Strategies to reduce informal payments in health systems: a systematic review.

BACKGROUND: Informal payment is a major barrier to universal health coverage, particularly in low and middle-income countries. AIMS: The aim of this study was to determine appropriate methods to reduce informal payments in health care via a systematic review. METHODS: For this systematic review, we searched the Cochrane Library, PubMed and SCOPUS covering the period 2000-2014: 10 papers which considered reduction strategies for IP were finally included in the review. Three of the authors independently extracted data and assessed the papers against inclusion and exclusion criteria. RESULTS: Improving public awareness and measures towards changing the culture were the main policies to combat informal payment. In addition, providing additional financial support to motivate physicians and other health service providers, appropriate monitoring of legislation, and converting informal to formal payment through tailored new policies were other solutions mentioned towards reducing or removing informal payments. CONCLUSIONS: No unique strategy exists for reducing informal payments in any health system. Choosing an appropriate strategy depends on the context and financing structure of the health system in any particular setting.

Economic burden, impoverishment, and coping mechanisms associated with out-of-pocket health expenditure in India: A disaggregated analysis at the state level.

INTRODUCTION: The high share of out-of-pocket (OOP) health expenditure imposes an extreme financial burden on households, and they have to incur a substantial amount of expenditure to avail health care services. This study analyses the inter-state differentials in the economic burden of OOP health expenditure, resultant impoverishment impact, and sources of finance used as coping mechanisms. MATERIALS AND METHODS: The study is based on health expenditure survey, namely the 71st Round on "Key Indicators of Social Consumption in India: Health," (2014) conducted in India by the National Sample Survey Organisation. The study uses headcount, payment gap, and concentration index to measure the economic burden, impoverishment impact of OOP health expenditure, and the level of inequality. RESULTS: On the basis of results, the states can be divided into four distinct categories: (1) States with low economic burden and low poverty impact of OOP health expenditure, (2) low economic burden and high poverty impact of OOP health expenditure, (3) high economic burden and low poverty impact of OOP health expenditure, and (4) high economic burden and high poverty impact of OOP health expenditure. CONCLUSIONS: Inter-state differentials in OOP health expenditure and impoverishment need proper attention of the government especially the policy makers.

Microfinance and health interventions: Factors influencing loan repayment success with young men in Dar es Salaam, Tanzania.

Poverty is associated with numerous poor health outcomes. Youth unemployment in Tanzania is approximately 13.7%, and concentrates in urban areas. These youth lack relevant job skills and access to financial capital. Microfinance continues to be implemented globally to address poverty, and increasingly has been linked to health interventions. Men less frequently are recipients of microfinance loans. We offered microcredit to young men in an area of Dar es Salaam with high poverty as part of a randomised controlled-trial to assess the efficacy of a microfinance and health leadership intervention in preventing STI acquisition. We used mixed methods to understand predictors of successful loan repayment. Our qualitative sub-study showed that leader influence, prior business experience, personal motivation, and planning facilitated repayment. Using a modified Poisson approach, our quantitative analysis showed that successful repayment was associated with business experience, education, increasing number of children, community of residence, percentage of network members trained in business, and repayment success of peer leaders. Our results suggest that enforcing group accountability and repayment rules, offering ongoing training, and using successful entrepreneurs as role models could increase repayment success in similar populations. These strategies could provide financial opportunity for men while minimising risk for microfinance institutions.

Supporting Low-income Cancer Patients: Recommendations for the Public Financial Aid Program in the Republic of Korea.

