Defining the "Health Benefit Basket" in nine European countries. Evidence from the European Union Health BASKET Project

Understanding the extent of economic evidence usage for informing policy decisions in the context of India's national health insurance scheme: Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY)

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.

The roads to managed competition for mixed public-private health systems: a conceptual framework

Health systems' insurance/funding can be organised in several ways. Some countries have adopted systems with a mixture of public-private involvement (e.g. Australia, Chile, Ireland, South Africa, New Zealand) which creates two-tier health systems, allowing consumers (groups) to have preferential access to the basic standard of care (e.g. skipping waiting times). The degree to which efficiency and equity are achieved in these types of systems is questioned. In this paper, we consider integration of the two tiers by means of a managed competition model, which underpins Social Health Insurance (SHI) systems. We elaborate a two-part conceptual framework, where, first, we review and update the existing pre-requisites for the model of managed competition to fit a broader definition of health systems, and second, we typologise possible roadmaps to achieve that model in terms of the insurance function, and focus on the consequences on providers and governance/stewardship.

Monitoring progress towards universal health coverage in Europe: a descriptive analysis of financial protection in 40 countries

Background

Ensuring that access to health care is affordable for everyone-financial protection-is central to universal health coverage (UHC). Financial protection is commonly measured using indicators of financial barriers to access (unmet need for health care) and financial hardship caused by out-of-pocket payments for health care (impoverishing and catastrophic health spending). We aim to assess financial hardship and unmet need in Europe and identify the coverage policy choices that undermine financial protection.

Methods

We carry out a cross-sectional study of financial hardship in 40 countries in Europe in 2019 (the latest available year of data before COVID-19) using microdata from national household budget surveys. We define impoverishing health spending as out-of-pocket payments that push households below or further below a relative poverty line and catastrophic health spending as out-of-pocket payments that exceed 40% of a household's capacity to pay for health care. We link these results to survey data on unmet need for health care, dental care, and prescribed medicines and information on two aspects of coverage policy at country level: the main basis for entitlement to publicly financed health care and user charges for covered services.

Findings

Out-of-pocket payments for health care lead to financial hardship and unmet need in every country in the study, particularly for people with low incomes. Impoverishing health spending ranges from under 1% of households (in six countries) to 12%, with a median of 3%. Catastrophic health spending ranges from under 1% of households (in two countries) to 20%, with a median of 6%. Catastrophic health spending is consistently concentrated in the poorest fifth of the population and is largely driven by out-of-pocket payments for outpatient medicines, medical products, and dental care-all forms of treatment that should be an essential part of primary care. The median incidence of catastrophic health spending is three times lower in countries that cover over 99% of the population than in countries that cover less than 99%. In 16 out of the 17 countries that cover less than 99% of the population, the basis for entitlement is payment of contributions to a social health insurance (SHI) scheme. Countries that give greater protection from user charges to people with low incomes have lower levels of catastrophic health spending.

Interpretation

It is challenging to identify with certainty the coverage policy choices that undermine financial protection due to the complexity of the policies involved and the difficulty of disentangling the effects of different choices. The conclusions we draw are therefore tentative, though plausible. Countries are more likely to move towards UHC if they reduce out-of-pocket payments in a progressive way, decreasing them for people with low incomes first. Coverage policy choices that seem likely to achieve this include de-linking entitlement from payment of SHI contributions; expanding the coverage of outpatient medicines, medical products, and dental care; limiting user charges; and strengthening protection against user charges, particularly for people with low incomes.

Funding

The European Union (DG SANTE and DG NEAR) and the Government of the Autonomous Community of Catalonia, Spain.

Criteria for the procedural fairness of health financing decisions: a scoping review

Due to constraints on institutional capacity and financial resources, the road to universal health coverage (UHC) involves difficult policy choices. To assist with these choices, scholars and policy makers have done extensive work on criteria to assess the substantive fairness of health financing policies: their impact on the distribution of rights, duties, benefits and burdens on the path towards UHC. However, less attention has been paid to the procedural fairness of health financing decisions. The Accountability for Reasonableness Framework (A4R), which is widely applied to assess procedural fairness, has primarily been used in priority-setting for purchasing decisions, with revenue mobilization and pooling receiving limited attention. Furthermore, the sufficiency of the A4R framework's four criteria (publicity, relevance, revisions and appeals, and enforcement) has been questioned. Moreover, research in political theory and public administration (including deliberative democracy), public finance, environmental management, psychology, and health financing has examined the key features of procedural fairness, but these insights have not been synthesized into a comprehensive set of criteria for fair decision-making processes in health financing. A systematic study of how these criteria have been applied in decision-making situations related to health financing and in other areas is also lacking. This paper addresses these gaps through a scoping review. It argues that the literature across many disciplines can be synthesized into 10 core criteria with common philosophical foundations. These go beyond A4R and encompass equality, impartiality, consistency over time, reason-giving, transparency, accuracy of information, participation, inclusiveness, revisability and enforcement. These criteria can be used to evaluate and guide decision-making processes for financing UHC across different country income levels and health financing arrangements. The review also presents examples of how these criteria have been applied to decisions in health financing and other sectors.

