethnicities (American Indian or Alaskan Native only; Native Hawaiian or other Pacific Islander only; and 2 or more races). In the status quo, mean household health care payments as a share of compensation was 24% to 27% (standard error [SE], 0.2%-1.2%) across income groups (median [IQR] 22% [4%-52%] below 139% of the federal poverty level [FPL]; 21% [4%-34%] for households above 1000% FPL [11% of the population]). Under rate setting, mean (SE) payments by households above 1000% FPL increased to 29% (0.6%) (median [IQR], 22% [6%-35%]) and decreased to 23% to 25% for other income groups. Under the spending growth target, mean (SE) payments decreased from 23% to 26% (SE, 0.2%-1.2%) across income groups. Under the single-payer system, mean (SE) payments declined to 15% (0.7%) (median [IQR], 4% [0%-30%]) for those below 139% FPL and increased to 31% (0.6%) (median [IQR], 23% [3%-39%]) for those above 1000% FPL. Uninsurance fell from 9% to 6% under rate setting due to improved Medicaid access, and to zero under the single-payer system., Conclusions and Relevance: Single-payer financing based on the current federal income tax schedule and a payroll tax could substantially increase progressivity of household payments by income. Rate setting led to slight increases in payments by higher-income households, who financed higher payment rates in Medicare and Medicaid. Spending growth targets reduced payments slightly for all households.

Objective: To calculate the current and projected financial burden of EGS hospital admissions in a single-payer healthcare system., Summary of Background Data: EGS is an important acute care service, which demands significant healthcare resources. EGS admissions and associated costs have increased over time, associated with an aging demographic. The National Health Service is the sole provider of emergency care in Scotland., Methods: Principal, high and low Scottish population projections were obtained for 2016 until 2041. EGS admission data were projected using an ordinary least squares linear regression model. An exponential function, fitted to historical length of hospital stay (LOS) data, was used to project future LOS. Historical hospital unit cost per bed day was projected using a linear regression model. EGS cost was calculated to 2041 by multiplying annual projections of population, admission rates, LOS, and cost per bed day., Results: The adult (age >15) Scottish population is projected to increase from 4.5 million to 4.8 million between 2016 and 2041. During this time, EGS admissions are expected to increase from 83,132 to 101,090 per year, cost per bed day from £786 to £1534, and overall EGS cost from £187.3 million to £202.5 million., Conclusions: The future financial burden of EGS in Scotland is projected to increase moderately between 2016 and 2041. This is in sharp contrast to previous studies from settings such as the United States. However, if no further reductions in LOS or cost per bed day are made, especially for elderly patients, the cost of EGS will rise dramatically., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite successes in the development of innovative anticancer therapies, the fiscal and capacity restraints of the Canadian public healthcare system result in challenges with drug access. A meaningful proportion of systemic therapies ultimately do not receive public funding despite supporting clinical evidence. In this study, we assessed Canadian medical oncologists' current attitudes toward discussing publicly unfunded cancer treatments with patients and predictors of different practices., Methods: A web-based survey consisting of multiple choice and case-based scenarios was distributed to medical oncologists identified through the Royal College of Physicians and Surgeons of Canada directory., Results: A total of 116 responses were received. Almost all respondents reported discussing publicly unfunded treatments, including those who did so for Health Canada (HC) approved treatments (50%) and those who discussed off-label treatments (i.e., not HC approved) as guided by national guidelines (48%). Respondents in practice for over 15 years versus less than 5 years (OR 0.14, 95% CI 0.04-0.50, p = 0.002) and those who worked in a community practice versus comprehensive cancer center (OR 0.17, 95% CI 0.03-0.91, p = 0.04) were significantly less likely to discuss off-label treatment options with their patients. Almost half of respondents (47%) indicated that their institution did not permit the administration of unfunded treatments., Conclusions: There is variability in medical oncologists' practices when it comes to discussing unfunded therapies. Given the limitations within Canada's publicly funded healthcare system, physicians are faced with the challenge of navigating an increasingly complex balance between patient care and available resources. Engagement of relevant stakeholders and policy makers is crucial in the continued evaluation of Canada's drug funding process.

