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Purpose: The purpose of this paper is to present proposed solutions and interventions to some of the major barriers to providing adequate access to healthcare in Kenya. Specific business models are proposed to improve access to quality healthcare in low- and middle-income countries. Finally, strategies are developed for the retail clinic concept (RCC). Design/methodology/approach: Google Scholar, PubMed and EBSCOhost were among the databases used to collect articles relevant to the purpose in Kenya. Various governmental and news articles were collected from Google searches. Relevant business models from other sectors were considered for potential application to healthcare and the retail clinic concept. Findings: After a review of current methodologies and approaches to business and franchising models in various settings, the most relevant models are proposed as solutions to improving quality healthcare in Kenya through the RCC. For example, authors reviewed physician recruitment strategies, insurance plans and community engagement. The paper is informed by existing literature and reports as well as key informants. Research limitations/implications: This paper lacks primary data collection within Kenya and is limited to a brief scoping review of literature. The findings provide effective strategies for various business and franchising models in healthcare. Originality/value: The assembling of relevant information specific to Kenya and potential business models provides effective means of improving health delivery through business and franchising, focusing on innovative approaches and models that have proven effective in other settings.

Background: Although Ghana is lauded for its National Health Insurance Scheme (NHIS), concerns exist about the scheme's functioning and sustainability. An often-cited issue—contributing to the scheme's decreasing membership, long-standing financial deficit, and frequent out-of-pocket payments among members—is the large benefits package (BP). While, on paper, the BP covers over 95% of the conditions occurring in Ghana, its design was not informed by any budget analysis, nor any systematic prioritization of interventions. This paper aims to provide evidence-based input into ongoing discussions regarding a review of the NHIS benefits package. Methods: An existing analytic framework is used to calculate net health benefit (NHB) for a range of interventions in order to assess their cost-effectiveness and enable the prioritization of 'best buys'. The framework is expanded upon by incorporating concerns for financial protection, and practical feasibility, as well as the political economy challenges of disinvesting in currently funded activities. Five different options for the benefits package, each based on policy discourse in Ghana's health sector, are presented and evaluated. Results: Implementing all interventions for which data was available to 100% of the population in need was estimated to cost GH₵4323 million (US$994 million), while the available NHIS budget was only GH₵970 million (US$223 million). Options for the benefits package that focussed on cost-effectiveness and primary care provision achieved the best health outcomes, while options reflecting the status quo and allowing for co-payments included a higher number of healthcare interventions. Apart from the package option focussing on primary care, all packages were faced with physician shortages. Conclusions: Current funding to the NHIS is insufficient to provide the historical benefits package, which promises to cover over 95% of disease conditions occurring in Ghana, to the total population. Shifting the NHIS focus from intervention coverage to population coverage is likely to lead to better health outcomes. A primary care package may be most feasible in the short-term, though additional physicians should be trained to provide higher-level care that is highly cost-effective, such as emergency neonatal care. [ABSTRACT FROM AUTHOR]

Summary: The paper estimates the causal effect of having health insurance on healthcare utilization, while accounting for potential endogeneity bias. The topic has important policy implications, because health insurance reforms implemented in the USA in recent decades have focused on extending coverage to the previously uninsured. Consequently, understanding the effects of those reforms requires an accurate estimate of the causal effect of insurance on utilization. However, obtaining such an estimate is complicated by the discreteness inherent in common measures of healthcare usage. The paper presents a flexible estimation approach, based on copula functions, that consistently estimates the coefficient of a binary endogenous regressor in count data settings. The relevant numerical computations can be easily carried out by using the freely available GJRM R package. The empirical results find significant evidence of favourable selection into insurance. Ignoring such selection, insurance appears to increase doctor visit usage by 62% but, adjusting for it, the effect increases to 134%. [ABSTRACT FROM AUTHOR]

In some countries, including France, patients can choose between consulting a physician working in the regulated sector (where, in general, fees are fully covered by health insurance) and a physician working in the unregulated sector (where a balance-billing scheme operates). In the latter, patients must make out-of-pocket payments. The paper analyzes the signalling properties of this mechanism. The model reveals that a small extra fee allows obtaining a separating equilibrium in which only patients with a high propensity to adhere to the treatment will opt for the unregulated sector and will benefit from a larger care effort on the part of their physician. We also analyze the other equilibria of the game. [ABSTRACT FROM AUTHOR]

Background: Evidence-based health workforce policies are essential to ensure the provision of high-quality health services and to support the attainment of universal health coverage (UHC). This paper describes the main characteristics of available health workforce data for 74 of the 75 countries identified under the 'Countdown to 2015' initiative as accounting for more than 95% of the world's maternal, newborn and child deaths. It also discusses best practices in the development of health workforce metrics post-2015.Methods: Using available health workforce data from the Global Health Workforce Statistics database from the Global Health Observatory, we generated descriptive statistics to explore the current status, recent trends in the number of skilled health professionals (SHPs: physicians, nurses, midwives) per 10 000 population, and future requirements to achieve adequate levels of health care in the 74 countries. A rapid literature review was conducted to obtain an overview of the types of methods and the types of data sources used in human resources for health (HRH) studies.Results: There are large intercountry and interregional differences in the density of SHPs to progress towards UHC in Countdown countries: a median of 10.2 per 10 000 population with range 1.6 to 142 per 10 000. Substantial efforts have been made in some countries to increase the availability of SHPs as shown by a positive average exponential growth rate (AEGR) in SHPs in 51% of Countdown countries for which there are data. Many of these countries will require large investments to achieve levels of workforce availability commensurate with UHC and the health-related sustainable development goals (SDGs). The availability, quality and comparability of global health workforce metrics remain limited. Most published workforce studies are descriptive, but more sophisticated needs-based workforce planning methods are being developed.Conclusions: There is a need for high-quality, comprehensive, interoperable sources of HRH data to support all policies towards UHC and the health-related SDGs. The recent WHO-led initiative of supporting countries in the development of National Health Workforce Accounts is a very promising move towards purposive health workforce metrics post-2015. Such data will allow more countries to apply the latest methods for health workforce planning. [ABSTRACT FROM AUTHOR]

