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The introduction of hybrid diagnosis-related groups (DRG) presents new challenges for healthcare providers and health insurances. The same applied in 2023 to the institute designated by the Federal Ministry of Health (BMG) to extract medical procedures and calculate remuneration levels for the first hybrid DRGs. A responsible calculation methodology and a realistic data basis are required as the result of the calculation can lead to controversy, even to a splitting among specialist groups and constructs. There is also the threat of mismanagement with subsequent supply problems. In this context, a loss of quality can occur due to the use of simple surgical procedures that are less complex and not expensive with respect to material costs and are economical but not state of the art and thus directly worsen the medical care of patients in the statutory health insurance (GKV). Furthermore, it is already becoming apparent that procedures that are uneconomical due to the miscalculation are partially no longer being comprehensively rendered by healthcare providers due to adjustment of the service portfolio. An appropriate compensation of procedures is only possible based on a remuneration that adequately covers the costs. In this respect, this article is not intended to be understood as a "solution to the problem of the internal distribution of the remuneration in hybrid DRGs" but more to offer suggestions for solutions for the required further development of the hybrid DRG compensation level calculation to prevent a threat to the treatment of GKV patients due to mismanagement. As required in § 115f of the Sozialgesetzbuch V (SGB V), the recalculation of an economic remuneration must be carried out urgently and promptly using an empirical calculation basis and methodology and this must be regularly adapted., Competing Interests: Einhaltung ethischer Richtlinien. Interessenkonflikt: T. Kisch, R. Müller-Rath, S. Gregor, R. Lorenz, A. Neumann, S. Dittrich, M. Müller, R. Lippert, J. Henniger, B. Lembeck, E.-M. Baur, J. Karst, F. Vescia und R. Schmitz geben an, dass kein Interessenkonflikt besteht. Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Despite the introduction of the diagnosis-related groups (DRG) system, costs in the German healthcare system have risen continuously for years. In order to reduce costs the federal government is aiming to shift inpatient services to the outpatient sector. Outpatient services affect many areas of medicine, including proctological operations as these are common and can often be carried out on an outpatient basis., Objective: The aim of the present work is to discuss which areas of proctology are suitable for outpatient treatment and which structural requirements are necessary., Material and Methods: The present article is intended to provide a narrative overview with reference to the literature on the topic of outpatient care in proctology. A literature search was carried out using the following keywords: outpatient care, selective sector-level remuneration, day care, proctological operations, AOP catalog and hybrid DRG., Results: In proctology, outpatient surgical care is implementable in many cases; however, not every patient is suitable for this. In addition to previous illnesses, patient compliance and the possibility of postoperative care from relatives must also be taken into account. In addition, emergency treatment must be guaranteed. Contraindications include severe heart and circulatory diseases as well as severe coagulation or organ dysfunction. Extensive abscesses, complex fistulas or sphincter reconstructions should be surgically treated in an inpatient setting. The prerequisite for successful outpatient care is to make the sector boundaries between outpatient and inpatient patient care more permeable and to adequately remunerate the interventions., Conclusion: In addition to the surgical indications, the prerequisites for successful proctological operations are the correct assessment of the operational capability and compliance. From an organizational and economic perspective, better networking between outpatient and inpatient treatment and equal remuneration across the sector boundaries are crucial., Competing Interests: Einhaltung ethischer Richtlinien. Interessenkonflikt: S. Fritz, C. Reissfelder und D. Bussen geben an, dass kein Interessenkonflikt besteht. Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

At the latest since the Medical Services Healthcare Insurance Reform Act (MDK), the declared will of the legislation is the conversion of operations previously carried out in an inpatient setting to an outpatient setting. In trauma surgery and orthopedics numerous operations are carried out that could principally also be performed in an outpatient setting; however, a prerequisite is a medical assessment of the suitability of patients as well as an economic and normative framework that makes outpatient surgery attractive. Both the Outpatient Surgery in Hospitals Catalogue (AOP-Katalog) and the first edition of the Hybrid Diagnosis-related Groups (DRG) define interventions in trauma surgery that could be carried out in an outpatient setting. Hospitals are therefore required to find solutions for these interventions under processual and economic provisos. These range from omission of outpatient operations to the expansion as a separate financial department in the hospital. With the introduction of the hybrid DRG, the legislation enables equal remuneration for outpatient versus short-term inpatient treatment and leaves the case management up to the hospital; however, the performance of the AOP in the setting of a hospital and also hybrid case flat rates are as a rule not economically viable and bear the risk of the failure of all efforts at conversion to outpatient settings. It is necessary to carry out a fundamental revision of the remuneration and framework conditions for outpatient operations in trauma surgery and orthopedics in hospitals, involving practitioners. This is the only way that the conversion to outpatient treatment can succeed., Competing Interests: Einhaltung ethischer Richtlinien. Interessenkonflikt: N. von Dercks, A. Schuster, C. Kleber und P. Hepp geben an, dass kein Interessenkonflikt besteht. Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Hybrid DRG is a new form of remuneration in the German healthcare system. Selected OPS codes apply to all sectors, which, in combination with a specified ICD, result in a flat fee, regardless of whether the patient is managed as an outpatient or inpatient. This new form of billing has a huge impact on hospitals. The revenue situation is significantly worse than under the previous form of billing and requires adjustments at the locations. If these changes are not made, supply would be demonstrably deficient. Therefore, increased outsourcing to an outpatient setting is necessary. The advantages are the efficient use of staff and a structured selection of patients. Ideally, outpatient surgical units have an advantage here, but outpatient paths can also be created via separate areas in the central operating theatre. Using the example of inguinal hernia, over 50% of patients can be treated on an outpatient basis if selection is optimised. The disadvantage of this form of billing is the necessary financial reserve for innovations, training and the use of expensive operational aids. With the addition of incisional hernias to the hybrid catalogue in 2025, future care will become more cost-oriented., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Despite the devastating effects of out-of-pocket healthcare expenditures on households' financial outlays, which potentially stifle household resources needed for food consumption, the health financing program-food insecurity nexus is yet to receive much needed attention in the literature. This study makes a significant contribution by investigating the effect of health financing program, conceptualised as membership of a National Health Insurance Scheme, on household food insecurity using the food insecurity experience scale (FIES) and several quasi-experimental methods. Using data from the seventh round of the Ghana Living Standards Survey, our endogeneity-corrected results indicate that membership of a health financing program can contribute to reduction in household food insecurity. The results are robust to alternative conceptualisations of food insecurity and different quasi-experimental methods. The effect of health financing programme membership on food insecurity is more pronounced among urban and female-headed households. Our findings further point to household savings as an important channel through which membership of health financing program reduces food insecurity., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To analyze the investments made in medicines by the federated entities and the asymmetries in these investments from 2016 to 2020, which may have an impact on the supply of and access to these medicines in the SUS., Methods: This is an exploratory, retrospective study to identify who are the main entities responsible for investment in Primary Care medicines in municipalities, the evolution, counterparts, and regional differences of this investment between 2016 and 2020., Results: The amounts spent on medicines by Brazilian municipalities were higher than the contribution to the CBAF from the MS or the MS + State in all the years analyzed. The average percentages of federal funds transferred and municipal spending varied according to the region of Brazil. The average per capita amount invested in medicines by municipalities increased between 2016 and 2020 (deflation applied), with a greater impact for municipalities with lower MHDI. The Farmácia Popular program mainly reaches municipalities with the largest populations and the highest MHDI and is therefore not enough to address the inequalities in access pointed out., Conclusions: There has been a widening of inequalities in the capacity of municipalities to ensure access to medicines, especially among the most vulnerable municipalities, accumulating even more risks of illnesses and deaths from primary care-sensitive diseases.