Objective: Excess administrative costs in the US health care system are routinely referenced as a justification for comprehensive reform. While there is agreement that these costs are too high, there is little understanding of what generates administrative costs and what policy options might mitigate them., Data Sources: Literature review and national utilization and expenditure data., Study Design: We developed a simulation model of physician billing and insurance-related (BIR) costs to estimate how certain policy reforms would generate savings. Our model is based on structural elements of the payment process in the United States and considers each provider's number of health plan contracts, the number of features in each health plan, the clinical and nonclinical processes required to submit a bill for payment, and the compliance costs associated with medical billing., Data Extraction: For several types of visits, we estimated fixed and variable costs of the billing process. We used the model to estimate the BIR costs at a national level under a variety of policy scenarios, including variations of a single payer "Medicare-for-All" model that extends fee-for-service Medicare to the entire population and policy efforts to reduce administrative costs in a multi-payer model. We conducted sensitivity analyses of a wide variety of model parameters., Principal Findings: Our model estimates that national BIR costs are reduced between 33% and 53% in Medicare-for-All style single-payer models and between 27% and 63% in various multi-payer models. Under a wide range of assumptions and sensitivity analyses, standardizing contracts generates larger savings with less variance than savings from single-payer strategies., Conclusion: Although moving toward a single-payer system will reduce BIR costs, certain reforms to payer-provider contracts could generate at least as many administrative cost savings without radically reforming the entire health system. BIR costs can be meaningfully reduced without abandoning a multi-payer system., (© 2021 Health Research and Educational Trust.)

Health care reform continues to be a topic of debate among lawmakers, politicians, physicians, and citizens of the United States. In recent years, proposed changes to the health care industry have grown in both granularity and popularity, with the possibility of adapting a single-payer health insurance system reaching an all-time high. The implications of such a policy are far-reaching and can be challenging to conceptualize, especially in isolation. The purpose of this article is to review some of the anticipated changes under this new system, specifically as they pertain to the field of plastic surgery.

Background: The United States is the only high-income nation without universal, government-funded or -mandated health insurance employing a unified payment system. The US multi-payer system leaves residents uninsured or underinsured, despite overall healthcare costs far above other nations. Single-payer (often referred to as Medicare for All), a proposed policy solution since 1990, is receiving renewed press attention and popular support. Our review seeks to assess the projected cost impact of a single-payer approach., Methods and Findings: We conducted our literature search between June 1 and December 31, 2018, without start date restriction for included studies. We surveyed an expert panel and searched PubMed, Google, Google Scholar, and preexisting lists for formal economic studies of the projected costs of single-payer plans for the US or for individual states. Reviewer pairs extracted data on methods and findings using a template. We quantified changes in total costs standardized to percentage of contemporaneous healthcare spending. Additionally, we quantified cost changes by subtype, such as costs due to increased healthcare utilization and savings due to simplified payment administration, lower drug costs, and other factors. We further examined how modeling assumptions affected results. Our search yielded economic analyses of the cost of 22 single-payer plans over the past 30 years. Exclusions were due to inadequate technical data or assuming a substantial ongoing role for private insurers. We found that 19 (86%) of the analyses predicted net savings (median net result was a savings of 3.46% of total costs) in the first year of program operation and 20 (91%) predicted savings over several years; anticipated growth rates would result in long-term net savings for all plans. The largest source of savings was simplified payment administration (median 8.8%), and the best predictors of net savings were the magnitude of utilization increase, and savings on administration and drug costs (R2 of 0.035, 0.43, and 0.62, respectively). Only drug cost savings remained significant in multivariate analysis. Included studies were heterogeneous in methods, which precluded us from conducting a formal meta-analysis., Conclusions: In this systematic review, we found a high degree of analytic consensus for the fiscal feasibility of a single-payer approach in the US. Actual costs will depend on plan features and implementation. Future research should refine estimates of the effects of coverage expansion on utilization, evaluate provider administrative costs in varied existing single-payer systems, analyze implementation options, and evaluate US-based single-payer programs, as available., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: CC is an executive board member of Students for a National Health Program (SNaHP). SNaHP had no role in study design, data collection, analysis, decision to publish or manuscript preparation.