Health Status and Access to Healthcare for Uninsured Migrants in Germany: A Qualitative Study on the Involvement of Public Authorities in Nine Cities

Non-governmental organisations (NGOs) regularly report data on their work with uninsured migrants (UM) within a (so-called) parallel health care system. The role and involvement of public authorities therein have yet been underrepresented in research. Our aim was to gain a better understanding of public authorities’ role in the parallel health care system and their view of the health situation of UM. We conducted qualitative semi-structured interviews with 12 experts recruited by purposive sampling from local public health authorities (LPHAs), state-level public health authorities (SPHAs), and social services offices (SSO) in nine cities, recorded, transcribed, and subjected the data to qualitative content analysis. LPHAs are more often directly involved in providing medical services, while SSOs and SPHAs function as gatekeepers for access to social benefits, including health insurance, and in grant-funded projects. NGOs keep substituting for the lack of access to regular health care from public institutions, but even in settings with extended services, public authorities and NGOs have not been able to provide sufficient care through the parallel health care system: Experts report gaps in the provision of health care with respect to the depth and height of coverage, due to the fragmentation of services and (ostensible) resource scarcity. Our study highlights the necessity for universal access to regular health care to overcome the fragmentation of services and improve access to needed health care for UM in Germany.

Exploring variation of coverage and access to dental care for adults in 11 European countries: a vignette approach

BACKGROUND

Oral health, coupled with rising awareness on the impact that limited dental care coverage has on oral health and general health and well-being, has received increased attention over the past few years. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach.

METHODS

We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists.

RESULTS

Completed vignettes were received from 11 countries: Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different physical barriers to accessing dental care. The limited availability of contracted dentists (especially in rural areas) and the unequal distribution and lack of specialised dentists are major access barriers to public dental care.

CONCLUSIONS

According to the results, statutory coverage of dental care varies across European countries, while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries, leading to high out-of-pocket spending. Socioeconomic status is thus a main determinant for access to dental care, but other factors such as geography, age and comorbidities can also inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care.

Differences in health outcomes for high-need high-cost patients across high-income countries

OBJECTIVE

This study explores variations in outcomes of care for two types of patient personas-an older frail person recovering from a hip fracture and a multimorbid older patient with congestive heart failure (CHF) and diabetes.

DATA SOURCES

We used individual-level patient data from 11 health systems.

STUDY DESIGN

We compared inpatient mortality, mortality, and readmission rates at 30, 90, and 365 days. For the hip fracture persona, we also calculated time to surgery. Outcomes were standardized by age and sex.

DATA COLLECTION/EXTRACTION METHODS

Data was compiled by the International Collaborative on Costs, Outcomes and Needs in Care across 11 countries for the years 2016-2017 (or nearest): Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States.

PRINCIPAL FINDINGS

The hip sample across ranged from 1859 patients in Aragon, Spain, to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia, and the majority of hip patients across countries were female. The congestive heart failure (CHF) sample ranged from 742 patients in England to 21,803 in the United States. Mean age ranged from 77.2 in the United States to 80.3 in Sweden, and the majority of CHF patients were males. Average in-hospital mortality across countries was 4.1%. for the hip persona and 6.3% for the CHF persona. At the year mark, the mean mortality across all countries was 25.3% for the hip persona and 32.7% for CHF persona. Across both patient types, England reported the highest mortality at 1 year followed by the United States. Readmission rates for all periods were higher for the CHF persona than the hip persona. At 30 days, the average readmission rate for the hip persona was 13.8% and 27.6% for the CHF persona.

CONCLUSION

Across 11 countries, there are meaningful differences in health system outcomes for two types of patients.

A methodology for identifying high-need, high-cost patient personas for international comparisons

OBJECTIVE

To establish a methodological approach to compare two high-need, high-cost (HNHC) patient personas internationally.

DATA SOURCES

Linked individual-level administrative data from the inpatient and outpatient sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States.

STUDY DESIGN

We outline a methodological approach to identify HNHC patient types for international comparisons that reflect complex, priority populations defined by the National Academy of Medicine. We define two patient profiles using accessible patient-level datasets linked across different domains of care-hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, long-term care, home-health care, and outpatient drugs. The personas include a frail older adult with a hip fracture with subsequent hip replacement and an older person with complex multimorbidity, including heart failure and diabetes. We demonstrate their comparability by examining the characteristics and clinical diagnoses captured across countries.

DATA COLLECTION/EXTRACTION METHODS

Data collected by ICCONIC partners.

PRINCIPAL FINDINGS

Across 11 countries, the identification of HNHC patient personas was feasible to examine variations in healthcare utilization, spending, and patient outcomes. The ability of countries to examine linked, individual-level data varied, with the Netherlands, Canada, and Germany able to comprehensively examine care across all seven domains, whereas other countries such as England, Switzerland, and New Zealand were more limited. All countries were able to identify a hip fracture persona and a heart failure persona. Patient characteristics were reassuringly similar across countries.

CONCLUSION

Although there are cross-country differences in the availability and structure of data sources, countries had the ability to effectively identify comparable HNHC personas for international study. This work serves as the methodological paper for six accompanying papers examining differences in spending, utilization, and outcomes for these personas across countries.

Comparison of outpatient coverage in Canada: Assistive and medical devices

Outpatient technologies are important for maintaining health and overall quality of life, yet the degree of access and coverage of these technologies remains variable within and across jurisdictions. In Canada, assistive technologies are not included in universal health coverage, and are not subject to the Canada Health Act's criteria and conditions that provinces and territories must fulfill to receive the full federal cash contribution under the Canada Health Transfer. As such, the thirteen Canadian provincial and territorial governments make separate decisions on programs and coverage. Drawing on the WHO Universal Coverage Cube we compare who gets access, the types of technologies that can be accessed, and the level of coverage (total costs covered) in Canada. Overall, each Canadian jurisdiction had at least one publicly supported program. All relied on a 'health assessment' of an individual's need to determine eligibility. Income and eligibility for social assistance was used as eligibility criteria in 6 of the 13 jurisdictions. Mobility aids as well as audio, visual, and communication aids were included in all jurisdictions. While some programs offered full financial support for some technologies, forms of cost sharing were common. The results are discussed in the context of international experiences, demographic changes, and health system trends to highlight areas for policy learning.