Background: The Australian Government began implementing Medicare policies in the late 1990s aiming to improve Indigenous Peoples' access to the primary care. No aggregate central list of what policies have been implemented exists. The aim of this review was twofold: first to perform a scoping review to identify any literature mentioning a policy implemented between 1996 and 2023 regarding Indigenous Peoples' access to Medicare or the Pharmaceutical Benefits Scheme for primary care, and secondly to synthesise and describe any policies to enable learning from past successes and failures., Methods: Scoping review following the PRISMA-ScR process. Seven electronic databases were searched for any papers identifying any policy implemented between 1996-2023 to improve Indigenous Peoples' access to primary care. This was supplemented with searches in Google, key government databases, hand searching and expert input., Results: Sixteen policies were implemented and organised into six categories according to the primary care barrier they targeted: Medicare Benefits Schedule (MBS) funding structure; lack of Indignenous-appropriate MBS items; Pharmaceutical Benefits Scheme (PBS) access barriers; inappropriate care from mainstream general practitioners; bureaucratic impediments to MBS and PBS access; and data gaps., Discussion/conclusion: This is the first synthesis of Medicare and PBS policy history to improve Indigenous Peoples' access to primary health care, and provides a platform for future analysis. Identifying the names of relevant policies in any area is key to accountability and reliance on individual expertise is no substitute for transparent and durable policy record-keeping. A searchable long-term policy repository should be established to ensure that related policies can be identified, and that key policy documentation is publicly available in perpetuity., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Low-income and middle-income countries, including Kenya, are pursuing universal health coverage (UHC) through the establishment of Social Health Insurance programmes. As Kenya rolls out the recently unveiled UHC strategy that includes a national indigent cover programme, the goal of this study is to evaluate the impact of health insurance subsidy on poor households' healthcare costs and utilisation. We will also assess the effectiveness and equity in the beneficiary identification approach employed., Methodology and Analysis: Using a quantitative design with quasi-experimental and cross-sectional methods, our matched cohort study will recruit 1350 households across three purposively selected counties. The 'exposure' arm, enrolled in the UHC indigent programme, will be compared with a control arm of eligible but unenrolled households over 12 months. Coarsened exact matching will be used to pair households based on baseline characteristics, analysing differences in expenses and catastrophic health expenditure. A cross-sectional design will be employed to evaluate the effectiveness and equity in beneficiary identification, estimating inclusion errors associated with the subsidy programme while assessing gender equity., Ethics and Dissemination: Ethical approval has been obtained from the Scientific and Ethics Review Unit at Kenya Medical Research Institute, with additional permissions sought from County Health Departments. Participants will provide written informed consent. Dissemination strategies include peer-reviewed publications, conference presentations and policy-maker engagement for broad accessibility and impact., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Mental health care in Nigeria relies heavily on out-of-pocket payments, creating financial barriers that hinder access. A pilot scheme linked to the National Health Insurance Authority (NHIA) Group, the Individual and Family Social Health Insurance Program (GIFSHIP) was initiated to alleviate these challenges., Objective: The study sought to assess the NHIA scheme's effectiveness in reducing costs, enhancing clinical outcomes, and improving patient satisfaction relative to traditional payment methods in mental health care, while also evaluating the feasibility of a pilot individual GIFSHIP., Methodology: The study examined the NHIA scheme over nine months at a tertiary mental health facility in Nigeria, involving patients with various mental health diagnoses eligible for insurance. Data on care costs, in-patient admission rates, and patient satisfaction were gathered through structured questionnaires and hospital records. A comparative analysis was performed between insured and non-insured patients., Results: Insured patients experienced a significant reduction in financial burden, with monthly out-of-pocket expenses approximately 40% lower than their non-insured counterparts. In-patient admission rates and patient satisfaction were similar across both groups. The hospital's indigent patient fund supported a pilot individual GIFSHIP program for individuals with mental illness. Anticipated cost benefits may enhance service uptake and revenue for the hospital., Conclusion: The pilot mental health GIFSHIP scheme may alleviate financial pressures on patients and enhance access to quality care. Policymakers and healthcare providers can advocate for similar insurance schemes, particularly in integrated care environments, to foster sustainable and equitable mental health care for all. Keywords: Mental health insurance, GIFSHIP, Nigeria, out-of-pocket payment., Competing Interests: The Authors declare that no competing interest exists, (Copyright © 2024 by West African Journal of Medicine.)

Background: Among frequent healthcare users is a small group called "high-care users", with ≥ 10 hospital visits annually. They consume a disproportionate share of the healthcare budget, and their care is often inappropriate and unnecessary., Objectives: To assess the prevalence and determinants of persistent high-care (PHC) use (≥ 10 visits in two consecutive years) among National Health Insurance Authority (NHIA) enrollees., Methods: This cross-sectional study analyzed the data of 380 randomly selected patients attending the NHIS Clinic of Aminu Kano Teaching Hospital between January and June 2022. Using a data sheet, we collected their 2018 and 2019 data on biodata, clinic visit characteristics, diagnoses, and cost of care (medicines and investigations) from their medical records., Results: There were more females (62.6%); their mean age was 37.5±16.0years. Three-quarters (285/380) of patients visited the clinic with an infectious disease in 2018/2019, while 37.6%(143/380) visited with a cardiovascular disease (CVD). Only 2.6%(10/380) were PHC users in the two years. The median cost of care for PHC users in 2018 was 30,549.0((IQR), 23,454 - 35,280) naira compared to the 10,290.0(5,856-18,079) naira consumed by non-PHC users. The median cost of care in 2019 was 41,238.5(25522-54020) naira (PHC users) versus 9,523.5(4709-19070) naira (nonPHC users). Older age, tribe and having CVD were significantly associated with PHC use; however, having CVD (OR=11.38, 95%CI [1.15 - 112.26], P=0.037) predicted PHC use., Conclusion: The prevalence of PHC users was low. However, they consumed 3 to 4 times more resources than the other enrollees. More robust studies will be required to ascertain the complete picture in order to provide appropriate interventions needed to reduce inappropriate/unnecessary visits and cost of care., Competing Interests: The Authors declare that no competing interest exists, (Copyright © 2024 by West African Journal of Medicine.)

Introduction: Enforcement of diagnosis-related group system for appendectomy under the National Health Insurance Service has gradually widened and since July 2013 it has been enforced in all medical institutions in Korea. We have analyzed Health Insurance Review & Assessment Service data to observe changes in claim patterns of pediatric appendectomy during this period., Methods: All claims data for appendectomy of patients younger than 18 y from 2011 to 2015 were collected. We analyzed the following factors of all cases: age, gender, length of hospital stay, medical cost, method of insurance claim and region., Results: A total of 112,143 claims were made for appendectomy during the study period. In that, 66,510 (59.3%) were boys and 45,633 (40.7%) were girls. Median length of stay was 5 d and median sum of reimbursement of each claim was 2,198,630 won. Annual number of claims for appendectomy showed a steady decline from 24,888 in 2011 to 19,070 in 2015. Median sum of reimbursement of each claim was 1,862,615, 1,975,500, 2,233,360, 2,376,700, and 2,468,000 won, respectively from 2011 to 2015. Reimbursement for complicated appendectomy increased from 4400 out of 24,888 cases (17.7%) in 2011 to 3865 out of 19,070 cases (20.3%) in 2015. Overall medical cost of all reimbursement for pediatric appendectomy increased from 46,113,202,580 to 47,572,253,300 won., Conclusions: Following the universal enforcement of the diagnosis-related group claim system for appendectomy by the National Health Insurance Service, we observed an increase in the median sum of reimbursement per claim and a rise in the rate of claims for complicated appendectomies. These changes were associated with an overall increase in national medical costs., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: In this study, using Taiwan's National Health Insurance (NHI) as an example of a single-payer system, we examined the extent of pharmaceutical procurement profits (PPP) and evaluated their impact on the financial performance of healthcare institutions., Methods: We extracted data from financial statements and healthcare service declarations of NHI-contracted hospitals from 2015 to 2021. Financial data concerning PPP, health service profits (HSP), and total operating profits (TOP) from each hospital were analyzed. The impact of PPP on hospitals with positive and negative HSP was further investigated., Results: The total PPP across all hospitals studied gradually increased from NT$30.6 billion in 2015 to NT$47.0 billion in 2021. In 2021, 28.1% of all hospitals reported a deficit in HSP. PPP appeared to have a significantly positive impact on the financial performance of these hospitals. It not only enhanced positive profits, but also helped mitigate or completely offset the negative profits from HSP. The effect of PPP seems to be more pronounced for hospitals with larger HSP values, suggesting that larger hospitals benefit more from PPP in absolute terms., Discussion: Average PPP increased during the study period, increasingly affecting hospitals' financial stability across all strata. The gap between TOP and HSP in medical centers has gradually widened, suggesting an increase in non-health service profits. In this study, we propose a payment policy reform that fosters sustainability of the healthcare and financing system under universal health coverage and corrects the potential distortions caused by PPP., Competing Interests: Declaration of competing interest Prof. Huang serves as independent board directors in three public Taiwanese biopharmaceutical companies and board director in another three biopharmaceutical companies, there is no conflict of interest involved in this manuscript. No potential conflict of interests exists among other authors., (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

