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Steve Thomas - One of the best experts on this subject based on the ideXlab platform.
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from Universal Health Insurance to Universal Healthcare the shifting Health policy landscape in ireland since the economic crisis
Health Policy, 2016Co-Authors: Sara Burke, Charles Normand, Sarah Barry, Steve ThomasAbstract:Ireland experienced one of the most severe economic crises of any OECD country. In 2011, a new government came to power amidst unprecedented Health budget cuts. Despite a retrenchment in the ability of Health resources to meet growing need, the government promised a Universal, single-tiered Health system, with access based solely on medical need. Key to this was introducing Universal free GP care by 2015 and Universal Health Insurance from 2016 onwards. Delays in delivering Universal access and a new Health minister in 2014 resulted in a shift in language from 'Universal Health Insurance' to 'Universal Healthcare'. During 2014 and 2015, there was an absence of clarity on what government meant by Universal Healthcare and divergence in policy measures from their initial intent of Universalism. Despite the rhetoric of Universal Healthcare, years of austerity resulted in poorer access to essential Healthcare and little extension of population coverage. The Irish Health system is at a critical juncture in 2015, veering between a potential path to Universal Healthcare and a system, overwhelmed by years of austerity, which maintains the status quo. This papers assesses the gap between policy intent and practice and the difficulties in implementing major Health system reform especially while emerging from an economic crisis.
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indicators of Health system coverage and activity in ireland during the economic crisis 2008 2014 from more with less to less with less
Health Policy, 2014Co-Authors: Sara Burke, Sarah Barry, Steve Thomas, Conor KeeganAbstract:A new Irish government came to power in March 2011 with the most radical proposals for Health system reform in the history of the state, including improving access to Healthcare, free GP care for all by 2015 and the introduction of Universal Health Insurance after 2016. All this was to be achieved amidst the most severe economic crisis experienced by Ireland since the 1930s.
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indicators of Health system coverage and activity in ireland during the economic crisis 2008 2014 from more with less to less with less
Health Policy, 2014Co-Authors: Sara Burke, Sarah Barry, Steve Thomas, Conor KeeganAbstract:A new Irish government came to power in March 2011 with the most radical proposals for Health system reform in the history of the state, including improving access to Healthcare, free GP care for all by 2015 and the introduction of Universal Health Insurance after 2016. All this was to be achieved amidst the most severe economic crisis experienced by Ireland since the 1930s. The authors assess how well the system coped with a downsizing of resources by an analysis of coverage and Health system activity indicators. These show a Health system that managed ‘to do more with less’ from 2008 to 2012. They also demonstrate a system that was ‘doing more with less’ by transferring the cost of care onto people and by significant resource cuts. From 2013, the indicators show a system that has no choice but ‘to do less with less’ with diminishing returns from crude cuts. This is evident in declining numbers with free care, of hospital cases and home care hours, alongside increased wait-times and expensive agency staffing. The results suggest a limited window of benefit from austerity beyond which cuts and rationing prevail which is costly, in both human and financial terms.
Sara Burke - One of the best experts on this subject based on the ideXlab platform.
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from Universal Health Insurance to Universal Healthcare the shifting Health policy landscape in ireland since the economic crisis
Health Policy, 2016Co-Authors: Sara Burke, Charles Normand, Sarah Barry, Steve ThomasAbstract:Ireland experienced one of the most severe economic crises of any OECD country. In 2011, a new government came to power amidst unprecedented Health budget cuts. Despite a retrenchment in the ability of Health resources to meet growing need, the government promised a Universal, single-tiered Health system, with access based solely on medical need. Key to this was introducing Universal free GP care by 2015 and Universal Health Insurance from 2016 onwards. Delays in delivering Universal access and a new Health minister in 2014 resulted in a shift in language from 'Universal Health Insurance' to 'Universal Healthcare'. During 2014 and 2015, there was an absence of clarity on what government meant by Universal Healthcare and divergence in policy measures from their initial intent of Universalism. Despite the rhetoric of Universal Healthcare, years of austerity resulted in poorer access to essential Healthcare and little extension of population coverage. The Irish Health system is at a critical juncture in 2015, veering between a potential path to Universal Healthcare and a system, overwhelmed by years of austerity, which maintains the status quo. This papers assesses the gap between policy intent and practice and the difficulties in implementing major Health system reform especially while emerging from an economic crisis.
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indicators of Health system coverage and activity in ireland during the economic crisis 2008 2014 from more with less to less with less
Health Policy, 2014Co-Authors: Sara Burke, Sarah Barry, Steve Thomas, Conor KeeganAbstract:A new Irish government came to power in March 2011 with the most radical proposals for Health system reform in the history of the state, including improving access to Healthcare, free GP care for all by 2015 and the introduction of Universal Health Insurance after 2016. All this was to be achieved amidst the most severe economic crisis experienced by Ireland since the 1930s.
