Study on the policy implementation effect of serious Illness medical insurance in the ethnic minority autonomous area of Western China

Objective: To evaluate the implementation effect of serious illness medical insurance in Guang Xi Zhuang Autonomous Region of western China. Study design: Through the collection of 2017-2021 Guang Xi serious illness medical insurance specific policy making such as fund usage, serious illness compensation, medical expenses data, and data analysis of a serious illness medical insurance effect. Method: Literature research, Policy text analysis, quantitative data collection method, using Excel and SPSS 19.0 data descriptive statistical analysis and comparative analysis. Results: Serious illness medical insurance has had some effect, e.g., from 2017 to 2021, the utilization rate of serious illness medical insurance fund in Guang Xi was 109.49% and 103.87% respectively, the fund balance rate was -9.45% and -8.54% respectively, and the accumulated balance was -2.3871 million CNY and -70.7955 million CNY. Conclusion: The serious illness medical insurance has reduced the burden of large medical expenses of patients to a certain extent, but the fund is under too much pressure, and there is a payment deficit. The coverage and security of serious illness medical insurance need to be expanded and strengthened, and the cooperation mechanism with commercial insurance institutions should be gradually explored to improve the serious illness medical insurance.

Objetivo: evaluar el efecto de la implementación de seguros médicos para enfermedades graves en la Región Autónoma Guang Xi Zhuang, al oeste de China. Diseño del estudio: a través de la recopilación de pólizas de seguro médico específicas para enfermedades graves de la región de Guang Xi entre 2017-2021, como por ejemplo: uso de fondos, compensación por enfermedades graves, datos de gastos médicos y análisis de datos del efecto de seguros médicos para enfermedades graves. Método: investigación de literatura, análisis de textos de políticas públicas, metodología de recolección de datos cuantitativos utilizando Excel y SPSS 19.0, análisis estadístico descriptivo de datos y análisis comparativo. Resultados: el seguro médico para enfermedades graves ha demostrado tener efectos, tales como: entre 2017 y 2021, la tasa de utilización de fondos de seguros médicos para enfermedades graves en Guang Xi fue de 109,49 % y 103,87 % respectivamente, las tasas de saldo del fondo fue de -9,45 % y -8,54 % respectivamente y el saldo acumulado fue de -2,3871 millones de CNY y -70,7955 millones de CNY. Conclusión: El seguro médico para enfermedades graves ha reducido en cierta medida la carga de los grandes gastos médicos de los pacientes, pero al existir un déficit de pagos está bajo demasiada presión. Por ello, es necesario ampliar y fortalecer la cobertura y seguridad del seguro médico para enfermedades graves, y explorar gradualmente mecanismos de cooperación con instituciones de seguros comerciales.

Objetivo: Avaliar o efeito da implementação de seguro médico para doenças graves na Região Autônoma de Guang Xi Zhuang da China Ocidental. Desenho do Estudo: Através da coleta de políticas específicas de seguro médico para doenças graves de Guang Xi 2017-2021, uso de fundos, compensação por doenças graves, dados de despesas médicas e análise de dados de um efeito de seguro médico para doenças graves. Método: Pesquisa na literatura, análise do texto da política, método de coleta de dados quantitativos usando Excel e SPSS 19.0, análise estatística descritiva de dados e análise comparativa. Resultados: Seguro médico de doenças graves teve um certo efeito. Em 2017 e 2021, a taxa de utilização do fundo de seguro médico para doenças graves em Guang Xi foi 109,49% e 103,87% respectivamente, a taxa de saldo do fundo foi -9,45% e -8,54% respectivamente e o saldo acumulado foi -2,3871 milhões de yuans e -70,7955 milhões de yuans. Conclusão: O seguro médico para doenças graves reduziu o ônus de grandes despesas médicas dos pacientes até certo ponto mas o fundo está sob demasiada pressão e há um déficit de pagamentos. A cobertura e segurança do seguro médico de doenças graves necessitam ser expandidas e fortalecidas, e o mecanismo de cooperação com instituições de seguros comerciais deve ser gradualmente explorado para melhorar o seguro médico para doenças graves.

