Journal of Health Policy,
Insurance and Management


Polityka Zdrowotna

e-czasopismo

Polityka Zdrowotna Journal of Health Policy, Insurance and Management VIII 2011

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RISK ADJUSTMENT JAKO ZASADA I NARZĘDZIE ZMIANY SPOŁECZNEJ W SYSTEMIE OCHRONY ZDROWIA - OD „PASYWNEJ” DO „AKTYWNEJ” KOREKTY

RISK ADJUSTMENT AS A PRINCIPLE AND A TOOL OF THE SOCIAL CHANGE IN HEALTH CARE SYSTEM – FROM “PASSIVE” TO “ACTIVE” ADJUSTMENT

Autor

Romuald Holly, Medical University of Łódź, Warsaw School of Economics, National Insurance Institute in Poland

Kai Michelsen,  Maastricht University, Faculty of Health, Medicine and Life Sciences, Department of International Health (The Netherlands)

ABSTRAKT

Risk adjustments are a promising approach to handle some of the major challenges of current health policies in many modern welfare states. They can be used to create transparency for the assessment of the quality of health services between health service providers (including decisions about the allocation of resources), or as a basis for a need orientated reallocation of resources between third party payers.

While the potential advantages of risk adjustments are acknowledged, a couple of challenges stimulate an ongoing debate about the further development of risk adjustments.

This article describes the debates about risk adjustment. It addresses the meanings of the term, summarizes discussion about opportunities and challenges, and develops some ideas for further research activities. The recommendations are based on three major assumptions: A) It is possible and beneficial
to cooperate in the development f an “algorithm of algorithms”. B) A generic risk adjustment system has to be adapted towards the specific situation of health systems. C) While differences between “old” EU Member States and “new” EU Member States as well as challenges to organize policy transfers and policy learning have to be taken into account, mutual learning is possible and beneficial– for the Member States and in the process of European integration.

Słowa kluczowe :

risk adjustment, wybór ryzyka, alokacji zasobów, system ochrony zdrowia, polityka zdrowotna, algorytm regulacji ryzyka

risk adjustment, risk selection, allocation of resources, health systems, health policy, risk adjustment algorithms


IDEA I METODA RISK ADJUSTMENT W SYSTEMACH OCHRONY ZDROWIA W WYBRANYCH KRAJACH EUROPEJSKICH I W POLSCE

THE IDEA AND METHOD OF RISK ADJUSTMENT IN REFORM OF HEALTH CARE IN POLAND

Autor

Cezary Głogowski, Insurance Institute in Poland

ABSTRAKT

The primary aim of the study was to verify the thesis of the need for comprehensive reform of the health care system in Poland and if the thesis confirmed to identify the areas which require to be prioritised. The assessment was based on research tools founded on an analysis of objective economic and health data and subjective consumer evaluations. The analysis used studies and reports prepared by international organisations and project groups: OECD, Eurostat, Karolinska Insitute, Eurocare Database, Health Consumer Powerhouse, EFPIA and others. The summary of data extracted from these multiple sources allows one to look at a wider picture and identify areas requiring increased concentration.

The collected data have confirmed the reasonableness of the ongoing discussion in Poland about the need to implement reforms of the health care system in Poland. The results of objective rankings clearly show that the low level of funding in practice very clearly translates into obtained health outcomes, although the relatively high scores in the rankings for each therapeutic area, except for oncology, should also be emphasised. In contrast to the objective measures, consumer perception of the quality of health care in Poland is already very pessimistic. Poland is ranked in a low position, yielding much to the Czech Republic, Slovakia and Hungary. The analysis made it possible to select a group of countries of approximately the same size as Poland, which take rather the leading positions in reports and rankings prepared by the international institutions listed above. These include the Netherlands, France, Germany, Switzerland and Belgium. The element common to these countries is the operation of competitive payers managing public funds for health care, utilising a risk adjustment methodology in the allocation of funds to individual payers. The analysis of financial and health indicators, supported by literature review confirmed that risk adjustment method can be useful method in the insurance model in which the primary source of funding of services is the insurance premium. Risk adjustment improves rational and justified allocation of financial resources depending on individual risks and reduced undesirable effect of adverse selection. It seems that the key to the success of reform in Poland is to increase financial resources in health care to balance the growing imbalance between the burdens resulting from rising health costs and an ageing population, but only with a parallel implementation of processes to increase the efficiency of their use. The analysis of the data collected in the study shows that the centralised system, organised, managed and finances by the state is in this respect dominated by the Bismarck model. Competition among payers having funds from health contributions or public charges seems to have the most effective impact on increasing the efficiency of funds invested.

