Financial protection of households against health shocks in Greece during the economic crisis.

BACKGROUND: Harsh funding cutbacks along with measures shifting cost to patients have been implemented in the Greek health system in recent years. Our objective was to investigate the evolution of financial protection of Greek households against out-of-pocket payments (OOPP) during the economic crisis. METHODS: National representative data of 33,091 households were derived from the Household Budget Surveys for the period 2008-2015. Financial protection was assessed by applying the approaches of catastrophic (CHE) and impoverishing OOPP. The determinants of CHE and impoverishment were examined using binary logistic regressions. RESULTS: OOPP dropped by 23.5% in real values between 2008 and 2015, though their share in households' budget rose from 6.9% to 7.8%, with an increasing trend since 2012. These outcomes were driven by significant increases in medical products (20.2%) and inpatient (63%) OOPP, while outpatient expenses decreased considerably (-62%). Both incidence and overshoot of CHE were significantly exacerbated. The additional burden was distributed progressively, hence, financial risk inequalities decreased. Food poverty increased, but its incidence still remains at very low levels. Both incidence and intensity of relative poverty increased considerably in real terms. The poverty impact of OOPP is aggravating following 2012, and 1.9% of individuals were impoverished due to OOPP in 2015. Households of higher size, lower expenditure quintile, in urban areas, without disabled, elderly or young children members, and with younger or retired, better-educated breadwinners were significantly less vulnerable to CHE. Households in the lower-middle expenditure quintile, in rural regions, and with elderly members were facing higher risk, while wealthier families exhibited a considerable lower likelihood of impoverishment. CONCLUSIONS: The expansion of reliance of healthcare funding on OOPP has increased the financial risk and hardship of Greek households, which may disrupt their living conditions and create barriers to healthcare access. Cost-sharing policies should recognise the different social protection needs of households.

¿Podemos responder a las crecientes expectativas sobre las artroplastias? / Can we respond to the rising expectations on arthroplasties?

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Sustitución segura de la lactancia materna para prevenir la transmisión vertical del VIH en la Provincia Central de Kenia / Safe replacement of breast milk to prevent VIH vertical transmission in the Central Province of Kenia

Introducción: la lactancia materna es responsable de hasta un 40% de los contagios perinatales del virus de la inmunodeficiencia humana (VIH) en el África subsahariana. La OMS aconseja evitar por completo la lactancia materna solo si la lactancia artificial es aceptable, factible, asequible, segura y sostenible (AFASS). Material y métodos: se analizaron datos de tres programas del Ministerio de Salud para la prevención de la transmisión vertical (PTV) del VIH, en la Provincia Central de Kenia. Las gestantes VIH+ recibieron información y consejo sobre cómo proteger al bebé durante el embarazo, el parto y el periodo de lactancia. Se administró zidovudina (AZT) desde la vigésimo octava semana, más nevirapina –dosis única– (SD-NVP) intraparto si los linfocitos CD4 eran mayores de 350 cel/mm3, o tratamiento antirretroviral de gran actividad (TARGA) si eran menores de 350 cel/mm3. Los neonatos expuestos recibieron AZT + NVP. Se suministró lactancia artificial (LA), filtros de agua y termos a las madres que optaron por no lactar a sus hijos. Se realizó reacción en cadena de la polimerasa (PCR) para ADN-VIH-1 a las seis semanas de vida. Las madres incluidas en el programa recibían apoyo psicológico individualizado y a través de terapias de grupo. Resultados: la mayoría de las madres (66-96%) se decidieron por la LA; 881 lactantes recibieron leche artificial bien desde el nacimiento o tras un periodo inicial con lactancia materna o con leche de vaca; 515 (58%) fueron dados de alta a los seis meses de edad; 272 (31%) permanecían en el programa (niños < 6 meses) en el momento del análisis de datos. Hubo 59 (6,7%) pérdidas de seguimiento y 12 (1,4%) traslados a otros programas. Un total de 23 (2,6%) lactantes fallecieron. Los neonatos infectados por VIH tuvieron diez veces más probabilidades de morir antes de cumplir seis meses que los no infectados (odds ratio [OR]: 10,55; IC 95% [intervalo de confianza del 95%]: 2,51-41,5), p < 0,001). La morbilidad fue baja; la incidencia de diarrea y de infecciones respiratorias fue de 15,3 y de 42,4 por cada 100 personas/año, respectivamente. Conclusiones: es factible y seguro apoyar la lactancia artificial para madres seropositivas y sus bebés en entornos con escasos recursos en programas integrados en instituciones sanitarias del sector público (AU)