Early characterization of an adult population at an insurer's point of entry as an opportunity to identify hospitalization risk

Introduction: Health Benefit Plan Administrators must manage the health risk of their members. Therefore, health characterization is performed from enrollment to support decision-making and timely intervention. Objective: To analyze the historical results of characterizing the adult population on admission to the insurance company in relation to the demand for all-cause and psychiatric hospitalization services. Materials and Methods: An observational cross-sectional study with members over 18 years of age, in which an analysis was made of the characterization of the adult population of the insurer and its association with the use of medical consultation services in primary care and all-cause and psychiatric hospitalizations. Bivariate and multivariate analysis was made, and odds ratios (OR) were calculated in logistic regression. Results: Variables significantly associated with having an all-cause hospitalization were identified: having referred history of heart disease OR=1.71(95%CI: 1.33; 2.20), respiratory disease OR= 1. 30(95%CI: 1.04; 1.61), chronic kidney disease OR=1.66(95%CI: 1.13; 2.45), cancer OR=1.65(95%CI: 1.14; 2.40), taking any medication permanently OR=1.35(95%CI: 1.174; 1.56) and smoking OR=1.44(95%CI: 1.12; 1.85). For psychiatric hospitalizations, a history of discouragement, depression, or little hope was relevant with OR=5.12(95%CI: 1.89; 13.87). Discussion: The characterization of patients during enrolment allowed the identification of predictor variables of hospitalization, guiding management from the primary care level minimizing costs and catastrophic health events. Conclusion: The timely identification of specific patient profiles allows timely actions to minimize health costs and catastrophic health events.

The function of competitive intelligence in South African insurance post-COVID-19 outbreak

Background: Competitive intelligence (CI) involves monitoring competitors and providing organizations with actionable and meaningful intelligence. Some studies have focused on the role of CI in other industries post-COVID-19 pandemic. Objectives: This article aims to examine the impact of COVID-19 on the South African insurance sector and how the integration of CI and related technologies can sustain the South African insurance sector post-COVID-19 epidemic. Method: Qualitative research with an exploratory-driven approach was used to examine the impact of the COVID-19 pandemic on the South African insurance sector. Qualitative secondary data analyses were conducted to measure insurance claims and death benefits paid during the COVID-19 pandemic. Results: The research findings showed that the COVID-19 pandemic significantly impacted the South African insurance industry, leading to a reassessment of pricing, products, and risk management. COVID-19 caused disparities in death benefits and claims between provinces; not everyone was insured. Despite challenges, South African insurers remained well-capitalised and attentive to policyholders. Integrating CI and analytical technologies could enhance the flexibility of prevention, risk management, and product design. Conclusion: COVID-19 requires digital transformation and CI for South African insurers' competitiveness. Integrating artificial intelligence (AI), big data (BD), and CI enhances value, efficiency, and risk assessments. Contribution: This study highlights the importance of integrating CI strategies and related technologies into South African insurance firms' operations to aid in their recovery from the COVID-19 crisis. It addresses a research gap and adds to academic knowledge in this area.

Health benefit utilization and out-of-pocket expenses in outpatient care and hospitalizations: Baseline surveys of three primary care sites in the Philippines

Background@#The Philippine Primary Care Studies (PPCS) is a network of pilot studies that developed, implemented, and tested strategies to strengthen primary care in the country. These pilot studies were implemented in an urban, rural, and remote setting. The aim is to use the findings to guide the policies of the national health insurance program (PhilHealth), the main payor for individualized healthcare services in the country.@*Objective@#The objective of this report is to compare baseline outpatient benefit utilization, hospitalization, and health spending, including out-of-pocket (OOP) expenses, in three health settings (urban, rural, and remote). These findings were used to contextualize strategies to strengthen primary care in these three settings.@*Methods@#Cross-sectional surveys were carried out using an interviewer-assisted questionnaire on a random sample of families in the urban site, and a stratified random sample of households in the rural and remote sites. The questionnaire asked for out-patient and hospitalization utilization and spending, including the OOP expenses. @*Results@#A total of 787 families/households were sampled across the three sites. For outpatient benefits, utilization was low in all sites. The remote site had the lowest utilization at only 15%. Unexpectedly, the average annual OOP expenses for outpatient consults in the remote site was PhP 571.92/per capita. This is 40% higher than expenses shouldered by families in the rural area, but similar with the urban site. For hospital benefits, utilization was lowest in the remote site (55.7%) compared to 75.0% and 78.1% for the urban and rural sites, respectively. OOP expenses per year were highest in the remote site at PhP 2204.44 per capita, probably because of delay in access to healthcare and consequently more severe conditions. Surprisingly, annual expenses per year for families in the rural sites (PhP 672.03 per capita) were less than half of what families in the urban sites spent (PhP 1783.38 per capita). @*Conclusions@#Compared to families in the urban site and households in the rural sites, households in remote areas have higher disease rates and consequently, increased need for outpatient and inpatient health services. When they do get sick, access to care is more difficult. This leads to lower rates of benefit utilization and higher out-of-pocket expenses. Thus, provision of “equal” benefits can inadvertently lead to “inequitable” healthcare, pushing disadvantaged populations into a greater disadvantage. These results imply that health benefits need to be allocated according to need. Families in poorer and more remote areas may require greater subsidies.