This study presents first descriptive statistics on the usage behavior relating to discounted tickets for public transportation as part of an initiative of the German Federal Government in 2022. During a three-month period, 103 psychiatric outpatients of the University Clinic - Charité Berlin provided self-reported data by completing a survey. In general results suggested a high usage rate of the so-called "9-Euro-ticket" of 89,3%. Due to its purchase, 37,9% (N=39) of the participants felt motivated to explore unknown places. Furthermore, approximately one third of the sample (34,9%; n=36) reported an increase of social contacts as a result of their ticket usage. A higher influence of costs on participants' activity levels was associated with an increase in main symptoms. Higher age was correlated with a decrease of patients' core symptoms due to their activity. Results indicate a high usage of reduced-price tickets for subsidized public transport by the patients concerned., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objectives: Cancer patients often have compromised oral health, making them vulnerable to severe dental caries and restoration failures. Due to the nature of cervical or anterior caries in cancer patients, the use of adequate restorative materials is important. However, public dental insurance coverage for composite treatments varies among countries and only glass ionomer cements (GICs) are covered in all age groups in South Korea. This study examined the cost-effectiveness of expanding national health insurance coverage to include resin composite (RC) restorations as compared with GIC in cancer patients., Methods: Data from cancer patients who received direct restoration using GIC were identified from the National Health Screening Cohort. The relative effect of RC compared to GIC was determined through a meta-analysis, which was then utilized in calculating corresponding transition probabilities within a multi-state model. A Markov-chain Monte Carlo microsimulation was performed to estimate useful life-years and total treatment costs at the tooth level. The incremental cost-effectiveness ratio (ICER) of RC versus GIC was calculated, considering scenarios with and without expanded national health insurance coverage. The robustness of the results was confirmed through various sensitivity analyses., Results: Between the two materials, RC resulted in a 0.4-year longer useful life. From a limited societal perspective, it cost $9.6 less with expanded coverage but $24.3 more without expansion, resulting in an ICER of -$25.2 and $63.9 per tooth-year, respectively. From a patient's perspective, the ICER values were -$72.7 versus $138.8 per tooth-year, respectively, translating into $200 more in savings with the expansion. Various sensitivity analyses consistently demonstrated a smaller ICER when insurance coverage was expanded., Conclusions: The expansion of national health insurance coverage to include RC restorations for cancer patients appears to be clearly cost-effective. This emphasizes the need for further policy considerations to ensure access to dental care for cancer patients., Clinical Significance: Timely management of dental caries is crucial for cancer patients, as untreated caries can escalate into severe oral conditions, negatively impacting treatment outcomes and increasing care costs. Expanding a national health insurance coverage for cancer patients in the treatment of early dental lesions is necessary to prevent advanced dental diseases., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Seokyung Hahn reports financial support was provided by National Research Foundation of Korea, Korea Health Industry Development Institute. Areum Han reports financial support was provided by National Research Foundation of Korea, Korea Health Industry Development Institute. Hee-Kyung Park reports financial support was provided by Korea Health Industry Development Institute. Eun-Gee Park reports financial support was provided by National Research Foundation of Korea, Korea Health Industry Development Institute. If there are other authors, they 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 © 2024 Elsevier Ltd. All rights reserved.)

Objective: To propose a method for detecting and analyzing under-registration and highlight its potential financial effect in view of the implementation of the Previne Brasil Program., Methods: An ecological study was carried out to analyze cytopathological exams in programmatic area 3.1 in the municipality of Rio de Janeiro. The data was collected from the Departamento de Informática do Sistema Único de Saúde (DATASUS - Department of Informatics of the Unified Health System) database, including information on reports from outsourced cytopathology laboratories and those available in the Sistema de Informação em Saúde para a Atenção Básica (SISAB - Health Information System for Primary Care) and the Sistema de Informação do Câncer do Colo do Útero (SISCOLO - Cervical Cancer Information System) of DATASUS/Ministry of Health., Results: The estimated under-registrations per health unit totaled 108,511 exams in the last two years in the programmatic area 3.1 area, which corresponds to an estimated total of R$ 435,129.00 that would have been foregone if the Previne Brasil Program had been in place during the period studied., Conclusion: The article's main contribution lies in the presentation of empirical evidence of the potential effects of under-registration on Primary Health Care financing. In addition, there are two other significant findings - firstly, it highlights weaknesses in the process of recording health information inherent to vulnerable regions; secondly, it indicates a vicious circle potentially fueled by sudden changes in Primary Health Care funding conditions, in addition to potential consequences for other levels of care.

Background: After the establishment of the public health emergency of international concern in 2020, health systems worldwide and in Brazil observed the need to apply more extraordinary logistical efforts and possibly resources to combat the imminent pandemic., Methods: Using the historical series of public expenditures of the National Health Fund (FNS), 2015 to 2021, the number of confirmed cases of COVID-19, and a seasonal ARIMAX model, we sought to assess how the increase in the new virus infections affected the systematic financing of the SUS in Brazil., Results: There were signs of seasonality and an increasing trend in the expenditure variable, which in practical terms, only indicated that the resource contributions followed an increasing trajectory already underway before the advent of the pandemic. The 1% increase in COVID-19 cases, with a one-month lag, contributes to the 0.062% increase in the variation in FNS expenditures but a decrease of 0.058% with a two-month lag., Conclusion: The tests showed no evidence to confirm a positive shift on FNS spending growth trajectory due to the increase of COVID-19 cases, only observing a significant increase one month after the occurrence of COVID cases, probably due to their worsening after this period, which was followed by a similar and comparable decrease in percentage of growth in the following month., (© 2024. The Author(s).)

