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Article
Publication date: 1 November 2002

Rowena Jacobs and Maria Goddard

This paper examines some of the key features of social health insurance systems by drawing on experiences in Germany, Switzerland, France and The Netherlands. These countries have…

2586

Abstract

This paper examines some of the key features of social health insurance systems by drawing on experiences in Germany, Switzerland, France and The Netherlands. These countries have all implemented a variety of reforms, including some competition between health insurers in order to meet some of their health care objectives. The paper highlights some of the strengths and weaknesses inherent in these systems and how they perform on a number of criteria and suggests a number of trade‐offs which policymakers will have to grapple with to attain some of their (often competing) health system goals of efficiency, choice, solidarity and equity. This paper should provide useful information for countries with health care systems in transition or those considering adopting aspects of social health insurance systems.

Details

International Journal of Social Economics, vol. 29 no. 11
Type: Research Article
ISSN: 0306-8293

Keywords

Article
Publication date: 31 December 2015

Kathryn Flynn

The purpose of this article is to explore financial fraud in the private health insurance sector in Australia. Fraud in this sector has commonalities to other countries with…

2225

Abstract

Purpose

The purpose of this article is to explore financial fraud in the private health insurance sector in Australia. Fraud in this sector has commonalities to other countries with similar health systems but in Australia it has garnered some unique characteristics. This article sheds light on these features, especially the fraught relationship between the private health funds and the public health insurance agency, Medicare and the problematic impact of the Privacy Act on fraud detection and financial recovery.

Design/methodology/approach

A qualitative methodological approach was used, and interviews were conducted with fraud managers from Australia’s largest private health insurance funds and experts in fields connected to health fraud detection.

Findings

All funds reported a need for more technological resources and higher staffing levels to manage fraud. Inadequate resourcing has the predictable outcome of a low detection and recovery rate. The fund managers had differing approaches to recovery action and this ranged from police action, the use of debt recovery agencies, to derecognition from the health fund. As for present and future harm to the industry, the funds found on-line claiming platforms a major threat to the integrity of their insurance system. In addition, they all viewed the Privacy Act as an impediment to managing fraud against their organizations and they desired that there be greater information sharing between themselves and Medicare.

Originality/value

This paper contributes to the knowledge of financial fraud in the private health insurance sector in Australia.

Details

Journal of Financial Crime, vol. 23 no. 1
Type: Research Article
ISSN: 1359-0790

Keywords

Article
Publication date: 9 January 2019

Joanna Khoo, Helen Hasan and Kathy Eagar

The purpose of this paper is twofold: first, to present patient-level utilisation patterns of hospital-based mental health services funded by private health insurers; and second…

Abstract

Purpose

The purpose of this paper is twofold: first, to present patient-level utilisation patterns of hospital-based mental health services funded by private health insurers; and second, to examine the implications of the findings for planning and delivering private mental health services in Australia.

Design/methodology/approach

Analysing private health insurance claims data, this study compares differences in demographic and hospital utilisation characteristics of 3,209 patients from 13 private health insurance funds with claims for mental health-related hospitalisations and 233,701 patients with claims for other types of hospitalisations for the period May 2014 to April 2016. Average number of overnight admissions, length of stay and per patient insurer costs are presented for each group, along with overnight admissions vs same-day visits and repeat services within a 28-day period following hospitalisation. Challenges in analysing and interpreting insurance claims data to better understand private mental health service utilisation are discussed.

Findings

Patients with claims for mental health-related hospitalisations are more likely to be female (62.0 per cent compared to 55.8 per cent), and are significantly younger than patients with claims for other types of hospitalisations (32.6 per cent of patients aged 55 years and over compared to 57.1 per cent). Patients with claims for mental health-related hospitalisations have significantly higher levels of service utilisation than the group with claims for other types of hospitalisations with a mean length of stay per overnight admission of 15.0 days (SD=14.1), a mean of 1.3 overnight admissions annually (SD=1.2) and mean hospital costs paid by the insurer of $13,192 per patient (SD=13,457) compared to 4.6 days (SD=7.3), 0.8 admissions (SD=0.6) and $2,065 per patient (SD=4,346), respectively, for patients with claims for other types of hospitalisations. More than half of patients with claims for mental health-related hospitalisations only claim for overnight admissions. However, the findings are difficult to interpret due to the limited information collected in insurance claims data.

