Healthcare utilization and catastrophic health expenditure in rural Tanzania: does voluntary health insurance matter?

BACKGROUND: Over 150 million people, mostly from low and middle-income countries (LMICs) suffer from catastrophic health expenditure (CHE) every year because of high out-of-pocket (OOP) payments. In Tanzania, OOP payments account for about a quarter of the total health expenditure. This paper compares healthcare utilization and the incidence of CHE among improved Community Health Fund (iCHF) members and non-members in central Tanzania. METHODS: A survey was conducted in 722 households in Bahi and Chamwino districts in Dodoma region. CHE was defined as a household health expenditure exceeding 40% of total non-food expenditure (capacity to pay). Concentration index (CI) and logistic regression were used to assess the socioeconomic inequalities in the distribution of healthcare utilization and the association between CHE and iCHF enrollment status, respectively. RESULTS: 50% of the members and 29% of the non-members utilized outpatient care in the previous month, while 19% (members) and 15% (non-members) utilized inpatient care in the previous twelve months. The degree of inequality for utilization of inpatient care was higher (insured, CI = 0.38; noninsured CI = 0.29) than for outpatient care (insured, CI = 0.09; noninsured CI = 0.16). Overall, 15% of the households experienced CHE, however, when disaggregated by enrollment status, the incidence of CHE was 13% and 15% among members and non-members, respectively. The odds of iCHF-members incurring CHE were 0.4 times less compared to non-members (OR = 0.41, 95%CI: 0.27-0.63). The key determinants of CHE were iCHF enrollment status, health status, socioeconomic status, chronic illness, and the utilization of inpatient and outpatient care. CONCLUSION: The utilization of healthcare services was higher while the incidence of CHE was lower among households enrolled in the iCHF insurance scheme relative to those not enrolled. More studies are needed to establish the reasons for the relatively high incidence of CHE among iCHF members and the low degree of healthcare utilization among households with low socioeconomic status.

Whether or not to enroll, and stay enrolled? A Tanzanian cross-sectional study on voluntary health insurance.

Lower-middle income countries (LMICs) have invested significant effort into expanding insurance coverage as a means of improving access to health care. However, it has proven challenging to fulfill these ambitions. This study investigates to what extent variables associated with the enrollment decision (stay never-insured or enroll) differ from variables associated with the dropout decision (stay insured or drop out). A cross-sectional survey that included 722 households from rural districts in Tanzania was conducted and multinomial logistic regressions were performed to determine the associations between independent variables and membership status (never-insured, dropouts, or currently insured). Both the decision to enrollment and the decision to drop out were significantly associated with the presence of chronic disease and perceptions about the quality of services provided, insurance scheme management, and traditional healers. The effect of other variables, such as age, gender and educational level of the household head, household income, and perceptions about premium affordability and benefit-premium ratios, varied across the two groups. To improve voluntary health insurance coverage, policymakers must simultaneously increase the enrollment rate among the never-insured and reduce the dropout rate among the insured. Our conclusions suggest that policies to increase insurance scheme enrollment rates should differ for the two uninsured groups.

The role of risk preferences: voluntary health insurance in rural Tanzania.

BACKGROUND: Lower-middle-income countries (LMICs) have a common goal to achieve universal health coverage (UHC) through voluntary health insurance schemes. This is important to improve access to healthcare services and ensure financial protection for all by reducing out-of-pocket expenditures. This study aimed to examine the role of risk preferences on enrollment status (currently insured, previously insured, and never insured) into a Tanzanian voluntary health insurance scheme targeted at the informal sector. METHODS: Data were collected from households in a random sample of 722 respondents. The risk preference measure was based on a hypothetical lottery game which applies the BJKS instrument. This instrument measures income risk where the respondents are to choose between a certain income and a lottery. Both multinomial and simple logistic regression models have been used to analyze the relationship between risk aversion and enrollment status. RESULTS: On average, the respondents have a high degree of risk aversion, and the insured are more risk averse than the uninsured (previously insured and never insured). There is a weak tendency for the wealthiest, measured by household income or total household expenditure, to be somewhat more risk averse than the less wealthy. Logistic and multinomial logistic regressions show that risk aversion is strongly associated with enrollment status. A higher degree of risk aversion significantly increases the probability of being insured, relative to being previously insured, and relative to being never insured. CONCLUSION: Risk aversion matters in a decision to enroll into the iCHF scheme. Strengthening the benefit package for the scheme, might increase the enrollment rate and hence improve access to healthcare services for people in rural areas and those employed in the informal sector.

Do household perceptions influence enrolment decisions into community-based health insurance schemes in Tanzania?

