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Background: Despite the direct access to clients in physiotherapy worldwide, Iran has yet to achieve significant improvements in the educational standards and professional responsibilities of physiotherapists. Currently, Iranian physiotherapists do not have direct access to patients. This study aims to present solutions for the professional development of physiotherapy, based on the perspectives of scholars in this field. Methods: This qualitative content analysis study explored the experiences of 12 physiotherapy scholars from three levels of study (bachelor's, master's, and doctorate) through structured and semi-in-depth face-to-face interviews. Data analysis was conducted concurrently with data collection using Granheim and Ludman's content analysis method. Results: The identified potential solutions include continuous review of the curriculum, strengthening clinical education, elevation of the basic level of physiotherapy education to a professional doctorate or master's degree, post-graduation competency assessment, revision of educational priorities, establishing a strong presence in hospital and community departments, preventing the influence and interference of other disciplines, raising public awareness of the capabilities and potential of the profession, and paying greater attention to professional ethics. Conclusion: In the absence of entry-level general doctor of physiotherapy and direct access to patients, the quality of physiotherapy services will not improve, leading to suboptimal health outcomes for clients and consequent waste of time and financial resources for both patients and insurance providers. [ABSTRACT FROM AUTHOR]

We examine the heterogeneous effects of reference pricing, a health insurance reform introduced by the California Public Employees Retirement System (CalPERS), on the distribution of spending by patients and insurers. Using medical claims data for CalPERS and a comparison group not subject to reference pricing, we use the changes-in-changes approach to estimate the quantile treatment effects of the program across different medical procedures. We find that the quantile treatment effects vary across the patient spending distributions, with a range of positive and negative estimates of the QTE, depending on the medical procedure considered. However, across all procedures, the insurers spending distributions tend to shift left, with the largest reductions occurring in the right-tail of the spending distributions. These effects are not captured by mean estimates but have important policy implications.

Background Moyamoya is a rare arteriopathy affecting the intracranial circulation with a risk of stroke in the pediatric population. High‐volume centers provide improved outcomes after surgical revascularization compared with low‐volume centers. However, private insurers are often reluctant to approve care out‐of‐network. We hypothesized that rare diseases that can be treated in a single procedure, such as revascularization for moyamoya, can yield improved clinical outcomes with substantial cost savings to insurance companies when approved for care at high‐volume centers of excellence. Methods Longitudinal deidentified data of pediatric patients undergoing surgical revascularization for moyamoya from January 2018 to December 2020 (N = 125) were obtained from national commercial insurers by an independent third‐party analytics core. Patients were selected according to International Classification of Diseases, Tenth Revision (ICD‐10) diagnosis and procedure codes. For a 9‐month episode, clinical and cost outcome metrics were compared across centers, with patients from the highest volume center designated as the primary cohort. Results Patients in the primary cohort were on average younger at time of surgery, with greater medical comorbidities, yet exhibited decreased postoperative complications and fewer unplanned readmissions. The primary cohort had an overall 42% lower expense compared with patients treated at other single institution health systems ($89 000 versus $153 000). The primary cohort minimized out‐of‐network costs with implementation of a partnership care model, using local resources for preoperative workup in 68% of episodes, compared with only 8% of episodes at a comparator high‐volume center. Conclusion Implementation of a partnership model takes advantages of the surgical resources of a high‐volume center while maximizing local resource use for preoperative and postoperative care. Referral to high‐volume centers for pediatric moyamoya revascularization provides both improved outcomes for the patients and substantial cost savings for the insurers. These data suggest the development of high‐volume centers of excellence for select conditions requiring neurosurgical treatment confer benefit to both patients and insurers, even in cases of out‐of‐network care.