Background: In Canada, health care is covered by provincial health insurance programs; patients do not directly participate in paying for their acute care expenses. The aim of this study is to assess the willingness of Canadian patients to contribute to the costs of novel total joint arthroplasty implants., Methods: We administered a questionnaire to patients attending an outpatient arthroplasty clinic in Ontario. In the questionnaire, the longevity and risk of complications of a “standard” implant were described. We asked if participants would be willing to contribute to the cost of 3 novel implants that had differing longevities and risks of complications compared with the standard implant., Results: One hundred and fifteen patients completed our questionnaire. Up to 62% of patients were willing to contribute a copayment to get an implant with greater longevity. Willingness to pay decreased to 40% for an implant with greater longevity but an increased risk of complications. Forty percent of participants were willing to pay for an implant with the same longevity as the standard implant but a decreased risk of complications. Participants with a higher income were more willing than other participants to contribute to the cost of a novel implant with greater longevity or lower complication rates., Conclusion: This study demonstrated that up to 62% of our sample of patients in Ontario were willing to share the costs of a novel total joint replacement implant. Willingness to pay was associated with the proposed benefits of the implant and certain patient characteristics. Our study shows that a high proportion of Canadian patients may be willing to copay to have access to new technologies., Competing Interests: R. Schwarzkopf reports owning stocks in Intellijoint Surgical and Gauss Surgical and receiving consulting fees from Smith & Nephew and Intellijoint Surgical. D. Backstein reports owning stocks in Intellijoint Surgical and receiving consulting fees and royalties from MicroPort Orthopedics. No other competing interests were declared., (© 2019 Joule Inc. or its licensors)

Background: Research has shown that a small proportion of patients account for the majority of health care spending. The objective of this analysis was to determine the amount and proportion of preventable acute care spending among high-cost patients., Methods: We examined a population-based sample of all adult high-cost patients using linked administrative health care data housed at ICES in Toronto, Ontario. High-cost patients were defined as those in and above the 90th percentile of the cost distribution. Preventable acute care (emergency department visits and hospitalisations) was defined using validated algorithms. We estimated costs of preventable and non-preventable acute care for high- and non-high-cost patients by category of visit/condition. We replicated our analysis for persistent high-cost patients and high-cost patients under 65 years and those 65 years and older., Results: We found that 10% of all acute care spending among high-cost patients was considered preventable; this figure was higher for non-high-cost patients (25%). The proportion of preventable acute care spending was higher for persistent high-cost patients (14%) and those 65 years and older (12%). Among ED visits, the largest portion of preventable care spending was for primary care treatable conditions; for hospitalisations, the highest proportions of preventable care spending were for COPD, bacterial pneumonia and urinary tract infections., Conclusions: Although high-cost patients account for a substantial proportion of health care costs, there seems to be limited scope to prevent acute care spending among this patient population. Nonetheless, care coordination and improved access to primary care, and disease prevention may prevent some acute care.

Health financing is a complex health system function, which cannot be analysed accurately without tracking each step of the flow of funds separately. We analysed the revenue mix of the Hungarian health insurance fund from 1994 to 2015 and discuss the policy implications of our findings. We used the System of Health Accounts published in 2000 and the revised version of 2011, which introduced separate classifications for the sources of health expenditure. Based on the 2000 version, health insurance contributions were the main source of public funding in Hungary. According to the 2011 version, nearly 70% of health insurance fund revenues came from government tax transfers in 2015, illustrating the striking difference in how revenues and expenditures are reported using this version. Use of the 2011 version will better inform national policy-making and international comparisons and facilitate documentation and analysis of how countries have adapted their revenue mix to changing macroeconomic circumstances. The finding that Hungary has a predominantly tax-funded social health insurance system suggests that traditional understanding and description of health-financing models are no longer adequate and may limit consideration of potential resource-generation options. Hungary is also a good example of how separating revenue generation and pooling broadens policy options to tackle gaps in social health insurance coverage, although the government did not act on these due to the lack of a consistent health-financing strategy. The findings may be particularly relevant for low- and middle-income countries that are trying to expand social health insurance coverage despite limited formal employment.