BACKGROUND: Several countries including Tanzania, have established voluntary non-profit insurance schemes, commonly known as community-based health insurance schemes (CBHIs), that typically target rural populations and the informal sector. This paper considers the importance of household perceptions towards CBHIs in Tanzania and their role in explaining the enrolment decision of households. METHODS: This was a cross-sectional household survey that involved 722 households located in Bahi and Chamwino districts in the Dodoma region. A three-stage sampling procedure was used, and the data were analyzed using both factor analysis (FA) and principal component analysis (PCA). Statistical tests such as Bartlett's test of sphericity, Kaiser-Meyer-Olkin (KMO) for sampling adequacy, and Cronbach's alpha test for internal consistency and scale reliability were performed to examine the suitability of the data for PCA and FA. Finally, multivariate logistic regressions were run to determine the associations between the identified factors and the insurance enrolment status. RESULTS: The PCA identified seven perception factors while FA identified four factors. The quality of healthcare services, preferences (social beliefs), and accessibility to insurance scheme administration (convenience) were the most important factors identified by the two methods. Multivariate logistic regressions showed that the factors identified from the two methods differed somewhat in importance when considered as independent predictors of the enrollment status. The most important perception factors in terms of strength of association (odds ratio) and statistical significance were accessibility to insurance scheme administration (convenience), preferences (beliefs), and the quality of health care services. However, age and income were the only socio-demographic characteristics that were statistically significant. CONCLUSION: Household perceptions were found to influence households' decisions to enroll in CBHIs. Policymakers should recognize and consider these perceptions when designing policies and programs that aim to increase the enrolment into CBHIs.

Supply factors as determinants of treatment costs: clinicians' assessments of a given set of referrals to community mental health centers in Norway.

BACKGROUND: Previous works that uses patterns of prior spending to predict future mental health care expenses (utilization models) are mainly concerned with demand (need) variables. In this paper, we introduce supply variables, both individual rater variables and center variables. The aim is to assess these variables' explanatory power, and to investigate whether not accounting for such variables could create biased estimates for the effects of need variables. METHODS: We employed an observational study design where the same set of referrals was assessed by a sample of clinicians, thus creating data with a panel structure being particularly relevant for analyzing supply factors. The referrals were obtained from Norwegian Community Mental Health Centers (outpatient services), and the clinicians assessed the referrals with respect to recommended treatment costs and health status. RESULTS: Supply variables accounted for more than 10% of the total variation and about one third of the explained variation. Two groups of supply variables, individual rater variables and center variables (institutions) were equally important. CONCLUSIONS: Our results confirm that supply factors are important but ignoring such variables, when analyzing demand variables, do not generally seem to produce biased (confounded) coefficients.

Effects on length of stay and costs with same-day retransfer to the referring hospitals for patients with acute coronary syndrome after angiography and/or percutaneous coronary intervention.

BACKGROUND: Fast track interventions may generate benefits for patients and hospitals by representing a potential for shorter hospital stay. The aim of this study was to investigate how same-day retransfers to the referring hospital after angiographic examination and/or percutaneous coronary intervention (PCI) at the PCI centre affected length of stay and hospital treatment costs for patients with acute coronary syndrome. METHODS AND RESULTS: Three hundred and ninety-nine consecutive admitted patients were prospectively randomized to ordinary care with overnight stay or fast track with same-day retransfer. Length of stay at both the PCI centre and the referring hospital after the stay at the PCI centre were recorded. Costs at the PCI centre related to examinations and treatments were also collected. The ordinary care group included 206 patients and the fast track group 193 patients. Forty-six per cent underwent PCI and 10% coronary artery bypass graft (CABG) in the ordinary care group. In the fast track group 40% had PCI and 6% CABG. Length of stay was reduced at the PCI centre from a median 1.25 days for the ordinary care group to median 0.24 days for the FT group (p<0.001). Length of stay at the PCI centre was significantly reduced after selective coronary angiography and PCI but not for patients undergoing CABG. No significant difference was identified in length of stay for the referring hospitals. Total median treatment costs were reduced from NOK23,657 (US$3838) for the ordinary care group to NOK15,730 (US$2552) for the fast track group (p<0.001). The main contributor to this reduction was shorter length of stay and the corresponding reduction in ward costs at the PCI centre. CONCLUSIONS: We conclude that fast-track intervention with same-day retransfer for patients with acute coronary syndrome to the referring hospital reduced length of stay and the hospital treatment costs for patients undergoing selective coronary angiography and PCI.

Is the hospital decision to seek accreditation an effective one?

The rapid expansion in the number of accredited hospitals justifies inquiry into the motives of hospitals in seeking accreditation and its social effectiveness. This paper presents a simple decision-theoretic framework where cost reductions and improved quality of care represent the endpoint benefits from accreditation. We argue that hospital accreditation, although acting as a market-signaling device, might be a socially inefficient institution. First, there is at present no convincing evidence for accreditation causing output quality improvements. Second, hospitals could seek accreditation, even though doing so is socially inefficient, because of moral hazard, consumer misperceptions, and nonprofit motivations. Finally, hospitals that seek accreditation need not themselves believe in output quality improvements from accreditation. Consequently, while awaiting additional evidence on accreditation, policy makers and third-party payers should exercise caution in encouraging such programs.