This study assessed the relationship between hospital ownership of physician organizations (known as hospital-physician vertical integration) and facility fees billed to commercial insurers and physician service prices. Healthcare claims came from the IBM® MarketScan® Commercial Database (2012-2016, N = 30,716,800 office visit claims [CPT codes 99211-99215]), and hospital-physician vertical integration measures were from SK&A Office Based Physicians Database provided by IQVIA. Multi-variate, fixed-effect models were used to regress prices on market-level hospital-physician vertical integration; models included geographic market and year fixed effects, claim-level variables, and time-varying market-level variables. Analyses did not find that market-level hospital-physician vertical integration was associated with the billing of facility fees for office visits. However, vertical integration was associated with office visit physician prices for some specialties. A 10-percentage-point increase in vertical integration was associated with a 1.0% price increase for primary care, a 0.6% increase for orthopedics, and a 0.5% increase for cardiology; no such association was found for obstetrics/gynecology or oncology. When comparing metropolitan statistical areas (MSAs) in the bottom quartile of changes in vertical integration from 2012 to 2016 to MSAs in the top quartile, we found the following relative price increases based on predicted values for claims in the top quartile: $1.64 (1.9% of mean 2012 predicted price) for primary care to $2.30 (3.1%) for orthopedics to $3.13 (3.4%) for cardiology. Differences in predicted price accounted for an estimated $45.8 million in additional expenditure on primary care office visits in the top quartile of MSAs in 2016. In summary, market-level hospital-physician vertical integration was positively associated with physician prices for select specialties, but was not associated with changes in the use of facility-fee billing. More evidence on the quality effects of hospital-physician vertical integration is needed, as price increases that are not accompanied by measurable quality improvements should be part of any regulatory review.

BackgroundA growing proportion of Medicare beneficiaries is covered by private insurers through Medicare Advantage, yet little is known about how these plans are structured in terms of relationships with physicians and implications for quality of care.ObjectiveThe objective of this study was to assess whether greater physician concentration of services across insurers was associated with higher quality in Medicare Advantage (MA), overall and particularly among MA insurers serving a high proportion of vulnerable enrollees.Research designA retrospective cohort design with regression analysis.Data sourcesThe primary dataset was 2014 MA encounter records submitted by insurers to the Centers for Medicare and Medicaid Services, covering 600,329 physicians across 119 insurers. These data were merged with Centers for Medicare and Medicaid Services data on MA contract quality rating as well as physician characteristics in the Medicare Data on Provider Practice and Specialty file.MeasuresTwo measures were generated to capture the concentration of physician services across insurers: the percentage of a physician's Medicare services which was through MA (MA penetration); and the percentage of a physician's MA services with a specific insurer (insurer share of MA services).ResultsGreater MA penetration and insurer share of MA services were each associated with higher MA plan quality. The relationship between insurer share and quality was stronger in contracts with a relatively high percentage of disabled enrollees.ConclusionGreater physician concentration of services across MA insurers was associated with a higher quality of care overall and especially among vulnerable enrollees.

Next-generation sequencing promises major advancements in precision medicine but faces considerable challenges with insurance coverage. These challenges are especially important to address in oncology in which next-generation tumor sequencing (NGTS) holds a particular promise, guiding the use of life-saving or life-prolonging therapies. Payers' coverage decision making on NGTS is challenging because this revolutionary technology pushes the very boundaries of the underlying framework used in coverage decisions. Some experts have called for the adaptation of the coverage framework to make it better equipped for assessing NGTS. Medicare's recent decision to cover NGTS makes this topic particularly urgent to examine. In this article, we discussed the previously proposed approaches for adaptation of the NGTS coverage framework, highlighted their innovations, and outlined remaining gaps in their ability to assess the features of NGTS. We then compared the three approaches with Medicare's national coverage determination for NGTS and discussed its implications for US private payers as well as for other technologies and clinical areas. We focused on US payers because analyses of coverage approaches and policies in the large and complex US health care system may inform similar efforts in other countries. We concluded that further adaptation of the coverage framework will facilitate a better suited assessment of NGTS and future genomics innovations.

This study examined the evolving landscape of insurer competition in the Medicare Advantage (MA) program from both national and local perspectives. Data from the Centers for Medicare and Medicaid Services revealed that the MA market has become more concentrated. National carriers expanded their national market share significantly from 2012 to 2023, whereas the collective market share of regional carriers without affiliation to Blue Cross and Blue Shield organizations declined because of acquisitions. For example, the combined national market share of national carriers increased from 46 percent in 2012 to 66 percent in 2023, while the combined national market share of non-Blue regional carriers decreased from 25 percent to 6 percent. Conversely, concentration in local markets has declined but remains highly concentrated, and evidence suggests that further declines may be unlikely. Specifically, declines in local market concentration have been limited to markets with low MA penetration. Once MA penetration exceeds 20 percent, further MA growth is not associated with further drops in concentration, on average. Thus, policy makers should be aware that MA program reforms that assume MA markets are competitive are unlikely to achieve program goals without ensuring the competitiveness of those markets.