Introduction: In vascular surgery too, more services and procedures will have to be shifted from the previous inpatient to the outpatient sector in the future. Therefore, the previous and new legal requirements as well as their implementation in vascular surgery will be explained and evaluated., Material and Methods: Professional policy analysis from a perspective of medical vascular surgery., Results: The AOP catalog from 01.01.2023 was extended by 208 additional OPS codes. The inpatient performance of services which, according to the AOP contract, must be regularly performed on an outpatient basis, are now to be justified on the basis of context factors.A special sector-equivalent remuneration, which is independent of whether the remunerated service is performed on an outpatient or inpatient basis, is a prerequisite for a cost-covering expansion of outpatient operations and inpatient-replacing services. The rehabilitation of primary varicosis under outpatient conditions is undoubtedly the standard. The majority of AV shunt installations are performed as inpatient procedures. No new OPS codes were added to the 2023 AOP catalog for varicose vein, shunt and endovascular surgery., Discussion: The shift of inpatient services to the outpatient sector can be a feasible path, based on the experience of other European countries. However, the structures, economic conditions and incentives should first be created to successfully promote transfer to outpatients. Integrated care offers the possibility for the health insurance funds to conclude contracts with the service providers named in § 140a of the Social Code, paragraph 3, for special care. The use of telemedicine in the sense of tele-premedication or tele-monitoring can be a way to expand outpatient surgery, especially in rural regions. In order to enable therapy concepts from one expert in vascular medicine, the outpatient service billing of interventional procedures must also be demanded by vascular surgeons and specialists., Conclusion: The potential to transform inpatient services into the outpatient setting of service provision is realisable in vascular surgery in the core areas of varicose vein surgery, shunt surgery and peripheral interventional procedures under specific conditions., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: The positive impact of pharmaceutical care in improving medication safety is considered proven. Little is known about the economic benefit of clinical pharmaceutical services in Germany., Objective: In 2020, a pilot project was started at the Ernst von Bergmann Hospital to introduce ward-based clinical pharmacists in intensive care medicine, also in order to determine the economic benefit of the medication management offered., Methods: By a team of experienced intensive care physicians and clinical pharmacists on the basis of a consensus principle, each pharmaceutical intervention (PI) was assigned a probability score (Nesbit probability score) with which an adverse drug event (ADE) would have occurred. Assuming that each ADE results in an increased length of stay, the costs of intensive care treatment/day were used as potential savings. The model thereby combines the findings of two international publications to enable an economic analysis of pharmaceutical services., Results: During the study period, 177 pharmaceutical interventions were evaluated and corresponding probability scores for the occurrence of ADE were determined. From this, annual savings of € 80,000 through avoided costs were calculated., Conclusion: In this project, the economic benefit of pharmaceutical services in intensive care medicine was proven. Ward-based clinical pharmacists are now an integral part of the intensive care treatment team at the Ernst von Bergmann Hospital., (© 2024. The Author(s).)

Objective: To evaluate the cost-effectiveness of a single-pill combination (SPC) of perindopril/amlodipine/indapamide versus its free equivalent combination (FEC) in adults with hypertension in Italy., Methods: A Markov model was developed to perform a cost-utility analysis with a lifetime horizon and an Italian healthcare payer's perspective. In the model, the additional effect of the SPC on blood pressure level compared with the FEC was translated into a decreased risk of cardiovascular events and CKD, which was modeled via Framingham risk algorithms. Difference in persistence rates of SPC and FEC were modeled via discontinuation rates., Results: A perindopril/amlodipine/indapamide SPC is associated with lower cost and better health outcomes compared to its FEC. Over a lifetime horizon, it is associated with a 0.050 QALY gain and cost savings of €376, resulting from lower cardiovascular event rates. In the alternative scenario, where different approach for modeling impact of adherence was considered, incremental gain of 0.069 QALY and savings of €1,004 were observed. Results were robust to sensitivity and scenario analyses, indicating that use of this SPC is a cost-effective strategy., Conclusions: The findings indicate that a perindopril/amlodipine/indapamide SPC is a cost-saving treatment option for hypertension in Italy, compared to its FEC.

Objective: This study aimed to quantify the health and economic impacts of alcohol consumption in Brazil for 2019., Study Design: Ecological study using secondary data sources., Methods: We calculated the disease burden using estimates from the Global Burden of Disease study, which incorporated data from health surveys and hospital records. Costs were estimated based on direct expenses recorded in the Hospital and Outpatient Information System of the Unified Health System, with data by sex, age group, cause, and Federative Units., Results: Alcohol consumption was a necessary cause for 30,355 deaths and approximately 1.69 million disability-adjusted life years in Brazil, representing 2.2% and 2.6% of the national totals, respectively. The impact was more pronounced among men, in the Northeast region and within the 40- to 64-year-old age group. The total costs attributed to these outcomes reached approximately Int$43.1 million, with hospital admissions accounting for 94.16% of these expenses., Conclusion: In 2019, alcohol consumption had a significant impact on both the health of Brazilians and the expenses of the health system. As a preventable risk factor, alcohol consumption necessitates effective intersectoral strategies to mitigate its burden., (Copyright © 2024 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Objective: To analyze the impact of the fiscal austerity policy (PAF) on health spending in Brazilian municipalities, considering population size and source of funds., Methods: The interrupted time series method was used to analyze the effect of the PAF on total expenditure, resources transferred by the Federal Government, and own/state per capita resources allocated to health in the municipalities. The time series analyzed covered the period from 2010 to 2019, every six months. The first semester of 2015 was adopted as the start date of the intervention. The municipalities were grouped into small (up to 100,000 inhabitants), medium (101,000 to 400,000 inhabitants), and large (over 400,000 inhabitants). The data was obtained from the Sistema de Informações sobre Orçamentos Públicos em Saúde (Information System on Public Health Budget)., Results: The results for the national average of municipalities show that the PAF had a negative impact on the level of total expenditure and own/state resources allocated to health in the first half of 2015, without causing statically significant changes in the trends of any of the indicators analyzed in the period after 2015. Small municipalities saw a drop in total expenditure, while large municipalities saw a drop in own/state resources, and medium-sized municipalities saw a drop in both variables. There was no statistically significant drop in the volume of funds transferred by the Federal Government in the immediate aftermath of the implementation of the PAF in any of the municipal groups analyzed. In the medium-term, the PAF only had a negative impact on the large municipalities, which saw significant reductions in the trends of own/state resources and those transferred by the Union for health., Conclusion: In general, the impact of the PAF on health financing in municipalities was immediate and based on the decrease in own/state resources allocated to health. In large municipalities, however, the impact lasted from 2015 to 2019, mainly affecting health expenditure from federal funds.

Background: Gastric cancer is the fourth most common cancer and highly prevalent in South Korea. As one of the predictors of gastric cancer, we focused on health utilization patterns and expenditures, as the surrogate variables of health conditions. This nested case-control study aimed to identify the association between health expenditure trajectory and incidence of gastric cancer., Methods: Data from the National Health Insurance Service Senior Cohort of South Korea were used. Individuals diagnosed with gastric cancer (N = 14,873) were matched to a non-diagnosed group (N = 44,619) in a 1:3 ratio using a nested case-control design. A latent class trajectory analysis was performed to identify the patterns of health expenditure among the matched participants. Furthermore, conditional logistic regression analysis was conducted to examine the relationship between healthcare expenditure trajectories and gastric cancer incidence., Results: Seven distinct health expenditure trajectories for five years were identified; consistently lowest (13.8%), rapidly increasing (5.9%), gradually increasing (13.8%), consistently second-highest (21.4%), middle-low (18.8%), gradually decreasing (13.1%), and consistently highest (13.2%). Compared to the middle-low group, individuals in the rapidly increasing [odds ratio (OR) = 2.11, 95% confidence interval (CI); 1.94-2.30], consistently lowest (OR = 1.40, 95% CI; 1.30-1.51), and gradually increasing (OR = 1.26, 95% CI; 1.17-1.35) groups exhibited a higher risk of developing gastric cancer., Conclusions: Our findings suggest that health expenditure trajectories are predictors of gastric cancer. Potential risk groups can be identified by monitoring health expenditures., (© 2024. The Author(s).)