PURPOSE: As the recent term of "financial toxicity" implies, cancer causes a treatment-related financial harm. Financial Aid Program for Cancer Patient (FAPCP) is a government's financial support for low-income patients in the Republic of Korea. This study aimed to describe FAPCP applicants' condition and to investigate factors influencing financial burden, which would provide the basis for implementing a strategy for FAPCP administration. MATERIALS AND METHODS: The telephone survey results from 2,700 FAPCP participants were analyzed, including demographic, socioeconomic, and disease characteristics and experiences associated with financial burden and the actions or measures to cope with them. RESULTS: Overall, 87.6% experienced financial burden more than moderate degree, 39.2% got financial help/a loan, 17.8% disposed of their property, and 10.2% changed or stopped treatment owing to medical costs. Monthly household income was connected to financial burden, and the highest income group was associated with the lowest financial burden (odds ratio [OR], 0.21; 95% confidence interval [CI], 0.11 to 0.38) and the lowest rate of changing/stopping care (OR, 0.23; 95% CI, 0.05 to 1.00). Parents of childhood cancer patients got financial help/a loan (OR, 2.24; 95% CI, 1.03 to 4.88) and disposed of their property (OR, 3.18; 95% CI, 1.40 to 7.22) more frequently, and Medical Aids applicants showed the highest rate of changing/stopping care (OR, 3.01; 95% CI, 1.89 to 4.78). CONCLUSION: FAPCP targets low income groups; however, financial burden and the consequent actions taken still exist disproportionately, depending on the income of the applicants. FAPCP should focus on more vulnerable groups including Medical Aid applicants and parents of childhood cancer patients, by increasing funds and expanding their support coverage.

A novel income security intervention to address poverty in a primary care setting: a retrospective chart review.

OBJECTIVE: To examine the development and implementation of a novel income security intervention in primary care. DESIGN: A retrospective, descriptive chart review of all patients referred to the Income Security Heath Promotion service during the first year of the service (December 2013-December 2014). SETTING: A multisite interdisciplinary primary care organisation in inner city Toronto, Canada, serving over 40 000 patients. PARTICIPANTS: The study population included 181 patients (53% female, mean age 48 years) who were referred to the Income Security Health Promotion service and engaged in care. INTERVENTION: The Income Security Health Promotion service consists of a trained health promoter who provides a mixture of expert advice and case management to patients to improve income security. An advisory group, made up of physicians, social workers, a community engagement specialist and a clinical manager, supports the service. OUTCOME MEASURES: Sociodemographic information, health status, referral information and encounter details were collected from patient charts. RESULTS: Encounters focused on helping patients with increasing their income (77.4%), reducing their expenses (58.6%) and improving their financial literacy (26.5%). The health promoter provided an array of services to patients, including assistance with taxes, connecting to community services, budgeting and accessing free services. The service could be improved with more specific goal setting, better links to other members of the healthcare team and implementing routine follow-up with each patient after discharge. CONCLUSIONS: Income Security Health Promotion is a novel service within primary care to assist vulnerable patients with a key social determinant of health. This study is a preliminary look at understanding the functioning of the service. Future research will examine the impact of the Income Security Health Promotion service on income security, financial literacy, engagement with health services and health outcomes.

Determining the Public/Private Mix: Options for Financing Targeted Universality in Long-Term Care.

The way in which we pay for long-term care (LTC) services is going to come under enormous pressure as Canada's baby boomers age. Once baby boomers start to turn 75, in 2021, the demand for LTC services will see a sharp upward trend. A number of independent projections have demonstrated how this will put pressure on the public finances in coming years. It should be concerning to Canadians that we have not publicly discussed how we will make the tough choices to cope with these pressures. Moreover, it's equally troubling that our provincial LTC systems already are unable to cope with the current level of demand for services, with less than a decade before the first wave of boomers enter age groups where demand for LTC is high, and alternate level of care patients, made up mostly of frail elderly, occupying over 15% of Canadian hospital beds on a daily basis as they await care elsewhere. Although we think it is unlikely that Canadian provinces will add LTC to the list of fully subsidized health services (hospitals and doctors), we should do a better job of targeting the existing public subsidies for LTC - and do so while putting LTC financing on a more sustainable footing.

[Four Ways Consumers Are Demanding Changes in the Healthcare Payments Experience].