Dilemma and promotion strategy of “dual channel”management policy for China’s medical insurance negotiated drugs / 中国药房

OBJECTIVE To provide reference for the smooth implementation of the “dual channel” management policy for China’s medical insurance negotiated drugs. METHODS Based on Smith policy implementation process model， the dilemmas for the implementation of “dual channel” policy for medical insurance negotiated drugs were analyzed from four aspects： implementation details and regulatory system， drug selection， drug provision and quality control， the situation of medical insurance funds and information technology capabilities. The corresponding promotion strategies were put forward. RESULTS & CONCLUSIONS The “dual channel” policy for medical insurance negotiated drugs in China might face implementation difficulties such as a lack of clear implementation rules and a full process supervision system， the suitability and operability of some medical insurance negotiated drugs need to be considered in the “dual channel” management， difficulties in drug allocation and quality control， differences in the management and operation of medical insurance funds in different regions， and insufficient informatization capability. In this regard， this study suggests that measures， such as improving the implementation rules of the “dual channel” policy， enhancing the rationality of the “dual channel” drug catalog， establishing a dynamic exit mechanism for “dual channel” pharmacies， promoting professional delivery services， and improving the electronic prescription circulation platform， which can be taken to enhance the implementation effect of the “dual channel” policy.

Analysis of Subject Related Costs in Medical Research / 中国医学伦理学

The development of medical research is completed by the cooperation of sponsors, investigators, subjects, and ethics committees. Clinically, it mainly includes clinical trials of medical devices, clinical medicine and new technology research. This paper analyzed the game and the relationship between rights, responsibilities and interests of relevant parties in medical research, combined with the relevant costs and sharing principles involved in medical research, and found that the use of the word "free" in the informed consent is easy to cause misunderstanding and the lack of relevant compensation costs in the informed consent, while the compensation and insurance costs had some problems, such as the imperfect subject compensation mechanism and the insufficient insurance purchase by the sponsor, which can not protect the basic rights and interests of the subjects. Therefore, in order to standardize the cost management of clinical medical research, it is necessary to standardize the process and content of informed consent, strengthen the supervision of medical research process, establish medical research damage compensation fund and research damage insurance system, so as to better protect the rights and interests of subjects.

Quality of life and factors associated among public university employees retired due to disabilities / Qualidade de vida e fatores associados entre servidores aposentados por invalidez de universidades públicas / Calidad de vida y factores asociados de empleados jubilados por invalidez de universidades públicas

Abstract Objective: to analyze quality of life and factors associated among public university employees retired due to disabilities. Method: a cross-sectional study conducted with a sample of public university employees retired due to disabilities. A characterization questionnaire and the World Health Organization Quality of Life - Disabilities instrument were applied via telephone or online contacts from November 2019 to September 2020. The associated factors were verified through multiple linear regression. Results: of the 80 retirees due to disability, 15% were professors and 85% had a technical-administrative career. As for the factors associated with Quality of Life, continuous medication use (βadj: -0.25; p=0.02) and problems in the nervous system (βadj: -0.21; p<0.05) were associated with the Overall domain; continuous medication use (βadj: -0.23; p=0.04), to the Physical domain; smoking (βadj: -0.21; p<0.05) and mental and behavioral disorders (βadj: -0.21; p<0.01), to the Psychological domain; smoking (βadj: -0.46; p<0.01) and respiratory (βadj: -0.21; p=0.03) and circulatory (βadj: -0.21; p=0.03) problems, to the Social domain; smoking (βadj: -0.33; p<0.01) and problems in the nervous system (βadj: -0.22; p=0.04), to the Environmental domain; mental and behavioral disorders, to the Disabilities module (βadj: -0.29; p<0.01) and to the Discrimination domain (βadj: -0.21; p<0.05); and smoking (βadj: -0.32; p<0.01) and problems in the nervous system (βadj: -0.20; p<0.05), to the Inclusion domain. The Autonomy domain did not present any association. Conclusion: the retirees under study presented impaired Quality of Life.