Measuring outcomes in healthcare economics using Artificial Intelligence: With application to resource management

The quality of service in healthcare is constantly challenged by outlier events such as pandemics (i.e., Covid-19) and natural disasters (such as hurricanes and earthquakes). In most cases, such events lead to critical uncertainties in decision-making, as well as in multiple medical and economic aspects at a hospital. External (geographic) or internal factors (medical and managerial) lead to shifts in planning and budgeting, but most importantly, reduce confidence in conventional processes. In some cases, support from other hospitals proves necessary, which exacerbates the planning aspect. This paper presents three data-driven methods that provide data-driven indicators to help healthcare managers organize their economics and identify the most optimum plan for resources allocation and sharing. Conventional decision-making methods fall short in recommending validated policies for managers. Using reinforcement learning, genetic algorithms, traveling salesman, and clustering, we experimented with different healthcare variables and presented tools and outcomes that could be applied at health institutes. Experiments are performed; the results are recorded, evaluated, and presented.

Shedding Light on Reimbursement Policies of Companion Diagnostics in European Countries

OBJECTIVES

Ensuring access to precision medicine has been an issue because in some European countries, desynchronized reimbursement decision-making occurs between the medicine and the companion diagnostic (CDx). This has resulted in cases in which precision medicine is reimbursed but not the CDx. In overcoming this issue, an alignment of the decision-making process for reimbursement between the 2 entities should be considered. As pharmaceutical reimbursement procedures are meticulously covered in the literature, we set out to systematically map in vitro diagnostic (IVD) reimbursement procedures and identify policies for aligning these procedures with the pharmaceutical reimbursement procedures.

METHODS

We selected 8 European countries for this analysis. For each country, we characterized the national benefit basket entailing the IVD medical acts in outpatient care, evaluated the procedure for inclusion, and identified alternative reimbursement practices for CDx. Targeted searches, using publicly accessible sources, were conducted to identify relevant reimbursement policies and laws.

RESULTS

We systematically describe the reimbursement process in 8 European countries. Alternative procedures for CDx reimbursement were identified in Belgium and Germany. Alternative policies attributed to the practice of precision medicine were identified in England and Italy. In France, some CDx are included in the "coverage with evidence" development program. Specifically, the health technology assessment agencies of France and England commented on the assessment of companion diagnostics and their clinical utility.

CONCLUSION

CDx reimbursement procedures have recently been implemented in some countries. This was seemingly done primarily to ensure access to the precision medicine and only secondary to the value they would provide.

A challenge to all. A primer on inter-country differences of high-need, high-cost patients

BACKGROUND

Across countries, a small group of patients accounts for the majority of health care spending. These patients are more likely than other patients to experience problems with quality and safety in their care, suggesting that efforts targeting efficiency and quality among this population might have significant payoffs for health systems. Better understanding of similarities and differences in patient characteristics and health care use in different countries may ultimately inform further efforts to improve care for HNHC patients in these health systems.

METHODS

We conducted a cross-sectional descriptive study using one year of patient-level data on high-cost patients in seven high-income OECD member countries. Countries were selected based on availability of detailed information (large enough samples of claims, administrative, and survey data of high-cost patients). We studied concentration of spending among high-cost patients, characteristics of high-cost patients, and per capita spending on high-cost patients.

FINDINGS

Cost-concentration of the top 5% of patients varied across countries, from 41% in Japan to 60% in Canada, driven primarily by variation in the top 1% of spenders. In general, high-cost patients were more likely to be female (57.7% on average), had a significant number of multi-morbidities (up to on average 10 major diagnostic categories (ICD chapters), and had a lower socioeconomic status. Characteristics of high-cost patients varied as well: median age ranged from 62 in the Netherlands to 75 in Germany and the difference in socioeconomic status is particularly stark in the US. Lastly, utilization, particularly for inpatient care, varied with an average number of inpatient days ranging from 6.6 nights (US) to 97.7 nights in Japan.

INTERPRETATION

In this descriptive study, there is substantial variation in the cost concentration, characteristics, and per capita spending on high-cost patient populations across high-income countries. Differences in the way that health systems are structured likely explains some of this variation, which suggests the potential of cross-system learning opportunities. Our findings highlight the need for further studies including comparable performance metrics and institutional analysis.

Worlds of Healthcare: A Healthcare System Typology of OECD Countries

In this paper, we present an extended typology of OECD healthcare systems. Our theoretical framework integrates the comparative-institutional perspective of existing classifications with current ideas from the international health policy research debate. We argue that combining these two perspectives provides a more comprehensive picture of modern healthcare systems and takes the past decade's dynamic of reforms into account. Moreover, this approach makes the typology more beneficial in terms of understanding and explaining cross-national variation in population health and health inequalities. Empirically, we combine indicators on supply, public-private mix, and institutional access regulations from earlier typologies with information on primary care orientation and performance management in prevention and quality of care. The results from a series of cluster analyses indicate that at least five distinct types of healthcare systems can be identified. Moreover, we provide quantitative information on the consistency of cluster membership for individual countries via system types.

Who wants to cross borders in the EU for healthcare? An analysis of the Eurobarometer data in 2007 and 2014

Background

The European Union (EU) Directive on Patients' Rights in Cross-border Healthcare clarified the entitlements to medical care in other EU Member states. However, little is known about whether EU citizens have been travelling or are willing to travel to receive care. This study aimed to measure the determinants of cross-border patient mobility and willingness to travel to receive medical care in the EU, before and after the adoption of the Directive.