BackgroundNew payment and care organization approaches, such as those of accountable care organizations (ACOs), are reshaping accountability and shifting risk, as well as decision making, from payers to providers, within the Triple Aim context of health reform. The Triple Aim calls for improving experience of care, improving health of populations, and reducing health care costs.ObjectivesTo understand how the transition to the ACO model impacts decision making on adoption and use of innovative technologies in the era of accelerating scientific advancement of personalized medicine and other innovations.MethodsWe interviewed representatives from 10 private payers and 6 provider institutions involved in implementing the ACO model (i.e., ACOs) to understand changes, challenges, and facilitators of decision making on medical innovations, including personalized medicine. We used the framework approach of qualitative research for study design and thematic analysis.ResultsWe found that representatives from the participating payer companies and ACOs perceive similar challenges to ACOs' decision making in terms of achieving a balance between the components of the Triple Aim-improving care experience, improving population health, and reducing costs. The challenges include the prevalence of cost over care quality considerations in ACOs' decisions and ACOs' insufficient analytical and technology assessment capacity to evaluate complex innovations such as personalized medicine. Decision-making facilitators included increased competition across ACOs and patients' interest in personalized medicine.ConclusionsAs new payment models evolve, payers, ACOs, and other stakeholders should address challenges and leverage opportunities to arm ACOs with robust, consistent, rigorous, and transparent approaches to decision making on medical innovations.

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In health insurance markets with regulated competition, regulators face the challenge of preventing risk selection. This paper provides a framework for analyzing the scope (i.e., potential actions by insurers and consumers) and incentives for risk selection in such markets. Our approach consists of three steps. First, we describe four types of risk selection: (a) selection by consumers in and out of the market, (b) selection by consumers between high- and low-value plans, (c) selection by insurers via plan design, and (d) selection by insurers via other channels such as marketing, customer service, and supplementary insurance. In a second step, we develop a conceptual framework of how regulation and features of health insurance markets affect the scope and incentives for risk selection along these four dimensions. In a third step, we use this framework to compare nine health insurance markets with regulated competition in Australia, Europe, Israel, and the United States., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Total knee arthroplasty (TKA) is a commonly performed knee surgery and prior arthroscopic meniscectomy (AM) has been linked to an increased risk of TKA in the general population., Objective: To study the relationship between AM and TKA among injured workers whose medical care is paid for under workers' compensation (WC)., Method: A total of 17,247 lost-time claims depicting all arthroscopic knee surgical procedures performed from 2007 to 2017 were followed to the end of 2022 and analyzed., Results: The odds ratio of undergoing a TKA for those with a preceding AM is 2.20, controlling for age, sex, and attorney involvement., Conclusions: Undergoing an AM is associated with an increased risk of TKA in WC claimants., Competing Interests: Conflict of interest: None declared., (Copyright © 2024 American College of Occupational and Environmental Medicine.)

Competing Interests: Conflicts of interest Dr Mostaghimi has received consulting or royalty fees from Pfizer, hims, Digital Diagnostics, Concert, Lilly, AbbVie, Equillium, Boehringer Ingelheim, LEO, and ACOM. Dr Charrow has received consulting fees from Novartis. Authors Ly, Manjaly, and Kamal and Dr Theodosakis have no conflicts of interest to declare.

Many community-rated health insurance markets include risk equalization (also known as risk adjustment) to mitigate risk selection incentives for competing insurers. Empirical evaluations of risk equalization typically quantify selection incentives through predictable profits and losses net of risk equalization for various groups of consumers (e.g. the healthy versus the chronically ill). The underlying assumption is that absence of predictable profits and losses implies absence of selection incentives. This paper questions this assumption. We show that even when risk equalization perfectly compensates insurers for predictable differences in mean spending between groups, selection incentives are likely to remain. The reason is that the uncertainty about residual spending (i.e., spending net of risk equalization) differs across groups, e.g., the risk of substantial losses is larger for the chronically ill than for the healthy. In a risk-rated market, insurers are likely to charge a higher profit mark-up (to cover uncertainty in residual spending) and a higher safety mark-up (to cover the risk of large losses) to chronically ill than to healthy individuals. When such differentiation is not allowed, insurers face incentives to select in favor of the healthy. Although the exact size of these selection incentives depends on contextual factors, our empirical simulations indicate they can be non-trivial. Our findings suggest that - in addition to the equalization of differences in mean spending between the healthy and the chronically ill - policy measures might be needed to diminish (or compensate insurers for) heteroscedasticity of residual spending across groups., (© 2023. The Author(s).)