Resumo Objetivo: analisar a qualidade de vida e os fatores associados entre servidores de universidades públicas aposentados por invalidez. Método: estudo transversal, com amostra de servidores aposentados por invalidez de universidades públicas. Um questionário de caracterização e o World Health Organization Quality of Life - Disabilities foram aplicados por contato telefônico ou online no período de novembro de 2019 a setembro de 2020. Verificaram-se os fatores associados por regressão linear múltipla. Resultados: dos 80 aposentados por invalidez, 15% eram docentes e 85% da carreira técnica-administrativa. Quanto aos fatores associados à qualidade de vida, o uso de medicação contínua (βaj: -0,25; p=0,02) e os problemas do sistema nervoso (βaj: -0,21; p<0,05) associaram-se ao domínio Overall; o uso de medicação contínua (βaj: -0,23; p=0,04) ao domínio físico; o tabagismo (βaj: -0,21; p<0,05) e os transtornos mentais e comportamentais (βaj: -0,21; p<0,01) ao domínio psicológico; o tabagismo (βaj: -0,46; p<0,01), os problemas respiratórios (βaj: -0,21; p=0,03) e circulatórios (βaj: -0,21; p=0,03) ao domínio social; o tabagismo (βaj: -0,33; p<0,01) e os problemas do sistema nervoso (βaj: -0,22; p=0,04) ao domínio ambiental; os transtornos mentais e comportamentais ao módulo incapacidades (βaj: -0,29; p<0,01) e ao domínio discriminação (βaj: -0,21; p<0,05); o tabagismo (βaj: -0,32; p<0,01) e os problemas do sistema nervoso (βaj: -0,20; p<0,05) ao domínio inclusão. O domínio autonomia não apresentou associação. Conclusão: os aposentados estudados apresentaram uma qualidade de vida prejudicada.

Resumen Objetivo: analizar la calidad de vida y los factores asociados de empleados de universidades públicas jubilados por invalidez. Método: estudio transversal, con una muestra de trabajadores jubilados por invalidez de universidades públicas. Se aplicó un cuestionario de caracterización y el World Health Organization Quality of Life - Disabilities mediante contacto telefónico u online desde noviembre de 2019 hasta septiembre de 2020. Los factores asociados se verificaron mediante regresión lineal múltiple. Resultados: de los 80 jubilados por invalidez, el 15% era docente y el 85% era técnico-administrativo. En cuanto a los factores asociados a la calidad de vida, el uso continuo de medicamentos (βaj: -0,25; p=0,02) y los problemas del sistema nervioso (βaj: -0,21; p<0,05) se asociaron al dominio overall; el uso continuo de medicamentos (βaj: -0,23; p=0,04) el dominio físico; el tabaquismo (βaj: -0,21; p<0,05) y los trastornos mentales y conductuales (βaj: -0,21; p<0,01) al dominio psicológico; el tabaquismo (βaj: -0,46; p<0,01), los problemas respiratorios (βaj: -0,21; p=0,03) y circulatorios (βaj:-0,21;p=0,03) al dominio social; el tabaquismo (βaj: -0,33; p<0,01) y los problemas del sistema nervioso (βaj: -0,22; p=0,04) al dominio ambiental; los trastornos mentales y conductuales al módulo discapacidad (βaj: -0,29; p<0,01) y al dominio discriminación (βaj: -0,21; p<0,05); el tabaquismo (βaj: -0,32; p<0,01) y los problemas del sistema nervioso (βaj: -0,20; p<0,05) al dominio inclusión. El dominio autonomía no mostró asociación. Conclusión: la calidad de vida de los jubilados por invalidez que participaron del estudio estaba deteriorada.

Government Health Insurance Schemes and Their Benefits to The Indian Population: An Overview

In today’s scenario accelerating cost of health significantly impact the health of people and the populace creat-ing a monetary burden on poor households. One of the key concerns while tackling healthcare disparities is out-of-pocket expenses (OOPE). Providing financial safety and provide universal coverage to the entire popu-lace are the main goal of health schemes. Health policies in India are based on equity prioritising the needs of the poor and underprivileged. Likewise, there is a discrepancy in the consistency of information and knowledge regarding the scheme among the beneficiaries. A review was created to help medical and nursing professionals to gain comprehensive knowledge of various health schemes. We tried to give an overview of various health schemes including Ayushman Bharat Yojana, Aam Aadmi Bima Yojana (AABY), Pradhan Mantri Suraksha Bima Yojana (PMSBY), Rashtriya Swasthya BimaYojana (RSBY), Central Government Health Scheme (CGHS), Employees State Insurance Scheme (ESIC), Employee Health Scheme and various state-level health schemes. include, Yeshasvini Health Insurance Scheme, Mahatma Jyotiba Phule Jan Arogya Yojana, Chief Min-ister Comprehensive Health Insurance Scheme, Mukhyamantri Amrutum Yojana, Karunya Health Scheme, Awaz Health Insurance Scheme, Telangana State Govt Employees and Journalist Health Scheme, Dr Ysr Aarog-yastri Health Care Trust, Mukhyamantri Chiranjeevi Yojana, Rajasthan Government Health Scheme (RGHS), and Aarogya Raksha.

