SELECTED FOR YOU... JANUARY 2009: books of the month - working papers

All the Selected for you


Health technology assessment and health policy-making in Europe : Current status, challenges and potential.

Velasco Garrido M., Borlum Kristensen F., Palmhoj Nielsen C., Busse R.

Copenhague : OMS - Bureau régional de l'Europe : 2008 : 14 p. + 181 p.

Health technology assessment (HTA) aims to inform health policy and decision making processes concerning health technologies on organizational, societal and ethical issues . HTA has a strong foundation in research on the health effects and broader implications of the use of technology in health care. Its potential for contributing to safer and more effective health care is widely acknowledged in Europe and interest in this field has been growing steadily. Since the establishment of the first national HTA agency in Sweden in the 1980s, the number of institutions involved in the assessment of health technologies has multiplied in Europe. Most European Member States have established a formal HTA programme or are considering the feasibility of establishing HTA intelligence to inform health policy-making. Since its inception, the HTA community has acknowledged the need for international collaboration and networking. This book has been produced as a collaboration between the EUnetHTA Project and the European Observatory on Health Systems and Policies with the aim of reviewing the relationship between HTA and policy-making from different perspectives, with a special focus on Europe. The purpose of this cooperation is to transmit the value of HTA to a wide public in decision-making and healthcare management in order to increase their awareness of HTA activities and evidence-based decision-making.

Integrating mental health into primary care. A global perspective

Organisation Mondiale de la Santé. (OMS). Genève. CHE, World Organization of Family Doctors. (WONCA). Singapour.

Genève : OMS, Singapour : WONCA : 2008 : 206 p.

This report on integrating mental health into primary care, which was developed jointly by the World Health Organization (WHO) and the World Organization of Family Doctors (Wonca), presents the justification and advantages of providing mental health services in primary care. At the same time, it provides advice on how to implement and scale-up primary care for mental health, and describes how a range of health systems have successfully undertaken this transformation. Mental disorders affect hundreds of millions of people and, if left untreated, create an enormous toll of suffering, disability and economic loss. Yet despite the potential to successfully treat mental disorders, only a small minority of those in need receive even the most basic treatment. Integrating mental health services into primary care is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need. Primary care for mental health is affordable, and investments can bring important benefits. This report is divided into distinct parts, with different needs in mind. Part 1 provides the context for understanding primary care for mental health within the broader health care system. Part 2 explains how to successfully integrate mental health into primary care and highlights 10 common principles which are central to this effort. It also presents 12 detailed case examples to illustrate how a range of health systems have undertaken this transformation. Finally, Annex 1 provides information about the skills and competencies that are required to effectively assess, diagnose, treat, support and refer people with mental disorders. As this report will show, treating mental disorders as early as possible, holistically and close to the person's home and community lead to the best health outcomes. In addition, primary care offers unparalled opportunities for the prevention of mental disorders and mental health promotion, for family and community education.

Reinsuring health. Why more middle-class people are uninsured and what government can do.

Swartz K.

New York : Russel Sage Foundation : 2006 : 203 p.

This book describes the changing nature of the uninsured and how the high cost of health insurance is driving healthy people out of the insurance market. It emphasizes changes in the economy and labor markets, the rise in professional temporary workers and changes in demographic patterns as having contributed to the growth in the number of uninsured. It proposes a mechanism to cover those who are uninsured and defined as middle class based on income. To expand coverage, issues regarding risk selection—a choice of healthier, and therefore, lower cost individuals—must be addressed. Swartz advocates for reinsurance and insurance for insurers, to protect insurers from extreme cost. Swartz believes that the benefits of a $5 to $20 billion per year government reinsurance program that "took responsibility for people who have the top one percent of all medical expenses among everyone covered by small group or individual insurance," would include: Lower premiums for coverage in the small group and individual market by 20 to 40 percent; insurance coverage for at least 15 million uninsured individuals; decreases in unnecessary medical expenses; reduction in selection mechanisms by insurers; increases in offerings by private health insurers. Finally, Swartz notes that the idea of reinsurance is not new and cites several examples where the federal government has taken the responsibility for the worst risks, including the Federal National Mortgage Association, Medicare and the Terrorism Risk Insurance Act of 2002.


Just health: meeting Health needs fairly.

Daniels N.

Cambridge : Cambridge University Press : 2008 : 397 p.