Practical implications

This study shows the challenges of understanding utilisation patterns with one data source. Analysing insurance claims reveals information on mental health-related hospitalisations but information on community-based care is lacking due to the regulated role of the private health insurance sector in Australia. For mental health conditions, and other chronic health conditions, multiple data sources need to be integrated to build a comprehensive picture of health service use as care tends to be provided in multiple settings by different medical and allied health professionals.

Originality/value

This study contributes in two areas: patient-level trends in hospital-based mental health service utilisation claimed on private health insurance in Australia have not been previously reported. Additionally, as the amount of data routinely collected in health care settings increases, the study findings demonstrate that it is important to assess the quality of these data sources for understanding service utilisation.

Details

Journal of Health Organization and Management, vol. 33 no. 1
Type: Research Article
ISSN: 1477-7266

Keywords

Book part
Publication date: 6 July 2007

James B. Davies and Michael Hoy

We adopt a standard distributional impact methodology, based on Atkinson's cost of inequality approach, to estimate the degree of implicit redistribution created through public…

Abstract

We adopt a standard distributional impact methodology, based on Atkinson's cost of inequality approach, to estimate the degree of implicit redistribution created through public funding of health insurance in Canada. The first stage of the exercise is to determine the public health insurance benefits received by families of various age and composition and to add these to measured after-tax incomes. In our base case, which uses the Atkinson Mean Logarithmic Deviation as inequality index, we find that accounting for public health insurance benefits implies a reduction in inequality equivalent to 2.4% of per capita income. We then model the implications of moving to a hypothetical fully privatized system while proportionately refunding to individuals the tax revenues saved in doing so. This would give rise to a further 2.4% equivalent per capita income reduction resulting from increased inequality in the distribution of after-tax income. Thus, for this scenario, moving from public financing of health insurance in Canada to a fully privatized system implies an overall increase in inequality equivalent to a loss of 4.8% of per capita income. This corresponds to an increase of about 25% in existing inequality. Not surprisingly, the impact of publicly financed health insurance in reducing inequality is strongest for the elderly.

Details

Equity
Type: Book
ISBN: 978-0-7623-1450-8

Article
Publication date: 15 June 2010

Daniel Simonet

This paper aims to analyse health reforms carried out in a sample of European countries.

4231

Abstract

Purpose

This paper aims to analyse health reforms carried out in a sample of European countries.

Design/methodology/approach

Using a country‐specific approach, outstanding health reform features such as: greater competition between sickness funds in Germany; fund‐holding practices in the UK; managed care models in Switzerland; health networks in France; and healthcare system decentralisation in Italy are analysed.

Finding

There have been different approaches to controlling healthcare costs. Some states relied on public sector competition by creating quasi‐markets (UK), insurance sector competition, particularly in Switzerland and Germany, organisational reforms in France by creating health networks and decentralisation in Italy.

Research limitations/implications

Societal and legal aspects are not discussed.

Originality/value

The paper compares healthcare reform effectiveness in a number of western European countries.

Details

International Journal of Health Care Quality Assurance, vol. 23 no. 5
Type: Research Article
ISSN: 0952-6862

Keywords

Article
Publication date: 24 May 2011

Mercy Akosua Akortsu and Patience Aseweh Abor

The financing of healthcare services has been of a major concern to all governments in the face of increasing healthcare costs. For developing countries, where good health is…

5157

Abstract

Purpose

The financing of healthcare services has been of a major concern to all governments in the face of increasing healthcare costs. For developing countries, where good health is considered a poverty reduction strategy, it is imperative that the hospitals used in the delivery of healthcare services are well financed to accomplish their tasks. The purpose of this paper is to examine how public hospitals in Ghana are financed, and the challenges facing the financing modes adopted.

Design/methodology/approach

To achieve the objectives of the study, one major public healthcare institution in Ghana became the main focus.

Findings

The findings of the study revealed that the main sources of financing the public healthcare institution are government subvention, internally‐generated funds and donor‐pooled funds. Of these sources, the internally generated fund was regarded as the most reliable, and the least reliable was the donor‐pooled funds. Several challenges associated with the various financing sources were identified. These include delay in receipt of government subvention, delay in the reimbursement of services provided to subscribers of health insurance schemes, influence of government in setting user fees, and the specifications to which donor funds are put.

