Health Economics Policy and Law最新文献

Private sector entities can invest in and own the means of healthcare provision, creating opportunities and risks for health systems. While private investment can enhance access to capital, promote competition, and foster innovation, it can also exacerbate incentives for providers to engage in supplier-induced demand, undue price increases, quality compromises, and 'cherry-picking' of the most profitable patients and services. Despite the growing presence of private investors in the healthcare sector, heterogeneity in investor types remains poorly understood. This limits the ability of policymakers to consider whether, and to what extent, regulatory intervention is called for in relation to different forms of investor-ownership. By drawing on principal-agent theory, this article begins to address this gap by presenting a typology of investor-ownership in health services provision. Examining the policy relevance of such a typology, we present a case study analysis of current regulations directed at ownership across five countries, representing different health system models. We find that regulatory frameworks that differentiate between types of for-profit investor-ownership are largely absent in Europe, but more developed in the US. We argue that growing private investments require a combination of entry regulation and behavioural oversight to better align the incentives of investor-owners with public health objectives.

Growing demand for social care and resource constraints compel decision-makers to decide how to allocate public resources to social care. Such decisions may result in differences in access to social care between groups in society. In this study we conducted a secondary analysis of articles included in a systematic review on the underpinnings of resource allocation decisions in social care, extending that work to examine the potential consequences of such decisions. We conducted the review in accordance with the PRISMA framework. Through a thematic framework analysis of 37 of the 42 articles included in the parent review, we identified five groups in society that may be disproportionately affected by the consequences of resource allocation decisions on social care: (1) individuals with long-term social care needs (2) informal caregivers, (3) lower socio-economic groups, (4) individuals with limited health literacy skills, and (5) individuals living across different regions. Our findings highlight that allocation decisions in social care particularly affect women and individuals facing language barriers and may create local variation in provision of social care. These findings suggest potential for inequitable access to social care in society and underscore the need for decision-makers to consider the consequences of their allocation decisions.

How the role of health technology assessment (HTA) agencies in relation to medical technologies (MedTech) is framed in the literature reflects and influences governance, shaping perceptions and guiding decisions. We identify different academic discourses to advance MedTech policy debates, in light of several factors potentially influencing this role. This is the first time that discourse on the role of HTA agencies in relation to MedTech has been reviewed. We conducted a comprehensive search, screened for eligibility, and synthesised findings using discourse analysis. 119 articles were included, from which 5 discourses were constructed. The first discourse describes the HTA agency as an independent evaluator of appropriate evidence for all health technologies. The second discourse explicitly categorises MedTech as separate from pharmaceuticals and expands the role of evaluator to include encouraging evidence generation for MedTech. The third discourse moves away from the role of independent evaluator and describes the HTA agency as a convenor of all stakeholder perspectives, using an experimental approach. The fourth and fifth discourses critically reflect on the role of HTA agencies, the fourth on their level of normative reflection and the fifth on their level of nuanced, clinical expertise. We conclude with recommendations for policy and research.

The role of healthcare provider ownership in shaping health system performance remains contested. An umbrella review was conducted to synthesise evidence on the relationship between healthcare provider ownership and performance in high-income countries. Systematic reviews were included that examined performance of healthcare providers based on ownership status. Searches yielded 1,862 results, with 31 systematic reviews meeting the inclusion criteria, and one further systematic review identified through grey literature searches. Following the exclusion of 10 reviews classified as low-quality and two previous umbrella reviews both published in 2014, 20 reviews were eligible for data extraction and synthesis. Inconsistent evidence was found across reviews between healthcare provider ownership and several performance indicators including health outcomes, technical efficiency, and patient satisfaction. Private hospitals tend to serve wealthier patients, select less complex or costly patients, and charge higher payments for care than public comparators. Private for-profit (FP) providers of hospital and long-term care generally had poorer workforce outcomes than private not-for-profit or public providers, including reduced staffing levels, higher workloads, and lower job satisfaction. Private PF hospitals and nursing homes had improved financial performance based on revenues or profit margins. Our findings underscore the need for nuanced regulatory responses to the expansion of private FP provision within publicly funded systems.