Australian osteopaths predominately work in private practice. The vast majority of patients who present to osteopaths fund their own care, with many receiving a rebate through their private health insurance cover. While there is little that describes the relationship between the Australian osteopathy profession and private health insurers, such information could provide an opportunity for insurers to improve coverage of osteopathy through enhanced benefits. To identify the extent of private health insurance cover available for osteopathy and to explore the attitudes of private health insurers towards the Australian osteopathy profession. This qualitative study used: 1) content analysis of Australian private health insurers offerings for osteopathy, and 2) the Theoretical Domains Framework (TDF) to inform interviews with representatives from Australian private health insurers. The interviews were transcribed and coded with respect to the TDF. Of the 35 private health insurers in Australia, 33 offered benefits for osteopathy. Four interviews were conducted with representatives from the 10 largest private health insurers who provide benefits. Osteopathy represents a very small proportion of their services. The inclusion of osteopathic services is market driven. Private health insurance representatives had limited knowledge and understanding of osteopathy, however, they acknowledged the value that some of their members saw in receiving osteopathic care. Osteopathy is bundled with complementary and allied health services by 91.4% of insurers. Osteopathy is included in the majority of Australian private health insurers' offerings because the service value-adds to their products. Further research into the efficacy and cost-effectiveness of osteopathy as well as an educational campaign that provides private health insurers with information about the scope of osteopathy are needed to secure its ongoing inclusion in private health insurance in Australia. • Benefits for osteopathic treatment are covered by most private health insurers in Australia. • Osteopathy is viewed favourably by these insurers. • The findings from this research will inform strategies to secure the ongoing inclusion of benefits for osteopathic treatment by private health insurers in Australia. [ABSTRACT FROM AUTHOR]

Managed care embodies an effort by employers, the insurance industry, and some elements of the medical profession to establish priorities and decide who gets what from the health care system. After a turbulent decade of trial and error, that experiment can be characterized as an economic success but a political failure. The strategy of giving with one hand while taking away with the other, of offering comprehensive benefits while restricting access through utilization review, has infuriated everyone involved. The protagonists of managed care now are in full retreat, broadening physician panels, removing restrictions, and reverting to fee-for-service payment. Governmental entities are avoiding politically volatile initiatives to balance limited resources and unlimited expectations. By default, if not by design, the consumer is emerging as the locus of priority setting in health care. The shift to consumerism is driven by a widespread skepticism of governmental, corporate, and professional dominance; unprecedented economic prosperity that reduces social tolerance for interference with individual autonomy; and the Internet technology revolution, which broadens access to information and facilitates the mass customization of insurance and delivery.

The use of many services is lower in Medicare Advantage (MA) compared with traditional Medicare, generating cost savings for insurers, whereas the quality of ambulatory services is higher. This study examined the role of selective contracting with providers in achieving these outcomes, focusing on primary care physicians. Assessing primary care physician costliness based on the gap between observed and predicted costs for their traditional Medicare patients, we found that the average primary care physician in MA networks was $433 less costly per patient (2.9 percent of baseline) compared with the regional mean, with less costly primary care physicians included in more networks than more costly ones. Favorable selection of patients by MA primary care physicians contributed partially to this result. The quality measures of MA primary care physicians were similar to the regional mean. In contrast, primary care physicians excluded from all MA networks were $1,617 (13.8 percent) costlier than the regional mean, with lower quality. Primary care physicians in narrow networks were $212 (1.4 percent) less costly than those in wide networks, but their quality was slightly lower. These findings highlight the potential role of selective contracting in reducing costs in the MA program.