This study investigated the factors associated with end-of-life health care use and spending in Korea. Chronically ill decedents, who were hospitalized for one of nine chronic conditions during the year before death, were identified from the National Health Insurance Database in 2017. For comparison, the end-of-life care spending for all decedents and the annual health care spending for the general population were analyzed. The inpatient and outpatient end-of-life care spending for the chronically ill decedents were sixteen and seven times the annual inpatient and outpatient spending for the general population respectively. The regional income level was positively associated with both inpatient and outpatient spending among the decedents with a stronger association in the chronically ill decedents, while a negative association was found in the general population. No significant association was found between the inpatient spending and the number of hospital beds for the chronically ill decedents, whereas the number of beds in small to medium-sized hospitals was positively associated with inpatient spending for the total decedents and the general population. The findings suggest that hospitalization for end-of-life care depends more on the income of the patients, while the inpatient spending for total decedents and the general population are more likely to be affected by the supply of beds.

Background: Value-based healthcare (VBHC) aims to increase patient outcomes in relation to the costs incurred, with a focus on measuring these outcomes using patient-reported outcome measures (PROMs). The German healthcare system faces the challenge of quality disparities in care amidst rising costs, making VBHC of interest., Objectives: This paper aims to illustrate how VBHC principles are currently being implemented in the field of internal medicine in Germany and to identify the potential that can be derived from VBHC pioneering examples from the Netherlands., Materials and Methods: Selected case studies are presented to illustrate how VBHC principles are already being applied in internal medicine, focusing on where PROMs are utilized and how value-based reimbursement supports VBHC implementation-both in Germany and the Netherlands., Results: In Germany, various cross-provider initiatives and individual providers implement the VBHC element of PROMs measurement. In addition, the Baden-Württemberg selective contract in cardiology demonstrates how financing VBHC elements in regular care was already made possible in Germany. Pioneers such as the Dutch center of excellence Diabeter and the multidisciplinary care network Netherlands Heart Network provide further inspiration for the implementation of VBHC in internal medicine., Conclusion: While various initiatives support the measurement of PROMs in the German context, the use of these results in care practice is not apparent. The utilization of PROMs and strategies identified in Dutch examples could be initial steps toward fostering VBHC in Germany., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objectives: This study investigated the epidemiology, treatment patterns, and resource utilization in patients with alopecia areata (AA) in Taiwan using the National Health Insurance Research Database. AA severity was determined by treatment use and diagnostic codes in the year after enrollment (including corticosteroids, systemic immunosuppressants, topical immunotherapy, and phototherapy)., Methods: The cross-sectional analysis was conducted to estimate the incidence and prevalence of AA from 2016 to 2020. For the longitudinal analysis, 2 cohorts were identified: mild/moderate and severe. The cohorts were matched based on age, gender, and comorbidities. Patients were enrolled upon their first claim with an AA diagnosis during the index period of 2017-2018., Results: The number of patients with AA increased from 3221 in 2016 to 3855 in 2020. The longitudinal analysis identified 1808 mild/moderate patients and 452 severe patients. Mild/moderate patients used higher levels of topical corticosteroids (82.41%) than severe patients (73.45%). Conversely, severe patients used more topical nonsteroids (41.81%) and systemic therapies (51.77%) than mild/moderate patients (0.44% and 16.15%, respectively). Oral glucocorticoids use was higher in severe patients (47.57%) relative to mild/moderate patients (14.88%), whereas the use of injectable forms was similar. The most used systemic immunosuppressants were methotrexate, cyclosporin, and azathioprine. Topical immunotherapy utilization decreased with subsequent treatment lines for severe patients. Treatment persistence at 6 months was low for all treatments. Severe patients had higher annual AA-related outpatient visits than the mild/moderate cohort., Conclusions: These findings highlight the need for additional innovations and therapies to address the clinical and economic burden of AA., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2024 International Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

This study aimed to estimate the cost-effectiveness of four therapeutic approaches available for mucosal leishmaniasis in Brazil: miltefosine, meglumine antimoniate, combined with and without pentoxifylline, and liposomal amphotericin B. The perspective adopted was that of the Brazilian Unified National Health System (SUS). The outcome of interest was "cured patient", which was analyzed using a decision tree model. Estimates of direct costs and effectiveness were obtained from the scientific literature. Meglumine antimoniate alone was the base comparator strategy; liposomal amphotericin B showed an incremental cost-effectiveness ratio (ICER) of USD 7,409.13 per cured patient, and the combination of meglumine antimoniate with pentoxifylline presented an ICER of USD 85.13. Miltefosine was absolutely dominated, with higher cost and similar effectiveness when compared to meglumine antimoniate. Sensitivity analyses, varying the cost by ±25%, did not change the results. However, when the cost of miltefosine was estimated at less than USD 171.23, this strategy was dominant over meglumine antimoniate alone. The results confirm that treatment with liposomal amphotericin B remains the option with the highest ICER among the approaches analyzed. Miltefosine may be cost-effective based on the variation in the acquisition price, which deserves attention because it is the only available oral option. The non-accounting of other aspects prevent the use of these results immediately to support decision-making, but they point out the need to negotiate the prices of drugs available for mucosal leishmaniasis and indicates the need of encouraging technology transfer or other actions aimed at expanding the performance of the Brazilian national industrial complex.

Background: The impact of metabolic syndrome (MetS) on healthcare costs remains unclear in the literature., Objectives: To determine the impact of MetS on primary healthcare costs of adults, as well as to identify the impact of physical activity and other covariates on this phenomenon., Design and Setting: This cross-sectional study was conducted in the city of Presidente Prudente, State of São Paulo/Brazil, in 2016., Methods: The sample comprised 159 older adults (> 50 years) of both sexes (110 women) who were identified from their medical records in the Brazilian National Health Service. Healthcare costs (US$) were assessed through medical records and divided into medical consultations, medications, laboratory tests, and total costs. MetS was assessed using medical records., Results: The Brazilian National Health Service spent more on consultations (US$ 22.75 versus US$ 19.39; + 17.3%) and medication (US$ 19.65 versus US$ 8.32; + 136.1%) among adults with MetS than among those without MetS, but the costs for laboratory tests were similar (P = 0.343). Total costs were 53.9% higher in adults with MetS than in those without the diagnosis of the disease (P = 0.001). Regarding total costs, there was an increase of US$ 38.97 when five components of MetS were present (P = 0.015), representing an increase of approximately 700%, even after adjusting for sex, age, and physical activity., Conclusion: In conclusion, the presence of the MetS is responsible for increasing primary care costs among older adults, especially in those related to medicines.

Background: India launched a national health insurance scheme named Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in 2018 as a key policy for universal health coverage. The ambitious scheme covers 100 million poor households. None of the studies have examined its impact on the quality of care. The existing studies on the impact of AB-PMJAY on financial protection have been limited to early experiences of its implementation. Since then, the government has improved the scheme's design. The current study was aimed at evaluating the impact of AB-PMJAY on improving utilisation, quality, and financial protection for inpatient care after four years of its implementation., Methods: Two annual waves of household surveys were conducted for years 2021 and 2022 in Chhattisgarh state. The surveys had a sample representative of the state's population, covering around 15,000 individuals. Quality was measured in terms of patient satisfaction and length of stay. Financial protection was measured through indicators of catastrophic health expenditure at different thresholds. Multivariate adjusted models and propensity score matching were applied to examine the impacts of AB-PMJAY. In addition, the instrumental variable method was used to address the selection problem., Results: Enrollment under AB-PMJAY was not associated with increased utilisation of inpatient care. Among individuals enrolled under AB-PMJAY who utilised private hospitals, the proportion incurring catastrophic health expenditure at the threshold of 10% of annual consumption expenditure was 78.1% and 70.9% in 2021 and 2022, respectively. The utilisation of private hospitals was associated with greater catastrophic expenditure irrespective of AB-PMJAY coverage. Enrollment under AB-PMJAY was not associated with reduced out-of-pocket expenditure or catastrophic health expenditure., Conclusions: AB-PMJAY has achieved a large coverage of the population but after four years of implementation and an evidence-based increase in reimbursement prices for hospitals, it has not made an impact on improving utilisation, quality, or financial protection. The private hospitals contracted under the scheme continued to overcharge patients, and purchasing was ineffective in regulating provider behaviour. Further research is recommended to assess the impact of publicly funded health insurance schemes on financial protection in other low- and middle-income countries., (© 2024. The Author(s).)