This paper empirically assesses selection effects and determinants of the demand for supplemental health insurance that covers hospital and dental benefits in Germany. Our representative data set provides doctor-diagnosed indicators of the individual's health status, risk attitude, demand for medical services and insurance purchases in other lines of insurance, as well as rich demographic and socio-economic information. Controlling for a wide range of individual preferences, we find evidence that individuals aged 65 and younger with hospital coverage are sicker than those without. In addition, insurance propensity and income are the most important drivers of the demand for supplemental hospital and dental coverage. [ABSTRACT FROM AUTHOR]

Despite the significant responsibility that physicians have in healthcare delivery, we know surprisingly little about why physician practice styles vary within or across institutions. Estimating variation in physician practice styles is complicated by the fact that patients are rarely randomly assigned to physicians. This paper uses the quasi-random assignment of patients to physicians in emergency departments (EDs) to show how physicians vary in their treatment of patients with minor injuries. The results reveal a considerable degree of variation in practice styles within EDs; physicians at the 75th percentile of the spending distribution spend 20% more than physicians at the 25th percentile. Observable physician characteristics do not explain much of the variation across physicians, but there is a significant degree of sorting between physicians and EDs over time, with high-cost physicians sorting into high-cost EDs as they gain experience. The results may shed light on why some EDs remain persistently higher-cost than others. [ABSTRACT FROM AUTHOR]

Background/Objectives: Benign paroxysmal positional vertigo (BPPV) is the most common cause of recurrent vertigo and the most common peripheral vestibular disorder. It is characterized by intense vertigo triggered by head and position changes. This study investigates the risk of subsequent injury in BPPV patients and the effects of treatment. Methods: A population-based retrospective cohort study was conducted using data from the Longitudinal Health Insurance Database 2005 in Taiwan. Patients with and without BPPV were identified between 2000 and 2017. The study outcomes were diagnoses of all-cause injuries. The Kaplan–Meier method determined the cumulative incidence rates of injury in both cohorts, and a log-rank test analyzed the differences. Cox proportional hazard models calculated each cohort's 18-year hazard ratios (HRs). Results: We enrolled 50,675 patients with newly diagnosed BPPV and 202,700 matched individuals without BPPV. During follow-up, 47,636 patients were diagnosed with injuries (13,215 from the BPPV cohort and 34,421 from the non-BPPV cohort). The adjusted HR for injury in BPPV patients was 2.63 (95% CI, 2.49–2.88). Subgroup analysis showed an increased incidence of unintentional and intentional injuries in BPPV patients (aHR 2.86; 95% CI, 2.70–3.13 and 1.10; 95% CI, 1.04–1.21, respectively). A positive dose–response relationship was observed with increasing BPPV diagnoses. Treatment with canalith repositioning therapy (CRT) or medications reduced the risk of injury slightly but not significantly (aHR, 0.78; 95% CI, 0.37–1.29, 0.88; 95% CI, 0.40–1.40, respectively). Conclusions: BPPV is independently associated with an increased risk of injuries. CRT or medications have limited effects on mitigating this risk. Physicians should advise BPPV patients to take precautions to prevent injuries even after treatment. [ABSTRACT FROM AUTHOR]

Background: The Family Physician Programme is a key health reform in Iran that faces significant challenges in urban areas, particularly in Mazandaran and Fars provinces The study aims to critically evaluate the challenges encountered in the Urban Family Physician Program, with a particular focus on the perspectives of insurance organizations. Methods: A qualitative approach was adopted, involving semi-structured interviews with 22 experts and managers from basic health insurance funds. Snowball sampling facilitated participant selection, and interviews proceeded until saturation. Data analysis utilized content analysis and Atlas-T software, adhering to COREQ criteria. Results: Implementation problems of the urban family physician program were categorized into ten Categories and 22 Subcategories, including financing, stewardship, human resources, structure, culture, information system, payment, monitoring and control, the function of insurance organizations, and implementation. Conclusion: The urban family physician program's implementation challenges, as viewed by health insurance organizations, underscore the necessity for strategic decision-making in financing, payment models, electronic system integration, structural adjustments, comprehensive monitoring, evaluation, cultural considerations, and appropriate devolution to insurance entities. [ABSTRACT FROM AUTHOR]

Copyright of GesR: Gesundheitsrecht is the property of De Gruyter and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Primary health care has been recognized as a critical strategy for improving population health in developing countries. This paper investigates the effect of primary care physicians on the infant mortality rate in Brazil using a dynamic panel data approach. This method accounts for the endogeneity problem and the persistence of infant mortality over time. The empirical analysis uses an eight-year panel of municipalities between 2005 and 2012. The results indicate that primary care physician supply contributed to the decline of infant mortality in Brazil. An increase of one primary care physician per 10,000 population was associated with 7.08 fewer infant deaths per 10,000 live births. This suggests that, in addition to other determinants, primary care physicians can play an important role in accounting for the reduction of infant mortality rates. [ABSTRACT FROM AUTHOR]

Purpose -- The purpose of this paper is to study, inequalities between general physicians' and specialists' visits in Shiraz. Also, the factors effecting the utilization of visits were determined. Design/methodology/approach -- Concentration index and curves, ranked by income and quality of life were used to estimate the amount of inequality in the utilization of services. Health utilization data which had been gathered already were used for this purpose. Poisson regression was used to construct the models. Findings -- Results of the study showed that, inequalities in specialists' visits were higher than GPs'. Complementary insurances users and females used more specialist services. People with higher quality of life utilized fewer GPs' and specialists' services. Originality/value -- New evidences about inequality in health services utilization and its components in Iran was surveyed. [ABSTRACT FROM AUTHOR]

This paper uses two nationally representative sets of medical claims data from medical assistance and universal public health insurance systems to examine how medical assistance system assignment affects short-term inpatient health care provision. In Japan, the medical assistance system, which is part of a public assistance system, provides medical care services for its beneficiaries without imposing any financial burdens, such as copayments or advance premium payments. These circumstances can lead to inpatient costs, as physicians may provide more treatments because there is a financial incentive. Because the assignment of public assistance in Japan is not random but is subject to means testing by the local government, I employ the instrumental variable model to control the potential correlation. I find that medical expenditure is significantly higher for medical assistance patients than for universal public health insurance patients, with an arc elasticity of approximately 0.20. This elasticity is slightly greater than that found for inpatient care in the randomized RAND Health Insurance Experiment and recent empirical studies on low-income populations. In addition, the elasticities for patients who receive medication, treatment and surgery are greater. [ABSTRACT FROM AUTHOR]