Consumers in today's healthcare economy are more invested in their healthcare decisions. Experiences from innovators in other industries - such as clear payment communication and convenient, digital payment options - set expectations for the healthcare payment experience. However, healthcare payments have been slow to change, despite this evolution in the consumer's role, and continue to rely on disjointed, paper-based processes that leave consumers confused and frustrated. As a result, many consumers are demanding changes to the healthcare payments experience.

Prevalence and compensation of academic leaders, professors, and trustees on publicly traded US healthcare company boards of directors: cross sectional study.

OBJECTIVE: To identify the prevalence, characteristics, and compensation of members of the boards of directors of healthcare industry companies who hold academic appointments as leaders, professors, or trustees. DESIGN: Cross sectional study. SETTING: US healthcare companies publicly traded on the NASDAQ or New York Stock Exchange in 2013. PARTICIPANTS: 3434 directors of pharmaceutical, biotechnology, medical equipment and supply, and healthcare provider companies. MAIN OUTCOME MEASURES: Prevalence, annual compensation, and beneficial stock ownership of directors with affiliations as leaders, professors, or trustees of academic medical and research institutions. RESULTS: 446 healthcare companies met the study search criteria, of which 442 (99%) had publicly accessible disclosures on boards of directors. 180 companies (41%) had one or more academically affiliated directors. Directors were affiliated with 85 geographically diverse non-profit academic institutions, including 19 of the top 20 National Institute of Health funded medical schools and all of the 17 US News honor roll hospitals. Overall, these 279 academically affiliated directors included 73 leaders, 121 professors, and 85 trustees. Leaders included 17 chief executive officers and 11 vice presidents or executive officers of health systems and hospitals; 15 university presidents, provosts, and chancellors; and eight medical school deans or presidents. The total annual compensation to academically affiliated directors for their services to companies was $54,995,786 (£35,836,000; €49,185,900) (median individual compensation $193,000) and directors beneficially owned 59,831,477 shares of company stock (median 50,699 shares). CONCLUSIONS: A substantial number and diversity of academic leaders, professors, and trustees hold directorships at US healthcare companies, with compensation often approaching or surpassing common academic clinical salaries. Dual obligations to for profit company shareholders and non-profit clinical and educational institutions pose considerable personal, financial, and institutional conflicts of interest beyond that of simple consulting relationships. These conflicts have not been fully addressed by professional societies or academic institutions and deserve additional review, regulation, and, in some cases, prohibition when conflicts cannot be reconciled.

Planning for life after orthopaedics.

The word retirement is going out of fashion. Many orthopaedic surgeons want to work in some capacity when they stop performing surgery. Making a smooth transition from a busy orthopaedic practice to alternative work demands advanced planning. The surgeon must consider personal issues that involve how to use human capital (his or her accumulated knowledge and experience). New ventures, hobbies, travel, and spending time with family and friends are some possibilities. Plans for slowing down or leaving the practice should be discussed and agreed on well ahead of time. Agreements for buyouts may be difficult to work out and will require creative thinking. The solo practitioner can close the practice or hire a successor. Financial planning is perhaps the most important consideration and should be started by approximately age 40. It is recommended that the surgeon develop a portfolio of secure investments and annuities to provide adequate income for as long as is needed and then to turn the residual income to one's family, favorite charities, or other desired cause. A team of competent advisors is needed to help develop and achieve one's goals, create financial security, and provide the discipline to carry out the needed planning for life after orthopaedics.

Pathways to assignment of payees.

How clients come to be assigned representative payees and/or conservators to manage their funds is not well understood. We compared clients assigned a payee during a clinical trial of a money management-based intervention to those not assigned payees and examined antecedents to payee assignment. One year after randomization, significantly more clients assigned to the advisor teller money manager (ATM) money management intervention were assigned payees than participants in the control condition (10 of 47 vs. 2 of 43; p = .02); those assigned payees had lower baseline GAF scores and participated more in study therapies. Several ATM clients were assigned payees after third parties paid more attention to clients' finances, and others after having negotiated storage of their funds with the ATM money manager during the study. Assignment of payees appears to be influenced by whether third parties critically attend to how clients' manage funds and by clients' receptiveness to having a payee.