Judge Juan Manuel Padilla Garcia, ChatGPT, and a controversial medicolegal milestone

Chat Generative Pre-Trained Transformer (ChatGPT) has revolutionized how we perceive artificial intelligence (AI).: Judge Juan Manuel Padilla Garcia created history by mentioning its use while passing judgment about an autistic child and payment for his medical treatment by his insurance company. The use of AI is not new and is helping the judiciary system in many ways. However, this judgment given on January 30, 2023, has ignited controversy among Judge Garcia’s peers and the global community (a Google search produced more than 70 million hits on February 5, 2023). EU has established guidelines that are to be followed before calling any AI tool trustworthy. This requires stringent compliance with the verification and due diligence process. In this instance, ChatGPT was used within 2 months of its launch, even when it has been shown to give incomplete, incorrect, and misleading answers in many instances. Hasty adaption of unproven technology, however good it may be, should not be our path. This might fuel the misguided fear amongst people about robots taking over from human judges.

Impacto del Aseguramiento en Salud en la Economía de los Hogares Peruanos, 2010-2019

Objetivo : Determinar el impacto del aseguramiento en salud en la economía de los hogares peruanos en el periodo 2010-2019. Materiales y Métodos : Estudio analítico transversal, que utilizó la base de datos de la Encuesta Nacional de Hogares de los años 2010, 2014 y 2019 para analizar el impacto del aseguramiento en salud en términos de gasto de bolsillo en salud, gasto catastrófico y empobrecimiento de los hogares peruanos, así como determinar qué otros factores se encuentran asociados. Resultados : Durante el periodo de estudio se observó que los hogares peruanos presentaron una disminución del gasto de bolsillo en salud promedio mensual (S/.119,9 en 2010 a S/.107,9 en 2019), así como del porcentaje de hogares con gasto catastrófico en salud (4,06 % en 2010 a 3,47 % en 2019) y del porcentaje de hogares que empobrecen por gastos de bolsillo en salud (1,78 % en 2010 a 1,51 % en 2019). Los factores asociados al gasto catastrófico en salud y al empobrecimiento fueron el menor nivel de escolaridad del jefe del hogar, la presencia de miembros con enfermedad crónica y el área de residencia rural. La ausencia de aseguramiento en salud se asoció significativamente a un mayor riesgo de gasto de bolsillo en salud catastrófico, mas no al empobrecimiento. Conclusiones : El aumento de la cobertura de aseguramiento en salud contribuye a la protección financiera de los hogares peruanos frente al gasto de bolsillo en salud; sin embargo, las barreras para el acceso efectivo a los servicios de salud y otros factores socioeconómicos pueden limitar significativamente su impacto.

Objective : To determine the impact of health insurance in the economy of Peruvian households during the 2010-2019 period. Material and Methods : This is a cross-sectional analytical study that used the database of the National Peruvian Household Surveys from years 2010, 2014, and 2019, aiming to analyze the impact of health insurance in terms of pocket money spending for health issues, catastrophic healthcare spending, and impoverishment in Peruvian households, and also to determine the presence of other associated factors. Results : During the study period, it was observed that Peruvian households reduced their monthly average pocket money spending for health issues (119.9 PEN in 2010 and 107.9 PEN in 2029), as well as the percentage of household with catastrophic healthcare expenses (4.06% in 2010 to 3.47% in 2019), and the percentage of households who became impoverished because of pocket money expenses for health issues (1.78% in 2020 to 1.51% in 2019). Factors associated to catastrophic healthcare expenses and to impoverishment were lower educational level for the household leader, the presence of family members with chronic diseases, and living in a rural area. The absence of health insurance was significantly associated to a greater risk for catastrophic healthcare expenses, but not to impoverishment. Conclusions : Increased healthcare insurance coverage contributes to financial protection of Peruvian households against pocket money spending for health issues; however, barriers for effective access to healthcare services, and other socioeconomical factors may significantly limit this impact.

Professional indemnity/medical malpractice insurance—Awareness among medical students and consultants of India: An online survey study

Introduction: Professional indemnity (PI) or medical malpractice insurance (MMI) has been a hot topic considering the increasing number of medical negligence cases rising worldwide. However, there is a palpable difference in understanding and usage of this tool in developed countries and regions such as India. Aim: This study aimed to analyze the general understanding of resident doctors and consultants about MMI and knowledge about its technical jargon. Materials and Methods: We distributed short Google Form questionnaires about various aspects of MMI. We recorded the data from 141 resident doctors and 42 consultants in the Navi Mumbai area of India. As it was a survey, we required no ethical review. Results: As consultants’ experience grew, so did their understanding of medical indemnity. Approximately 90%, 64%, and 22% of consultants with 10 years, 5–10 years, and 5 years of experience had acquired PI. The AOY:AOT (any one year:anyone time) ratio was known to just 35% of these specialists. About half of the resident doctors were aware of PI and the effects of medical specialization on PI. Around a fifth of the individuals had only acquired the PI. Conclusion: There needs to be more clarity between the need and knowledge of MMI in India. This needs to be addressed by teaching medical postgraduates about it during training. “There should be special emphasis on medical indemnity in terms of its need, clauses, and cost during postgraduate medical training.”