One in eight adults in Iran is estimated to have major depressive disorder (MDD) - a leading cause of disability in the country. Many remain undiagnosed, and some receive only partial treatment. An estimated 60% of those with MDD were reported to have received no treatment during the past year. In this paper, we have critically reviewed the current health-care structure in the country along with prevailing patterns of health-care service utilization. We have addressed the role of psychiatrists, general practitioners (GPs), psychologists, and other health-care personnel in the treatment and care of patients with MDD, with an emphasis on the quality of service provision. In addition, the strengths and weaknesses of primary healthcare (PHC), the health insurance system, and inpatient care have been discussed. We have paid attention to the contextual issues such as mental health literacy, stigma, and healthcare inequity where relevant. Finally, practical recommendations have been provided to improve the quality of care for patients with MDD in Iran. [ABSTRACT FROM AUTHOR]

Abstract We exploit the discontinuity in health insurance coverage rates at the Medicare eligibility age of 65 to investigate the impact of Medicare on health-care utilization and spending among the elderly. We find that the discrete change in insurance coverage rates at age 65 leads to a significant increase in office-based physician and outpatient visits, which is mainly driven by those who were not insured before age 65. We also document that Medicare eligibility at age 65 is associated with up to 36.5 percent decrease in out-of-pocket spending for physician and outpatient visits. On the other hand, we find that Medicare eligibility does not have a significant impact on the utilization of inpatient or emergency department services. [ABSTRACT FROM AUTHOR]

The phenomenon of elderly patients staying in hospital emergency department observation units for extended time in urban China poses a challenge to China’s healthcare system and presents a social problem of inequality. In this paper, we analyse statistics collected from 16 major public hospitals in Beijing to assess the extent and intensity of the problem and examine interviews of medical professionals to understand the mechanisms linking the issue to the Chinese healthcare system. We study the issue with the literature on market transition theory and on China’s recent healthcare reforms and view this age-based inequality as an outcome of the economic and social transformations in China. We make a few policy recommendations including using age-specific bed turnover and mortality rates for evaluating performance, employing three different release-status dependent mortality rates of emergency department patients for the evaluation of hospitals, and improving the capacity of post-acute, ambulatory care and geriatric care services in urban China. [ABSTRACT FROM AUTHOR]

The objective of universal health care systems is to achieve equality in the use of health services at the same level of care need. This study evaluates the relationship of socioeconomic position with the frequency of doctor visits in subjects with and without chronic diseases in Germany and Spain. The dependent variables included number of consultations and if a medical consultation occurred. The socioeconomic factors were income and education. The magnitude of the relationship between socioeconomic position and medical consultation frequency was estimated by calculating the percentage ratio using binomial regression and by calculating the difference in consultations by analysis of the covariance, in the case of number of visits. Statistically significant findings according to education were not observed. The percentage ratio in the medical consultations among those with lower and higher income was 1.03 (95% confidence interval [CI] 1.01-2.88) in Germany and 1.11 (95% CI 1.03-1.20) in Spain among subjects with any of the studied chronic conditions. Also, in Germany the difference in the average number of consultations comparing lower income subjects with higher was 3.98 (95% CI 2.40-5.57) in those with chronic conditions. In both countries, there were no differences in the frequency of doctor visits according to education. However, a pro-inequality trend exists in favor of subjects with lower income. [ABSTRACT FROM AUTHOR]

Background: Fear of physicians is associated with a variety of negative relationship and clinical outcomes. Culturally competent communication has been suggested as a way for physicians to reduce patient fear. Previous research has not, however, assessed whether patients’ perceptions of physicians’ cultural competence are associated with the level of felt fear. This study assessed associations between patients’ fear of physicians and their perceptions of physicians’ cultural competence in healthcare interactions. Method: In this cross-sectional study, a purposive sample of 306 patients were recruited from the patient base of a local clinic system with three locations, one rural, one suburban, and one urban in Appalachian Ohio. Using validated paper-and-pencil questionnaires, we assessed patients’ perceptions of physicians’ cultural competence in four domains (macro cultural issues, proxemics/chronemics, language issues, and patient-centeredness) as well as fear of physicians. Results: Fear of physicians was associated with perceptions that physicians’ accommodated cultural differences related to issues of personal space and time and with perceptions of physicians’ provision of patient-centered care. Other domains of intercultural competence indicated negative association, but were not significant. Conclusions: The findings of this study provide evidence that some forms of physician accommodation of cultural difference are associated with reduced fear of physicians. These findings have implications for promoting physicians' cultural competence in healthcare interactions. These implications, with a focus on patient-physician communication are discussed. [ABSTRACT FROM AUTHOR]

Background: Mental health service providers are increasingly interested in patient perspectives. We examined rates and predictors of patient-reported satisfaction and perceived helpfulness in a cross-national general population survey of adults with 12-month DSM-IV disorders who saw a provider for help with their mental health. Methods: Data were obtained from epidemiological surveys in the World Mental Health Survey Initiative. Respondents were asked about satisfaction with treatments received from up to 11 different types of providers (very satisfied, satisfied, neither satisfied nor dissatisfied, somewhat dissatisfied, very dissatisfied) and helpfulness of the provider (a lot, some, a little, not at all). We modelled predictors of satisfaction and helpfulness using a dataset of patient-provider observations (n = 5,248). Results: Most treatment was provided by general medical providers (37.4%), psychiatrists (18.4%) and psychologists (12.7%). Most patients were satisfied or very satisfied (65.9-87.5%, across provider) and helped a lot or some (64.4-90.3%). Spiritual advisors and healers were most often rated satisfactory and helpful. Social workers in human services settings were rated lowest on both dimensions. Patients also reported comparatively low satisfaction with general medical doctors and psychiatrists/psychologists and found general medical doctors less helpful than other providers. Men and students reported lower levels of satisfaction than women and nonstudents. Respondents with high education reported higher satisfaction and helpfulness than those with lower education. Type of mental disorder was unrelated to satisfaction but in some cases (depression, bipolar spectrum disorder, social phobia) was associated with low perceived helpfulness. Insurance was unrelated to either satisfaction or perceived helpfulness but in some cases was associated with elevated perceived helpfulness for a given level of satisfaction. Conclusions: Satisfaction with and perceived helpfulness of treatment varied as a function of type of provider, service setting, mental status, and socio-demographic variables. Invariably, caution is needed in combining data from multiple countries where there are cultural and service delivery variations. Even so, our findings underscore the utility of patient perspectives in treatment evaluation and may also be relevant in efforts to match patients to treatments. [ABSTRACT FROM AUTHOR]