Background: Single disease payment program based on clinical pathway (CP-based SDP) plays an increasingly important role in reducing health expenditure in china and there is a clear need to explore the scheme from different perspectives. This study aimed at evaluating the effect of the scheme in rural county public hospitals within Anhui, a typical province of China,using uterine leiomyoma as an example., Methods: The study data were extracted from the data platform of the New Rural Cooperative Medical Office of Anhui Province using stratified-random sampling. Means, constituent ratios and coefficients of variations were calculated and/or compared between control versus experiment groups and between different years., Results: The total hospitalization expenditure (per-time) dropped from 919.08 ± 274.92 USD to 834.91 ± 225.29 USD and length of hospital stay reduced from 9.96 ± 2.39 days to 8.83 ± 1.95 days(P < 0.01), after CP-based SDP had implemented. The yearly total hospitalization expenditure manifested an atypical U-shaped trend. Medicine expense, nursing expense, assay cost and treatment cost reduced; while the fee of operation and examination increased (P < 0.05). The expense constituent ratios of medicine, assay and treatment decreased with the medicine expense dropped the most (by 4.4%). The expense constituent ratios of materials, ward, operation, examination and anesthetic increased,with the examination fee elevated the most (by 3.9%).The coefficient of variation(CVs) of treatment cost declined the most (- 0.360); while the CV of materials expense increased the most (0.186)., Conclusion: There existed huge discrepancies in inpatient care for uterine leiomyoma patients. Implementation of CP-based SDP can help not only in controlling hospitalization costs of uterine leiomyoma in county-level hospitals but also in standardizing the diagnosis and treatment procedures.

Described as "universal prepayment," the national health insurance (or single-payer) model of universal health coverage is increasingly promoted by international actors as a means of raising revenue for health care and improving social risk protection in low- and middle-income countries. Likewise, in the United States, the recent failed efforts to repeal and replace the Affordable Care Act have renewed debate about where to go next with health reform and arguably opened the door for a single-payer, Medicare-for-All plan, an alternative once considered politically infeasible. Policy debates about single-payer or national health insurance in the United States and abroad have relied heavily on Canada's system as an ideal-typical single-payer system but have not systematically examined health system performance indicators across different universal coverage models. Using available cross-national data, we categorize countries with universal coverage into those best exemplifying national health insurance (single-payer), national health service, and social health insurance models and compare them to the United States in terms of cost, access, and quality. Through this comparison, we find that many critiques of single-payer are based on misconceptions or are factually incorrect, but also that single-payer is not the only option for achieving universal coverage in the United States and internationally.

Background: Anterior cruciate ligament tears are an unfortunate, but common, event in the United States, with an estimated 100-300,000 reconstructions performed annually. Limited literature has been published analyzing the reimbursement patterns for the reconstruction of this ligament and, thus, cost-effectiveness studies have relied mainly on data from a limited number of subjects and hospitals., Purpose: The purpose of this study was to perform an epidemiological cost analysis of anterior cruciate ligament reconstructions and to analyze and describe the reimbursement patterns for this procedure that can be used as reference for future cost-analysis studies. We conducted a retrospective review of a large private payers insurance company records to identify patients who underwent ACL reconstruction (ACLR) between 2007 and 2014., Materials and Methods: This was achieved through a structured query of the database with the use of current procedural terminology (CPT) codes. Inclusion criteria for this study were patients housed in the insurer database between the ages of 10 and 59. Reimbursements were calculated at the day of surgery and the 90-day global period. Statistical analysis was based on growth and cohort comparison according to demographic. The consumer price index (CPI) of the Bureau of Labor Statistics was used to calculate inflation., Results: The adjusted mean same-day costs were $11,462 (standard deviations [SD] of $869) for female patients and $12,071 (SD of 561) for males (p=0.07), with no significant difference among same-day costs in either females (p=0.023 for ages 10 to 34 and p=0.037 for ages 35 to 59) or males (p=0.46 for ages 10 to 34 and p=0.26 for ages 35 to 59). The adjusted mean 90-day costs were $14,569 (SD of $835) for females and $14,916 (SD of $780) for males, with no significant difference among 90-day costs in either females (p=0.229 for ages 10 to 34 and p= 0.386 for ages 35 to 39) or males (p=0.425 for ages 10 to 34 and p=0.637 for ages 35 to 39). A matched-age cost analysis demonstrated that gender did not play a significant role in costs (p<0.01 for all groups)., Conclusion: In the setting of arthroscopic ACLR, both same-day and 90-day costs do not significantly differ between age-matched males and females.