Słowa kluczowe :

zdrowie publiczne, risk adjustment, efektywność, jakość, finansowanie

public health, reform, risk adjustment, effectiveness, quality, funding


STATISTICAL AND ECONOMETRIC RISK ADJUSTMENT METHODS FOR MEASURING THE QUALITY OF HOSPITALS

RISK ADJUSTMENT – STATYSTYCZNE I EKONOMETRYCZNE METODY POMIARU JAKOŚCI W SZPITALACH

Autor

Alexander C. Tsai, Harvard University (USA)

John F.P. Bridges, Johns Hopkins Bloomberg School of Public Health (USA)

ABSTRAKT

The past two decades have witnessed an expansion in efforts to publicly disseminate data on hospital performance based on comparisons of risk-adjusted outcomes for the purpose of affecting reimbursement or patient choice. While much is known about which risk factors should be adjusted for, less is known about the appropriate statistical methods that should be used in deriving such quality measures. We discuss the literature on profiling and risk adjustment, with an emphasis on recent econometric and statistical methods, highlighting key assumptions involved in the various analytical techniques. Particularly problematic for the traditional methods of analysis are the problems of inadequate sample sizes and unobserved severity of illness. We illustrate how these issues affected recent public profiling initiatives and highlight how recent contributions from the econometric and statistical literature may be helpful in ameliorating these problems.

Słowa kluczowe :

metody ważenia ryzyka, jakości opieki zdrowotnej

risk adjustment methods, health care quality


RISK ADJUSTMENT IN THE GERMAN HEALTH INSURANCE SYSTEM – DOES THE RISK COMPENSATION SYSTEM LEAVE INCENTIVES FOR RISK SELECTION?

RISK ADJUSTMENT W NIEMIECKIM SYSTEMIE ZABEZPIECZENIA ZDROWOTNEGO – CZY SYSTEM KOMPENSACJI RYZYKA STANOWI ZACHĘTĘ DO JEGO SELEKCJI?

Autor

Anna Drabik, Markus Lüngen, Stephanie Stock, University Hospital of Cologne (Germany)

ABSTRAKT

The German Statutory Health Insurance (SHI) more or less dates back to the late 19th century when Chancellor Bismarck implemented the forerunner of the present system to combat social unrest. Without any doubt this was a great achievement for the social welfare state in Germany of which the SHI is one pillar  – and the SHI has proved to be remarkably stable ever since both against reform efforts and social change.