Background: breast feeding accounts for up to 40% of perinatally acquired HIV infection in sub-Saharan Africa. HIV infected mothers are advised by World Health Organization (WHO) to completely avoid breast feeding only if replacement feeding is acceptable, feasible, affordable, safe and sustainable (AFASS). Methods: data were obtained from 3 Ministry of Health PMTCT programs in Central Province, Kenya. HIV positive pregnant women received AZT starting at 28 weeks + intrapartum SD-NVP if CD4>350 or TARGA if CD4<350. HIV exposed infants received AZT + NVP. Infant formula, water filters and thermos flasks were provided to women opting not to breast-feed their infants. ADN-PCR for HIV was obtained at 6 weeks of age. Results: most mothers (66-96%) opted for replacement feeding (RF). Eight hundred and eighty one infants received RF either from birth or after initial breast feeding or cow’s milk. Five hundred and fifteen infants (58%) were discharged after reaching 6 months of age; 272 (31%) were still active (<6 months). There were 59 defaulters (6.7%) and 12 relocations (1.4%). Twenty three infants died (2.6%). HIV-infected infants were more than 10 times more likely to die before 6 months of age than HIV-uninfected infants [OR 10.55 (2.51-41.5) P < 0.001]. Morbidity was low; the incidence of diarrhoea and respiratory tract infection was 15.3 and 42.4 per 100 person-years respectively. Interpretation: it is possible to support safe replacement feeding in resource-limited contexts under routine program conditions within public sector health facilities by employing a feeding methodology that is feasible for mothers and safe for infants (AU)

El control estadístico de proceso puede ayudar a prevenir los errores de tratamiento sin aumentar los costes en radioterapia / Statistical Process Control (SPC) can help prevent treatment errors without increasing costs in radiotherapy

Objetivo. El control estadístico de proceso (SPC) fue aplicado para monitorizar la estabilidad del proceso de colocación de pacientes en un tratamiento de radioterapia. Una vez medidos los errores de colocación, si estos indicaban una pérdida de estabilidad se identificaba la causa principal y se procedía a eliminarla para prevenir dichos errores. Material y métodos. Se midieron los errores de colocación en las dimensiones medial-laterales, craneal-caudal y anterior-posterior y se calcularon los límites de control superiores. Una vez conocidos los límites de control y el rango de variabilidad era aceptable, se procedió a observar los errores de colocación utilizando subgrupos de tres pacientes tres veces cada turno y se representaron en una gráfica de control a tiempo real. Resultados. Los valores de límite de control mostraron que la variabilidad existente era aceptable. Los errores de colocación, medidos y representados en un gráfico de promedio del proceso, ayudaron a controlar la estabilidad del proceso de colocación, ya que si la estabilidad se perdía, el tratamiento se interrumpía, se identificaba la causa específica responsable del patrón no aleatorio y se llevaba a cabo una acción correctora antes de proceder con el tratamiento. Conclusiones. El protocolo del SPC se centra en el control de la variabilidad debido a una causa asignable en lugar de centrarse en la variabilidad paciente a paciente, la cual no existe normalmente. Conclusiones A diferencia del método actual, que consiste en un único control semanal de colocación por paciente y, por tanto, solo asegura la correcta colocación del paciente en dicha sesión, el SPC permite prevenir el error de colocación de todos los pacientes en todas las sesiones al mismo tiempo que se reducen los costes de control(AU)