This article explores the challenges of implementing the proposed National Health Insurance for South Africa (SA), based on the six building blocks of the World Health Organization Health System Framework. In the context of the current SA health system, leadership, finance, workforce, technologies, information and service delivery are explored from the perspective of the people at ground level. Through considerations such as these, the universal health coverage goals of health equity, efficiency, responsiveness and financial risk protection, might be realised.

Background: Single-payer systems have been proposed as a health care reform alternative in the United States. However, there is no consensus on the definition of single-payer. Most definitions characterize single-payer as one entity that collects funds and pays for health care on behalf on an entire population. Increased flexibility for state health care reform may provide opportunities for state-based single-payer systems to be considered., Objective: To explore the concept of single-payer and to describe the contents of single-payer health care proposals., Design: We compared single-payer definitions and proposals. We coded the proposal text for provisions that would change how the health care system functions and could impact health care access, quality, and cost., Main Measures: The share of proposals that include changes to the financing, pooling, purchasing, and delivery of health care; and possible impact on access, quality, and costs., Key Results: We identified 25 proposals for national or state single-payer plans from journal and legislative databases. The proposals typically call for wide-ranging reform; nearly all include changes across the financing, pooling, purchasing, and delivery of health care services. Many provisions aiming to improve access, quality, and cost containment are also included, but the proposals vary in how they plan to achieve these improvements. Common provisions are related to comprehensive benefits, patient choice of providers, little or no cost sharing, the role of private insurance, provider guidelines and standards, periodic reviews of the benefits package, electronic medical records and billing, prescription drug formulary, global budgets, administrative cost thresholds, payment reform and studies, and the authority to implement cost-containment strategies., Conclusions: Single-payer systems are heterogeneous. Acknowledgment of what is considered as single-payer and the characteristics that are variable is important for nuanced policy discussions on specific reform proposals.

In October 2016, the State of Vermont signed an unprecedented agreement (The All-Payer Accountable Care Model) with the Federal Government to completely reform how health care is delivered and paid for in Vermont. This innovative agreement builds on sweeping 2011 legislation that set Vermont on a course towards payment reform designed to eliminate the fragmentation, overtreatment, and high costs associated with fee-for-service reimbursement. The strong emphasis on care coordination, preventative care, the patient experience, and population health ensures a crucial and growing role for nurses in this innovative environment and provides a model to inform the nation. Such state-led reform may have particular importance during the Trump administration, given the expected emphasis on state's rights and state leadership.

Numerous papers have been written comparing the Canadian and US healthcare systems, and a number of health policy experts have recommended that the Americans implement their single-payer system to save 12-20% of its healthcare expenditures. This paper is different in that it assumes that neither country will undertake a significant philosophic or structural change in their healthcare system, but there are lessons to be learned that are inherent in one that could be a major breakthrough for the other. Following the model in Canada and in Western Europe, the USA could implement universal health insurance so that the 32.0 million (2015) Americans still uninsured would have at least minimal coverage when incurring medical expenditures. Also, the USA could use smart cards to evaluate eligibility and to process health insurance claims; these changes resulting in an estimated 15% reduction in US health expenditures without adversely effecting access or quality of care. Such a strategy would result in the eventual loss of 2.5 million white-collar jobs at hospitals, physician offices and insurance companies, a long-term economic gain. Only a few would agree with the statement that Canada already functions with a multi-payer reimbursement system as evidenced by (1) a federal-provincial, tax-supported plan, administered by each of the provinces, providing universal coverage for hospital and physician services and (2) roughly 60% of its residents receiving employer-paid health insurance benefits, underwritten primarily by investor-owned plans, that are less than effective to reimburse for pharmaceuticals, dental and other healthcare services. What could be learned from the USA and particularly from Western European countries is possibly implementing an approach, whereby at least upper-income Canadians could opt out of their federal-provincial plan and purchase private insurance coverage - being eligible for far more comprehensive "private" benefits for hospital, physician, pharmaceutical, dental and other healthcare services. Aside from generating billions of additional needed revenues from the private sector, it could (1) help eliminate long waits for non-emergent physicians' care by appointing newly minted specialists to their medical staffs; (2) offer prompt admissions for elective cases to "private" wings of hospitals; (3) increase available funding for what is currently an undercapitalized system; (4) enhance the system's sluggish operations; and (5) encourage more competition among various providers. Although such a two-tier approach, such as available in the USA and elsewhere, is politically dead on arrival in Canada today, private insurance being already legal and commonly available there. Interestingly, this recommended solution is utilized in most western European countries where there is a higher percentage than in Canada of public (versus private) funding of their total health expenditures. Because of various vested interests, attempts to implement any of the aforementioned proposals will undoubtedly result in considerable political rancor. There is greater likelihood, however, that the Canadians because their need to be more effective and efficient in their delivery of care, and their overall long-term fiscal outlook will agree to the further privatization of their healthcare system before the Americans will mandate universal access, use the smart card to process insurance eligibility and claims or will impose price controls on high-tech services and on pharmaceuticals. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Many problems facing the Affordable Care Act would disappear if the nation were instead implementing Medicare for All - the extension of Medicare to every age group. Every American would be automatically covered for life. Premiums would be replaced with a set of Medicare taxes. There would be no patient cost sharing. Individuals would have free choice of doctors. Medicare's single-payer bargaining power would slow price increases and reduce medical cost as a percentage of gross domestic product (GDP). Taxes as a percentage of GDP would rise from below average to average for economically advanced nations. Medicare for All would be phased in by age., (Copyright © 2015 by Duke University Press.)