Originality/value

The findings of this study have important implications for improving the financing of public healthcare institutions in Ghana. A number of recommendations are provided in this regard.

Details

Journal of Health Organization and Management, vol. 25 no. 2
Type: Research Article
ISSN: 1477-7266

Keywords

Article
Publication date: 16 May 2016

Goce Gavrilov, Elena Vlahu- Gjorgievska and Vladimir Trajkovik

Information systems play a significant role in the improving of health and healthcare, as well as in the planning and financing of health services. Fund’s Information System is an…

Abstract

Purpose

Information systems play a significant role in the improving of health and healthcare, as well as in the planning and financing of health services. Fund’s Information System is an essential component of the information infrastructure that allows assessment of the impact of changes in health insurance and healthcare for the population. The purpose of this paper is to give a brief overview of the affection of e-services and electronic data exchange (between Fund’s information systems and other IT systems) at the quality of service for insured people and savings funds.

Design/methodology/approach

The authors opted for an exploratory study using the e-services implemented in Health Insurance Fund (HIF) of Macedonia and data which were complemented by documentary analysis, including brand documents and descriptions of internal processes. In this paper is presented an analysis of the financial aspects of some e-services in HIF of Macedonia by using computer-based information systems and calculating the financial implications on insured people, companies and healthcare providers.

Findings

The analysis conducted in this paper shows that the HIF’s e-services would have a positive impact for the insured people, healthcare providers and companies when fulfilling their administrative obligations and exercising their rights.

Originality/value

The analysis presented in this paper can serve as a valuable input for the healthcare authorities in making decisions related to introducing e-services in healthcare. These enhanced e-services will improve the quality service of the HIF.

Details

Journal of Health Organization and Management, vol. 30 no. 3
Type: Research Article
ISSN: 1477-7266

Keywords

Book part
Publication date: 11 June 2009

Josephine Borghi, John Ataguba, Gemini Mtei, James Akazili, Filip Meheus, Clas Rehnberg and Di McIntyre

Objective – Measurement of the incidence of health financing contributions across socio-economic groups has proven valuable in informing health care financing reforms. However…

Abstract

Objective – Measurement of the incidence of health financing contributions across socio-economic groups has proven valuable in informing health care financing reforms. However, there is little evidence as to how to carry out financing incidence analysis (FIA) in lower income settings. We outline some of the challenges faced when carrying out a FIA in Ghana, Tanzania and South Africa and illustrate how innovative techniques were used to overcome data weaknesses in these settings.

Methodology – FIA was carried out for tax, insurance and out-of-pocket (OOP) payments. The primary data sources were Living Standards Measurement Surveys (LSMS) and household surveys conducted in each of the countries; tax authorities and insurance funds also provided information. Consumption expenditure and a composite index of socio-economic status (SES) were used to assess financing equity. Where possible conventional methods of FIA were applied. Numerous challenges were documented and solution strategies devised.

Results – LSMS are likely to underestimate financial contributions to health care by individuals. For tax incidence analysis, reported income tax payments from secondary sources were severely under-reported. Income tax payers and shareholders could not be reliably identified. The use of income or consumption expenditure to estimate income tax contributions was found to be a more reliable method of estimating income tax incidence. Assumptions regarding corporate tax incidence had a huge effect on the progressivity of corporate tax and on overall tax progressivity. LSMS consumption categories did not always coincide with tax categories for goods subject to excise tax (e.g. wine and spirits were combined, despite differing tax rates). Tobacco companies, alcohol distributors and advertising agencies were used to provide more detailed information on consumption patterns for goods subject to excise tax by income category. There was little guidance on how to allocate fuel levies associated with ‘public transport’ use. Hence, calculations of fuel tax on public transport were based on individual expenditure on public transport, the average cost per kilometre and average rates of fuel consumption for each form of transport. For insurance contributions, employees will not report on employer contributions unless specifically requested to and are frequently unsure of their contributions. Therefore, we collected information on total health insurance contributions from individual schemes and regulatory authorities. OOP payments are likely to be under-reported due to long recall periods; linking OOP expenditure and illness incidence questions – omitting preventive care; and focusing on the last service used when people may have used multiple services during an illness episode. To derive more robust estimates of financing incidence, we collected additional primary data on OOP expenditures together with insurance enrolment rates and associated payments. To link primary data to the LSMS, a composite index of SES was used in Ghana and Tanzania and non-durable expenditure was used in South Africa.