Objectives: To analyze US commercial insurance payments associated with COVID-19 as a function of severity and duration of disease., Study Design: Retrospective database analysis., Methods: Patients with COVID-19 between April 1, 2020, and June 30, 2021, in the Merative MarketScan Commercial database were identified and stratified as having asymptomatic, mild, moderate (with and without lower respiratory disease), or severe/critical (S/C) disease based on the severity of the acute COVID-19 infection. Duration of disease (DOD) was estimated for all patients. Patients with DOD longer than 12 weeks were defined as having post-COVID-19 condition (PCC). Outcomes were all-cause payments (ACP) and disease-specific payments (DSP) for the entire DOD. Variables included demographic and comorbidities at the time of acute disease. Adjusted payments by disease severity were estimated using generalized linear models (γ distribution with log link)., Results: A total of 738,339 patients were included (374,401 asymptomatic, 156,220 mild, 180,213 moderate, and 27,505 S/C cases). DSP increased from $217 (95% CI, $214-221) for asymptomatic cases to $2744 (95% CI, $2678-$2811) for moderate cases with lower respiratory disease and $28,250 (95% CI, $26,963-$29,538) for S/C cases. ACP increased from $505 (95% CI, $497-$512) for asymptomatic cases to $46,538 (95% CI, $44,096-$48,979) for S/C cases. The DSP and ACP further increased by $50,736 (95% CI, $45,337-$56,136) and $94,839 (95% CI, $88,029-$101,649), respectively, in S/C cases with PCC vs a DOD of fewer than 4 weeks., Conclusions: COVID-19 payments for S/C cases were more than 10-fold greater than those of moderate cases and further increased by nearly $95,000 in S/C cases with PCC vs a DOD of fewer than 4 weeks.

Brazil's private health insurance market is the second largest in the world, behind only the United States, making it a valuable source of real-world evidence. This paper documents how physicians' inpatient reimbursement fees vary in the country and explores the relationship between these fees and the market share of health providers and health insurance companies. We implement a fixed-effects panel regression and take advantage of an unprecedented database that contains national administrative records of inpatient procedures paid by health insurance companies in 2016. We find a positive correlation between reimbursement for ICU procedures and provider market share. Conversely, we observe a negative correlation with insurers' market share. Additionally, we document substantial variation in procedure prices, both across and within Brazilian states, and observe that more competitive markets in Brazil tend to have higher population and GDP levels. Overall, our research enhances our understanding of the price setting dynamics of physician reimbursement fees in the context of a developing country. The insights gained from this study can assist policymakers in formulating appropriate regulations to ensure appropriate access to healthcare services., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

This study examined if greater insurer market power was associated with consistently lower negotiated prices within each hospital for 44 shoppable and emergency procedures, using price transparency data disclosed by 1,506 hospitals in metropolitan areas. We used multi-level fixed effects models to estimate the within-hospital variation in plan-level insurer-negotiated prices (from the largest insurer, the second largest insurer, other major insurers, and nonmajor insurers) and cash-pay prices as a function of insurer market power. For shoppable services, relative to nonmajor insurers, the largest, second largest, and other major insurers negotiated 23%, 16%, and 3% lower prices, respectively, while cash prices were 17% higher. For emergency room visits, while the largest insurers paid 5% less than nonmajor insurers, the second largest and other major insurers did not pay lower prices. Stratified analyses by type of shoppable services found varying magnitudes and patterns of price discounts associated with insurer market power., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To understand the current utilisation of the clinical framework for delivery of health services to manage compensable musculoskeletal injuries from the perspectives of insurer case managers and clinical panel members., Materials and Methods: Using a qualitative descriptive approach, 15 semi-structured interviews were conducted with members of key organisations including WorkSafe Victoria and Transport Accident Commission Victoria. All interviews were recorded and transcribed verbatim and analysed using thematic analysis., Results: Four over-arching themes were identified: (i) current use of the framework and principles is suboptimal leading to several problems including lack of evidence-based treatment by clinicians; (ii) barriers to optimal use of the framework include lack of adequate training of healthcare professionals on the framework principles and financial aspects of the compensation system; (iii) utilisation of the framework could be improved with training from peak associations, insurers, and regulating bodies; and (iv) optimal use of the framework will result in better health and work outcomes., Conclusions: The current use of the framework and its principles is suboptimal but can be improved by addressing the identified barriers.IMPLICATIONS FOR REHABILITATIONRehabilitation of compensable musculoskeletal injuries is often complex.Implementing the "Clinical Framework for Delivery of Health Services" can lead to provision of time and cost effective, evidence-based rehabilitation for compensable injuries, ultimately improving patient outcomes.Clinicians can enhance the implementation of the framework principles by integrating evidence-based practice and recommendations from clinical practice guidelines in treatment of compensable musculoskeletal injuries.Implementation of the framework principles may be enhanced by reviewing the compensation funding model to allow the healthcare practitioners adequate time and remuneration to adopt the framework principles when treating persons with compensable injuries.