In May 2011, a year after the passage of the Affordable Care Act (ACA), Vermont became the first state to lay the groundwork for a single-payer health care system, known as Green Mountain Care. What can other states learn from the Vermont experience? This article summarizes the findings from interviews with nearly 120 stakeholders as part of a study to inform the design of the health reform legislation. Comparing Vermont's failed effort to adopt single-payer legislation in 1994 to present efforts, we find that Vermont faced similar challenges but greater opportunities in 2010 that enabled reform. A closely contested gubernatorial election and a progressive social movement opened a window of opportunity to advance legislation to design three comprehensive health reform options for legislative consideration. With a unified Democratic government under the leadership of a single-payer proponent, a high-profile policy proposal, and relatively weak opposition, a framework for a single-payer system was adopted by the legislature - though with many details and political battles to be fought in the future. Other states looking to reform their health systems more comprehensively than national reform can learn from Vermont's design and political strategy., (Copyright © 2015 by Duke University Press.)

On its twentieth anniversary, Taiwan's National Health Insurance (NHI) stands out as a high-performing single-payer national health insurance system that provides universal health coverage to Taiwan's 23.4 million residents based on egalitarian ethical principles. The system has encountered myriad challenges over the years, including serious financial deficits. Taiwan's government managed those crises through successive policy adjustments and reforms. Taiwan's NHI continues to enjoy high public satisfaction and delivers affordable modern health care to all Taiwanese without the waiting times in single-payer systems such as those in England and Canada. It faces challenges, including balancing the system's budget, improving the quality of health care, and achieving greater cost-effectiveness. However, Taiwan's experience with the NHI shows that a single-payer approach can work and control health care costs effectively. There are lessons for the United States in how to expand coverage rapidly, manage incremental adjustments to the health system, and achieve freedom of choice., (Project HOPE—The People-to-People Health Foundation, Inc.)

The pressure to contain health expenditures is unprecedented. In England a flattening of the health budget but increasing demand led the National Health Service (NHS) to seek reductions in health expenditures of 17 percent over four years. The spending cuts were to be achieved through improvements in service quality and efficiency, including reducing the use of ineffective, overused, or inappropriate procedures. However, the NHS left it to the local commissioning (or funding) organizations, known as primary care trusts, to determine what steps to take to reduce spending. To assess whether the initiative had an impact, we examined six low-value procedures: spinal surgery for lower back pain, myringotomy to relieve eardrum pressure, inguinal hernia repair, cataract removal, primary hip replacement, and hysterectomy for heavy menstrual bleeding. We found significant reductions in three of the six procedures-cataract removal, hysterectomy, and myringotomy-in the program's first year, compared to prior years' trends. However, changes in the rates of all examined procedures varied widely across commissioning organizations. Our findings highlight some of the challenges of making major budget cuts in health care. Reducing ineffective spending remains a significant opportunity for the US health care system, and the English experience may hold valuable lessons., (Project HOPE—The People-to-People Health Foundation, Inc.)