Insurance coverage increases health care consumption, but less is known whether moderate copayments affect adults' primary care utilization in a system characterized by gatekeeping. We analyze whether abolishing a 14-euro copayment for visits to general practitioners (GP) in Helsinki, the capital of Finland, increased the number of GP visits among adults and especially among low-income individuals. Using a difference-in-differences (DD) design and combining several administrative registers from 2011 to 2014, we find that the abolition is associated with only a small increase in GP visits (+0.04 visits annually, or +4.4 %, for all adults). The increase is driven by low-income adults (+0.06 visits, or +4.5 %, at the bottom 40 %). Although the point estimates are rather robustly positive, the conclusions regarding the statistical significance are sensitive to how we account for clustering in a setting characterized by only one treated cluster and a finite number of comparison clusters. [ABSTRACT FROM AUTHOR]

The availability and affordability of medicine is an essential issue in any population globally, and drug regulatory agencies need the information to prevent an unforeseen matter and take necessary decisions by relevant agencies so that medicine will be available at an affordable price. Moreover, it is also essential to assess the consumer perception of patterns and knowledge about medicine use, subject to perception bias and belief bias. The current study examines consumers’ perceptions of medicine availability, medicine spending, affordability of medicine, patterns and knowledge of medication use. A nationwide cross-sectional study was performed in Mongolia. The survey consists of nineteen closed-ended questionnaire items. The manuscript has presented according to The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines on the crosssectional study. A total of seven thousand five hundred and thirty-two (n=7532) had participated in the study. The average spending of medicine per month in Mongolia is 4.00 USD-17.00 USD/= per month. A large percentage of the population (47.8%) has skipped buying prescription drugs due to affordability issues. 47.4% of the population believe that the price of the drug sold in the market is expensive. A surprisingly 56% of study population indicate that the pharmacy does not have enough type and stock of drug. The study population (40.4%) does not have enough awareness about falsified medicine, and 30.4% cannot buy discounted medicine covered by the health insurance fund. A considerable percentage of the population (74.2%) take medicine according to doctor instructions and is firmly in favour of the government to regulate the drug prices (79.9%). [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to present a series of cases of international students being treated in a specialized early intervention service for first-episode psychosis (FEP), describing the particular challenges that arise in this process, and to provide recommendations addressing these challenges.Design/methodology/approach Two researchers independently reviewed the charts of seven international students and discussed them with their treating clinicians. Recurring themes were identified through an iterative process of discussion and consensus.Findings Four themes were identified which demonstrated specific challenges faced by international students being treated for FEP: difficulty maintaining student visa status, limited social and family support, financial and health insurance issues, and service disengagement.Originality/value The study suggests that international students with FEP may present with numerous and unique challenges, thereby requiring special attention in their treatment. Although these are preliminary findings based on a small case series, the findings can inform recommendations for mental health services in cities with a sizeable international student population and guide future research on this topic. [ABSTRACT FROM AUTHOR]

Copyright of Marketing & Management of Innovations / Marketing ì Menedžment Ìnnovacìj is the property of Sumy State University, Department of Marketing & Management of Innovative Activity and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The impending expiration of patent protection for recombinant insulins provides the opportunity to introduce cost-saving copies, named biosimilars, onto the market. Although there is broad experience in the production and characterisation of insulins, the development of copies is still a challenge. In this paper, the main features of insulins and the EU regulatory framework for their biosimilar products are reviewed. The main focus is on rapid-acting insulin analogues (Humalog; Novolog/NovoRapid; Apidra). Since they differ by one or two amino acids in chain B, production of one biosimilar for all three drug products is not feasible. However, from post-marketing-collected clinical data, rapid-acting insulin analogues seem to have similar therapeutic efficacy. It is reasonable to suppose that, for prescription to treatment-naïve patients, the cheaper biosimilar would be the preferred choice of physicians, either spontaneously or induced by health insurance. Therefore, its introduction will affect the market share of all the other rapid-acting insulin analogues. [ABSTRACT FROM AUTHOR]

Purpose: As an important management method of the global healthcare system, diagnosis related groups (DRGs) classify patients into different cost groups and pay more attention to the equitable distribution of medical resources and the quality of medical services. At present, most countries have used DRGs to help medical institutions and doctors to treat patients more accurately, avoid the waste of medical resources, and improve treatment efficiency. Methods: The Web of Science database was searched to collect all relevant literature on DRGs from 2013 to 2022. The literature information was imported into CiteSpace, Vosviewer, and Histcite for data analysis and visualization of the results. Analyze the cooperative relationship among the countries, institutions, journals, and authors. The usage trend of keywords; Highlight the content of the cited articles. Results: The number of articles published in this decade was stable, and the number of citations in 2014 was the highest. The United States and Germany, as the first countries to use the DRGs system, are ahead of other countries in terms of the number and quality of articles. We have carried out content research on the articles with high citations, and summarized the application range of DRGs; classification method; advantages and disadvantages of the application. In general, the development trend of DRGs in foreign countries is to continuously optimize the classification method, expand the scope of application, and improve the application effect. These provide support and reference for the improvement of medical services and the perfection of the medical insurance system. Conclusion: The application of DRGs can improve the quality and efficiency of medical services, and reduce the waste of medical expenses. It can also promote the rational allocation of medical resources and the equity of medical services. In the future, DRGs will pay more attention to the personalized diagnosis and treatment and fine management of patients, and the sharing and standardization of medical data, to promote the development of medical informatization. [ABSTRACT FROM AUTHOR]

This paper reports research on improving decisions about hospital discharges – decisions that are now made by physicians based on mainly subjective evaluations of patients’ discharge status. We report an experiment on uptake of our clinical decision support system (CDSS) which presents physicians with evidence-based discharge criteria that can be effectively applied at the point of care where the discharge decision is made. One experimental treatment we report prompts physician attentiveness to the CDSS by replacing the default option of universal “opt in” to patient discharge with the alternative default option of “opt out” from the CDSS recommendations to discharge or not to discharge the patient on each day of hospital stay. We also report results from experimental treatments that implement the CDSS under varying conditions of time pressure on the subjects. The experiment was conducted using resident physicians and fourth-year medical students at a university medical school as subjects. [ABSTRACT FROM AUTHOR]