Methods

We used individual data from the Eurobarometer 210 (2007) and 425 (2014). In the 2 years, 53 439 EU citizens were randomly selected. We performed a logistic regression on the cross-border patient mobility and willingness to travel to other EU countries to use healthcare services as a function of the year (2007 or 2014), adjusting for age, gender, education and country size.

Results

In 2007, 3.3% of citizens reported cross-border mobility and 4.6% in 2014. The odds of cross-border patients' mobility were 11% higher in 2014, compared with 2007 [odds ratio (OR) 1.11, 95% confidence interval (CI) 1.02-1.21]. Also, mobility was 19% higher in males (OR 1.19, 95% CI 1.08-1.30) and 20% higher amongst the more educated (OR 1.20, 95% CI 1.09-1.31). However, the odds decreased 11% per decade of age (OR 0.89 per decade, 95% CI 0.85-0.93) and country size. In 2014, the willingness to travel decreased by 20% compared with 2007.

Conclusions

Cross-border patient mobility is more likely amongst the younger, the more educated and those from smaller countries. The directive does not seem to have promoted mobility at a large scale among the neediest citizens.

Who should receive treatment? An empirical enquiry into the relationship between societal views and preferences concerning healthcare priority setting

INTRODUCTION

Policy makers increasingly need to prioritise between competing health technologies or patient populations. When aiming to align allocation decisions with societal preferences, knowledge and operationalisation of such preferences is indispensable. This study examines the distribution of three views on healthcare priority setting in the Netherlands, labelled "Equal right to healthcare", "Limits to healthcare", and "Effective and efficient healthcare", and their relationship with preferences in willingness to trade-off (WTT) exercises.

METHODS

A survey including four reimbursement scenarios was conducted in a representative sample of the adult population in the Netherlands (n = 261). Respondents were matched to one of the three views based on their agreement with 14 statements on principles for resource allocation. We tested for WTT differences between respondents with different views and applied logit regression models for examining the relationship between preferences and background characteristics, including views.

RESULTS

Nearly 65% of respondents held the view "Equal right to healthcare", followed by "Limits to healthcare" (22.5%), and "Effective and efficient healthcare" (7.1%). Most respondents (75.9%) expressed WTT in at least one scenario and preferred gains in quality of life over life expectancy, maximising gains over limiting inequality, treating children over elderly, and those with adversity over those with an unhealthy lifestyle. Various background characteristics, including the views, were associated with respondents' preferences.

CONCLUSIONS

Most respondents held an egalitarian view on priority setting, yet the majority was willing to prioritise regardless of their view. Societal views and preferences concerning healthcare priority setting are related. However, respondents' views influence preferences differently in different reimbursement scenarios. As societal views and preferences are heterogeneous and may conflict, aligning allocation decisions with societal preferences remains challenging and any decision may be expected to receive opposition from some group in society.

Scoping literature review on the basic health benefit package and its determinant criteria

BACKGROUND

There are various criteria and methods to develop Basic Health Benefit Package (BHBP) in world health systems. The present study aimed to extract criteria used in health systems in different countries around the world using scoping review method.

METHODS

A systematic search was carried out in Cochrane Library, PubMed, Scopus, Science Direct, Web of Science, ProQuest, World Bank, World Health Organization, and Google databases between January and April 2016. Papers and reports were gathered according to selected keywords and were examined by two authors. Finally, the criteria were extracted from the selected papers.

RESULTS

The primary search included 8876 papers. After studying the articles' titles, abstracts, and full texts, 9 articles and 14 reports were selected for final analysis. After the final analysis, 19 criteria were extracted. Due to diversity of criteria in terms of number and nature, they were divided into three categories. The categories included intervention-related criteria, disease-related criteria, and community-related criteria. The largest number of criteria belonged to the first category. Indeed, the most widely applied criteria included cost-effectiveness (20), effectiveness (19), budget impact (12), equity (12), and burden of disease (10).

CONCLUSION

According to the results, different criteria were identified in terms of number and nature in developing BHBP in world health systems. It seems that certain criteria, such as cost-effectiveness, effectiveness, budget impact, burden of disease, equity, and necessity, that were most widely utilized in countries under study could be for designing BHBP with regard to social, cultural, and economic considerations.

Expensive lifesaving treatments: allocating resources and maximizing access

Avisar et al. present an exemplary model for outreach aimed at ensuring that a maximum of patients eligible for expensive Hepatitis C (HPC) drugs receive treatment. We enlarge the picture to put their model in the political, economic and regulatory framework for financing and providing these drugs in Israel and a number of other countries. We then return to delivery system level and consider issues such as cost of outreach, the need for health care coordinators and dealing with Hepatitis C patients not yet entitled to receive the drugs under national health coverage determinations.Regarding national coverage decisions, we find that countries such as Australia, New Zealand, the United Kingdom and Israel all extended coverage for Hepatitis C drugs, given the clear high effectiveness of the latter. However, to limit budget impact, all these countries target coverage to patients based on disease genotype and stage.The model presented by Avisar et al., while impressive, leaves some items to address. These include: whether all resources allocated to HPC drugs are actually used for this purpose, the roles of outreach to HPC patients who do not meet the guidelines for treatment, and a comparison of the effectiveness of the model vs. a variety of costs associated with it.

The bare necessities? A realist review of necessity argumentations used in health care coverage decisions

CONTEXT

Policy makers and insurance companies decide on coverage of care by both calculating (cost-) effectiveness and assessing the necessity of coverage.

AIM

To investigate argumentations pertaining to necessity used in coverage decisions made by policy makers and insurance companies, as well as those argumentations used by patients, authors, the public and the media.