Awareness, willingness, and challenges of the informal sector toward state National Health Insurance Services in Benin City, Nigeria

Background: As access to vital health services expands and universal health coverage is attained, health insurance is projected to serve as a critical risk protection for families and small enterprises. Aim: To assess the informal sector’s awareness, willingness, and problems in enrolling in the state national health insurance program. Materials and Methods: This cross-sectional descriptive study was done in Benin City, Nigeria, in the unorganized sector. A self-structured questionnaire was created, distributed, and retrieved for this study, which was conducted among 155 artisans chosen through a stratified random sample procedure. To evaluate the data, Statistical Package for the Social Sciences, SPSS version 22 was used. Results: In total, 138 people (89.0%) are aware of the National Health Insurance Scheme (NHIS), while only 93 people (60.0%) know that Edo state has a state-owned Health Insurance Scheme (SHIS). Only 17 people, or 11.0%, are engaged in the NHIS/SHIS program, whereas 107 people, or 77.5%, have expressed interest. Lack of accessibility to authorized healthcare facilities near house 22 (71.0%) is a significant deterrent to enrollment in the program. Long lines at service points (3.88, 1.093), the time it takes to enroll new members in the program (3.78, 1.101), the time it takes for health maintenance organizations to issue authorization codes (3.62, 1.316), the accessibility of NHIS services outside of registration institutions (3.29, 1.289), and the standard of drugs provided by the SHIS (3.12, 1.358) are all factors that hinder utilization. Sex and place of residence each strongly correlated with readiness to sign up for the program (AOR = 4.234, P = 0.017, 95% CI: 1.293–13.873 and AOR = 5.224, P = 0.007, 95% CI: 1.557–17.530, respectively). Conclusion: The artisans have a low rate of health insurance coverage but are eager to sign up for the program. State policymakers should increase their reach and make enrollment required to attain a higher range.

Healthcare providers' satisfaction with participation in private health insurance scheme in a city in the southern Nigeria

Health insurance coverage in Nigeria is still very low as over 70% of health care expenditure is financed by out-of-pocket payment. Health care providers are critical participants in the private health insurance scheme, therefore, their perception and satisfaction with the scheme is fundamental in ensuring sustainability. This study assessed health providers' satisfaction with private health insurance scheme in Port Harcourt Rivers State.Method: A descriptive cross-sectional study which engaged a two-stage sampling method to recruit 60 participating health facilities and 180 responding health personnel by simple random sampling at each stage. A structured, pretested interviewer-administered questionnaire was used to collect data on the levels of satisfaction with the four major domains of satisfaction viz; billing rate, payment models, HMO administrative processes and claims management. Data was analysedusing of SPSS, version 26. Characteristics of the responding facilities were tabulated and compared. Level of satisfaction was deduced by Likert Scale according to the domains of satisfaction. Regression analysis with p-value was set at less than or equal to 0.05 was used to determine the predictors of satisfaction with participation in health insurance. The level of satisfaction with negotiated billing rates, payment models, HMO administrative processes and claims management were analyseddescriptively, and results were presented as means, standard deviation, frequencies and percentages, in tables, pie and bar charts

Determinants of enrolment in health insurance scheme among HIV patients attending a clinic in a tertiary hospital in South-eastern Nigeria

Objective: The study aimed to assess the determinants of enrolment in health insurance schemes among people living with HIV. Design: The study was a cross-sectional study. A pre-tested interviewer-administered questionnaire was used to collect information from 371 HIV clients attending the clinic. Chi-square statistic was used for bi-variate analysis, and analytical decisions were considered significant at a p-value less than 0.05. Logistic regression was done to determine predictors of enrolment in health insurance. Setting: The study was carried out in the HIV clinic of Alex Ekwueme Federal University Teaching Hospital Abakaliki, Nigeria Participants: HIV clients attending a clinic Result: Mean age of respondents was 45.4±10.3, and 51.8% were males. Almost all the respondents were Christians. Only 47.7% were married, and most lived in the urban area. Over 70% had at least secondary education, and only 34.5% were civil servants. About 60% of the respondents were enrolled in a health insurance scheme. Being single (AOR: 0.374, CI:0.204-0.688), being self-employed (AOR: 4.088, CI: 2.315-7.217), having a smaller family size (AOR: 0.124, CI: 0.067-0.228), and having the higher income (AOR: 4.142, CI: 2.07-8.286) were predictors of enrolment in a health insurance scheme. Conclusion: The study has shown that enrolment in a health insurance scheme is high among PLHIV, and being single, self-employed, having a smaller family size, and having a higher monthly income are predictors of enrolment in the health insurance scheme. Increasing the number of dependants that can be enrolled so that larger families can be motivated to enrol in health insurance is recommended