In the beginning the SHI system was not designed to foster competition. Rather, sickness funds, as health insurance corporations are called in the SHI, were forced to contract and act uniformly to ensure equity and to maximize market power. This was necessary as i.e. in the middle of the 20th century there were still more than 1800 sickness funds – many of them operating only regionally. Also, cost-containment policies which were in place until the mid-1970s did not encourage competition. Only as late as the early 1990s did the political will change and the implementation of competitive elements into the SHI was seen as a way to raise efficiency potentials.  This was the result of a general shift in the social climate favoring deregulation, questioning the effectiveness of top-down cost containment regulations and a raising societal debate over unequal options in choosing and switching sickness funds.  As a consequence the health Care Structure Act was passed in December 1992 which gave almost all mandatorily insured including blue- and white collar workers the same right to choose a sickness fund to promote competition among sickness funds. From now on, sickness funds could be switched on a yearly basis with three months notice starting in 1997. To provide all sickness funds with a level basis for competition a risk compensation system (RCS) was implemented two years before free choice of sickness funds was granted. Thus, the implementation of open enrollment in Germany was a joint development of the concern to provide equity of choice to all mandatorily insured along with the hope to improve efficiency within the system by strengthening competition. With time the discussion concerning the RCS evolved to transforming the RCS to linking the risk compensation system to incentives for sickness funds to manage care and to implement a fully morbidity adjusted RCS while providing sickness funds with increasing leeway to compete with each other. Further refinement of the RCS therefore, has been on the political agenda ever since its implementation in 1994 leading to various expertise and evaluations of the functioning of the RCS and its role in leaving incentives for risk selection. In this article we focus on the latest health care reform refining the RCS and present an empirical analysis of its effects on risk selection for sickness funds.

Słowa kluczowe :

ustawowe ubezpieczenia zdrowotne, ochrona zdrowia, wyrównanie ryzyka, dostosowawcza korekta ryzyka

Statutory Health Insurance, health care, risk compensation system, risk adjustment


APPLICATION OF DATA WAREHOUSE FOR RISK ADJUSTMENT ALGORITHMS

ZASTOSOWANIE HURTOWNI DANYCH W ALGORYTMACH RISK ADJUSTMENT

Autor

Petre Iltchev, Medical University of Łódź (Poland)

ABSTRAKT

The main objective of this paper is to present a framework for designing a research data warehouse to analyse risk adjustment algorithms. The framework provides a methodological foundation for a systems approach to analyse risk adjustment models. The data warehouse offers a foundation for modelling and a multidimensional analysis of risk adjustment algorithms. The data warehouse stores data from many insurers, sickness funds and other source systems.

Słowa kluczowe :

hurtownie danych, algorytmy korekcji ryzyka, modelowanie ubezpieczeń zdrowotnych

data warehouse, risk adjustment algorithms analysis, modelling health insurance


EFFICIENCY OF HEALTH CARE SYSTEMS ON THE COMPETITIVE HEALTH CARE MARKET

SKUTECZNOŚĆ SYSTEMÓW OCHRONY ZDROWIA NA KONKURENCYJNYM RYNKU PŁATNIKA TRZECIEJ STRONY

Autor

Barbara Więckowska, Warsaw School of Economics (Poland)

ABSTRAKT

Due to changes in the demographic structure of societies and medical technology improvement, governments are trying to find more efficient ways of spending public resources on health care systems. This article tries to answer the question of whether the introduction of competition between third party payers (TPPs) in the base health care system will contribute to an increase in the system’s efficiency. The model defined for analyzing the relationship between the system’s input and output factors indicates that there is no significant correlation between competition among TPPs and the efficiency of the health care system – even with competitive TPPs there are systems with output indicator lower than those expected on the basis of input one. The reason can be that systems with competitive TPPs face problems with non-selective risk pooling systems (relation between standard and additional coverage) and, what is probably the most important, with need for an adequate risk adjustment systems (ex ante vs. ex post). That’s why implementing competitive TPPs system shouldn’t be the only reason for  reforming healthcare system in order to increase system efficiency.

Słowa kluczowe :

system ochrony zdrowia, rynek usług medycznych, efektywność

health care systems, health care market, efficiency, inputs indicators, outputs indicators


POSSIBLE APPROACHES TO BENCHMARKING VOLUNTARY HEALTH INSURANCE FUNDS IN BULGARIA

MOŻLIWE PODEJŚCIA W BENCHMARKINGU DOBROWOLNYCH FUNDUSZY UBEZPIECZEŃ ZDROWOTNYCH W BUŁGARII

Autor

Petko Salchev, Nikolai Hristov, Lidia Georgieva, Medical University of Sofia (Bulgaria)

ABSTRAKT

Following the adoption of the Health Insurance Law in Bulgaria (1999), which provided the legal framework for the development of the voluntary health insurance, several health insurance funds were established. Bulgaria had two licensed voluntary health insurance funds in 2001; in 2003 their number grew to six; and in 2009 this number stands over twenty. Despite the increased number of funds in recent years, their share of healthcare spending stayed at 1-1.5%, which is below European average.