Objectives: Excess weight, measured by a high body mass index (BMI), is associated with the onset of many diseases, which can, in turn, lead to disability and premature death, subsequently placing a significant burden on healthcare services. This study analysed the burden of disease and the direct costs to the Brazilian Unified Health System (Sistema Único de Saúde [SUS]) attributable to high BMI in the Brazilian population., Study Design: Ecological study., Methods: This ecological study had two components: (1) a time-series assessment to analyse the burden of diseases attributable to high BMI from 1990 to 2019 in Brazil; and (2) a cross-sectional design to estimate the direct costs of SUS hospitalisations and outpatient procedures attributable to high BMI in 2019. Estimates from the Global Burden of Disease study and the costs of hospital admissions and outpatient procedures from the Department of Informatics of the Brazilian Unified Health System were used. Deaths, years of life lost to premature death (YLLs), years lived with disability (YLDs), and years of life lost adjusted for disability (DALYs) were analysed. The direct health cost was obtained in Brazilian Real (R$) and converted in international Dollars (INT$)., Results: The current study found a reduction in the number of DALYs, YLLs, and deaths per 100,000 population of cardiovascular disease (CVD) attributable to high BMI and an increase in YLD due to diabetes and cardiovascular disease attributable to high BMI from 1990 to 2019. In 2019, high BMI resulted in 2404 DALYs, 658 YLDs, 1746 YLLs, and 76 deaths per 100,000 inhabitants. In the same year, INT$377.30 million was spent on hospitalisations and high- and medium-complexity procedures to control non-communicable diseases attributable to high BMI. The states in the South and Southeast regions of Brazil presented the highest total cost per 10,000 inhabitants. CVDs and chronic kidney disease showed the highest costs per hospital admission, whereas neoplasms and CVDs presented the highest costs for outpatient procedures., Conclusions: High BMI causes significant disease burden and financial costs. The highest expenses observed were not in locations with the highest burden of disease attributable to high BMI. These findings highlight the need to improve current public policies and apply cost-effective intervention packages, focussing on equity and the promotion of healthier lifestyles to reduce overweight/obesity, especially in localities with low socioeconomic status., (Copyright © 2024 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Objective: The aim of this study was to estimate the budget impact of adding cabergoline to the Brazilian Unified Health System (SUS) formulary for the treatment of patients with Cushing's disease (CD) who do not achieve disease control after transsphenoidal surgery., Materials and Methods: We conducted a budget impact analysis (BIA) from the perspective of the Brazilian SUS over a 5-year time horizon. We compared two scenarios: ketoconazole (Scenario 1) versus including cabergoline as a treatment option (Scenario 2). All analyses were conducted using Microsoft Excel. Uncertainty was explored in univariate sensitivity analyses., Results: The total costs were BRL $25,596,729 for Scenario 1 and BRL $32,469,169 for Scenario 2. The budget impact of adding cabergoline to the formulary for CD treatment within the SUS would be BRL $6,091,036 over 5 years. On univariate analyses, variations in the rates of surgical failure and CD recurrence had the greatest potential to affect the final costs associated with cabergoline., Conclusions: The estimated budget impact of adding cabergoline to the formulary for CD treatment within the Brazilian SUS would be about BRL $6 million. While cost savings cannot be expected, the budget impact of adding cabergoline would be lower than that of adding other treatment options for CD., Competing Interests: Disclosure: no potential conflict of interest relevant to this article was reported.

Objectives: We compared the cost-effectiveness of hospital-based treatment and that of community treatment centres (CTCs)., Design: We performed statistical analysis to compare the expenses incurred by COVID-19 patients who received hospital care with those incurred by COVID-19 patients who went to CTCs., Setting and Participants: A study was conducted on 411 530 COVID-19 inpatients and 243 329 CTC patients from January 2020 to December 2021., Main Outcome Measures: We calculated the probability of severe disease, hospitalisation period and medical expenses for inpatients and CTC patients. Subsequently, we analysed the cost-effectiveness of CTC compared with hospitalisation., Results: Comparing medical expenses, CTC patients incurred 2 220 000 KRW on average, which is less than the expenses incurred by hospitalised COVID-19 patients., Conclusions: The study suggests that using a CTC may be more cost-effective than a hospital service alone., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To estimate hospital services utilisation and cost among the Indonesian population enrolled in the National Health Insurance (NHI) program before and after COVID-19 hospital treatment., Methods: 28,159 Indonesian NHI enrolees treated with laboratory-confirmed COVID-19 in hospitals between May and August 2020 were compared to 8,995 individuals never diagnosed with COVID-19 in 2020. A difference-in-difference approach is used to contrast the monthly all-cause utilisation rate and total claims of hospital services between these two groups. A period of nine months before and three to six months after hospital treatment were included in the analysis., Results: A substantial short-term increase in hospital services utilisation and cost before and after COVID-19 treatment was observed. Using the fifth month before treatment as the reference period, we observed an increased outpatient visits rate in 1-3 calendar months before and up to 2-4 months after treatment (p<0.001) among the COVID-19 group compared to the comparison group. We also found a higher admissions rate in 1-2 months before and one month after treatment (p<0.001). Consequently, increased hospital costs were observed in 1-3 calendar months before and 1-4 calendar months after the treatment (p<0.001). The elevated hospital resource utilisation was more prominent among individuals older than 40. Overall, no substantial increase in hospital outpatient visits, admissions, and costs beyond four months after and five months before COVID-19 treatment., Conclusion: Individuals with COVID-19 who required hospital treatment had considerably higher healthcare resource utilisation in the short-term, before and after the treatment. These findings indicated that the total cost of treating COVID-19 patients might include the pre- and post-acute period., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Rizal 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.)

Background: Previous studies have shown that financial strategies are beneficial for improving the appropriate use of antibiotics within a limited period of time. Long-term effects have rarely been explored., Methods: This study evaluated the changes in expenditure and prescription patterns of antibacterial agents under the global budget (GB) program and drug price adjustment of a National Health Insurance scheme. Two structural methods, that is, the Laspeyres method and Fisher's Ideal Index decomposition method, were used to illustrate the impacts of price, volume, and drug change., Results: During the first 5 years of the GB program (ie, 2001-2006), the expenses of antibacterial agents increased by 54.1%, while the volume decreased by 11% to 21.3%. Therapeutic choice was the predominant cause of expense growth. In the second and third 5-year periods (ie, 2006-2011 and 2011-2016), the driving force of therapeutic choice gradually decreased. The antibacterial expense remained stable with a slight increase in prescription volume. Periodic price adjustment contributed steadily to cost containment, by 21.9% to 39.9%., Conclusions: The GB program led to a remarkable increase in antibacterial expenses mainly attributed to therapeutic choice, especially in the early stage. In contrast, periodic price adjustment, provided steady benefits to pharmaceutical budget control without a noticeable increase in drug volume., (Copyright © 2024 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