In this new book by the award-winning author of Just Healthcare, Norman Daniels develops a comprehensive theory of justice for health that answers three key questions: What is the special moral importance of health? When are health inequalities unjust? How can we meet health needs fairly when we cannot meet them all? Daniels' theory has implications for national and global health policy: Can we meet health needs fairly in ageing societies? Or protect health in the workplace while respecting individual liberty? Or meet professional obligations and obligations of justice without conflict? When is an effort to reduce health disparities, or to set priorities in realising a human right to health, fair? What do richer, healthier societies owe poorer, sicker societies? Just Health: Meeting Health Needs Fairly explores the many ways that social justice is good for the health of populations in developed.


Health Insurance

Private Health Insurance in Canada.

Hurley J., Guindon G.E.
Hamilton : McMaster University : 2008/10 : 31 p.

This study reviews the role of private health insurance in Canada. It begins with a brief overview of the Canadian health care system; considers the historical path that led to the current role for private health insurance; examines the current market for private health insurance; assesses the evidence for how private insurance contributes to or detracts from health financing goals; and offers some concluding comments on private health insurance in Canada.

The Effect of Managed and Traditional Care Insurance Plans on Horizontal Inequity in Access to Health Care in the United States.

Puffer F., Pitney Seidler E.
Worcester : College of the Holy Cross : 2008/11 : 37 p.

This study examines income inequity in access to health care in the United States. Given the predominant and growing presence of managed care organizations as a source of medical insurance and care in both the private and public settings, replacing traditional indemnity plans as a lower cost prophylactic alternative, we speculate that the presence of Managed Care Organizations would reduce, if not eliminate, any pro wealthy bias in access to health care for the insured population in the U.S. We rely on previously developed methodology from the EcuityII project, incorporating the health inequity index (HIWV), to estimate income inequity in traditional indemnity and managed care plans. Our results are surprisingly counterintuitive to the expected result that managed care was designed to have on access to care. The calculated HIWV indicates a relatively greater pro wealthy bias in the managed care group. This result has important and direct policy implications as public insurance programs in the U.S. contract with managed care organizations as a lower cost alternative for Medicaid and Medicare beneficiaries.

Health inequalities

Reflections on the Development of Health Inequalities Policy in the United Kingdom.

Oliver A.
Londres : LSE : 2008/10 : 32 p.

Abstracts are written to summarise documents and to whet the reader's interest. Alas, many readers just use them as a substitute for reading the whole paper, which given the brevity of abstracts can give a somewhat distorted impression. I hope that having read this abstract, you will read on. If you do, you will find that I offer a little personal history and a little impersonal history on the development of interest in the issue of health inequalities in the United Kingdom. I then summarise the policy response of recent Labour governments, briefly detail the effects of this response, and finally offer my own three-pronged policy attack on our thus far really quite stubborn inequalities in health.

Unfair inequalities in health and health care.

Fleurbaey M., Schokkaert E.
Louvain : Université Catholique de Louvain : 2007/11 : 46 p.

Inequalities in health and health care are caused by different factors. Measuring "unfair" inequalities implies that a distinction is introduced between causal variables leading to ethically legitimate inequalities and causal variables leading to ethically illegitimate inequalities. An example of the former could be life-style choices, an example of the latter is social background. We show how to derive measures of unfair inequalities in health and in health care delivery from a structural model of health care and health production: “direct unfairness”, linked to the variations in medical expenditures and health in the hypothetical distribution in which all legitimate sources of variation are kept constant; “fairness gap”, linked to the differences between the actual distribution and the hypothetical distribution in which all illegitimate sources of variation have been removed. These two approaches are related to the theory of fair allocation. In general they lead to different results. We propose to analyse the resulting distributions with the traditional apparatus of Lorenz curves and inequality measures. We compare our proposal to the more common approach using concentration curves and analyse the relationship with the methods of direct and indirect standardization. We discuss how inequalities in health care can be integrated in an overall evaluation of social inequality.


Choosing and Successfully Sustaining Competitive Strategies in the European Pharmaceutical Industry.

Herrmann A.M.
Cologne : Max Planck Institute : 2008/10 : 32 p.

It is a central claim of the national competitiveness literature that firms exploit the comparative advantages of their environment by choosing to pursue the product market strategy that is facilitated by national financial- and labour-market institutions. Other­wise, so goes the argument, firms are punished in that strategies receiving no institutional support are less successful and therefore not sustainable in the long run. My analyses of pharmaceutical firms in Germany, Italy and the United Kingdom challenge these arguments on the choice and success of competitive strategies. Given that different measures of strategy success do not indicate that the latter is in line with national institutional advantages, I develop an alternative explanation for the strategy choices of firms. On the basis of my qualitative interviews with managers, I argue that technological opportunities to transform inventions or imitations into marketable products are a primary concern when entrepreneurs choose their firm's strategy.