Objectives: To use publicly available price transparency data files to establish empirical regularities about hospital-insurer contracting., Study Design: Retrospective analysis of 10 price transparency data files from HCA Healthcare., Methods: Cross-sectional qualitative analysis of 524 hospital-insurer contracts across 10 hospitals., Results: We ascertain 4 empirical regularities in these files. First, hospitals contract with many payers, ranging from 35 to 82 across the hospitals in the sample. Second, contract structure varies significantly within and across hospitals: Of the 524 contracts in our sample, the median contract contained 9 contract elements, whereas the mean contract contained 1285 contract elements. Third, most of the contracts in our sample contained multiple contracting methodologies (eg, both fixed fee and percentage of charges). Fourth, these contracts indicated substantial variation for the same service within and across hospitals, validating findings from analyses based on claims data and hospital price transparency files., Conclusions: Hospital-insurer contracts dictate the flow and structure of a significant portion of total health care expenditure in the US. Increased attention by both researchers and policy makers would lead to a greater understanding of this vital-yet understudied-element of the market for hospital services.

Background: Hospitals can leverage their position between the ultimate buyers and sellers of drugs to retain a substantial share of insurer pharmaceutical expenditures., Methods: In this study, we used 2020-2021 national Blue Cross Blue Shield claims data regarding patients in the United States who had drug-infusion visits for oncologic conditions, inflammatory conditions, or blood-cell deficiency disorders. Markups of the reimbursement prices were measured in terms of amounts paid by Blue Cross Blue Shield plans to hospitals and physician practices relative to the amounts paid by these providers to drug manufacturers. Acquisition-price reductions in hospital payments to drug manufacturers were measured in terms of discounts under the federal 340B Drug Pricing Program. We estimated the percentage of Blue Cross Blue Shield drug spending that was received by drug manufacturers and the percentage retained by provider organizations., Results: The study included 404,443 patients in the United States who had 4,727,189 drug-infusion visits. The median price markup (defined as the ratio of the reimbursement price to the acquisition price) for hospitals eligible for 340B discounts was 3.08 (interquartile range, 1.87 to 6.38). After adjustment for drug, patient, and geographic factors, price markups at hospitals eligible for 340B discounts were 6.59 times (95% confidence interval [CI], 6.02 to 7.16) as high as those in independent physician practices, and price markups at noneligible hospitals were 4.34 times (95% CI, 3.77 to 4.90) as high as those in physician practices. Hospitals eligible for 340B discounts retained 64.3% of insurer drug expenditures, whereas hospitals not eligible for 340B discounts retained 44.8% and independent physician practices retained 19.1%., Conclusions: This study showed that hospitals imposed large price markups and retained a substantial share of total insurer spending on physician-administered drugs for patients with private insurance. The effects were especially large for hospitals eligible for discounts under the federal 340B Drug Pricing Program on acquisition costs paid to manufacturers. (Funded by Arnold Ventures and the National Institute for Health Care Management.)., (Copyright © 2024 Massachusetts Medical Society.)

In advising the preferred therapy for the individual patient the expected results of the proposed intervention and possible side effects are the most relevant considerations. However, predicting the results of an intervention is difficult, especially when well designed randomized clinical trials (RCT's) are lacking or not conclusive. Artificial intelligence (AI) algorithms based on routine clinical data (real world data) can support clinical decision making, but in daily practice AI is still scarcely used. In this article one large radiotherapy facility and two health insurers describe their joint opinion on the possible role of AI based on real world data as an aid in clinical decision making when evidence from RCT's is not available. The introduction of proton radiotherapy in The Netherlands is being used as case model for AI model based clinical decision making.