Medical data are important in diagnosis, treatment, recovery, and medical accident investigation. The integrity and availability of medical data are the basic guarantee for the smooth operation of these activities. The privacy of medical data is a natural demand from the sensitivity of medical data. At present, there are mainly two ways to protect the privacy of medical data. One way is to store medical data in a local database and set up an access control strategy of the database. The other way is to encrypt medical data with the patient's key and to share the key when needed. The problem with the first method is that the data in the local database may be modified or deleted. The problem with the second method is that the key cannot be shared when the patient dies during the diagnosis and treatment. These two problems will damage the availability of data. This paper proposes to establish a shared key that could be reconstructed by the legitimate parties before the process of diagnosis and treatment begins. The data in the diagnosis and treatment process is encrypted and stored in a blockchain using the shared key. The proposal meets the integrity, availability and privacy requirements of medical data. It uses the sibling intractable function families (SIFF) to establish a shared key, and uses the Hyperledger Fabric to store encrypted data. The simulation shows that the system has good efficiency. Additionally, it is the first time to introduce SIFF to a blockchain application. [ABSTRACT FROM AUTHOR]

Objective: To quantify impacts of early Affordable Care Act (ACA) Medicaid expansions on Medicaid participation for primary care physicians. Data Sources: The study uses secondary Medicaid Analytic eXtract (MAX) data from the United States for 2009–2012, as well as secondary National Plan and Provider Enumeration System (NPPES) data from the United States for 2015. Study Design: The study uses a quasi‐experimental difference‐in‐differences study design where the policy change is Medicaid expansion in six states that adopted early ACA Medicaid expansions during 2010 and 2011: California, Connecticut, the District of Columbia, Minnesota, New Jersey, and Washington. The key outcome variables are five monthly measures of physician participation: the number of Medicaid visits, the number of Medicaid patients, seeing at least 1 Medicaid patient, seeing at least 25 Medicaid patients, and seeing at least 50 Medicaid patients. Data Collection/Extraction Methods: The sample consists of all physicians who were active between 2005 and 2015, according to the NPPES. Principal Findings: For primary care physicians, Medicaid expansion led to a 29% increase in Medicaid visits (5.88 per month; 95% CI: 2.49–9.27), a 29% increase in Medicaid patients (4.59 per month; 95% CI: 2.16–7.02), and did not affect the probability of any Medicaid participation. Medicaid expansion also led to a 22% increase in the probability of seeing at least 25 Medicaid patients per month (4.58 percentage points; 95% CI: 1.27–7.89) and a 31% increase in the probability of seeing at least 50 Medicaid patients per month (2.99 percentage points; 95% CI: 0.99–4.99). Conclusions: Early ACA Medicaid expansions led to increased Medicaid visits for primary care physicians but did not affect the probability of any Medicaid participation. Primary care physicians who had previously served Medicaid patients responded to early ACA Medicaid expansions by serving substantially more Medicaid patients. [ABSTRACT FROM AUTHOR]

When considering proposed reforms of the U.S. health care system, some physicians dismiss the single-payer model (Medicare for All or state-based universal health care proposals) out of concern that their reimbursement and thus their income would be reduced. This study is an effort to quantitate that concern in the case of state-based plans and, in so doing, to suggest a template for evaluating the financial consequences for physicians of single-payer health care reform in general. To put the data into concrete, practical terms, I envision a hypothetical primary care physician's practice and develop its plausible financial components in the present multi-payer system and in five proposed state-based, single-payer systems. The calculations reveal that in all five single-payer plans evaluated, the hypothetical physician's Total Net Income (take-home pay) would exceed that in the current multi-payer system. Whether these results apply to actual practices or not, they suggest that, when considering the financial impact of single-payer reform on their practices, physicians should consider all the financial consequences of such reform, not just the proposed reimbursement level. More quantitative analyses of these important financial variables in different practice settings must be pursued. [ABSTRACT FROM AUTHOR]

Background Lipoprotein apheresis (LA) is an officially accepted therapeutic approach in Germany. Reliable population-based data on the patients are scarce. It is of special interest to learn what are the main indications for this extracorporeal treatment and how many new patients started over the last years. Methods This paper is a summary of the situation of the treatment of high-risk patients via LA in the federal state of Saxony, Germany. The documentation of all patients who agreed to be included into this study have been evaluated. Patients were treated at the University Hospital Dresden (UHD) and in private practices of nephrologists. This evaluation aimed at the characterization of patients treated with LA in Saxony with respect to age, gender, lipid pattern, to the number of new patients per year and the development of the ratio of patients to the Saxon population between 2010 and 2013. The obtained data were compared with the official statistics published by the National Association of Statutory Health Insurance Physicians for whole Germany. Results In 2013, 181 patients, primarily males, were treated in 15 LA centers by 32 doctors. Still, the number of apheresis doctors per 1 million inhabitants is under the average in Germany (Saxony: 7.7/1 million inhabitants, average: 12/1 million inhabitants). The usage of LA is 45 per 1 million inhabitants in Saxony; in comparison to 2010, this is an increase of 16 per 1 million inhabitants. The number of new patients in 2013 with an isolated elevation of Lipoprotein(a) (Lp(a)) is twice as high than it was in 2011. The mean duration of all patients being treated with LA, most on a weekly basis, was 5.75 years (UHD: 6.2 years, range: 1 month to 23.1 years; other centers: 5.3 years, range: 1 month to 19.2 years). About 19.3% of all patients suffered from elevated triglyceride (TG) levels (>5 mmol/L). Non-high- density lipoprotein cholesterol (Non-HDL-C) was calculated, which is also acutely reduced by LA sessions. The following data were reported for those patients who are treated outside the UHD: risk factors such as hypertension and familial predisposition could be seen in almost every patient, and several others such as type 2 diabetes mellitus, genetic defects and obesity were also present. Almost all patients had suffered from cardiovascular events (CVE) occurring before the start of apheresis treatment. LA therapy led to a reduction in occurrence of CVE during LA therapy. In particular, patients with an isolated increased Lp(a) had the highest reduction when comparing CVE before and during apheresis therapy. In the official statistics published by the National Association of Statutory Health Insurance Physicians the number of LA patients with homozygous familial hypercholesterolemia (HoFH) is clearly too high. Moreover, these statistics do not include patients who are treated at hospitals like the UHD. Conclusion All in all it can be shown that the extracorporeal therapy is performed effectively in Saxony, and that more centers than 2010 (additional 5) were conducting this therapy when lipid-lowering medication was not sufficiently effective. It is certain that the number of patients requiring LA will increase in the future. [ABSTRACT FROM AUTHOR]