To this date, there are no serious and profound studies in the field among the scientific community in Bulgaria. The economic data published by the Commission of Financial Surveillance (CFS), conforms to EC regulations, but do not allow non-specialists to assess realistically voluntary health insurance funds (VHIF).

This article introduces a methodology for comparing VHIF and establishment of a complex index (Benchmark Index - BI) based on 5 groups of indicators, related to several available variables. This index is intended as a tool for analyzing the voluntary health insurance sector and managing resources through a set of analytic indicators and variables. It can be used to create a certain type of ranking of VHIF.

Słowa kluczowe :

dobrowolne ubezpieczenia zdrowotne, rynek, metody porównania, benchmark indeks

voluntary health insurance, market, comparing methods, benchmark index


THE DEVELOPMENT OF THE PRIVATE HEALTH INSURANCE AND MEDICAL SERVICES MARKET IN POLAND IN THE YEARS 2005–2010

KSZTAŁTOWANIE SIĘ RYNKOWEJ OFERTY PRYWATNYCH USŁUG MEDYCZNYCH I UBEZPIECZEŃ ZDROWOTNYCH W POLSCE W LATACH 2005-2010

Autor

Magdalena Szczepaniak, Romuald Holly, Medical University of Łódź (Poland)

ABSTRAKT

The reforms of the Polish health care system in the years 1999–2004, including the reform of health care financing, made it possible for private health care providers and insurers to design and launch a new range of products. By 2004, these products had become sufficiently mature and differentiated to undertake systematic research on the development of this market segment. Thus, the Observatory of the Health Insurance and Medical Services Market started to monitor the number of organizations offering supplementary health insurance coverage and subscription-based medical services; the number and type of products sold to corporate and individual customers, as well as the range, type, and availability of services and benefits. The major parameters of the structure of these products were also examined. The above monitoring gives a clear picture of the determining factors and development of the private health insurance and medical services market in Poland, as well as its impact on the evolution of the health care system in the years 2004–2010.

This paper focuses in particular on those findings which reveal the processes of adjusting health products to the needs and expectations of consumers/patients. Another major interest is how insurers and providers aggregate health risks and segment their clients to make their products not only profitable, but also compatible with the Polish health care system and with its legal and organizational framework to the greatest possible extent.

The results of our research and analyses indicate that risk adjustment methods can be used to design health insurance and medical service products that would be both attractive to the consumers/patients and profitable to the insurers and providers.

Słowa kluczowe :

zabezpieczenie zdrowotne, świadczenie zdrowotne, koszyk świadczeń gwarantowanych, prywatne ubezpieczenie zdrowotne, abonament medyczny, rynek ochrony zdrowia

health insurance, health benefits, guaranteed benefit package, private health insurance, subscription-based medical services, health care market


CONCEPTUAL APPROACHES TO FORMATION OF NEW PREVENTIVE STRATEGY IN PUBLIC HEALTH SERVICES AND PUBLIC HEALTH

PREWENCYJNA STRATEGIA ZDROWIA PUBLICZNEGO – KONCEPTUALIZACJA NOWEGO PODEJŚCIA

Autor

Vitaly Fedorovych Moskalenko, National Academy of Medical Science and Bogomolets National Medical University of Kiev (Ukraine)

ABSTRAKT

Public health services systems in the global market have serious problems and difficulties associated with stability of their functioning and resource, including financial security. Therefore, efforts to shape perfection of systems of public health services, formation of bases of the future adequate model are aimed at a number of strategic documents of World Health Organization (WHO), resolutions of sessions of Executive Committee of the World Assembly of public health services.