Background: In 2020, Zorgverzekeraars Nederland (ZN), the umbrella organization of nine health insurers in The Netherlands. presented a vision of the future of mental health care in the Netherlands in ‘De GGZ in 2025. Vergezicht op de geestelijke gezondheidszorg’ (‘Outlook on mental health care’). This document can be seen as marking the fact that key stakeholders share a common vision on the future of the GGZ in the Netherlands. Contracting care is often difficult. The tension between providing quality and sufficient care and available funding leads to friction. Congruence in vision, goals and practices are important conditions for adequate relationship building. Does the vision document contribute to this?, Aim: To discuss the experiences of mental health care administrators and health insurers in contracting and collaboration., Method: Conducting interviews with both directors of mental health institutions and the strategic (policy) advisors of health insurers. In the approach we used the salience model., Results: The relationship between mental health care administrators and health insurers is perceived to be distrustful and complex, and has deteriorated slightly in 2021 compared to 2019. Perceived power, legitimacy and urgency affect the relationship. Almost all health insurers are characterized as dominant stakeholders based on the salience model. Both parties are open to improving the relationship, which requires more transparency and mutual understanding., Conclusion: With the supported content of the vision document, there is to some extent shared governance. The change steps (shared innovation) considered desirable will be promoted by partly granting the intended benefits to each other (shared savings).

Introduction: The pressure on general practitioners (GPs) is rising due to the increasing demand for care and a decreasing availability of GPs. eHealth is seen as one of the solutions to enhance accessibility and reduce workload. A platform supporting the organization and communication in general practice has been developed offering services, such as econsultations. This study aims to evaluate healthcare usage and costs of patients using this platform by comparing these outcomes (1) before and after implementation and (2) an intervention with a matched control group., Material and Methods: This study is a retrospective observational cohort study. To evaluate the longitudinal impact of the implementation on healthcare usage, mixed model Poisson analyses were used with time as a factor term for the within-subject analysis and exposure to the platform as a factor term and an interaction term (i.e., exposure X 6-months) in the between-subject analysis. Cost analyses were done with mixed model analyses of variance over time., Results: The total number of GP consultations significantly increased after compared to before implementation (i.e., Rate = 1.52; p < 0.001). The number of GP consultations was higher in the intervention compared to the control group (respectively, Rate = 1.23; p = 0.035). Healthcare costs increased for GP consultations after compared to before implementation (€13,57; p < 0.001). The costs for GP consults were significantly higher in the intervention compared to the control group (€7,06; p 0.018)., Conclusion: This study showed a rise in GP consultations and costs when implementing a digital platform. This increase was presumably and partly caused by circumstances in one of the two included practices. Moreover, creating new options for contacting and communicating with the GP can enhance care accessibility and thereby driving an increase in consultations. This digital platform is a promising working method in general practice to facilitate patients and provide GPs with more flexibility., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Medicare's prospective payment system (PPS) for hospital cases is based on diagnosis-related groups (DRGs). A wide variety of other third-party payers for hospital care have adapted elements of this system for their own use. The extent of DRG use varies considerably both by type of payer and by geographical area. Users include: 21 State Medicaid programs, 3 workers' compensation systems, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), more than one-half of the Blue Cross and Blue Shield Association (BCBSA) member plans, several self-insured employers, and a few employer coalitions. We describe how each of these payers use DRGs. No single approach is dominant. Some payers negotiate specific prices for so many combinations of DRG and hospital that the paradigm that payment equals rate times weight does not apply. What has emerged appears to be a very flexible payment system in which the only constant is the use of DRGs as a measure of output.

Background: There is less attention to assessing how health services meet the expectations of private health insurance (PHI) actors, clients, insurers, and providers in developing countries. Interdependently, the expectations of each actor are stipulated during contract negotiations (duties, obligations, and privileges) in a PHI arrangement. Complementary service roles performed by each actor significantly contribute to achieving their expectations. This study assessed the role of PHI in meeting the expectations of clients, insurers, and providers in Kampala. Lessons from this study may inform possible reviews and improvements in Uganda's proposed National Health Insurance Scheme (NHIS) to ensure NHIS service responsiveness., Methods: This study employed a qualitative case-study design. Eight (8) focus group discussions (FGDs) with insured clients and nine (9) key informant interviews (KIIs) with insurer and provider liaison officers between October 2020 and February 2021 were conducted. Participants were purposively selected from eligible institutions. Thematic analysis was employed, and findings were presented using themes with corresponding anonymized narratives and quotes., Results: Client-Provider, Client-Insurer, and Provider-Insurer expectations were generally not met. Client-provider expectations: Although most facilities were clean with a conducive care environment, clients experienced low service care responsiveness characterized by long waiting times. Both clients and providers received inadequate feedback about services they received and delivered respectively, in addition to prompt care being received by a few clients. For client-insurer expectations, under unclear service packages, clients received low-quality medicines. Lastly, for provider-insurer expectations, delayed payments, selective periodic assessments, and inadequate orientation of clients on insurance plans were most reported. Weak coordination between the client-provider and insurer did not support delivery processes for responsive service., Conclusion: Health care service responsiveness was generally low. There is a need to commit resources to support the setting up of clearer service package orientation programs, and efficient monitoring and feedback platforms. Uganda's proposed National Health Insurance Act may use these findings to: Inform its design initiatives focusing on operating under realistic expectations, investment in quality improvement systems and coordination, and efficient and accountable client care relationships., (© 2023. The Author(s).)