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indicators of Health system coverage and activity in ireland during the economic crisis 2008 2014 from more with less to less with less
Health Policy, 2014Co-Authors: Sara Burke, Sarah Barry, Steve Thomas, Conor KeeganAbstract:A new Irish government came to power in March 2011 with the most radical proposals for Health system reform in the history of the state, including improving access to Healthcare, free GP care for all by 2015 and the introduction of Universal Health Insurance after 2016. All this was to be achieved amidst the most severe economic crisis experienced by Ireland since the 1930s. The authors assess how well the system coped with a downsizing of resources by an analysis of coverage and Health system activity indicators. These show a Health system that managed ‘to do more with less’ from 2008 to 2012. They also demonstrate a system that was ‘doing more with less’ by transferring the cost of care onto people and by significant resource cuts. From 2013, the indicators show a system that has no choice but ‘to do less with less’ with diminishing returns from crude cuts. This is evident in declining numbers with free care, of hospital cases and home care hours, alongside increased wait-times and expensive agency staffing. The results suggest a limited window of benefit from austerity beyond which cuts and rationing prevail which is costly, in both human and financial terms.
Miqdad Asaria - One of the best experts on this subject based on the ideXlab platform.
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Analysis of multi drug resistant tuberculosis (MDR-TB) financial protection policy: MDR-TB Health Insurance schemes, in Chhattisgarh state, India
Health Economics Review, 2018Co-Authors: Debashish Kundu, Nandini Sharma, Sarabjit Chadha, Samia Laokri, George Awungafac, Lai Jiang, Miqdad AsariaAbstract:Introduction There are significant financial barriers to access treatment for multi drug resistant tuberculosis (MDR-TB) in India. To address these challenges, Chhattisgarh state in India has established a MDR-TB financial protection policy by creating MDR-TB benefit packages as part of the Universal Health Insurance scheme that the state has rolled out in their effort towards attaining Universal Health Coverage for all its residents. In these schemes the state purchases Health Insurance against set packages of services from third party Health Insurance agencies on behalf of all its residents. Provider payment reform by strategic purchasing through output based payments (lump sum fee is reimbursed as per the MDR-TB benefit package rates) to the providers – both public and private Health facilities empanelled under the Insurance scheme was the key intervention. Aim To understand the implementation gap between policy and practice of the benefit packages with respect to equity in utilization of package claims by the poor patients in public and private sector. Methods Data from primary Health Insurance claims from January 2013 to December 2015, were analysed using an extension of ‘Kingdon’s multiple streams for policy implementation framework’ to explain the implementation gap between policy and practice of the MDR-TB benefit packages. Results The total number of claims for MDR-TB benefit packages increased over the study period mainly from poor patients treated in public facilities, particularly for the pre-treatment evaluation and hospital stay packages. Variations and inequities in utilizing the packages were observed between poor and non-poor beneficiaries in public and private sector. Private providers participation in the new MDR-TB financial protection mechanism through the Universal Health Insurance scheme was observed to be much lower than might be expected given their share of Healthcare provision overall in India. Conclusion Our findings suggest that there may be an implementation gap due to weak coupling between the problem and the policy streams, reflecting weak coordination between state nodal agency and the state TB department. There is a pressing need to build strong institutional capacity of the public and private sector for improving service delivery to MDR-TB patients through this new Health Insurance mechanism.
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analysis of multi drug resistant tuberculosis mdr tb financial protection policy mdr tb Health Insurance schemes in chhattisgarh state india
Health Economics Review, 2018Co-Authors: Debashish Kundu, Nandini Sharma, Samia Laokri, George Awungafac, Lai Jiang, Sarabjit Singh Chadha, Miqdad AsariaAbstract:There are significant financial barriers to access treatment for multi drug resistant tuberculosis (MDR-TB) in India. To address these challenges, Chhattisgarh state in India has established a MDR-TB financial protection policy by creating MDR-TB benefit packages as part of the Universal Health Insurance scheme that the state has rolled out in their effort towards attaining Universal Health Coverage for all its residents. In these schemes the state purchases Health Insurance against set packages of services from third party Health Insurance agencies on behalf of all its residents. Provider payment reform by strategic purchasing through output based payments (lump sum fee is reimbursed as per the MDR-TB benefit package rates) to the providers – both public and private Health facilities empanelled under the Insurance scheme was the key intervention. To understand the implementation gap between policy and practice of the benefit packages with respect to equity in utilization of package claims by the poor patients in public and private sector. Data from primary Health Insurance claims from January 2013 to December 2015, were analysed using an extension of ‘Kingdon’s multiple streams for policy implementation framework’ to explain the implementation gap between policy and practice of the MDR-TB benefit packages. The total number of claims for MDR-TB benefit packages increased over the study period mainly from poor patients treated in public facilities, particularly for the pre-treatment evaluation and hospital stay packages. Variations and inequities in utilizing the packages were observed between poor and non-poor beneficiaries in public and private sector. Private providers participation in the new MDR-TB financial protection mechanism through the Universal Health Insurance scheme was observed to be much lower than might be expected given their share of Healthcare provision overall in India. Our findings suggest that there may be an implementation gap due to weak coupling between the problem and the policy streams, reflecting weak coordination between state nodal agency and the state TB department. There is a pressing need to build strong institutional capacity of the public and private sector for improving service delivery to MDR-TB patients through this new Health Insurance mechanism.