Health and Employment

Cumulative Effects of Job Characteristics on Health.

Fletcher J., Sindelar J.L., Yamaguchi S.
Ontario : McMaster University : 2008/11 : 31 p.

We present what we believe are the best estimates of how job characteristics of physical demands and environmental conditions affect individual's health. Five-year cumulative measures of these job characteristics are used to reflect findings in the physiologic literature that cumulative exposure is most relevant for the impact of hazards and stresses on health. Using data from the Panel Study of Income Dynamics we find that individuals who work in jobs with the ‘worst' conditions experience declines in their health, although this effect varies by demographic group. For example, for non-white men, a one standard deviation increase in cumulative physical demands decreases health by an amount that offsets an increase of two years of schooling or four years of aging. Job characteristics are found more detrimental to the health of females and older workers. These results are robust to inclusion of occupation fixed effects, health early in life and lagged health.

Primary health care

The remuneration of general practictitioners and specialists in 14 OECD Countries : what are the factors influencing variations across countries ?

Fujisawa E., Lafortune G.
Paris : OCDE : 2008/12 : 61 p.

Ce document de travail présente une analyse descriptive de la rémunération des médecins dans 14 pays de l'OCDE pour lesquels on trouve des données raisonnablement comparables dans Eco-santé OCDE 2007 (Allemagne, Autriche, Canada, Danemark, États-Unis, Finlande, France, Hongrie, Islande, Luxembourg, Pays-Bas, République tchèque, Royaume-Uni et Suisse). Les données sont présentées séparément pour les généralistes (omnipraticiens) et les spécialistes. La comparaison des niveaux de rémunération entre pays est faite sur la base d'une monnaie commune (le dollar américain, ajusté pour la parité des pouvoirs d'achat), ainsi qu'en rapport avec le salaire moyen de l'ensemble des travailleurs dans chacun des pays. Cette étude constate qu'il y a de fortes variations dans les niveaux de revenu des généralistes entre les pays, et que les variations sont encore plus prononcées concernant les spécialistes. La rémunération des généralistes oscille entre deux fois le niveau du salaire moyen en Finlande et République tchèque, à un niveau trois fois et demi plus élevé aux États-Unis et en Islande. La rémunération des spécialistes varie encore plus, allant de une fois et demi à deux fois le salaire moyen pour les spécialistes salariés en Hongrie et en République tchèque, à cinq à sept fois plus élevé pour les spécialistes travaillant en mode libéral aux Pays-Bas, aux États-Unis et en Autriche. Une partie de la variation dans les rémunérations entre pays peut s'expliquer par l'utilisation de différentes méthodes de rémunération (par exemple, le salariat ou le paiement par acte pour les médecins libéraux), par le rôle joué par les généralistes en tant que médecin référant, par des différences dans la charge de travail (tel que mesuré, par exemple, par les heures de travail) et par le nombre de médecins par habitant. Cependant, ces facteurs institutionnels ou d'offre ne peuvent pas expliquer toutes les variations. Par ailleurs, lorsque l'on compare la rémunération des généralistes et des spécialistes dans chaque pays, cette étude indique que dans pratiquement tous les pays, la rémunération des spécialistes a eu tendance à augmenter plus rapidement que celle des généralistes au cours des dix dernières années, creusant encore plus l'écart. Cet écart grandissant a probablement contribué à l'augmentation du nombre et de la part des spécialistes dans le nombre total de médecins dans la plupart des pays au cours de la dernière décennie, et à accroître les inquiétudes concernant une pénurie de généralistes.

Compensation and Incentives in Medical Networks with Gate-keeping and Case Management.

Schumacher P.
Munich : university of Munich : 2008/11 : 15 p.

New approaches in health care, such as e.g. Integrated Delivery Systems, affect the role and tasks of medical suppliers. More and more, medical suppliers are incorporated into the process of guiding patients to medical specialists and hospitals and thus managing the course of disease. In this context, the role of medical gate-keepers and case managers may provide opportunities for undesirable behavior (from the network's point of view). Therefore, compensation-induced incentives for gatekeepers and case managers are in the main focus of the paper. Different health care payment systems and the impact of financial and non-financial incentives on case managers and gate-keepers in medical networks are analyzed. Another focus is laid on medical suppliers that are not involved in managing diseases and guiding patients. Due to their smaller margin of actions and possibilities to take advantage of it, reimbursement should emphasize different aspects than for case managers.

Towards a National Primary Health Care Strategy. A Discussion Paper from the Australian Government.

Australian Government. Department of Health and Ageing. Canberra. AUS
Canberra : Commonwealth of Australia : 2008 : 49 p.

