Objective To systematically review the effects of cost sharing in health insurance schemes, so as to provide evidence for better designing cost sharing ratio in health insurance scheme. Methods The search terms were discussed, tested and then chosen by subject matter experts and search coordinators. The total 20 databases including comprehensive scope, health, economics, sociology, and grey literatures were searched to retrieve all the description or evaluation studies on the effects of cost sharing, such as health services utilization, financial burden or moral hazard. The information from the included studies was extracted into a pre-designed data extraction form, and then it was analyzed and summarized. Results A total of 73 studies were included, covering 17 countries like Australia, Canada, and China, etc. The results of statistical analyses showed that, a) Cost sharing methods were applied to every kind of health insurance scheme. The target population included general population, the elder, the poor, those with chronic disease and children, etc. The services covered clinic, hospitalization, mental health, prevention and drug; and b) The effects brought from cost sharing included: From full fee to cost sharing scheme, the enrollee in developing countries increased their health care utilization, and decreased their financial burden. From full coverage to cost sharing, the utilization of health services decreased in developed countries, but the cost of health insurance could not be reduced, and some undesirable effects were brought due to the decrease of both essential health service utilization and essential drugs compliance.
Objective To assess the effectiveness of outreach strategies for expanding insurance coverage of children who are eligible for health insurance schemes. Methods We searched The Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 2), PubMed (1951 to 2010), EMBASE (1966 to 2009), PsycINFO (1967 to 2009) and other relevant databases and websites. In addition, we searched the reference lists of included studies and relevant reviews, and carried out a citation search for included studies to find more potentially relevant studies. Randomized controlled trials, controlled clinical trials, controlled before-after studies and interrupted time series which evaluated the effects of outreach strategies on increasing health insurance coverage for children. The included strategies were increasing awareness of schemes, modifying enrolment, improving management and organization of insurance schemes, and mixed strategies. Two review authors independently screened literatures, extracted data and assessed the risk of bias. We narratively summarized the data. Results We included two studies, both from the United States. One randomized controlled trial study with a low risk of bias showed that community-based case managers who provided health insurance information, application support were effective in enrolling Latino American children into health insurance schemes (RR=1.68, 95%CI 1.44 to 1.96, n=257). The second quasi-randomized controlled trial, with an unclear risk of bias, indicated that handing out insurance application materials in hospital emergency departments can increase enrolment of children into health insurance (RR=1.50, 95% CI 1.03 to 2.18, n=223). Conclusion The two studies included in this review provide evidence that providing health insurance information and application assistance and handing out application materials in hospital emergency departments can probably both improve insurance coverage of children. But the application of the interventions to other countries beyond the US still depends on contextual factors of health medical systems. Further studies evaluating the effectiveness of different outreach strategies for expanding health insurance coverage of children in different countries are needed, with careful attention given to study design.
Objectives To describe the range of strategies for expanding health insurance coverage for vulnerable population and how the authors have assessed these strategies. Methods Search words were chosen by both health policy experts and search coordinators after discussion and pilot. What was searched included 28 electronic databases, 12 websites of health institutions, 3 grey literature databases and search engine Google. Any report of implemented strategies to expand health insurance coverage for vulnerable population was included. Pre-designed data extraction form was used for collecting strategies and study methods of the included studies. Then the extracted information was analyzed and described. Results A total of 86 studies were included, most of which were the ones in the U.S. and the main targeted population was children. In terms of the study objective, 61 studies aimed to describe strategies and 25 ones are to evaluate effectiveness of the strategies. All strategies could be categorized into 6 groups based on the theoretical framework: changing eligibility criteria of health insurance, increasing awareness, making premium affordable, innovating enrollment approaches, improving health care delivery and strengthening management capacity. Most of the studies evaluating effectiveness were retrospective analysis of longitude data, and there were also two experimental studies. Conclusions The U.S. and other developed countries have implemented a great many strategies for expanding insurance coverage, while few strategies and related studies are found in developing countries. However, developing countries can learn from the developed countries in extending health insurance coverage. The 25 included studies evaluating strategies need further systematic reviews to assess the effectiveness of these strategies.