Prior studies suggest that hospital care is countercyclical among Medicare beneficiaries, and if anything, procyclical among the non-elderly. In this paper, we provide the first physician-level analysis of changes in healthcare provision to Medicare and privately insured patients across the business cycle. Using Florida discharge data aggregated to the physician level, we find that as county unemployment rates increase, physicians treat fewer privately insured patients in both inpatient and outpatient settings. In contrast, physicians who are more exposed to income losses during recessions provide more care to Medicare patients as the unemployment rate rises. Further analysis suggests that easing capacity constraints may contribute to this rise in Medicare volume; however, even in areas that are not capacity constrained, care provided to Medicare patients remains countercyclical among physicians with a large share of privately insured patients. This pattern is consistent with demand inducement in response to a negative income shock. [ABSTRACT FROM AUTHOR]

Justification: The WHO 95-95-95 targets for 2030 do not imply that people living with HIV (PLHIV) achieve a good quality of life. The current 30-day dispensing interval for antiretroviral (ART) burdens the healthcare system. Lengthening dispensing intervals could alleviate this burden as well as enhance patient well-being. Objectives: To capture perceptions on 90-day dispensing interval (90D) for ART from the perspective of PLHIV, people on pre-exposure prophylaxis (PrEP), doctors, and pharmacists. Methods: Multi-centre observational survey led in France from 16 to 20 October 2020, among doctors agreeing to participate via regional coordinated care organisations for HIV, all PLHIV or people on PrEP consulting these outpatient-clinic doctors, and pharmacists doing ART dispensing. Results: The survey was completed by 220 doctors who saw 1087 people (999 PLHIV; 88 on PrEP) and 176 pharmacists from 55 centres. Among the PLHIV, 855 (85.6%, 95% CI: 83.2%–87.7%) and among the patients on PrEP, 70 (79.5%, 95% CI: 69.6%–87.4%) stated they would be interested in 90D. All in all, patients who were more likely to endorse 90D are those who opt exclusively for hospital dispensing (OR 3.22 [1.57–6.58]) and who rotate between hospital and community pharmacy dispensing (OR 3.29 [1.15–9.32]). Patients who were less likely to endorse 90-D were those who consult in a city located outside the 3 French high HIV prevalence regions (OR 0.66 [0.44–0.99]), receive 2 vs 1 pill QD regimens (OR 0.53 [0.31–0.91]), and anticipate at least one vs no limitation to 90D (OR 0.27 [0.17–0.42]). 90D was perceived as possible by 152 pharmacists (86.4%), including 8 (5%) without restriction, and 219 doctors (99.6%), including 42 (19.2%) regardless of PLHIV's immunovirologic status or social conditions (health insurance coverage, access to housing or accommodation, access to rights, resources). Comparison of the benefits and limitations of a 90-day ART dispensing interval as perceived by PLHIV and people on PrEP, doctors and pharmacists shows that doctors anticipate a higher number of benefits than people on ART and/or pharmacists, chiefly that 90D would be more convenient and create less risk of drug shortages and that patients would gain autonomy and a better quality of life. Pharmacists were found to clearly perceive the economic benefits (90D would be less expensive) but anticipate more drawbacks than doctors and the people on ART themselves: more administrative burdens, more non-dispensing if doses get lost, harder to track adherence and more drug–drug interaction issues, and more work as they shall have to warn the patient of potential risks of shortages due to the cost of the stock. Conclusion: A clear majority of PLHIV, people on PrEP, doctors, and pharmacists endorsed 90D of ART. Most patients thought that 90D would be a good option, whereas most pharmacists and doctors thought that eligibility for 90D dispensing should depend on immunovirologic factors and social condition criteria. Moreover, pharmacists thought it would be necessary to commit regulatory resources and a better follow-up on adherence and drug–drug interactions. [ABSTRACT FROM AUTHOR]

Skin cancer is one of the most common cancers worldwide and the number of patients is steadily increasing. In skin cancer care, greater interdisciplinary cooperation is required for prevention, early detection, and new complex systemic therapies. However, the implementation of innovative medical care is a major challenge, especially for rural regions with an older than average, multimorbid population, with limited mobility, that are long distances from medical facilities. Solutions are necessary to ensure comprehensive oncological care in rural regions. The aim of this study was to identify indicators to establish a regional care network for integrated skin cancer care. To capture the perspectives of different stakeholder groups, we conducted two focus groups with twenty skin cancer patients and their relatives, a workshop with eight physicians, and three semi-structured interviews with health insurance company representatives. Qualitative data were recorded, transcribed, and analyzed following Mayring's content analysis methods. We generated ten categories based on the reported optimization potentials; five categories were assigned to all three stakeholder groups: Prevention and early diagnosis, accessibility of physicians/clinics, physicians' resources, care provider's responsibilities, and information exchange. The results indicate the need for stronger integration of care in the region. They provide the basis for regional networking as, for example, the conception of treatment pathways or telemedicine with the aim to improve a comprehensive skin cancer care. Our study should raise awareness and postulate as a demand that all patients receive guideline-based therapy, regardless of where they live. [ABSTRACT FROM AUTHOR]

Background: Patient medical out-of-pocket expenses are thought to be rising worldwide yet data describing trends over time is scant. We evaluated trends of out-of-pocket expenses for patients in Australia with one of five major cancers in the first-year after diagnosis.Methods: Participants from the QSKIN Sun and Health prospective cohort Study with a histologically confirmed breast, colorectal, lung, melanoma, or prostate cancer diagnosed between 2011 and 2015 were included (n = 1965). Medicare claims data on out-of-pocket expenses were analysed using a two-part model adjusted for year of diagnosis, health insurance status, age and education level. Fisher price and quantity indexes were also calculated to assess prices and volumes separately.Results: On average, patients with cancer diagnosed in 2015 spent 70% more out-of-pocket on direct medical expenses than those diagnosed in 2011. Out-of-pocket expenses increased significantly for patients with breast cancer (mean AU$2513 in 2011 to AU$6802 in 2015). Out-of-pocket expenses were higher overall for individuals with private health insurance. For prostate cancer, expenses increased for those without private health insurance over time (mean AU$1586 in 2011 to AU$4748 in 2014) and remained stable for those with private health insurance (AU$4397 in 2011 to AU$5623 in 2015). There were progressive increases in prices and quantities of medical services for patients with melanoma, breast and lung cancer. For all cancers, prices increased for medicines and doctor attendances but fluctuated for other medical services.Conclusion: Out-of-pocket expenses for patients with cancer have increased substantially over time. Such increases were more pronounced for women with breast cancer and those without private health insurance. Increased out-of-pocket expenses arose from both higher prices and higher volumes of health services but differ by cancer type. Further efforts to monitor patient out-of-pocket costs and prevent health inequities are required. [ABSTRACT FROM AUTHOR]