Shouhsia Cheng - One of the best experts on this subject based on the ideXlab platform.
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is there a disparity in the hospital care received under a Universal Health Insurance program in taiwan
International Journal for Quality in Health Care, 2013Co-Authors: Yuyu Hsiao, Shouhsia ChengAbstract:Objective. To analyze the disparity in hospital care among people of various socio-economic status (SES) under a Universal Health Insurance scheme. Design. A survey questionnaire was mailed to discharged patients in October 2010. Setting. This study included 183 large-scale hospitals in Taiwan. Participants. A total of 3015 patients/caregivers completed the questionnaires, which yielded a response rate of 58%. Main Outcome Measures. Three variables were included. The two access-to-care variables were admission route and accreditation level of the hospital in which the patient stayed. A structured questionnaire, the patient-reported hospital quality (PRHQ), was included to characterize patient’s experience of hospital stay. Results. Patients with lower education were less likely to be admitted to a hospital according to a planned schedule, or to choose an Medical Center Hospital. However, SES was not associated with the PRHQ scores. Furthermore, patients with unplanned admission were associated with lower PRHQ scores than those with planned admission to the hospital. Conclusions. Under the Universal Health Insurance system in Taiwan, lower education is associated with unplanned admission to a hospital, which might result in poorer perceived quality of care. Reducing unplanned admission is a challenge for Health authorities in the future.
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continuity of care potentially inappropriate medication and Health care outcomes among the elderly evidence from a longitudinal analysis in taiwan
Medical Care, 2012Co-Authors: Chichen Chen, Shouhsia ChengAbstract:BACKGROUND: Better continuity of care (COC) is associated with improved Health care outcomes, such as decreased hospitalization and emergency department visit. However, little is known about the effect of COC on potentially inappropriate medication. OBJECTIVES: This study aimed to investigate the association between COC and the likelihood of receiving inappropriate medication, and to examine the existence of a mediating effect of inappropriate medication on the relationship between COC and Health care outcomes and expenses. METHODS: A longitudinal analysis was conducted using claim data from 2004 to 2009 under Universal Health Insurance in Taiwan. Participants aged 65 years and older were categorized into 3 equal tertiles by the distribution of COC scores. This study used a propensity score matching approach to assign subjects to 1 of 3 COC groups to increase the comparability among groups. Generalized estimating equations were used to examine the association between COC, potentially inappropriate medication, and Health care outcomes and expenses. RESULTS: The results revealed that patients with the best COC were less likely to receive drugs that should be avoided [odd ratios (OR), 0.44; 95% confidence interval (CI), 0.43-0.45) or duplicated medication (OR, 0.22; 95% CI, 0.22-0.23) than those with the worst COC. The findings also indicated that potentially inappropriate medication was a partial mediator in the association between COC and Health care outcomes and expenses. CONCLUSION: Better COC is associated with fewer negative Health care outcomes and lower expenses, partially through the reduction of potentially inappropriate medication. Improving COC deserves more attention in future Health care reforms.
