Developments in health economics and public policy最新文献

The National Health Service (NHS) has been the body of the health care system in the United Kingdom (UK) for over 60 years and has sought to provide the population with a high quality service free of user charges for most services. The information age has seen the NHS rapidly transformed from a socialist, centrally planned and publicly provided system to a more market based system orientated towards patients as consumers. The forces of globalization have provided patients in the UK with greater choice in their health care provision, with NHS treatment now offered from any public or approved private provider and the possibility of treatment anywhere in the European Economic Area (EEA) or possibly further. The financial crisis, a large government deficit and austerity public spending policies have imposed a tight budget constraint on the NHS at a time of increasing demand for health care and population pressure. Hence, further rationing of care could imply that patients are incentivised to seek private treatment outside the constraints of the NHS, where the possibility of much greater choice exists in an increasingly globally competitive health care market. This chapter examines the evidence on the response of patients to the possibilities of increased choice and mobility within the internal NHS and external overseas health care markets. It also considers the relationships between patient mobility, health care provision and health policy. Patients are more mobile and willing to travel further to obtain better care outcomes and value for money, but are exposed to greater risk.

Policymakers fear that health insurers when exposed to competition will engage in cream-skimming (i.e. selection of good risks) rather than trying to improve their benefit to premium ratio. This fear surfaced also when Swiss federal government proposed pro-competitive Law on social health insurance, which barely passed a popular referendum in 1994. While a risk equalization mechanism based on age, gender, and place of residence has already been created, there is a considerable interest in improving its formula. This paper shows that a dummy variable indicating an individual's death during the period of observation causes the coefficient of determination to jump from 0.039 to 0.111. More-over, simulations of the risk selection process suggest that risk equalization should be made a permanent institution rather than being limited to a life of 10 years as prescribed by present legislation. In fact, the formula in use, with all its shortcomings, can be shown to neutralize to a great extent insurer interest in cream skimming provided he takes a longer-run view.

The life expectancy gain produced by a reduction in mortality can be determined by three different methods with respect to the timing of the gained life-years. One method adds the life expectancy gain to the expected end of life. Another method places the gain at the time of occurrence of the mortality reduction. A third method distributes the gained life-years over the maximum lifespan according to the differences in survival probabilities after and before the reduction in mortality. The three methods are all used in the literature together with a quasi-deterministic and a probabilistic approach to the notion of life expectancy. The counted numbers of gained life-years are the same, but due to different timing of life expectancy gains the discounted numbers are different. Several discounting models are identified when combining the three methods of counting with the deterministic and the probabilistic approaches to life expectancy. Some are symmetrical, some are not. However, most importantly, they come out with potentially very large differences in the discounted number of gained life-years. They differ by a factor of approximately (1 + r)e(a)-1, where r is a constant discount rate and e(a) is remaining life expectancy at age a, when the reduction of mortality occurs. For a new-born, discounting at 7% p.a., one discounting model provides a present value that is 150 times larger than another discounting model, the other models being in between. The various counting and discounting models for life expectancy gains are presented formally, graphically, and with numerical examples using Danish male mortality data. We show how three different discounting models provide large differences in discounted life expectancy gains and hence cost-effectiveness ratios in an economic evaluation of a colorectal cancer screening programme in Denmark. These different discounting models co-exist in the evaluation literature. Choice of method is rarely made explicit. Sensitivity analysis with respect to this choice is even rarer. We argue that one counting-discounting model is sufficient and that this should be to discount the differences between the two survival probability curves.

The system of remunerating general practitioners (GPs) in Britain underwent significant changes in April 1990 with the implementation of a new contract between individual GPs and health authorities. The changes were a precursor to a wide-ranging programme of reforms of the British National Health Service. This paper investigates the relationship between financial incentives and the provision of primary health care services in Britain. A comprehensive anonymized data set was used, comprising information on 208 general practices in Scotland which serve just under one million people. An econometric model was tested to identify the determinants of cross-practice variation in the magnitude of the changes in GPs' remuneration levels between the two contracts. A linear programming model was used to examine the GPs' response to the financial incentives built into the new contract. The results of the econometric model indicated that the main beneficiaries of the 1990 contract were the practices which had expanded over the 1989-92 period, re-structured the GPs' partnership and made use of managerial skills by employing a practice manager; those practices also had larger lists in 1992 and relatively more patients attracting deprivation payments. The linear programming model showed that only a small minority of the practices (4.8%) maximised the remuneration from the new contract. Optimal solutions concerning income maximization strategies identified financial disincentives in the fee structure of the remuneration system associated with the provision of selected services and the care of particular groups of patients. The successful adoption of these strategies would involve cream skimming and selective service provision. However, there is no conclusive evidence of British GPs engaging in such activities.