Health policy reforms often fail due to design flaws, implementation gaps, and political barriers. This paper examines the role of government stewardship in addressing these barriers drawing on lessons from healthcare reforms in Sanming, China, a city that has become a nationally recognised model for comprehensive health system reform. Employing a qualitative approach, the analysis traces how six core stewardship functions - strategic visioning, institutional alignment, instrument design, partnership management, accountability reinforcement, and learning facilitation - enabled Sanming's government to control costs and improve service delivery and health outcomes. Sanming's experience illustrates the potential for local government stewardship to catalyse reform in the face of constraints. Interviews indicated that strengthened stewardship enabled the government to set strategic direction for the health system, mobilise stakeholders, formulate workable policies, and adapt to changing needs during implementation. However, participants identified persistent challenges, including uneven distribution of capacity across agencies, changes in the external policy environment, and deficient stakeholder feedback loops. While specific to the local context, the core stewardship competencies identified in the paper offer a generalisable framework for strengthening reform governance in other settings. As countries seek to build resilient and equitable health systems, the lessons from Sanming's stewardship model provide a timely contribution to the global health reform discourse.

Legal provisions in trade agreements, including those related to intellectual property (IP), can impede access to medicines. The 12-party Comprehensive and Progressive Agreement for Trans-Pacific Partnership (CPTPP) is currently undergoing a review. This provides an opportunity to update the CPTPP's Intellectual Property Chapter to remove certain provisions that were negotiated in the context of its precursor, the Trans Pacific Partnership (TPP), many of which have been suspended. These include several 'TRIPS-Plus' provisions - IP provisions exceeding the requirements of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). This paper reviews the CPTPP's TRIPS-Plus provisions, including those suspended and those still in place, and argues for their removal based on evidence of their likely effects on medicines access and recent changes in the political environment. Since the CPTPP was signed in 2018, accumulated evidence has demonstrated that TRIPS-Plus provisions negatively impact access to medicines. Lack of access to COVID-19 medical products in low- and middle-income countries has highlighted major problems with TRIPS. Furthermore, the US has diverged from a TRIPS-Plus agenda, rendering the suspended provisions obsolete. Removing the CPTPP's TRIPS-Plus provisions, while challenging, would preserve Parties' policy flexibility to design their laws in ways that protect access to medicines.

Mixed markets can enhance welfare compared to full public or private provision. However, this welfare gain depends on the extent to which market distortions exist. Recent literature demonstrates distortions in mixed long-term care markets worldwide. Our study explores potential distortions in the Dutch institutional market. While all Dutch residential nursing homes are non-profit, for-profit organisations, including private equity (PE) firms, have increasingly entered the market, offering round-the-clock care provided in home-like settings as an alternative to non-profit residential care.We analysed claims data from 2017-2021 for dementia patients aged 70 and older using multinomial logit and Cox Proportional Hazards models. Specifically, we compared risk selection, upgrading, and care quality (measured by avoidable hospitalisations and mortality) between for-profit and non-profit providers.Our findings do not suggest increased risk selection, higher upgrading, or lower care quality by for-profit (PE-owned) providers compared to non-profit providers. Consequently, we did not find evidence of strong market distortions in the Dutch institutional long-term care market. These results contrast with the existing international literature, suggesting that adverse incentives in the Netherlands may be influenced more by the way care is provided (in home-like settings versus in residential nursing homes) and financing structures rather than ownership type alone.

The European Union (EU) is currently overhauling its pharmaceutical regulations, seeking to mature a single market for medicines as part of a 'European Health Union'. We reflect on the interactions between regulations and markets in these reforms and investigate what this single market for medicines may mean in practice. We note how the proposed reforms aim to ensure equitable access to innovative treatments, yet at the same time, tie this access directly to regulatory exclusivities, limiting price competition. The reforms also do not seek full pricing transparency: prices will remain largely opaque and be set at the national levels rather than created through market exchange and open competition at the EU level. The envisioned single market for medicines thus remains a market that operates without direct reference to price - a situation not addressed head-on by the proposed reforms.

Compounded by 14 years of public welfare austerity, health equality presents a challenge that extends beyond healthcare in isolation because it also engages the more recondite politics of public health. Recent policy has addressed the issue by requiring National Health Service (NHS) bodies to integrate their services with those of local authorities. We consider how this adds significant new difficulty to the already complex process of NHS resource allocation. We argue that these duties require a new framework to gauge the values, evidence and criteria needed to set priorities for public health; not simply as a desirable objective, but a necessity in law. We consider current approaches to priority setting for medical treatment, and the responses already offered by current ethical frameworks. We then discuss the new ethical, political, and practical challenges posed by public health priority setting for health equality. Informed by this context, we engage an intersectional lens to explore a 'non-ideal' solution grounded in Professor Sir Michael Marmot's framework to reduce health inequalities.