To explore the preferable way of use and design of a work ability prognosis support tool for insurance physicians (IPs) and labour experts (LEs), based on a prediction model for future changes in work ability among individuals applying for a work disability benefit. We conducted three focus groups with professionals of the Dutch Social Security Institute (17 IPs and 7 LEs). Data were audio recorded and qualitatively analysed according to the main principles of thematic analysis. Clarity and ease of use were mentioned as important features of the tool. Most professionals preferred to make their own judgement during the work disability assessment interview with the claimant and afterwards verify their evaluation with the tool. Concerning preferences on the design of the tool, dividing work disability claimants into categories based on the outcome of the prediction model was experienced as the most straightforward and clear way of presenting the results. Professionals expected that this encourages them to use the tool and act accordingly. The tool should be easy to access and interpret, to increase the chance that professionals will use it. This way it can optimally help professionals making accurate prognoses of future changes in work ability. A work ability prognosis support tool based on a prediction model for changes in work ability at one-year follow-up can help occupational health professionals in making accurate prognosis of individuals applying for a work disability benefit. To be used in occupational health practice, these tools should have a simple and easy-to-use design. Graphical risk presentation can be used to provide intuitive meaning to numerical information and support users' understanding. Taking professionals' preferences into account when developing these tools encourages professionals to use the tools and act accordingly. [ABSTRACT FROM AUTHOR]

Importance Several recent policy proposals have sought to expand the role of Medicaid in providing health insurance for low-income Americans, but there is little recent information on how physician participation in Medicaid compares with alternative forms of coverage for low-income Americans. Objective To compare the number of office-based physicians included in Medicaid managed care and health insurance exchange plans that operate in the same geographic markets. Design, Setting, and Participants This cross-sectional study used administrative data from physician network directories and survey data from office-based physicians for Kansas, Nebraska, New York, Tennessee, and Washington. The number of participants totaled 67 057 office-based physicians in the 5 sample states. Data were collected and analyzed from May 2018 to June 2019. Exposures Physician participation in a Medicaid managed care or health insurance exchange plan network. Main Outcomes and Measures The percentage of office-based physicians in a county who indicated during a phone survey that they participated in Medicaid; the percentage of office-based physicians in a county who participated in each Medicaid managed care and health insurance exchange plan network; and the percentage of office-based physicians in a county who participated in at least one Medicaid managed care plan or, separately, at least one health insurance exchange plan. Results Of the 67 057 office-based physicians in our sample, 49 983 reported in a telephone survey that they accepted Medicaid. This survey-based measure undercounted the percentage of physicians participating in Medicaid by 5.2% (95% CI, 2.3%-8.1%; P < .001) relative to a measure based on physician network directories. Medicaid managed care physician networks covered a mean (SD) of 63.4% (20.5%) of office-based physicians compared with health insurance exchange physician networks, which covered 51.0% (25.2%). In adjusted analyses, Medicaid managed care plans covered 6.2% (95% CI, 3.2%-9.3%, P < .001) more office-based physicians than health insurance exchange plans operating in the same counties. In the states where the same insurers participated in both markets (New York, Tennessee, Washington), the Medicaid managed care physician networks were 6.5% (95% CI, 3.2%-9.8%, P < .001) larger than the health insurance exchange networks offered by the same insurer. Conclusions and Relevance In this cross-sectional study of physician network data, Medicaid managed care physician networks included more office-based physicians than the physician networks of health insurance exchange plans operating in the same geographic markets. This suggests that Medicaid remains a viable option for expanding coverage in the United States. [ABSTRACT FROM AUTHOR]

Background: Since 2015, all pilot cities of public hospital reform in China have allowed the zero-markup drug policy and implemented the policy of Separating of Hospital Revenue from Drug Sales (SHRDS). The objective of this study is to evaluate whether SHRDS policy reduces the burden on patients, and to identify the mechanism through which SHRDS policy affects healthcare expenditure. Methods: In this study, we use large sample data of urban employee's healthcare insurance in Chengdu, and adopt the difference in difference model (DID) to estimate the impact of the SHRDS policy on total healthcare expenditures and drug expenditure of patients, and to provide empirical evidence for deepening medical and health system reform in China. Results: After the SHRDS policy's implementation, the total healthcare expenditure kept growing, but the growth rate slowed down between 2014 to 2015. The total healthcare expenditure of patients decreased by only 0.6%, the actual reimbursement expenditure of patients decreased by 4.1%, the reimbursement ratio decreased by 2.6%. and the drugs expenditure dropped by 14.4%. However, the examinations expenditure increased by 18.2%, material expenditure increased significantly by 38.5%, and nursing expenditure increased by 12.7%. Conclusions: After implementing the SHRDS policy, the significant reduction in drug expenditure led to more physicians inducing patients' healthcare service needs, and the increased social healthcare burden was partially transferred to the patients' personal economic burden through the decline in the reimbursement ratio. The SHRDS policy is not an effective way to control healthcare expenditure. [ABSTRACT FROM AUTHOR]

Abstract In this study, we document the effect of food stamp access on adult health-care utilization. While the Food Stamp Program is one of the largest safety net programs in the United States today, the universal nature of the program across geographic areas and over time limits the potential for quasi-experimental analysis. To circumvent this issue, we use variation in documented immigrants' eligibility for food stamps across states and over time due to welfare reform in 1996. Our estimates indicate that access to food stamps reduced physician visits. These findings have important implications for cost-benefit analyses of the Food Stamp Program, as reductions in physician visits due to food stamps may offset some of the program's impact on the overall government budget because of the existence of government-provided health insurance programs such as Medicaid. [ABSTRACT FROM AUTHOR]