Policy implications – We show how data constraints can be overcome for FIA in lower income countries and provide recommendations for future studies.

Details

Innovations in Health System Finance in Developing and Transitional Economies
Type: Book
ISBN: 978-1-84855-664-5

Book part
Publication date: 11 June 2009

Dov Chernichovsky, Gabriel Martinez and Nelly Aguilera

Objective – Tanzania, Mexico, and the United States are at vastly different points on the economic development scale. Yet, their health systems can be classified as “developing”…

Abstract

Objective – Tanzania, Mexico, and the United States are at vastly different points on the economic development scale. Yet, their health systems can be classified as “developing”: they do not live up to their potential, considering the resources available to them. The three, representing many others, share a common structural deficiency: a segregated health care system that cannot achieve its basic goals, the optimal health of its people, and their possible satisfaction with the system. Segregation follows and signifies first and foremost the lack of financial integration in the system that prevents it from serving its goals through the objectives of equity, cost containment and sustainability, efficient production of care and health, and choice.

Method – The chapter contrasts the nature of the developing health care system with the common goals, objectives, and principles of the Emerging Paradigm (EP) in developed, integrated – yet decentralized –systems. In this context, the developing health care system is defined by its structural deficiencies, and reform proposals are outlined.

Findings – In spite of the vast differences amongst the three countries, their health care systems share strikingly similar features. At least 50% of their total funding sources are private. The systems comprise exclusive vertically integrated, yet segregated, “silos” that handle all systemic functions. These reflect and promote wide variations in health insurance coverage and levels of benefits – substantial portions of their populations are without adequate coverage altogether; a considerable lack of income protection from medical spending; an inability to formalize and follow a coherent health policy; a lack of financial discipline that threatens sustainability and overall efficiency; inefficient production of care and health; and an dissatisfied population. These features are often promoted by the state, using tax money, and donors.

Policy implications – The situation can be rectified by (a) “centralizing” – at any level of development and resource availability – health system finance around a set package of core medical benefits that is made available to the entire population and (b) “decentralizing” consumption and provision of care. The first serves equity and cost containment and sustainability. The second supports efficiency and client satisfaction.

Originality/value of chapter – The chapter views commonly discussed problems of the health care system – a lack of insurance coverage and income protection – as symptoms of a large problem: health system segregation.

Details

Innovations in Health System Finance in Developing and Transitional Economies
Type: Book
ISBN: 978-1-84855-664-5

Book part
Publication date: 11 June 2009

Heather McLeod and Pieter Grobler

Objective – The South African health system has long been characterised by extreme inequalities in the allocation of financial and human resources. Voluntary private health

Abstract

Objective – The South African health system has long been characterised by extreme inequalities in the allocation of financial and human resources. Voluntary private health insurance, delivered through medical schemes, accounts for some 60% of total expenditure but serves only the 14.8% of the population with higher incomes. A plan was articulated in 1994 to move to a National Health Insurance system with risk-adjusted payments to competing health funds, income cross-subsidies and mandatory membership for all those in employment, leading over time to universal coverage. This chapter describes the core institutional mechanism envisaged for a National Health Insurance system, the Risk Equalisation Fund (REF). A key issue that has emerged is the appropriate sequencing of the reforms and the impact on workers of possible trajectories is considered.

Methodology – The design and functioning of the REF is described and the impact on competing health insurance funds is illustrated. Using a reference family earning at different income levels, the impact on workers of various trajectories of reform is demonstrated.

Findings – Risk equalization is a critical institutional component in moving towards a system of social or national health insurance in competitive markets, but the sequence of its implementation needs to be carefully considered. The adverse impact of risk equalization on low-income workers in the absence of income cross-subsidies and mandatory membership is considerable.

Implications for policy – The South African experience of risk equalization is of interest as it attempts to introduce more solidarity into a small but highly competitive private insurance market. The methodology for considering the impact of reforms provides policy-makers and politicians with a clearer understanding of the consequences of reform.

Details

Innovations in Health System Finance in Developing and Transitional Economies
Type: Book
ISBN: 978-1-84855-664-5

1 – 10 of over 15000