METHODS

This study is designed as a realist review, adhering to the RAMESES quality standards. Embase, Medline and Web of Science were searched and 98 articles were included that detailed necessity-based argumentations.

RESULTS

We identified twenty necessity-based argumentation types. Seven are only used to argue in favour of coverage, five solely for arguing against coverage, and eight are used to argue both ways. A positive decision appears to be facilitated when patients or the public set the decision on the agenda. Moreover, half the argumentation types are only used by patients, authors, the public and the media, whereas the other half is also used by policy makers and insurance companies. The latter group is more accepted and used in more different countries.

CONCLUSION

The majority of necessity-based argumentation types is used for either favouring or opposing coverage, and not for both. Patients, authors, the public and the media use a broader repertoire of argumentation types than policy makers and insurance companies.

Health Technology Assessment: Global Advocacy and Local Realities Comment on "Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, Not Just More Evidence on Cost-Effectiveness"

Cost-effectiveness analysis (CEA) can help countries attain and sustain universal health coverage (UHC), as long as it is context-specific and considered within deliberative processes at the country level. Institutionalising robust deliberative processes requires significant time and resources, however, and countries often begin by demanding evidence (including local CEA evidence as well as evidence about local values), whilst striving to strengthen the governance structures and technical capacities with which to generate, consider and act on such evidence. In low- and middle-income countries (LMICs), such capacities could be developed initially around a small technical unit in the health ministry or health insurer. The role of networks, development partners, and global norm setting organisations is crucial in supporting the necessary capacities.

Should Countries Set an Explicit Health Benefits Package? The Case of the English National Health Service

BACKGROUND

A fundamental debate in the transition towards universal health coverage concerns whether to establish an explicit health benefits package to which all citizens are entitled, and the level of detail in which to specify that package. At one extreme, the treatments to be funded, and the circumstances in which patients qualify for the treatment, might be specified in great detail, and be entirely mandatory. This would make clinicians little more than automata, carrying out prescribed practice. At the other extreme, priorities may be expressed in very broad terms, with no compulsion or other incentives to encourage adherence.

OBJECTIVES

The paper examines the arguments for and against setting an explicit benefits package, and discusses the circumstances in which increased detail in specification are most appropriate.

METHODS

The English National Health Service is used as a case study, based on institutional history, official documents and research literature.

RESULTS

Although the English NHS does not explicitly specify a health benefits package, it is in some respects establishing an 'intelligent' package, based on instruments such as an essential medicines list, clinical guidelines, provider payment and performance reporting, which acknowledges gaps in evidence and variations in local resource constraints.

CONCLUSIONS

Further moves towards a more explicit specification are likely to yield substantial benefits in most health systems. Considerations in determining the 'hardness' of benefits package specification might include the quality of information about the costs and benefits of treatments, the heterogeneity of patient needs and preferences, the financing regime in place, and the nature of supply side constraints.

Clinical effectiveness of cancer screening biomarker tests offered as self-pay health service: a systematic review

BACKGROUND

Biomarker tests are increasingly being offered by laboratories and clinicians as self-pay health services to screen asymptomatic individuals; however, sufficient evidence may not be available to support this practice. We investigated the benefit-harm tradeoffs associated with 11 biomarkers currently offered in Germany as self-pay tests to screen for cancer.

METHODS

We systematically searched bibliographic databases for health technology assessments, systematic reviews and randomized-controlled trials (RCTs) through September 2015. We included publications that analysed cancer screening biomarkers and reported patient-relevant outcomes (mortality, morbidity, quality of life), and potential harms of screening, among asymptomatic individuals in screening and non-screening arms. Language was restricted to English and German. Two reviewers independently screened references; data were extracted and quality of included studies was evaluated by a reviewer and validated by a second reviewer.

RESULTS

Six publications of secondary literature and four publications reporting results from two RCTs were included. For 10 cancer screening biomarkers, no direct evidence on patient-relevant outcomes was available. Only one trial, which simultaneously assessed cancer antigen 125 (CA125) and vaginal ultrasound for ovarian cancer screening, provided the outcome of interest. Screening compared with usual care did not reduce ovarian cancer mortality. Patient harms included overdiagnosis and false-positive results.

CONCLUSION

Although ovarian cancer screening with CA125 showed no benefit, false-positive tests, overdiagnosis and overtreatment were reported. Physicians and laboratories should provide patients with comprehensive information about the lack of evidence and potential harms caused by biomarker screening tests offered as a self-pay health service.

The Relationship Between the Scope of Essential Health Benefits and Statutory Financing: An International Comparison Across Eight European Countries

BACKGROUND

Both rising healthcare costs and the global financial crisis have fueled a search for policy tools in order to avoid unsustainable future financing of essential health benefits. The scope of essential health benefits (the range of services covered) and depth of coverage (the proportion of costs of the covered benefits that is covered publicly) are corresponding variables in determining the benefits package. We hypothesized that a more comprehensive health benefit package may increase user cost-sharing charges.

METHODS

We conducted a desktop research study to assess the interrelationship between the scope of covered health benefits and the height of statutory spending in a sample of 8 European countries: Belgium, England, France, Germany, the Netherlands, Scotland, Sweden, and Switzerland. We conducted a targeted literature search to identify characteristics of the healthcare systems in our sample of countries. We analyzed similarities and differences based on the dimensions of publicly financed healthcare as published by the European Observatory on Health Care Systems.