Background. One of the main strategies to improve access to and the quality and efficiency of healthcare systems is a family physician program (FPP) as the primary care provider within an appropriate referral system. Objectives. The aim of this study was to investigate the level of adherence of rural insured patients to family physicians (FP) and the referral system, as well as factors that affect self-referral. Material and methods. This multicenter, cross-sectional study was conducted between April 2018 and February 2019 in East Azerbaijan Province, Iran. A questionnaire-based survey was used to collect data on patient characteristics, adherence to the FPP and referral system, and the reasons for self-referral from 1,553 participants recruited using multistage cluster sampling. Results. Overall, 58.9% of participants adhered to the FPP and referral system. The total self-referral rate was 41.1%, including 24.3% patients who had attended an FP appointment only to obtain a referral code, and 16.8% had self-referred directly. Data on age, sex, family monthly expenditure, and place of residence were associated with self-referral. Structural pitfalls, societal knowledge and attitudes, and cultural challenges were identified as the patients' reasons for self-referring. Within these categories, the most frequent reasons included uncertainty about the knowledge and skills of FPs (74.2%), easy and inexpensive access to specialized services (66.7%), better quality of specialized services (59%), and a lack of awareness of the FPP and the services provided at level 1. Conclusions. A significant percentage of enrollees did not adhere to the FPP and referral system. Considering the unwelcome consequences of self-referral, designing and implementing practical interventions seems essential in order to encourage patients to be more compliant. [ABSTRACT FROM AUTHOR]

An estimated 1.2 million people in the United States are living with HIV. Of those living with HIV, only 40% are engaged in HIV care, 37% are prescribed antiretroviral therapy (ART), and 30% are virally suppressed. Individual-, interpersonal-, and structural-level factors that represent barriers to engagement along the HIV care continuum are important to identify in order to inform priority areas and interventions. 296 adult residents of Rhode Island living with HIV between November 2015 and January 2016 were asked to participate in an observational study (Ryan White Part B Health Resources and Services Administration-funded consumer needs assessment) to identify the multilevel factors associated with engagement in the HIV care continuum outcomes (i.e., being retained in care, being prescribed ART, adhering to ART, and achieving viral suppression—all in the past 12 months). Multivariable logistic regression models were fit to model the four HIV care continuum outcomes. The majority of participants were over age 30 (92.5%), racial/ethnic minorities (67.1%), cisgender men (56.9%), and identified as straight/heterosexual (60.5%). Overall, 95.2% of participants were retained in care in the past 12 months, 93.0% were prescribed ART, 87.1% were currently adherent to ART, and 68.2% were virally suppressed. Factors positively associated with not being retained in HIV care in the past 12 months included having no income and challenges navigating the HIV care system. Being age 18–29 and having a provider who does not know how to treat people with HIV/AIDS were each positively associated with not being prescribed ART. Factors positively associated with not being adherent to ART included being age 18–29 and substance use in the past 12 months. Finally, having private insurance and having a provider who is not trustworthy were each positively associated with not being virally suppressed. Regardless of the fact that many of the individuals living with HIV in this sample are able to achieve an undetectable viral load, challenges with retention in HIV care and ART adherence threaten to undermine the clinical and public health benefits of treatment as prevention. Future longitudinal research conducted to better understand how to boost the effectiveness of treatment as prevention in this population should focus on examining the unique multilevel factors, polymorbidities, and conditions (mostly social determinants of health including housing, socioeconomic position, etc.) associated with suboptimal engagement across the stages of the HIV care continuum. [ABSTRACT FROM AUTHOR]

Objective: To investigate the urban‐rural disparities in health risk factors, health status and outcomes in Tianjin, China and to make an international comparison with urban‐rural health in Australia. Design: A descriptive analytical cross‐sectional survey. Setting: Mobile research teams conducted door‐to‐door field surveys of each house or department. The teams included local administrative staff and Tianjin Center for Disease Control and Prevention's epidemiologists, clinicians and laboratory technicians. Participants: A total of 25 288 residents were interviewed and clinically observed, including 8583 urban residents and 16 705 rural residents. Main outcome measure: Health risk factors, health status and outcomes. Results: The age structure in urban areas of Tianjin was growing older. Rural residents received less high school education and university education than did urban residents. Urban residents had higher medical insurance coverage and paid more out‐of‐pocket medical expenditures than did rural residents. The prevalence of smoking and the crude alcohol consumption rate were higher in rural areas than in urban areas. Rural residents had feelings of higher self‐satisfaction concerning their health status than did urban residents. The prevalence of hypertensive disease, type 2 diabetes and heart, stroke and vascular diseases were significantly lower in rural areas than in urban areas. The incidence rate of serious injuries resulting from traffic accidents was significantly higher in rural areas than in urban areas. Conclusion: Contrary to Australian urban‐rural survey outcomes, the health status and outcomes of residents in rural areas of Tianjin seemed to be better than those of their counterparts in urban areas. The underlying determinants of these outcomes need to be explored with further study. [ABSTRACT FROM AUTHOR]

Background: Many countries in Europe have implemented managed competition and patient choice during the last decade. With the introduction of managed competition, health insurers also became an important stakeholder. They purchase services on behalf of their customers and are allowed to contract healthcare providers selectively. It has, therefore, become increasingly important to take one's insurance into account when choosing a provider. There is little evidence that patients make active choices in the way that policymakers assume they do. This research aims to investigate, firstly, the role of patients in choosing a healthcare provider at the point of referral, then the role of the GP and, finally, the influence of the health insurer/insurance policies within this process. Methods: We videotaped a series of everyday consultations between Dutch GPs and their patients during 2015 and 2016. In 117 of these consultations, with 28 GPs, the patient was referred to another healthcare provider. These consultations were coded by three observers using an observation protocol which assessed the role of the patient, GP, and the influence of the health insurer during the referral. Results: Patients were divided into three groups: patients with little or no input, patients with some input, and those with a lot of input. Just over half of the patients (56%) seemed to have some, or a lot of, input into the choice of a healthcare provider at the point of referral by their GP. In addition, in almost half of the consultations (47%), GPs inquired about their patients' preferences regarding a healthcare provider. Topics regarding the health insurance or insurance policy of a patient were rarely (14%) discussed at the point of referral. Conclusions: Just over half of the patients appear to have some, or a lot of, input into their choice of a healthcare provider at the point of referral by their GP. However, the remainder of the patients had little or no input. If more patient choice continues to be an important aim for policy makers, patients should be encouraged to actively choose the healthcare provider who best fits their needs and preferences. [ABSTRACT FROM AUTHOR]