Factors explaining priority setting at community mental health centres: a quantitative analysis of referral assessments.

BACKGROUND: Clinicians at Norwegian community mental health centres assess referrals from general practitioners and classify them into three priority groups (high priority, low priority, and refusal) according to need where need is defined by three prioritization criteria (severity, effect, and cost-effectiveness). In this study, we seek to operationalize the three criteria and analyze to what extent they have an effect on clinical-level priority setting after controlling for clinician characteristics and organisational factors. METHODS: Twenty anonymous referrals were rated by 42 admission team members employed at 14 community mental health centres in the South-East Health Region of Norway. Intra-class correlation coefficients were calculated and logistic regressions were performed. RESULTS: Variation in clinicians' assessments of the three criteria was highest for effect and cost-effectiveness. An ordered logistic regression model showed that all three criteria for prioritization, three clinician characteristics (education, being a manager or not, and "guideline awareness"), and the centres themselves (fixed effects), explained priority decisions. The relative importance of the explanatory factors, however, depended on the priority decision studied. For the classification of all admitted patients into high- and low-priority groups, all clinician characteristics became insignificant. For the classification of patients, into those admitted and non-admitted, one criterion (effect) and "being a manager or not" became insignificant, while profession ("being a psychiatrist") became significant. CONCLUSIONS: Our findings suggest that variation in priority decisions can be reduced by: (i) reducing the disagreement in clinicians' assessments of cost-effectiveness and effect, and (ii) restricting priority decisions to clinicians with a similar background (education, being a manager or not, and "guideline awareness").

Eliciting preferences for prioritizing treatment of rare diseases: the role of opportunity costs and framing effects.

BACKGROUND: Understanding societal preferences regarding resource allocation in the health sector has gained importance as countries increasingly base reimbursement decisions on economic evaluations. Preference elicitation using surveys, a common practice in the health sector, is subject to a range of framing effects. OBJECTIVE: This research investigates the importance of (theoretically relevant) opportunity costs and (theoretically irrelevant) framing effects on stated preferences for prioritizing treatment of rare (orphan) diseases. METHODS: We elicited preferences from Norwegians, aged 40-67, using simple trade-off exercises. Respondents were randomised to different opportunity costs of the rare disease or to different framings of the trade-off exercises. RESULTS: Respondents were quite sensitive to the visual presentation of the choice problem, and, to a lesser extent, to focusing and labelling effects. Elicited preferences varied little in response to large changes in opportunity costs, suggesting scope-insensitivity among respondents. CONCLUSIONS: Preferences for prioritizing treatment of rare diseases elicited using trade-off exercises are insensitive to (theoretically relevant) opportunity costs, but sensitive to (theoretically irrelevant) framing effects.

Horizontal equity and mental health care: a study of priority ratings by clinicians and teams at outpatient clinics.

BACKGROUND: In Norway, admission teams at Community Mental Health Centres (CMHCs) assess referrals from General Practitioners (GPs), and classify the referrals into priority groups according to treatment needs, as defined in the Act of Patient Rights. In this study, we analyzed classification of similar referrals to determine the reliability of classification into priority groups (i.e., horizontal equity). METHODS: Twenty anonymous case vignettes based on representative referrals were classified by 42 admission team members at 16 CMHCs in the South-East Health Region of Norway. All clinicians were experienced, and were responsible for priority setting at their centres. The classifications were first performed independently by the 42 clinicians (i.e., individual rating), and then evaluated utilizing team consensus within each CMHC (i.e., team rating). Interrater reliability was estimated using intraclass correlation coefficients (ICCs) while the reliability of rating across raters and units (generalizability) were estimated using generalizability analysis. RESULTS: The ICCs (2.1 single measure, absolute agreement) varied between 0.40 and 0.51 using individual ratings and between 0.39 and 0.58 using team ratings. Our findings suggest a fair (low) degree of interrater reliability, and no improvement of team ratings was observed when compared to individual ratings. The generalizability analysis, for one rater within each unit, yields a generalizability coefficient of 0.50 and a dependability coefficient of 0.53 (D study). These findings confirm that the reliability of ratings across raters and across units is low. Finally, the degree of inconsistency, for an average measurement, appears to be higher within units than between units (G study). CONCLUSION: The low interrater reliability and generalizability found in our study suggests that horizontal equity to mental health services is not ensured with respect to priority. Priority -setting in teams provides no significant improvement compared to individual rating, and the additional use of these resources may be questionable. Improved guidelines, tutorials, training and calibration of clinicians may be utilized to improve the reliability of priority-setting.