RESULTS

We found that the scope of services is comparable and comprehensive across our sample, with only marginal differences. Cost-sharing arrangements show the most variation. In general, we found no direct interrelationship in this sample between the ranges of services covered in the health benefits package and the height of public spending on healthcare. With regard to specific services (dental care, physical therapy), we found indications of an association between coverage of services and cost-sharing arrangements. Strong variations in the volume and price of healthcare services between the 8 countries were found for services with large practice variations.

CONCLUSION

Although reducing the scope of the benefit package as well as increasing user charges may contribute to the financial sustainability of healthcare, variations in the volume and price of care seem to have a much larger impact on financial sustainability. Policy-makers should focus on a variety of measures within an integrated approach. There is no silver bullet for addressing the sustainability of healthcare.

Using health technology assessment for informing coverage decisions in Thailand

This article aims to illustrate and critically analyze the results from the 1-year experience of using health technology assessment (HTA) in the development of the Thai Universal Coverage health benefit package. We review the relevant documents and give a descriptive analysis of outcomes resulting from the development process in 2009-2010. Out of 30 topics nominated by stakeholders for prioritization, 12 were selected for further assessment. A total of five new interventions were recommended for inclusion in the benefit package based on value for money, budget impact, feasibility and equity reasons. Different stakeholders have diverse interests and capabilities to participate in the process. In conclusion, HTA is helpful for informing coverage decisions for health benefit packages because it enhances the legitimacy of policy decisions by increasing the transparency, inclusiveness and accountability of the process. There is room for improvement of the current use of HTA, including providing technical support for patient representatives and civic groups, better communication between health professionals, and focusing more on health promotion and disease prevention.

Universal health coverage and user charges

There has been an explosion of interest in the concept of ‘universal health coverage’, fuelled by publication of the World Health Report 2010. This paper argues that the system of user charges for health services is a fundamental determinant of levels of coverage. A charge can lead to a loss of utility in two ways. Citizens who are deterred from using services by the charge will suffer an adverse health impact. And citizens who use the service will suffer a loss of wealth. The role of social health insurance is threefold: to reduce households’ financial risk associated with sickness; to promote enhanced access to needed health services; and to contribute to societal equity objectives, through an implicit financial transfer from rich to poor and healthy to sick. In principle, an optimal user charge policy can ensure that the social health insurance funds are used to best effect in pursuit of these objectives. This paper calls for a fundamental rethink of attitudes and policy towards user charges.

Transparency vs. closed-door policy: do process characteristics have an impact on the outcomes of coverage decisions? A statistical analysis

The aim of this study was to analyze influences of process- and technology-related characteristics on the outcomes of coverage decisions. Using survey data on 77 decisions from 13 countries, we examined whether outcomes differ by 14 variables that describe components of decision-making processes and the technology. We analyzed the likelihood of committees covering a technology, i.e. positive (including partial coverage) vs. negative coverage decisions. We performed non-parametric univariate tests and binomial logistic regression with a stepwise variable selection procedure. We identified a negative association between a positive decision and whether the technology is a prescribed medicine (p=0.0097). Other significant influences on a positive decision outcome included one disease area (p=0.0311) and whether a technology was judged to be (cost-)effective (p<0.0001). The first estimation of the logistic regression yielded a quasi-complete separation for technologies that were clearly judged (cost-)effective. In uncertain decisions, a higher number of stakeholders involved in voting (odds ratio=2.52; p=0.03) increased the likelihood of a positive outcome. The results suggest that decisions followed the lines of evidence-based decision-making. Despite claims for transparent and participative decision-making, the phase of evidence generation seemed most critical as decision-makers usually adopted the assessment recommendations. We identified little impact of process configurations.

An economic theory of the fourth hurdle

Third party payers' decision processes for financing health technologies ('fourth hurdle' processes) are subject to intensive descriptive empirical investigation. This paper addresses the need for a theoretical foundation of this research and develops a theoretical framework for analysing fourth hurdle processes from an economics perspective. On the basis of a decision-analytic framework and the theory of agents, fourth hurdle processes are described as sets of institutions to maximize the value derived from finite healthcare resources. Benefits are assumed to arise from the value of better information about and better implementation of the most cost-effective choice. Implementation is improved by decreased information asymmetries and better alignment of incentives. This decreases the effects of ex ante and ex post moral hazard on service provision. Potential indicators of high benefit include high costs associated with wrong decisions and large population sizes affected by the decision. The framework may serve as a basis both for further theoretical work, for example, on the appropriate degree of participation as well as further empirical work, for example, on comparative assessments of fourth hurdle processes. It needs to be complemented by frameworks for analysing fourth hurdle institutions developed by other disciplines such as bioethics or law.

Incorporating financial protection into decision rules for publicly financed healthcare treatments

Almost all health systems seek to offer some form of publicly financed healthcare insurance, and governments must therefore choose the size of the benefit package and the types of treatments to cover. Conventionally, the usual approach of economists has been to recommend choices on the basis of cost effectiveness of treatments, using metrics such as the 'cost per quality adjusted life year'. However, this approach is based on the assumption of health maximization subject to a budget constraint and ignores the potential impact of any additional concern with protecting individuals from the financial consequences of a health shock. Furthermore, it does not take account of the possible availability of complementary privately funded health care. This paper develops a model in which risk-averse individuals care about health but also place a value on protection from the financial consequences of rare but costly events. The paper shows how conventional cost-effectiveness analysis can readily be augmented to take account of financial protection objectives. The results depend on whether or not there exists a market in complementary privately funded health care. They have important implications for the methodology adopted by health technology assessment agencies and for the broader design of publicly funded health systems.