This Discussion Paper is intended to provide a broad framework and basic information on key issues impacting on primary health care. Its purpose is to stimulate input and comment to assist in the development of the Strategy. This Paper proposes 10 elements which could underpin a future primary health care system and for each one provides a snapshot of: What happens now? What does this mean for the community and health consumers? What does this mean for health professionals? Where could changes be made?

Do Optional Deductibles Reduce the Number of Doctor Visits? : Empirical Evidence with German Data.

Schmitz H.
Berlin : DIW : 2008/10 : 25 p.

Les franchises optionnelles réduisent-elles le nombre des visites de médecins ? une évidence empirique sur des données germaniques. SOEPpapers on Multidisciplinary Panel Data Research ; 141 Berlin : DIW : 2008/10 : 25p., 8 tabl. Deductibles in health insurance are often regarded as a means to contain health care costs when individuals exhibit moral hazard. However, in the absence of moral hazard, voluntarily chosen deductibles may instead lead to self-selection into different insurance contracts. We use a set of new variables in the German Socioeconomic Panel for the years 2002, 2004, and 2006 that measure individual health more accurately and include risk-attitudes towards health in order to determine the price elasticity of demand for health care. A latent class approach that takes into account the panel structure of the data reveals that the effect of deductibles on the number of doctor visits is negligible. Private add-on insurance increases the number of doctor visits. However, altogether the effects of the insurance state on the demand for doctor visits are small in magnitude.

Conflict in the doctor-patient relation and non-adherence: a game theory approach.

Stavropoulou C., Glycopantis D.
Londres : LSE : 2008/10 : 41 p.

Non-adherence to medication leads to reduced health outcomes and increased health care costs. More evidence and analysis is needed to understand the determinants of non-adherence, particularly the impact of the doctor-patient interaction. This relationship is often characterised by conflict during consultations. The aim of this paper is to investigate whether a game theoretic approach can explain the conflict during consultations that lead patients to non-adhere to medical recommendations. The game theoretic models constructed employ the Psychological Expected Utility theory. There is a distinction between information-loving and information-averse patients. Doctors do not always know the type of patient they have and on the basis of limited knowledge, they need to decide how much information to pass on. We relax the ssumption of perfect agency;and introduce the concept of the doctor's effort. Uncertainty is resolved under various hypotheses of bounded rationality. A complete resolution of the games is offered, and comparative statics results and economic interpretations are given. When a doctor knows with certainty the type of patient she has, she will transfer adequate information and the patient will adhere. If the doctor cannot recognize the patient's need the outcome may be non-adherence to recommendations. Doctors who understand patients' needs improve adherence rates. To enhance adherence, a number of policy recommendations are made. Financial incentives to the doctor do not benefit all types of patients.

Health care systems

Inequity in a market-based health system: evidence from Canada's dental sector.

Grignon M., Hurley J., Wang L., Allin S.
Hamilton : McMaster University : 2008/10 : 27 p.

We study the extent and drivers of income-related inequity in utilization of dental services in Canada using the concentration-index approach that has been widely applied to study equity in physician and hospital services. Because dental care is almost wholly privately financed in Canada, our estimates provide a benchmark for income-related inequity of utilization in private health systems. Although a number of studies document a link between income and utilization, our study is one of the few measuring income-related inequity in dental care utilization. A unique feature of our study is that we analyze separately equity in total dental visits and in preventive visits. This is important because the case for equity is much clearer for preventive dental care. We also examine the impact of controlling for need using a wider variety of need indicators than previous analyses. We confirm that most oral health indicators perform poorly as need adjustors because they reflect past dental care use: individuals with higher levels of utilization also are in better oral health.


Early retirement and inequality in Britain and Germany: How important is health ?

Roberts J., Rice N., Johns A.M.
York : HEDG. 36 p.

Both health and income inequalities have been shown to be much greater in Britain than in Germany. One of the main reasons seems to be the difference in the relative position of the retired, who, in Britain, are much more concentrated in the lower income groups. Inequality analysis reveals that while the distribution of health shocks is more concentrated among those on low incomes in Britain, early retirement is more concentrated among those on high incomes. In contrast, in Germany, both health shocks and early retirement are more concentrated among those with low incomes. We use comparable longitudinal data sets from Britain and Germany to estimate hazard models of the effect of health on early retirement. The hazard models show that health is a key determinant of the retirement hazard for both men and women in Britain and Germany. The size of the health effect appears large compared to the other variables. Designing financial incentives to encourage people to work for longer may not be sufficient as a policy tool if people are leaving the labour market involuntarily due to health problems.