It is known that the theory of risk factors is the heart of prevention concepts formation. The considerable attention paid to risk factors is connected with polyaetiological origin of many diseases. There is a possibility of using risk factors knowledge in practice for prevention, diseases prediction, diseases features and diagnostic process. The World Health Organization defines the leading health risk factors. For developing countries they are poverty, low weight, unsafe water, poor sanitary-and-hygienic conditions, unsafe sex, iron deficiency anaemia, smoke from solid fuels burning in premises. For economically developed countries the risk factors are high blood pressure, increased cholesterol content in blood, tobacco consumption, abuse of alcohol, obesity and low physical activity.

WHO recommends governments, Ministries of Health to occupy the leading role in developing of strategies of risk factors prevention to support scientific researches, to improve monitoring systems and to expand access to the global information. It is necessary for public health services systems to provide the holistic approach to service, including promotion to population health improvement, prevention and integrated programs of illnesses struggle.

The most important aspect of the public health services policy is to concentrate on formation and development of integral communities, systematic work with all sectors on purpose of health risk factors negative influence decrease, development of the sanitary potential in certain living conditions, establishments, institutions and organizations in the field of culture, education, industry, etc., providing conditions for all community members to realize their potential.

Słowa kluczowe :

zdrowie publiczne, czynniki ryzyka, programy profilaktyczne

public health services, risk factors, preventive programs


CURRENT AND FUTURE USE OF RISK ADJUSTMENT IN THE USA

OBECNE I PRZYSZŁE ZASTOSOWANIE RISK ADJUSTMENT W STANACH ZJEDNOCZONYCH

Autor

John Bertko, Center for Consumer Information and Insurance Oversight, Centers for Medicare & Medicaid Services (USA)

ABSTRAKT

The US has extensive experience with risk adjustment systems for the Medicare and Medicaid public insurance programs and many lessons have been learned.   With health care reform, there will be a great challenge to “get it right” for a very large new population (perhaps more than 70 million people) in order to make insurance offerings more transparent on price and quality. To the extent that risk adjustment assists with achieving this goal, the US may attain its twin goals of near-universal coverage at a more acceptable cost.

Słowa kluczowe :

regulacja, korekta ryzyka, Ustawa o ochronie pacjenta I zapewnienie przystępnej opieki, systemy zdrowotnych ubezpieczeń, Medicare, Medicaid

risk adjustment, Patient Protection and Affordable Care Act, health insurance systems, Medicare, Medicaid


CULTURAL DUALISM OF POLISH HOSPITALS

KULTURALNY DUALIZM POLSKICH SZPITALI

Autor

Łukasz Sułkowski, Joanna Sułkowska, Academy of Management SWSPiZ (Poland)

ABSTRAKT

This article sets out to analyze the issue of defining the concept of organizational culture and focuses on models and typologies used in reference materials. Moreover, based on the pilot quality study, it tries to explain peculiarity of this concept in relation to Polish hospitals.

Słowa kluczowe :

kultura organizacyjna, zarządzanie szpitalem

organizational culture, hospitals management


THE OPINIONS OF POLISH DOCTORS’, PHARMACISTS AND PATIENTS ABOUT GENERIC DRUGS – SURVEY RESULTS

OPINIE POLSKICH LEKARZY, FARMACEUTÓW I PACJENTÓW O LEKACH GENERYCZNYCH - WYNIKI ANKIETY

Autor

Paweł Lewek, Przemysław Kardas, Medical University of Łódź (Poland)

ABSTRAKT

The aim of this study was the assessment of Polish doctors’, pharmacists’ and patients’ knowledge and attitudes toward generic drugs. This was a questionnaire-based study. One-hundred-and-ninety-five participants took part in this study. Both doctors and pharmacists declared good knowledge of generic drugs. They also admitted that they informed their patients about generics frequently. However, patients did not confirm that. Patients rarely participated in the process of selection of drugs for themselves. In the most of cases, patients followed doctors’ and pharmacists’ recommendation when buying drugs. Patients believed that generic drugs were equally effective as original drugs. What is more, over a half of doctors and pharmacists admitted that they consider generics as worse than original drugs. Wider use of generics is advisable in order to increase the cost-effectiveness of the healthcare systems. In order to increase this use, appropriate information and motivation interventions should be targeted on doctors and pharmacists, who are the main source of information regarding drugs for the patients.