In France, addressing balance billing is essential for equitable healthcare access and reducing physician income disparities. The National Health Insurance (NHI) introduced financial incentive programs, namely the "Contract for Access to Care" (CAS) in 2014 and the "Option for Controlled Pricing" (OPTAM) in 2017, to encourage physicians to reduce extra fees and adhere to regulated prices. This study analyzed the impact of these programs on self-employed physicians using a comprehensive administrative dataset covering specialist physicians from 2005 to 2017. The dataset comprised 9891 surgical specialists (30,972 observations) and 6926 medical specialists (21,650 observations) between 2005 and 2017. Applying a difference-in-differences design with a two-way fixed effect model and matching through the "Coarsened Exact Matching" method, the study examined CAS and/or OPTAM membership effects on physicians' activity and fees. The results indicate that both the CAS and OPTAM successfully enhance access to care. Physicians treat more patients, particularly those with lower incomes who might have previously avoided care because of the extra fees. However, an increased patient load translates to a higher workload for physicians. Despite a fee increase, it was observed to be smaller than the surge in activity. Furthermore, if all physicians are appropriately rewarded for their efforts, this improvement in access comes at a cost to NHI. This study's findings provide crucial insights into the nuanced effects of these financial incentive programs on physicians' behavior, highlighting the tradeoff between improved access and increased NHI costs. Ultimately, these findings underscore the complexity of balancing financial incentives, physician workload, and healthcare accessibility in pursuit of a more equitable healthcare system., 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 article., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Congenital microtia presents challenges that encompass physical disabilities and psychosocial distress. It is reported that people with low income have a higher possibility of giving birth to babies with congenital malformations. At the end of June 2023, auricular reconstruction was partially incorporated into national health insurance in our hospital., Methods: Briefly, 1290 surgeries, including stage-I and stage-II auricular reconstruction with tissue expansion were performed in 2023, involving 779 patients. Patient data, including age, sex, length of stay, residence, and costs, were retrieved from the electronic medical record system. The final cost before and after health insurance coverage, as well as the medical insurance reimbursement ratio in each province and municipality were statistically analyzed., Results: Following insurance coverage, a significant increase in the number of surgeries was observed (514 [39.84%] vs. 776 [60.16%], χ 2 = 45.99, p = 0.000), with notable reductions in out-of-pocket costs for unilateral and bilateral stage-I and -II auricular reconstructions ($3915.01 vs. $6645.28, p < 0.05; $11546.80 vs. $5198.08, p < 0.05). Disparities in reimbursement rates across regions were evident, but showed no correlation to the local GDP per capita. There was a positive correlation between the length of stay and inpatient cost. Patient's age was not related to the inpatient cost, but to the length of stay., Conclusion: The health insurance coverage for microtia treatment significantly alleviated financial burdens on the patients' family and increased the number of auricular reconstruction surgeries. These findings underscore the critical role of insurance coverage in enhancing healthcare accessibility and affordability for patients with congenital microtia., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objectives: This study aimed to assess the impact of the reimbursement regulation of medical devices (Regulation), introduced by the National Health Insurance Administration (NHIA) in 2013, on patients' access to innovative medical devices in Taiwan., Methods: Analysis of the amount of time needed from application for NHIA reimbursement for new medical devices to receiving the decision from NHIA was done using the nonreimbursement product list featured on the NHIA website. Additionally, Welch analysis of variance was used to compare the amount of time it took from application to NHIA with reimbursement decisions made by the NHIA for different nonreimbursement code categories. Further, related Pharmaceutical Benefit Reimbursement Scheme meeting minutes were analyzed to obtain more detailed information concerning medical devices' reimbursement or not., Results: From December 2012 to June 2021, the overall reimbursement percentage was 56.7%, and the average amount of time between application and reimbursement was 856.7 ± 474.7 days. The mandatory reimbursement rate was about 45%. NHIA reimbursement decisions as special medical devices also take a longer amount of time, because the applicants need to agree to the decision (P < .05). The NHIA decision-making process for nonreimbursement medical devices requires a significantly longer amount of time than for general materials (eg, suture, etc) decisions., Conclusions: Although the Regulation resolves payment issues, it also increases the amount of time to reach reimbursement decisions, thus hindering patient access to innovative medical devices. The study suggests that the review process needs to be simplified concerning reimbursement notification, using local real-world data to support reimbursement decisions., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2024 International Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Background: Service use among employees with mental health problems and the associated costs for the health and social system have not yet been systematically analysed in studies or have only been recorded indirectly. The aim of this article is to report the service use in this target group, to estimate the costs for the health and social system and to identify possible influencing factors on the cost variance., Methods: As part of a multicentre study, use and costs of health and social services were examined for a sample of 550 employees with mental health problems. Service use was recorded using the German version of the Client Sociodemographic Service Receipt Inventory (CSSRI). Costs were calculated for six months. A generalized linear regression model was used to examine influencing cost factors., Results: At the start of the study, the average total costs for the past six months in the sample were € 5227.12 per person (standard deviation € 7704.21). The regression model indicates significant associations between increasing costs with increasing age and for people with depression, behavioural syndromes with physiological symptoms, and other diagnoses., Discussion: The calculated costs were similar in comparison to clinical samples. It should be further examined in longitudinal studies whether this result changes through specific interventions., (© 2024. The Author(s).)

The present article analyzes the transfers from parliamentary amendments by the Ministry of Health to municipalities to finance public health actions and services from 2015 to 2021. A descriptive and exploratory study was carried out with secondary data, including all Brazilian cities. Resources from amendments showed an increase, particularly from 2018 onwards, indicating the expansion of their relevance for financing SUS. From 2016 to 2021, over 80% was allocated to municipalities, representing 9.5% of all federal transfers, with 91.2% for operational expenses. Transfers from amendments differ from regular transfers due to greater instability and per capita variation among the amounts collected by municipalities and due to the fact that they allocate most resources to the Northeast and primary care to the detriment of the Southeast and medium and high complexity care. These transfers represent a differentiated modality of resource allocation in SUS that produces new distortions and asymmetries, with implications for intergovernmental relations, as well as between the executive and legislative powers, increasing the risk of the discontinuity of actions and services and imposing challenges for the municipal management.

Background: South Korea's National Health Insurance (NHI) system pursues universal health coverage, but it has not been able to alleviate patients' financial burden owing to limited coverage and a high proportion of out-of-pocket expenses. In 2017, the government announced a plan to strengthen universality by providing coverage for all unincluded services, expanding coverage, and alleviating household financial burden. We aimed to evaluate the effect of "Moon Care" with a focus on changes in health expenditures following policy implementation, and to provide empirical evidence for future policies to strengthen the NHI system's universality., Methods: Using data from the 2016 and 2018 Korea Health Panel (KHP), we established a treatment group affected by the policy and an unaffected control group; we ensured homogeneity between the groups using propensity score matching (PSM). Subsequently, we examined changes in NHI payments, non-payments, and out-of-pocket payments (OOP); we performed difference-in-differences (DID) analysis to evaluate the policy's effect., Results: Following policy implementation, the control group had a higher increase than the treatment group in all categories of health expenditures, including NHI payments, non-payments, and OOP. We noted significant decreases in all three categories of health expenditures when comparing the differences before and after policy implementation, as well as between the treatment and control groups. However, we witnessed a significant decrease in the interaction term, which confirms the policy's effect, but only for non-payments., Conclusions: We observed the policy's intervention effect over time as a decrease in non-payments, on the effectivity of remunerating covered medical services. However, the policy did not work for NHI payments and OOP, suggesting that it failed to control the creation of new non-covered services as noncovered services were converted into covered ones. Thus, it is crucial to discuss the financial spending of health insurance regarding the inclusion of non-covered services in the NHI benefits package., (© 2024. The Author(s).)