Comments on research status and future of rare diseases in China / 中国热带医学

@#Rare diseases, also known as "orphan diseases", refer to diseases with very low incidence. Countries and regions define rare diseases according to epidemiological standards, economic standards of rare drugs and disease severity. The World Health Organization (WHO) has suggested the prevalence rate of less than 6.5 to 10 per 10 000 people to define rare diseases. In May 2018, "China's First List of Rare Diseases" was released, including 121 rare diseases. Most rare diseases are hereditary diseases with early onset, severe disease, and poor prognosis. About 75% of rare genetic diseases occur in the neonatal period or childhood, which are important part of human birth defects and brings a huge burden to society and families. The effective prevention and treatment of rare diseases is one of the important goals of building a "Healthy China". With the development of molecular biology technology and the continuous research and development of advanced medical products in the field of gene therapy, the level of clinical diagnosis and treatment of rare diseases has risen to a new level, which provides a possibility for the cure of some rare diseases. In China, most rare diseases rely on imported drugs, which cost a lot and bring heavy economic burden to patients. Improving the medical insurance system for rare diseases has become a difficult point in the current medical reform. This paper mainly discusses the definition of rare diseases, the research status, efforts and future development direction of rare diseases in China, in order to deepen the understanding and response of medical workers and the whole society to rare diseases.

Analysis on the implementation effect of single disease payment policy for day surgery based on difference-in-differences model / 中华医院管理杂志

Objective:To analyze the implementation effect of single disease payment policy for day surgery (hereinafter referred to as the policy), for references for the reform of medical insurance payment.Methods:By collecting the information of inpatients from 2017 to 2019 in a tertiary hospital, the research group took patients with colorectal benign tumor and nodular goitre as the policy implementation group and the control group respectively. 2017-2018 was the pre implementation stage of the policy, and 2019 was the post implementation stage of the policy. The difference-in-differences (DID) model was used to analyze the changes in indicators such as length of stay and hospitalization expenses after policy implementation, under whether the policy is implemented or not, as well as before or after policy implementation.Results:A total of 2 419 patients were included, including 927 patients with nodular goiter in the control group and 1 492 patients with colorectal benign tumors in the policy implementation group (688 patients before the policy implementation and 804 patients after the policy implementation). The results of DID showed that the hospital days for patients with colorectal benign tumor decreased by 56.53%, the hospitalization expenses decreased by 26.51%, the out-of-pocket expenses decreased by 26.66%, the treatment expenses increased by 11.96%, the drug expenses decreased by 50.29% and the consumables expenses decreased by 20.23% after the implementation of the policy.Conclusions:The implementation of the policy could reduce length of stay, hospitalization expenses and out-of-pocket expenses, optimize the structure of hospitalization expenses, improve the efficiency of hospital diagnosis and treatment, and help the hospital realize its transformation from a size expansion to a quality and benefit expansion.

Analysis of factors influencing the medical insurance balance of hospitalization expenses for gastric cancer surgery patients under DRG payment / 中华医院管理杂志

Objective:To analyze the influencing factors of the medical insurance balance of hospitalization expenses for gastric cancer surgery patients under DRG payment, for reference for promoting the reform of DRG payment in public hospitals and controlling hospitalization expenses reasonably.Methods:The gastric cancer patients enrolled in the gastroenterology department of a tertiary comprehensive hospital from January to July 2022 were selected as the research subjects. The indicators such as patient age, medical insurance balance, hospitalization expenses and their composition were extracted from the hospital information management system and the medical insurance settlement system a certain city. Descriptive analysis was conducted for all data, and stepwise multiple linear regression was used to analyze the influencing factors of patients′ medical insurance balance. Monte Carlo simulation method was used to simulate different combination scenarios of various influencing factors to analyze the probability of medical insurance balance.Results:A total of 205 patients were contained, including 117 in the medical insurance balance group and 88 in the loss group. The difference in hospitalization expenses and medical insurance balance between the two groups of patients were statistically significant ( P<0.05). The intervention of medical insurance specialists, correct DRG enrollment, parenteral nutrition preparation costs, anti infective drug costs, examination costs, and consumables costs were the influencing factors of patient medical insurance balance ( P<0.05). Through Monte Carlo simulation verification, patients with different cost parenteral nutrition preparations, or different anti infective drug schemes had the higher probability of medical insurance balance in the scenario where the medical insurance commissioner intervenes and the DRG enrollment was correct. Conclusions:The hospital adopted interventions from medical insurance specialists to ensure the correct DRG enrollment of patients, accurate use of parenteral nutrition and anti infective drugs, and reasonable control the cost of examinations and consumables, which could increase the probability of medical insurance balance for gastric cancer surgery patients. In the future, hospitals should further promote the procurement of drug consumables in bulk, reduce unnecessary examinations, develop standardized perioperative nutritional interventions and anti infection treatment pathways, ensure the accuracy of DRG enrollment, optimize clinical diagnosis and treatment pathways to improve the efficiency of medical insurance fund utilization and provide high-quality medical services for patients.