Healthcare capital-to-labor ratios are examined for the 10 provincial single-payer health care plans across Canada. The data show an increasing trend-particularly during the period 1997-2009 during which the ratio as much as doubled from 3 to 6 %. Multivariate analyses indicate that every percentage point uptick in the rate of increase in this ratio is associated with an uptick in the rate of increase of real per capita provincial government healthcare expenditures by approximately $31 ([Formula: see text] 0.01). While the magnitude of this relationship is not large, it is still substantial enough to warrant notice: every percentage point decrease in the upward trend of the capital-to-labor ratio might be associated with a one percentage point decrease in the upward trend of per capita government healthcare expenditures. An uptick since 1997 in the rate of increase in per capita prescription drug expenditures is also associated with a decline in the trend of increasing per capita healthcare costs. While there has been some recent evidence of a slowing in the rate of health care expenditure increase, it is still unclear whether this reflects just a pause, after which the rate of increase will return to its baseline level, or a long-term shift; therefore, it is important to continue to explore various policy avenues to affect the rate of change going forward.

Both supporters and critics of the Patient Protection and Affordable Care Act (ACA) have argued that it is similar to Switzerland's Federal Law on Health Insurance (LAMal), which currently governs Swiss health care, and have either praised or condemned the ACA on the basis of this alleged similarity. I challenge these observers on the grounds that they overlook critical problems with the Swiss model, such as its inequities in access, and critical differences between it and the ACA, such as the roots in, and continuing commitment to, social insurance of the Swiss model. Indeed, the daunting challenge of attempting to impose the tightly regulated model of operation of the Swiss model on mega-corporations like UnitedHealth, WellPoint, or Aetna is likely to trigger no less ferocious resistance than a fully public, single-payer system would. I also conclude that the ACA might unravel in ways unintended or even opposed by its designers and supporters, as employers, confronted with ever-rising costs, retreat from sponsoring insurance, and workers react in outrage as they confront the unaffordable underinsurance mandated by the ACA. A new political and ideological landscape may then ensue that finally ushers in a truly national health program.

We examined the prognostic impact of SES, estimated by census median household income, in 312 adult MDS patients. Age, progression to AML, use of recombinant erythropoietin, WHO diagnosis and IPSS risk category were independent predictors of survival but there was no association between SES and survival. Unexpectedly, progression to AML was more prevalent in the highest income quartile (HR 3.96 for highest vs. lowest; p=0.0032). The previously demonstrated association of low SES with poor outcome MDS in the United States may have been driven primarily by reduced access to care rather than other SES-linked factors such as co-morbidity., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Public policy in healthcare affects physician and patient choices. In many ways it may limit choices. These choices present conflicts that are discussed here. Some issues depend on the laws enacted to enable either a single-payer system or that mixed with a private-payer system. In each case, the systems attain some cost controls through means such as gatekeepers, long wait lists, authorization processes, national fee schedules, complex coding schemes, or placing physicians on salary. National health systems are compared here. No one system has proven completely satisfactory, and each has its advantages. There are many factors that contribute to the escalating costs of care that lead to many healthcare public policies to constrain costs. Initiatives to incentivize preventive actions are a more positive step, but ones that are difficult to define in detail., (© 2013 Elsevier B.V. All rights reserved.)

The anticipated changes resulting from the passage of the Patient Protection and Affordable Care Act-including the proposed adoption of bundled payment systems and the promotion of accountable care organizations-have generated considerable controversy as U.S. healthcare industry observers debate whether such changes will motivate vertical integration activity. Using examples of accountable care organizations and bundled payment systems in the American post-acute healthcare sector, this article applies economic and sociological perspectives from organization theory to predict that as acute care organizations vary in the degree to which they experience environmental uncertainty, asset specificity, and network embeddedness, their motivation to integrate post-acute care services will also vary, resulting in a spectrum of integrative behavior.