Introduction: Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world's largest tax-funded insurance schemes. The present study was conducted to understand the decision-making process around the evolution (and revision) of health benefit packages (HBPs) and reimbursement rates within PM-JAY, with a specific focus on assessing the extent of use of economic evidence and role of various stakeholders in shaping these policy decisions., Methods: A mixed-methods study was adopted involving in-depth interviews with seven key stakeholders involved in HBP design and reimbursement rates decisions, and a survey of 80 government staff and other relevant stakeholders engaged in the implementation of PM-JAY. The data gathered were thematically analysed, and a coding framework was developed to explore specific themes. Additionally, publicly available documents were reviewed to ensure a comprehensive understanding of the decision-making processes., Results: Findings reveal a progressive transition towards evidence-based practices for policy decisions within PM-JAY. The initial version of HBP relied heavily on key criteria like disease burden, utilisation rates, and out-of-pocket expenditures, along with clinical opinion in shaping decisions around the inclusion of services in the HBP and setting reimbursement rates. Revised HBPs were informed based on evidence from a national-level costing study and broader stakeholder consultations. The use of health economic evidence increased with each additional revision with consideration of health technology assessment (HTA) evidence for some packages and reimbursement rates based on empirical cost evidence in the most recent update. The establishment of the Health Financing and Technology Assessment unit further signifies the use of evidence-based policymaking within PM-JAY. However, challenges persist, notably with regard to staff capacity and understanding of HTA principles, necessitating ongoing education and training initiatives., Conclusion: While substantial progress has been made in transitioning towards evidence-based practices within PM-JAY, sustained efforts and political commitment are required for the ongoing systematisation of processes., Competing Interests: Competing interests: SP formerly served as the executive director of the National Health Authority, Government of India., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Objective: Telepsychiatry items in the Australian Medicare Benefits Schedule (MBS) were expanded following the COVID-19 pandemic. However, their out-of-pocket costs have not been examined. We describe and compare patient out-of-pocket payments for face-to-face and telepsychiatry (videoconferencing and telephone) MBS items for outpatient psychiatric services to understand the differential out-of-pocket cost burden for patients across these modalities., Methods: out-of-pocket cost information was obtained from the Medical Costs Finder website, which extracted data from Services Australia's Medicare claims data in 2021-2022. Cost information for corresponding face-to-face, video, and telephone MBS items for outpatient psychiatric services was compared, including (1) Median specialist fees; (2) Median out-of-pocket payments; (3) Medicare reimbursement amounts; and (4) Proportions of patients subject to out-of-pocket fees., Results: Medicare reimbursements are identical for all comparable face-to-face and telepsychiatry items. Specialist fees for comparable items varied across face-to-face to telehealth options, with resulting differences in out-of-pocket costs. For video items, higher proportions of patients were not bulk-billed, with greater out-of-pocket costs than face-to-face items. However, the opposite was true for telephone items compared with face-to-face items., Conclusions: Initial cost analyses of MBS telepsychiatry items indicate that telephone consultations incur the lowest out-of-pocket costs, followed by face-to-face and video consultations., Competing Interests: DisclosureThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: We declare no competing interests. The views and opinions expressed in this Correspondence are those of the authors only and do not necessarily represent those of their affiliated organisations.

Background: Universal Health Coverage has been openly recognized in the United Nations health-related Sustainable Development Goals by 2030, though missing under the Millennium Development Goals. Ghana implemented the National Health Insurance Scheme programme in 2004 to improve financial access to healthcare for its citizens. This programme targeting low-income individuals and households includes an Exempt policy for older persons and indigents. Despite population ageing, evidence of the participation and perceptions of older persons in the scheme in cash grant communities is unknown. Hence, this paper examined the prevalence, perceptions and factors associated with health insurance enrollment among older persons in cash grant communities in Ghana., Methods: Data were from a cross-sectional household survey of 400 older persons(60 + years) and eight FGDs between 2017 and 2018. For the survey, stratified and simple random sampling techniques were utilised in selecting participants. Purposive and stratified sampling techniques were employed in selecting the focus group discussion participants. Data analyses included descriptive, modified Poisson regression approach tested at a p-value of 0.05 and thematic analysis. Stata and Atlas-ti software were used in data management and analyses., Results: The mean age was 73.7 years. 59.3% were females, 56.5% resided in rural communities, while 34.5% had no formal education. Two-thirds were into agriculture. Three-fourth had non-communicable diseases. Health insurance coverage was 60%, and mainly achieved as Exempt by age. Being a female [Adjusted Prevalence Ratio (APR) 1.29, 95%CI:1.00-1.67], having self-rated health status as bad [APR = 1.34, 95%CI:1.09-1.64] and hospital healthcare utilisation [APR = 1.49, 95%CI:1.28-1.75] were positively significantly associated with health insurance enrollment respectively. Occupation in Agriculture reduced insurance enrollment by 20.0%. Cited reasons for poor perceptions of the scheme included technological challenges and unsatisfactory services., Conclusion: Health insurance enrollment among older persons in cash grant communities is still not universal. Addressing identified challenges and integrating the views of older persons into the programme have positive implications for securing universal health coverage by 2030., (© 2024. The Author(s).)

Objective: To present the results of a cost analysis of remote consultations (teleconsultations) compared to in-person consultations for patients with type 2 diabetes, in the Brazilian public healthcare system (SUS) in the city of Joinville, Santa Catarina (SC). In addition to the costs from the local manager's perspective, the article also presents estimates from the patient's perspective, based on the transportation costs associated with each type of consultation., Method: Data were collected from 246 consultations, both remote and in-person, between 2021 and 2023, in the context of a randomized clinical trial on the impact of teleconsultation carried out in the city of Joinville, SC. Teleconsultations were carried out at Primary Health Units (PHU) and in-person consultations at the Specialized Health Center. The consultation costs were calculate by the method time and activity-based costing (TDABC), and for the estimate of transportation costs data was collected directly from the research participants . The mean costs and time required to carry out each type of consultation in different scenarios and perspectives were analyzed and compared descriptively., Results: Considering only the local SUS manager's perspective, the costs for carrying out a teleconsultation were 4.5% higher than for an in-person consultation. However, when considering the transportation costs associated with each patient, the estimated value of the in-person consultation becomes 7.7% higher and, in the case of consultations in other municipalities, 15% higher than the teleconsultation., Conclusion: The results demonstrate that the incorporation of teleconsultation within the SUS can bring economic advantages depending on the perspective and scenario considered, in addition to being a strategy with the potential to increase access to specialized care in the public network.

Background: With the introduction of §115f SGB V, the prerequisites for "sector-equal remuneration" ('Hybrid DRG') have been created. In an impact analysis, we assigned inpatient gastroenterological endoscopic (GAEN) cases in a matrix of future hybrid DRG versus outpatient surgery (AOP) or inpatient treatment., Methods: In selected DRGs (G47B, G67A, G67B, G67C, G71Z, H41D, H41E) an allocation matrix of GAEN cases was created on medical grounds. For this purpose, service groups from the DGVS service catalog ('Leistungskatalog') were assigned to the groups: 'Hybrid-DRG', 'AOP' and 'Inpatient' by a group of experts based on the DGVS position paper. Cost data from the DGVS-DRG project for the 2022 data year from 36 InEK calculation hospitals with a total of 232,476 GAEN cases were evaluated., Results: 26 service groups from the DGVS service catalog were assigned to a "Hybrid-DRG", 24 to the "inpatient" group, and 12 to the "AOP" group. 7 performance groups were splitted "depending on the OPS code" and classified at this level. Cases with additional fees were excluded from a hybrid DRG because these cannot be agreed there.The cost analysis shows that services that are already in the AOP have a similar cost level to services that have been classified as 'Hybrid-DRG'. With the cost calculation, a cost level could be presented for the hybrid DRGs formed., Conclusion: Based on clearly defined structural, procedural and personnel requirements, services from suitable DRGs can be transferred to a hybrid DRG. Assigning services without the involvement of clinical experts seems extremely difficult. Case assignment based on arbitrary contextual factors increases complexity without demonstrably increasing the quality of the assignment and needs to be further developed. A cost analysis can be derived from the known inpatient costs and must serve as the basis for the 2025 Hybrid DRG catalog., Competing Interests: Keiner der Autoren erklärt einen Interessenkonflikt. Die inspiring-health GmbH (Markus Rathmayer, Wolfgang Heinlein) erfasst und berechnet auf Honorarbasis die §-21-KHEntgG-Datensätze der am DGVS-DRG-Projekt teilnehmenden Häuser., (Thieme. All rights reserved.)