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physician performance information and consumer choice a survey of subjects with the freedom to choose between doctors
Quality & Safety in Health Care, 2004Co-Authors: Shouhsia Cheng, H Y SongAbstract:Background: Increasing efforts have been made to provide information to help consumers to select a Healthcare provider, but the public release of hospital performance data has had only a limited impact on consumer choice. Objectives: To understand the experience of consumers in searching for physician performance information and to investigate the potential impact on their propensity to change doctors if hypothetically provided with physician specific performance information. Design: A nationwide telephone interview survey using a structured questionnaire. Setting: The survey was conducted in Taiwan, a country with a Universal Health Insurance programme where residents are free to choose between physicians for any medical consultation. Participants: 4015 adults aged over 20 years contacted by random digit dialling telephone calls. Main outcome measures: Subjects were asked (1) if they have ever compared the quality of care provided by physicians in their area; (2) if they would consult a performance report if it was available; and (3) if they would change doctors on the basis of information provided in the report. Results: Approximately half the subjects had made comparisons between doctors; 73% stated that they would consult a performance report if it was available, and 77% were prepared to change doctors if their doctor performed badly in the report. Conclusions: Providing physician specific performance reports to the public may be viewed favourably by consumers of Health care and have a significant impact on physician selection and hence quality improvement.
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the effect of Universal Health Insurance on Health care utilization in taiwan results from a natural experiment
AH-Scopus to ORCID, 1997Co-Authors: Shouhsia Cheng, Tungliang ChiangAbstract:Context. —The government of Taiwan introduced Universal Health Insurance to cover all citizens in 1995. This national Health Insurance program was proposed to assure the accessibility to Health care at reasonable cost. Evaluation of the consequences, including Health care utilization and expenditure, is crucial for policy adjustment. Objectives. —To evaluate the effect of Taiwan's national Health Insurance on Health care utilization. Design. —Cohort survey conducted before and after the implementation of the national Health Insurance program. Participants. —A total of 1021 randomly selected Taiwanese adults. Main Outcome Measures. —Physician visits in the 2 weeks prior to the survey and hospital admissions and emergency department visits in the immediate past year. Results. —After the introduction of Universal Health Insurance, the newly insured consumed more than twice the amount of outpatient physician visits (0.21 vs 0.48, P P P Conclusion. —The Universal Health Insurance removed some barriers to Health care for those newly insured. The copayment design in the Insurance scheme seemed to have an insignificant effect on curbing medical care utilization. Taiwanese Health policy analysts should seriously consider the growth of Health care expenditures since the implementation of Universal Health Insurance.
Gary King - One of the best experts on this subject based on the ideXlab platform.
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the essential role of pair matching in cluster randomized experiments with application to the mexican Universal Health Insurance evaluation
arXiv: Methodology, 2009Co-Authors: Kosuke Imai, Gary King, Clayton NallAbstract:A basic feature of many field experiments is that investigators are only able to randomize clusters of individuals--such as households, communities, firms, medical practices, schools or classrooms--even when the individual is the unit of interest. To recoup the resulting efficiency loss, some studies pair similar clusters and randomize treatment within pairs. However, many other studies avoid pairing, in part because of claims in the literature, echoed by clinical trials standards organizations, that this matched-pair, cluster-randomization design has serious problems. We argue that all such claims are unfounded. We also prove that the estimator recommended for this design in the literature is unbiased only in situations when matching is unnecessary; its standard error is also invalid. To overcome this problem without modeling assumptions, we develop a simple design-based estimator with much improved statistical properties. We also propose a model-based approach that includes some of the benefits of our design-based estimator as well as the estimator in the literature. Our methods also address individual-level noncompliance, which is common in applications but not allowed for in most existing methods. We show that from the perspective of bias, efficiency, power, robustness or research costs, and in large or small samples, pairing should be used in cluster-randomized experiments whenever feasible; failing to do so is equivalent to discarding a considerable fraction of one's data. We develop these techniques in the context of a randomized evaluation we are conducting of the Mexican Universal Health Insurance Program.
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public policy for the poor a randomised assessment of the mexican Universal Health Insurance programme
The Lancet, 2009Co-Authors: Gary King, Emmanuela Gakidou, Nirmala Ravishankar, Ryan T Moore, Jason Lakin, Manett Vargas, Martha Maria Tellezrojo, Kosuke Imai, Clayton Nall, Juan Eugenio Hernandez AvilaAbstract:Summary Background We assessed aspects of Seguro Popular, a programme aimed to deliver Health Insurance, regular and preventive medical care, medicines, and Health facilities to 50 million uninsured Mexicans. Methods We randomly assigned treatment within 74 matched pairs of Health clusters—ie, Health facility catchment areas—representing 118 569 households in seven Mexican states, and measured outcomes in a 2005 baseline survey (August, 2005, to September, 2005) and follow-up survey 10 months later (July, 2006, to August, 2006) in 50 pairs (n=32 515). The treatment consisted of encouragement to enrol in a Health-Insurance programme and upgraded medical facilities. Participant states also received funds to improve Health facilities and to provide medications for services in treated clusters. We estimated intention to treat and complier average causal effects non-parametrically. Findings Intention-to-treat estimates indicated a 23% reduction from baseline in catastrophic expenditures (1·9% points; 95% CI 0·14–3·66). The effect in poor households was 3·0% points (0·46–5·54) and in experimental compliers was 6·5% points (1·65–11·28), 30% and 59% reductions, respectively. The intention-to-treat effect on Health spending in poor households was 426 pesos (39–812), and the complier average causal effect was 915 pesos (147–1684). Contrary to expectations and previous observational research, we found no effects on medication spending, Health outcomes, or utilisation. Interpretation Programme resources reached the poor. However, the programme did not show some other effects, possibly due to the short duration of treatment (10 months). Although Seguro Popular seems to be successful at this early stage, further experiments and follow-up studies, with longer assessment periods, are needed to ascertain the long-term effects of the programme. Funding Mexican Ministry of Health, the National Institute of Public Health of Mexico, and Harvard University Institute for Quantitative Social Science.