In 2005 leaders in the wealthy Emirate of Abu Dhabi inherited an health system from their predecessors that was well-intentioned in its historic design, but that did not live up to aspirations in any dimension. First, the Emirate defined a vision to deliver "world-class" quality care in response to citizen's needs. It has since introduced tiered mandatory health insurance for all inhabitants linked to a single standard payment system, which generates accurate data as an invaluable by-product. A newly created independent health system regulator monitors these data and licenses, audits, and inspects all health service professionals, facilities, and insurers accordingly. We analyse these health system reforms using the "Getting Health Reform Right" framework. Our analysis suggests that an integrated set of reforms addressing all reform levers is critical to achieving the outcomes observed. The reform programme has improved access, by giving all residents health cards. The approximate doubling of demand has been matched by flexible supply, with the private sector adding 5 new hospitals and 93 clinics to the health system infrastructure since 2006. The focus on reliable raw-data flows through the single standard payment system functions as a motor for improvement services, innovation, and investment, for instance by allowing payers to 'pay for quality', which may well be applicable in other contexts., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: More than 75% of people older than 65 years of age in the United States have prediabetes or diabetes. Diabetes is a burden on Medicare, the US health care payer. Intensive lifestyle interventions have successfully prevented diabetes cases, and medical nutrition therapy has also significantly reduced diabetes risk factors. Including medical nutrition therapy coverage for prediabetes is a policy decision to be made by Medicare, and cost-effectiveness data must support that decision., Objective: The aims of this study were to determine the thresholds of diabetes cases that need to be averted by prediabetes lifestyle interventions in order to be cost saving and/or cost-effective to a single health care insurance payer, such as Medicare; and to compare those thresholds with published intervention data to determine the feasibility of cost savings and/or cost-effectiveness., Design: This analysis used standard methods of cost-effectiveness and cost saving analysis. A health system perspective was used. Cost estimates for diabetes treatment and lifestyle interventions were based on published data. Costs for 3-, 6-, and 10-year lifestyle interventions were calculated. Sensitivity analyses were performed using least and most-conservative published data for health care and intervention costs., Results: The number of cases averted needed for base-case cost savings ranged from 882,883 to 2,443,686, and in sensitivity analysis from 394,148 to 6,738,678. Cost savings are likely in the base and least-conservative scenarios. The number of cases averted needed for base-case cost-effectiveness ranged from 454,755 to 1,258,692, and in sensitivity analysis from 212,225 to 4,843,262. Cost-effectiveness is likely in all interventions, except the 10-year interventions in the most-conservative scenario., Conclusions: Prediabetes lifestyle interventions for people aged 65 years or older are highly cost-effective and possibly cost saving to a health care insurance payer such as Medicare. It is likely that medical nutrition therapy could be even more cost saving and/or cost-effective than intensive lifestyle interventions. These results suggest that Medicare would receive financial benefit from providing coverage for these services., (Copyright © 2012 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate the appropriateness of the definition of outpatient-shopping behavior in Taiwanese patients., Study Design: Linked study of 3 databases (Taiwan Cancer Registry, National Health Insurance [NHI] claim database, and death registry database)., Methods: Outpatient shopping behavior was defined as making at least 4 or 5 physician visits to confirm a cancer diagnosis. We analyzed patient-related factors and the 5-year overall survival rate of the outpatient-shopping group compared with a nonshopping group. Using the household registration database and NHI database, we determined the proportion of outpatient shopping, characteristics of patients who did and did not shop for outpatient therapy, time between diagnosis and start of regular treatment, and medical service utilization in the shopping versus the nonshopping group., Results: Patients with higher incomes were significantly more likely to shop for outpatient care. Patients with higher comorbidity scores were 1.4 times more likely to shop for outpatient care than patients with lower scores. Patients diagnosed with more advanced cancer were more likely to shop than those who were not. Patients might be more trusting of cancer diagnoses given at higher-level hospitals. The nonshopping groups had a longer duration of survival over 5 years., Conclusions: Health authorities should consider charging additional fees after a specific outpatient- shopping threshold is reached to reduce this behavior. The government may need to reassess the function of the medical sources network by shrinking it from the original 4 levels to 2 levels, or by enhancing the referral function among different hospital levels.