Słowa kluczowe :

leki generyczne, leki markowe, oryginalne leki, badania, lekarze, farmaceuci, pacjenci

generic drugs, generics, brand-name drugs, original drugs, survey study, doctors, pharmacists, patients


RISK MANAGEMENT OF ADVERSE EVENTS IN HOSPITALS (CASE STUDY)

ZARZĄDZANIE RYZYKIEM ZDARZEŃ NIEPOŻĄDANYCH W SZPITALACH (STUDIUM PRZYPADKU)

Autor

Aleksandra Sierocka, Michal Marczak, Medical University of Łódź (Poland)

ABSTRAKT

The notion of risk management plays crucial role in the correct functioning of each unit, including a health care unit.

Hospitals, which provide medical benefits are institutions to which the issue of risk management of adverse events is of the utmost importance. The possibility to identify risk characteristic of these centres brings notable benefits not only for patients and the whole hospital environment but it also plays crucial role in proper functioning of health care institutions. We all realize that risk is constantly accompanying us in everyday life or at work; it is impossible to perform activities deprived of any hazards. However, it is important that an institution makes every effort so as to identify and assess adverse events which may occur, determine risk connected with them and implement, if possible, activities preventing negative results and possible harmful consequences of these hazards.

It should be also realized that the level of acceptable risk in the Polish health care system is too high. The central government as well as local authorities do not have any policies concerning this area, even an information policy. No activities are performed aiming at determining the range of the problem described by us. Simultaneously, the current state of knowledge and the potential of experts dealing with this problem in the health cares system is not great.

The author’s research problem was an attempt to identify causes, the structure and the number of adverse events occurring in one of the research hospitals in lodzkie voivodship; however, without pointing out to guilty parties and to select assessment aggregates which would enable one to hierarchize and eliminate adverse events. It included also an attempt to assess (with the use of measurement of indirect values) whether the determined complications, errors and acts of negligence had influence on the quality, result and the cost of the treatment. Thus, the activities performed will have a political as well as factual aspect (aiming at an improvement of situation in the health cares system).

Słowa kluczowe :

zarządzanie ryzykiem, czarny punkt, system ochrony zdrowia

risk management, black spots, health care system


DESIGN OF HEALTH INSURANCE PRODUCTS AS A PREREQUISITE FOR COMPETITIVE ADVANTAGE IN THE HEALTH CARE MARKET

KONSTRUKCJA PRODUKTU UBEZPIECZENIA ZDROWOTNEGO JAKO WARUNEK PRZEWAGI KONKURENCYJNEJ NA RYNKU OCHRONY ZDROWIA

Autor

Edyta Skibińska, Medical University of Łodź, Poland

ABSTRAKT

The principal thesis of this paper is the assumption that health insurance products can be efficient tools in enhancing the effectiveness and quality of the health care system. And, in a growing market, quality becomes an increasingly important asset, ensuring a competitive advantage.Efficient product management is possible due to the modular design of health insurance products, by preserving the right proportions of three basic modules: (1) the financial module, (2) the service module, and (3) the long-term care module, in relation to specific risk categories and the health needs and expectations of consumers/patients with various socio-demographic backgrounds. Therefore, the very design of health insurance products allows for their effective management, oriented at improving public health as well as gaining competitive advantage by the insurers.

Słowa kluczowe :

zarządzanie jakością w ochronie zdrowia, zarządzania produktem, produkt ubezpieczenia zdrowotnego

quality management in health care, product management, health insurance product


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