Using referrals and priority-setting rules to risk adjust budgets: the case of regional psychiatric centers.

BACKGROUND: An important objective of many health care systems is to ensure equal access to health care services. One way of achieving this is by having universal coverage (low or absent out-of-pockets payments) combined with tax-financed transfers (block grants) to providers with a catchment area responsibility. However, a precondition for equal access in such systems is that providers have similar capacities -- meaning that budgets must be perfectly adjusted for variations in treatment costs not being under the control of providers (risk adjustment). AIM: This study presents a method that can be applied to adjust global budgets for variation in health risks. The method is flexible in the sense that it takes into account the possibility that variation in needs may depend on the degree of rationing in supplying health care services. METHODS: The information being available from referrals is used to risk-adjust budgets. An expert panel ranks each individual on the basis of need. The ranking is performed according to priority-setting criteria for health care services. In addition, the panel suggests an adequate treatment profile (treatment category and treatment intensity) for each referral reviewed. By coupling the treatment profiles with cost information, risk-adjusted budgets are derived. Only individuals found to have a sufficiently high ranking (degree of need) will impact the derived risk-adjusted formula. RESULTS: The method is applied to four Regional Psychiatric Centers (RPC) supplying (i) outpatient services, (ii) day-patient care, and (iii) inpatient treatment for adults. The budget reallocations needed (positive and negative) to achieve an equal capacity across providers range between 10% and 42% of the current budgets. POLICY IMPLICATIONS: Our method can identify variations across providers when it comes to actual capacity and suggests budget reallocations that make the capacities to be equal across providers. In the case of the Regional Psychiatric Centers (RPCs) considered in this analysis, significant deviations in capacities are identified across providers and catchment areas. Thus, significant social gains can be gained, in terms of improved equal access, if our methodology is applied to risk adjust global budgets.

Societal views on orphan drugs: cross sectional survey of Norwegians aged 40 to 67.

OBJECTIVE: To determine whether a general societal preference for prioritising treatment of rare diseases over common ones exists and could provide a justification for accepting higher cost effectiveness thresholds for orphan drugs. DESIGN: Cross sectional survey using a web based questionnaire. SETTING: Norway. PARTICIPANTS: Random sample of 1547 Norwegians aged 40-67. MAIN OUTCOME MEASURE: Choice between funding treatment for a rare disease versus a common disease and how funds should be allocated if it were not possible to treat all patients, for each of two scenarios: identical treatment costs per patient and higher costs for the rare disease. Respondents rated five statements concerning attitudes to equity on a five point Likert scale (5=completely agree). RESULTS: For the equal cost scenario, 11.2% (9.6% to 12.8%) of respondents favoured treating the rare disease, 24.9% (21.7% to 26.0%) the common disease, and 64.9% (62.6% to 67.3%) were indifferent. When the rare disease was four times more costly to treat, the results were, respectively, 7.4% (6.1% to 8.7%), 45.3% (42.8% to 47.8%), and 47.3% (44.8% to 49.8%). Rankings for attitude on a Likert scale indicated strong support for the statements "rare disease patients should have the right to treatment even if more expensive" (mean score 4.5, SD 0.86) and "resources should be used to provide the greatest possible health benefits" (3.9, 1.23). CONCLUSIONS: Despite strong general support for statements expressing a desire for equal treatment rights for patients with rare diseases, there was little evidence that a societal preference for rarity exists if treatment of patients with rare diseases is at the expense of treatment of those with common diseases.

Medical errors: getting the incentives right.

This work examines the role of penalties as providers of incentives to prevent medical errors and ensure that such incidents, once they occur, become common knowledge. It is shown that a scheme with two penalties (accountability and non-report) induces the first-best solution. However, this scheme does not necessarily imply a punitive environment, but may, under given circumstances, yield insignificant and even negative penalties. Alternative sanction systems, such as voluntary reporting and immunity, are found to have less desirable properties. An exception is confidentiality (anonymity) which turns out to be an optimal scheme. Finally, the examination of various penalty restrictions (scope and scale) shows that such barriers may promote both tougher and softer sanction schemes.

Trading patients. Lessons from Scandinavia.

The next few decades will bring about more trade in services, among them health care. This paper describes a recent project on cross-border trading of patients initiated by the Norwegian parliament (The Patient Bridge). This health policy reform met some resistance among hospital physicians. However, patients were willing to participate if being properly informed and supported by local health care workers. The Patient Bridge turned out to be a relatively expensive project partly because of the transaction costs involved (transportation and escort) and partly because of high treatment costs. Excessive treatment costs were a result of insufficient cost-consciousness in the purchasing organization. The Patient Bridge revealed large price differentials not only between Norwegian and foreign hospitals, but also between hospitals abroad, even within the same country. This finding points to the possibilities of reaching mutual gains from trading patients across borders.