The rising cost of private health insurance and constraints within public health systems are global concerns. Genetic testing presents a transformative opportunity for health care to enhance health outcomes and optimise resource allocation through personalised medicine, early diagnosis, targeted treatments, managed care, and improved drug development. However, ethical and policy issues arise, including privacy, discrimination and equitable access to testing. Balancing these against potential health benefits poses a complex challenge. While some advocate for restricting health insurers from using genetic data, others argue that well-regulated private insurance can ensure affordability, improved health outcomes, and innovative care adoption. This article explores examples of improved health outcomes through genetic testing, identifies areas of risk related to insurers' use of genetic data, evaluates the adequacy of New Zealand's legal framework, and emphasises the need for ethical and equitable policy solutions. The broader issues of data governance, biases in algorithms, and implications of artificial intelligence and machine learning warrant separate exploration., Competing Interests: The author is also Director of NIB NZ Limited, a private health insurer, and NIB NZ Insurance Limited, a private life insurer.

This paper presents a contingent claim model designed to assess an insurer's equity within the framework of carbon trading regulations imposed on borrowing firms while also considering the integration of green lending. The development of this model is particularly relevant for regions with established carbon trading markets, with a specific focus on the post-period following the 2015 Paris Agreement concerning climate change. We focus on shareholders and policyholders to optimize equity and ensure maximum protection. Strict caps in cap-and-trade harm interest margins, reducing guaranteed rates for equity maximization and compromising policyholder protection. Government intervention through sustainable production carbon trading hinders win-win outcomes. Green subsidies can improve insurer margins, but achieving win-win solutions remains challenging. A collective approach is needed to share sustainable production and finance benefits among diverse economic sectors., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Chen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

In a healthcare system based on managed competition, health insurers are intended to be the prudent buyers of care on behalf of their enrollees. Equally, citizens are expected to be critical consumers when choosing a health insurance policy. The choice of a health insurance policy may be related to trust in the health insurer, as enrollees must believe that the health insurer will make the right choices for them when it comes to purchasing care. This study aims to investigate how enrollees' trust in health insurers is associated with their choice of a health insurance policy in the Netherlands. We will focus on the switching behaviour of enrollees and the choice of a policy with restrictive conditions. In February 2022, a questionnaire was sent to a representative sample regarding gender and age of the adult Dutch population. In total 1,125 enrollees responded, a response rate of 56%. Respondents were asked about the choices they made in choosing health insurance. Trust in health insurers was measured using the Health Insurer Trust Scale (HITS), a validated multiple item scale. Descriptive statistics, a paired t-test and logistic regression models were conducted to analyse the results. Of all respondents, 35% indicated that they agree, or completely agree, with the statement that they trust health insurers completely. In addition, trust in enrollees' own insurer is slightly higher than trust in other insurers (36.29 vs. 33.59, p<0.001). Furthermore, we found no significant associations between trust in health insurers, and whether enrollees have either switched health insurers or have chosen a policy with restrictive conditions. This study showed that enrollees' trust in health insurance in the Netherlands is relatively low and that trust in their own insurer is slightly higher than trust in other insurers. Furthermore, this study does not show a relationship between trust in health insurers and, either switching health insurers, or choosing a policy with restrictive conditions. Nevertheless, attention for increasing the trust in health insurers might still be important, as low trust may have negative consequences for other elements of the functioning of the healthcare system., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 van der Hulst et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)