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the essential role of pair matching in cluster randomized experiments with application to the mexican Universal Health Insurance evaluation
Statistical Science, 2009Co-Authors: Kosuke Imai, Gary King, Clayton NallAbstract:A basic feature of many field experiments is that investigators are only able to randomize clusters of individuals — such as households, communities, firms, medical practices, schools, or classrooms — even when the individual is the unit of interest. To recoup some of the resulting eciency loss, many studies pair similar clusters and randomize treatment within pairs. Other studies (including almost all published political science field experiments) avoid pairing, in part because some prominent methodological articles claim to have identified serious problems with this “matched-pair cluster-randomized” design. We prove that all such claims about problems with this design are unfounded. We then show that the estimator for matched-pair designs favored in the literature is appropriate only in situations where matching is not needed. To address this problem without modeling assumptions, we generalize Neyman’s (1923) approach and propose a simple new estimator with much improved statistical properties. We also introduce methods to cope with individual-level noncompliance, which most existing approaches incorrectly assume away. We show that from the perspective of, among other things, bias, eciency, or power, pairing should be used in cluster-randomized experiments whenever feasible; failing to do so is equivalent to discarding a considerable fraction of one’s data. We develop these techniques in the context of a randomized evaluation we are conducting of the Mexican Universal Health Insurance Program.
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a politically robust experimental design for public policy evaluation with application to the mexican Universal Health Insurance program
2007Co-Authors: Gary King, Emmanuela Gakidou, Nirmala Ravishankar, Ryan T Moore, Jason Lakin, Manett Vargas, Martha Maria Tellezrojo, Juan Eugenio Hernandez Avila, Mauricio Hernandez Avila, Hector Hernandez LlamaAbstract:We develop an approach to conducting large scale randomized public policy experiments intended to be more robust to the political interventions that have ruined some or all parts of many similar previous efforts. Our proposed design is insulated from selection bias in some circumstances even if we lose observations; our inferences can still be unbiased even if politics disrupts any two of the three steps in our analytical procedures; and other empirical checks are available to validate the overall design. We illustrate with a design and empirical validation of an evaluation of the Mexican Seguro Popular de Salud (Universal Health Insurance) program we are conducting. Seguro Popular, which is intended to grow to provide medical care, drugs, preventative services, and financial Health protection to the 50 million Mexicans without Health Insurance, is one of the largest Health reforms of any country in the last two decades. The evaluation is also large scale, constituting one of the largest policy experiments to date and what may be the largest randomized Health policy experiment ever.
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a politically robust experimental design for public policy evaluation with application to the mexican Universal Health Insurance program
Journal of Policy Analysis and Management, 2007Co-Authors: Gary King, Emmanuela Gakidou, Nirmala Ravishankar, Ryan T Moore, Jason Lakin, Manett Vargas, Martha Maria Tellezrojo, Juan Eugenio Hernandez Avila, Mauricio Hernandez Avila, Hector Hernandez LlamasAbstract:We develop an approach to conducting large-scale randomized public policy experiments intended to be more robust to the political interventions that have ruined some or all parts of many similar previous efforts. Our proposed design is insulated from selection bias in some circumstances even if we lose observations; our inferences can still be unbiased even if politics disrupts any two of the three steps in our analytical procedures; and other empirical checks are available to validate the overall design. We illustrate with a design and empirical validation of an evaluation of the Mexican Seguro Popular de Salud (Universal Health Insurance) program we are conducting. Seguro Popular, which is intended to grow to provide medical care, drugs, preventative services, and financial Health protection to the 50 million Mexicans without Health Insurance, is one of the largest Health reforms of any country in the last two decades. The evaluation is also large scale, constituting one of the largest policy experiments to date and what may be the largest randomized Health policy experiment ever. © 2007 by the Association for Public Policy Analysis and Management