Balancing equity and efficiency in the Dutch basic benefits package using the principle of proportional shortfall

Economic evaluations are increasingly used to inform decisions regarding the allocation of scarce health care resources. To systematically incorporate societal preferences into these evaluations, quality-adjusted life year gains could be weighted according to some equity principle, the most suitable of which is a matter of frequent debate. While many countries still struggle with equity concerns for priority setting in health care, the Netherlands has reached a broad consensus to use the concept of proportional shortfall. Our study evaluates the concept and its support in the Dutch health care context. We discuss arguments in the Netherlands for using proportional shortfall and difficulties in transitioning from principle to practice. In doing so, we address universal issues leading to a systematic consideration of equity concerns for priority setting in health care. The article thus has relevance to all countries struggling with the formalization of equity concerns for priority setting.

Pre-coverage assessments of new hospital interventions on Austria: methodology and 3 years of experience

OBJECTIVES

A new decision-making process was set up by the Austrian Ministry of Health to regulate coverage of new proposed Extra Medical Services (EMS; German: Medizinische Einzel-Leistung [MEL]) in 2008. As part of the annual decision-making process an independent academic institution (LBI-HTA) is evaluating relevant evidence on these new technologies and provides HTAs, including evidence-based recommendations for decision makers.

METHODS

About ten EMS assessments are performed annually by the LBI-HTA simultaneously between January and March. Each peer-reviewed report consists of a systematic literature review and critical appraisal of evidence using the GRADE methodology. The generation of numerous reports of good quality standards within the short timeframe is achieved by a standardized workflow with predefined assignment of tasks for all participants.

RESULTS

In total, the LBI-HTA performed twenty-five EMS assessments on thirty-three different interventions in the last three years. Coverage was recommended with limitation for eleven (33%) interventions, and not recommended for twenty-two (66%) interventions. The federal health commission decided on acceptance or preliminary acceptance of coverage in seven (22%) cases, rejection in eighteen (55%) cases and changed the status to "subject to approval" in seven (24%) cases.

CONCLUSIONS

Pre-coverage assessment of new hospital interventions was implemented successfully in Austria. It has proved to be a useful tool to support decision makers with objective evidence when deciding whether or not to reimburse medical services.

A systematic review of coverage decision-making on health technologies-evidence from the real world

OBJECTIVE

Quantitative analysis of real-world coverage decision-making offers insights into the revealed preferences of appraisal committees. Aim of this review was to structure empirical evidence of coverage decisions made in practice based on the components 'methods and evidence', 'criteria and standards', 'decision outcome' and 'processes'.

METHODS

Several electronic databases, key journals and decision committees' websites were searched for publications between 1993 and June 2011. Inclusion criteria were the analysis of past decisions and application of quantitative methods. Each study was categorized by the scope of decision-making and the components covered by the variables used in quantitative analysis.

RESULTS

Thirty-two studies were identified. Many focused on pharmaceuticals, the UK NICE or the Australian PBAC. The components were covered comprehensively, but heterogeneously. Seventy-two variables were identified of which the following were more prevalent: specifications of the decision outcome; the indications considered for appraisal, identification of incremental cost-effectiveness ratios, appropriateness of evaluation methods, type of economic or clinical evidence used for assessment, and the decision date.

CONCLUSIONS

Research was dominated by analysis of decision outcomes and appraisal criteria. Although common approaches were identified, the complexity of coverage decision-making - reflected by the heterogeneity of identified variables - will continue to challenge empirical research.

The evaluation of lifestyle interventions in the Netherlands

Current investments in preventive lifestyle interventions are relatively low, despite the significant impact of unhealthy behaviour on population health. This raises the question of whether the criteria used in reimbursement decisions about healthcare interventions put preventive interventions at a disadvantage. In this paper, we highlight the decision-making framework used in the Netherlands to delineate the basic benefits package. Important criteria in that framework are ‘necessity’ and ‘cost-effectiveness’. Several normative choices need to be made, and these choices can have an important impact on the evaluation of lifestyle interventions, especially when making these criteria operational and quantifiable. Moreover, the implementation of the decision-making framework may prove to be difficult for lifestyle interventions. Improvements of the decision-making framework in the Netherlands are required to guarantee sound evaluations of lifestyle interventions aimed at improving health.

Leadership and governance in seven developed health systems

This paper explores leadership and governance arrangements in seven developed health systems: Australia, England, Germany, the Netherlands, Norway, Sweden and Switzerland. It presents a cybernetic model of leadership and governance comprising three fundamental functions: priority setting, performance monitoring and accountability arrangements. The paper uses a structured survey to examine critically current arrangements in the seven countries. Approaches to leadership and governance vary substantially, and have to date been developed piecemeal and somewhat arbitrarily. Although there seems to be reasonable consensus on broad goals of the health system there is variation in approaches to setting priorities. Cost-effectiveness analysis is in widespread use as a basis for operational priority setting, but rarely plays a central role. Performance monitoring may be the domain where there is most convergence of thinking, although countries are at different stages of development. The third domain of accountability is where the greatest variation occurs, and where there is greatest uncertainty about the optimal approach. We conclude that a judicious mix of accountability mechanisms is likely to be appropriate in most settings, including market mechanisms, electoral processes, direct financial incentives, and professional oversight and control. The mechanisms should be aligned with the priority setting and monitoring processes.

International casemix and funding models: lessons for rehabilitation

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is ‘An understanding of the different international models for funding of health care services and casemix systems, as exemplified by those in the US, Australia and the UK.’

Background: Payment for treatment in healthcare systems around the world is increasingly based on fixed tariff models to drive up efficiency and contain costs. Casemix classifications, however, must account adequately for the resource implications of varying case complexity. Rehabilitation poses some particular challenges for casemix development.