Purpose. Statistical Process Control (SPC) was applied to monitor patient set-up in radiotherapy and, when the measured set-up error values indicated a loss of process stability, its root cause was identified and eliminated to prevent set-up errors. Materials and methods. Set up errors were measured for medial-lateral (ml), cranial-caudal (cc) and anterior-posterior (ap) dimensions and then the upper control limits were calculated. Materials and methods. Once the control limits were known and the range variability was acceptable, treatment set-up errors were monitored using sub-groups of 3 patients, three times each shift. These values were plotted on a control chart in real time. Results. Control limit values showed that the existing variation was acceptable. Set-up errors, measured and plotted on a X¯ chart, helped monitor the set-up process stability and, if and when the stability was lost, treatment was interrupted, the particular cause responsible for the non-random pattern was identified and corrective action was taken before proceeding with the treatment. Conclusion. SPC protocol focuses on controlling the variability due to assignable cause instead of focusing on patient-to-patient variability which normally does not exist. Compared to weekly sampling of set-up error in each and every patient, which may only ensure that just those sampled sessions were set-up correctly, the SPC method enables set-up error prevention in all treatment sessions for all patients and, at the same time, reduces the control costs(AU)

Hospital cost shifting revisited: new evidence from the balanced budget act of 1997.

This paper analyzes hospital cost shifting using a natural experiment generated by the Balanced Budget Act (BBA) of 1997. I find evidence that urban hospitals were able to shift part of the burden of Medicare payment reduction onto private payers. However, the overall estimated degree of cost shifting is small and varies according to a hospital's share of private patients. At hospitals where Medicare is a small payer relative to private insurers, up to 37% of BBA cuts was transferred to private payers through higher payments. In contrast, hospitals with greater reliance on Medicare were more financially distressed, as these hospitals saw large BBA cuts but were limited in their abilities to cost shift.

Hospital psychiatry for the twenty-first century.

Economic policies have shaped the provision of hospital psychiatric care. The main theme of the past fifty years has been the shift from long-stay public hospitals to acute care provided in private settings. States have reduced their costs by shifting their financial burden to federal dollars and commercial insurers through managed care practices. The net result has been a reduction in, and shortage of, psychiatric beds. Positive developments include better services in the continuum of care, the subspecialization of hospital psychiatry practice, and an increasing emphasis on patient choice and recovery.

Acercamiento asequible al cálculo de costes por procedimiento de un servicio. (El ejemplo de cirugía torácica) / An easy-to-understand approach to cost calculation per procedure in a health service (with the example of the Thoracic Surgery service)

Se presenta un sistema que permita, con los instrumentos existentes en cualquier hospital, conocer y controlar los costes originados por los procedimientos realizados en un servicio asistencial, a un nivel más detallado que el de los GRD. Para la realización de este trabajo se ha escogido el servicio de Cirugía torácica del Hospital Regional Universitario de Málaga. Los datos necesarios se han de obtener del sistema de costes del Hospital, en nuestro caso el COAN-HyD1 y del CMBD una vez agrupado por GRD: 1. Los datos de costes se usan a niel del área de Hospitalización del servicio que corresponda en el periodo de estudio 2. Los datos del CMBD sean de procesar de la forma que se explica en el artículo para obtener los procedimientos en los que partir el coste antedicho. 3. Este reparto se hace relacionando las variables de estancias, costes y porcentajes de codificación de forma que obtengamos como resultado final el coste de cada uno de los procedimientos del servicio (AU)

This article presents a system which, using the normal management tools of a hospital, makes it possible to know and control the costs originated by the procedures carried out in a health service, in greater detail that with the DRG system (Diagnosis Relational Groups). The Thoracic Surgery service of the Hospital Regional Universitario of Malaga was chosen in order to carry out this work (AU)

[Case allocation of extensive operations on head and neck within the German DRG system 2004-2007: what is the net result of the continued developments in case allocation?]. / Analyse der Abbildungsqualität grosser operativer Eingriffe an Kopf und Hals in den G-DRG-Systemen 2004-2007: Was hat die Weiterentwicklung der Fallpauschalen gebracht?