ObjectiveTo classify and analyze medical audit chargeback of a hospital and to propose management strategies. MethodsWe classified the project audit chargeback of a grade-three class-A comprehensive hospital in Chengdu from June to December 2013, and analyzed the underlying causes of the chargeback. ResultsThe total chargeback of the hospital from June to December 2013 was more than 30 000 items and the general amount involved was about 3 million yuan. The project number of recurring charges, excessive charges, unreasonable charges, anchored fees, inconsistent charges with doctors' advices, non-indications, disproportionate fees and charges over restriction accounts occupied respectively 42.99%, 39.71%, 9.15%, 5.73%, 0.35%, 0.17%, 1.44% and 0.46%; and the amount of money involved for those projects occupied respectively 8.84%, 52.55%, 14.44%, 10.70%, 2.54%, 1.15%, 8.91% and 0.88%. ConclusionThe reasons for project audit chargeback are complicated. By strengthening information technology, management of price and building negotiation mechanism with Medical Insurance and Pricing Management Institutes, we can reduce the amount of chargeback, protect the right of patients and enhance the efficient use of the health insurance fund, so that the hospital, medical insurance and patients can all get benefits.
This paper used the application of health technology assessment (HTA) in medical insurance directory adjustment as an example, introduced NICE’s HTA in UK from seeking legislative support for HTA, established the system of HTA, improved the process of HTA and increasing awareness of using HTA among decision-maker, and provided suggestions for the development and advancement of HTA in China.
ObjectivesTo analyze the economic burden caused by delay in the diagnosis and treatment of diabetes.MethodsThe employee/non-employee health insurance and medical examination data from Japan Medical Data Center (JMDC) and Milliman Inc. were used to analyze the health economic burden of the situation in case the diabetic population receives timelydiagnosis and treatment with real world data.ResultsThe overall population delaying the diabetes diagnosis and treatment in Japan was estimated to be 916 000, and the average time of delay was 39.6 months. The increase in time of delay was related with the increase in monthly medical costs after diabetes diagnosis. If the whole delayed population could receive timely diagnosis and treatment, it can totally save about 38.24 billion yuan (1.5% of the annual Japanese national medical expenditure.ConclusionsThe current study suggests a huge potential health economic burden that can be improved by promoting the diagnosis and treatment of diabetes, which provides reference for the economic evaluation of similar health policies and also the application of real world data in China in future.
Objective To perform data-driven, assisted prediction of health insurance reimbursement ratios for the major thoracic surgery group in CHS-DRG, in addition to providing an optional solution for health insurance providers and medical institutions to accurately and effectively predict the references of health insurance payments for the patient group. Methods Using the information on major thoracic surgery cases from a large tertiary hospital in Sichuan province in 2020 as a sample, 70% of the total dataset was used as a training dataset and 30% as a test dataset. This data was used to predict health insurance spending through a multiple linear regression model and an improved machine learning method that is based on feature selection. Results When the number of filtered features was the same via three machine learning methods including random forest, logistic regression, and support vector machine, there was no significant difference in the prediction effectiveness. The model with the best prediction effect had an accuracy of 78.96%, sensitivity of 83.93%, specificity of 71.27%, precision of 0.818 8, AUC value of 0.841 4, and a Kappa value of 0.610 8. Conclusion The basic characteristics such as the number of disease diagnoses and surgical operations, as well as the age of patients affect the reimbursement ratio. The cost of materials, drugs, and treatments has a greater impact on the reimbursement ratio. The combined method of feature selection and machine learning outperforms traditional statistical linear models. When dealing with a larger dataset that has many features, selecting the right number can enhance the prediction ability and efficiency of the model.
Assessing the clinical value of pharmaceuticals is crucial for comprehensive evaluation in clinical practice and plays a vital role in supporting decision-making for drug supply assurance. Real-world data (RWD) offers valuable insights into the actual diagnosis and treatment processes, serving as a significant data source for evaluating the clinical demand, effectiveness, and safety of drugs. This technical guidance aims to elucidate the scope of application of RWD for the clinical value assessment of pharmaceuticals, as well as the key considerations for conducting value assessment research. These considerations include identifying the dimensions of clinical value that necessitate RWD and effectively utilizing RWD for evaluation purposes. Additionally, this guidance provides essential points for implementing pharmaceutical clinical value assessment based on real-world data, with a specific focus on study design and statistical analysis. By doing so, this guidance assists researchers in accurately comprehending and standardizing the utilization of real-world research in conducting pharmaceutical clinical research.