Enlightenment of the DRG payment reform in the United States on the reform of China′s medical insurance payment methods / 中华医院管理杂志

In order to curb the excessive growth of medical expenses, the United States has initiated payment reform of diagnosis-related groups (DRG) since 1983, and developed a series of complementary measures to address issues such as overcoding and declining healthcare service quality which were exposed during the reform. The authors discussed the implementation of DRG payment reform in the United States, namely the case-mix specialization of medical institutions and the reduction of costs, as well as the relationship between the two. On this basis, the authors suggested that when implementing reforms to the medical insurance payment system in China, it is imperative to avoid such loopholes as overcoding by medical institutions and excessive pursuit of efficiency at the expense of quality control, as well as the decline of comprehensive rescue capability and quality of care incurred by the exacerbated specialization.

Game analysis on hospital outpatient payment methods of Chinese basic health insurance based on principle-agent theory / 中华医院管理杂志

As the major means of outpatient payment for basic medical insurance (the insurance for short) relies on fee-for-service, it tends to encourage unreasonable growth of medical expenses. Based on the principal-agent theory, this paper analyzed the principal-agent relationship between the insurance handling agencies and the hospitals designated by the insurance, and constructed a benefit game model of outpatient payment methods and the supporting supervision game model. This practice aims to explore the optimal and balanced benefit of the insurance payment methods and supporting supervision mechanism, and provide decision support for promoting the reform of medical insurance outpatient payment in China. The analysis results of the benefit game model of payment methods showed that a system mixing the post-payment and pre-payment could optimize and maximize the total benefits and interests of all the stakeholders within the system. Specifically, the practice recommended was a mixed payment integrating ambulatory-payment-classification, fee-for-service and global-budget-payment. The analysis of the supporting regulatory game model found that the factors that must be considered to ensure the expected utility of the above mixed payment mode as follows: the gap between the unreasonable income obtained by the hospital by out-of-control charging and the reward obtained by under-control charging, the size of the penalty after the unreasonable income of the hospital was discovered, the size of the regulatory cost and the loss of benefits of the government and the insured group. It is suggested to adopt the mixed payment method mainly based on the ambulatory-payment-classification supported by fee-for-service and global-budget. At the same time, medical insurance agencies can improve their supervision mechanism from such aspects as perfecting penalties, reducing supervision costs, leveraging government administrative power and advocating public supervision.

Analysis of compliance issues and management countermeasures of medical insurance fund in clinical research / 中华医学科研管理杂志

Objective:Clinical research is widely carried out in medical institutions, and there are differences in the use of research and conventional medical funds. This paper aimed to analyze the compliance issues of insurance fund in clinical research and explore the management strategies in the institutions conducting clinical trials or research.Methods:By consulting the literature, questionnaire, and work practice, this paper analyzed the current situation and existing problems of the compliance of the medical insurance fund in domestic clinical trials, proposed targeted management measures for the use of funds, and standardizes the corresponding workflow.Results:This paper summarized three payment methods of research-related funds and analyzed the main problems at present, including the definition of trial requirements, the payment of combined drugs specified in the protocol, the particularity of medical device trials, the payment of adverse events in clinical trial, the insurance of post-marketing research and clinical trial. According to the regulatory requirements and work practices, the corresponding management countermeasures were sorted out, including that the project funds and insurance audit should be carried out inside the medical institution. Clinical research, medical insurance management departments, ethics committees, and other departments should collaborate on establishing and improving a compliance management system. The research team should strengthen the management of adverse events, strengthen the publicity and education of the participants, and make good use of the sharing platform.Conclusions:The research institution should establish standardized and feasible processes, the research team should strengthen the management, and the use of the sharing platform is conducive to ensuring the compliance of the medical insurance fund and protecting the interests of the participants.