BACKGROUND: When the German DRG system was implemented there was some doubt about whether patients with extensive head and neck surgery would be properly accounted for. Significant efforts have therefore been invested in analysis and case allocation of those in this group. The object of this study was to investigate whether the changes within the German DRG system have led to improved case allocation. METHODS: Cost data received from 25 ENT departments on 518 prospective documented cases of extensive head and neck surgery were compared with data from the German institute dealing with remuneration in hospitals (InEK). Statistical measures used by InEK were used to analyse the quality of the overall system and the homogeneity of the individual case groups. RESULTS: The reduction of variance of inlier costs improved by about 107.3% from the 2004 version to the 2007 version of the German DRG system. The average coefficient of cost homogeneity rose by about 9.7% in the same period. Case mix index and DRG revenues were redistributed from less extensive to the more complex operations. Hospitals with large numbers of extensive operations and university hospitals will gain most benefit from this development. CONCLUSION: Appropriate case allocation of extensive operations on the head and neck has been improved by the continued development of the German DRG system culminating in the 2007 version. Further adjustments will be needed in the future.

Evidence of cost shifting in California hospitals.

We used 1993-2001 data from private hospitals in California to investigate whether decreases in Medicare and Medicaid prices were associated with increases in prices paid for privately insured patients. We found that a 1 percent relative decrease in the average Medicare price is associated with a 0.17 percent increase in the corresponding price paid by privately insured patients; similarly, a 1 percent relative reduction in the average Medicaid price is associated with a 0.04 percent increase. These relationships imply that cost shifting from Medicare and Medicaid to private payers accounted for 12.3 percent of the total increase in private payers' prices from 1997 to 2001.

Pharmacoutilization of statin therapy after acute myocardial infarction. A real practice analysis based on administrative data.

BACKGROUND: Despite randomized and controlled trials indicating continuous treatment with statin therapy as a factor in reducing morbidity and mortality after acute myocardial infarction, records reveal a high percentage of patients at risk who are either not receiving treatment or being treated inadequately. METHODS: An administrative database kept by the Local Health Unit of Ravenna and listing patient baseline characteristics, drug prescriptions and hospital admissions was used to perform: 1) an analysis of patients discharged alive from hospital each year between 1996 and 2000 with a diagnosis of acute myocardial infarction, and 2) a retrospective cohort study of drug utilization, and particularly the use of statins, year by year. All prescriptions for statins filled in the 6 months after hospital discharge were considered and used to classify patients in terms of their exposure to statin therapy and of their pharmacoutilization. RESULTS: A total of 2265 subjects were enrolled (446 in 1996, 440 in 1997, 443 in 1998, 443 in 1999, and 493 in 2000). The percentage of patients treated with statins increased each year (from 22.6% in 1996 to 43.8% in 2000) as did the percentage of adequately dosed patients (from 4.3% in 1996 to 23.9% in 2000). The overall cost of dispensed statins amounted to 10,610 euros in 1996 and 45,102 euros in 2000. The proportion of cost for statins accountable to adequately dosed patients ranged from 36.4% in 1996 to 77.4% in 2000. The average cost per adequately dosed patient ranged from 203.40 euros in 1996 to 296.00 euros in 2000 and increased year by year. CONCLUSIONS: Pharmacoutilization of statin therapy was found to be unsatisfactory in each study year. Interestingly, however, the trend indicated by the study suggests increasing percentages of patients being exposed to the treatment, and of adequately dosed patients. These results may be attributed to a greater awareness of the need for proper treatment, and may be considered as reflecting a significant improvement in drug management.

Why did employee health insurance contributions rise?

We explore the causes of the dramatic rise in employee contributions to health insurance over the past two decades. In 1982, 44% of those who were covered by their employer-provided health insurance had their costs fully financed by their employer, but by 1998 this had fallen to 28%. We discuss the theory of why employers might shift premiums to their employees, and empirically model the role of four factors suggested by the theory. We find that there was a large impact of falling tax rates, rising eligibility for insurance through the Medicaid system, rising medical costs, and increased managed care penetration. Overall, this set of factors can explain more than one-half of the rise in employee premiums over the 1982-1996 period.