Objective: The objectives of this educational narrative review are (a) to provide an overview of the development of casemix in rehabilitation, (b) to describe key characteristics of some well-established casemix and payment models in operation around the world and (c) to explore opportunities for future development arising from the lessons learned.

Results: Diagnosis alone does not adequately describe cost variation in rehabilitation. Functional dependency is considered a better cost indicator, and casemix classifications for inpatient rehabilitation in the United States and Australia rely on the Functional Independence Measure (FIM). Fixed episode-based prospective payment systems are shown to contain costs, but at the expense of poorer functional outcomes. More sophisticated models incorporating a mixture of episode and weighted per diem rates may offer greater flexibility to optimize outcome, while still providing incentive for throughput.

Conclusion: The development of casemix in rehabilitation poses similar challenges for healthcare systems all around the world. Well-established casemix systems in the United States and Australia have afforded valuable lessons for other countries to learn from, but have not provided all the answers. A range of casemix and payment models is required to cater for different healthcare cultures, and casemix tools must capture all the key cost-determinants of treatment for patients with complex needs.

A structured tool to analyse coverage decisions: development and feasibility test in the field of cancer screening and prevention

OBJECTIVES

The comparison of fourth hurdle processes is challenging because they are heterogeneous and decision practice may deviate from formal process rules. This study applies a published framework consisting of key steps of coverage decision processes to the area of cancer prevention.

METHODS

A research design was developed for analysis of case studies on past decision processes. Decisions were identified and information on the process steps was elicited by semi-structured telephone interviews with decision-makers and experts. The scheme was validated with experts from the areas of screening and prevention and fourth hurdle decision making.

RESULTS

Indicators for a structured empirical comparison of coverage decisions were derived. Corresponding ordinal rankings were proposed. Details on six decisions about cancer screening (colorectal and prostate cancer) and vaccination against human papillomavirus in Sweden, Austria and Lithuania are presented.

CONCLUSIONS

The development of the structured scheme for analysis of coverage decisions allows validation of official statements on decision processes and collection of larger data sets for empirical analysis. However, the semi-structured phone interviews were time-consuming for collecting information on a larger number of decisions. Further validation of the structured scheme and development of a research tool for large-scale empirical studies is still needed.

The Irish 'health basket': a basket case?

The Irish health care system is typically described as complex and inequitable and yet the source of the complexity is difficult to identify. This paper examines and documents the way in which the structure of the Irish system is complicated when compared with other countries. Analysis is conducted in the context of the 'health basket' framework. A health basket describes which health care services, and which individuals, are covered by public funding, and to what extent. The Irish health basket is outlined along three dimensions of breadth, depth, and height, and compared with the health baskets of the United Kingdom, Canada, Australia, Sweden and France. Results indicate that it is in the combination of breadth and height that distinguishes the Irish basket from others. The majority of Irish health care services are run on a cost sharing basis; user fees are higher than in other countries particularly in primary care; and the structure of entitlement restrictions are complex. It is difficult to identify other countries in which all these factors operate within one system. In addition, the way in which the Irish health basket is delivered in practice introduces further complexities into the breadth and height of coverage.

[Scientific evidence and the cost of innovations in the health-care system]

When depicting the relationship between evidence and the cost of an innovation in the health-care system, the overall risks of assessment, the redistribution of risks in a regulated market, and the ethical consequences must first be taken into account. There are also evidence-based criteria and economic considerations which are relevant when calculating the cost of an innovation. These topics can indicate, but not exhaustively deal with the complicated relationship between scientific evidence and calculating the cost of an innovation in the health-care system. The following three statements summarize the current considerations in the continuing discussion of this topic: *Scientific evidence undoubtedly exists which should be taken into consideration when calculating the cost of an innovation in the health-care system. *The existing scientific evidence is, however, not sufficient to reach such a decision. Additional information about the benefit perceived by the patient is required. *No standardized method exists to measure this additional information. Therefore, a definition problem also exists in the health-care system when setting a price according to scientific evidence.

Comparing methodologies for the cost estimation of hospital services

The aim of the study was to determine whether the total cost estimate of a hospital service remains reliable when the cost components of bottom-up microcosting were replaced by the cost components of top-down microcosting or gross costing. Total cost estimates were determined in representative general hospitals in the Netherlands for appendectomy, normal delivery, stroke and acute myocardial infarction for 2005. It was concluded that restricting the use of bottom-up microcosting to those cost components that have a great impact on the total costs (i.e., labour and inpatient stay) would likely result in reliable cost estimates.

Clearing up the hazy road from bench to bedside: a framework for integrating the fourth hurdle into translational medicine

BACKGROUND

New products evolving from research and development can only be translated to medical practice on a large scale if they are reimbursed by third-party payers. Yet the decision processes regarding reimbursement are highly complex and internationally heterogeneous. This study develops a process-oriented framework for monitoring these so-called fourth hurdle procedures in the context of product development from bench to bedside. The framework is suitable both for new drugs and other medical technologies.

METHODS

The study is based on expert interviews and literature searches, as well as an analysis of 47 websites of coverage decision-makers in England, Germany and the USA.

RESULTS

Eight key steps for monitoring fourth hurdle procedures from a company perspective were determined: entering the scope of a healthcare payer; trigger of decision process; assessment; appraisal; setting level of reimbursement; establishing rules for service provision; formal and informal participation; and publication of the decision and supplementary information. Details are given for the English National Institute for Health and Clinical Excellence, the German Federal Joint Committee, Medicare's National and Local Coverage Determinations, and for Blue Cross Blue Shield companies.

CONCLUSION

Coverage determination decisions for new procedures tend to be less formalized than for novel drugs. The analysis of coverage procedures and requirements shows that the proof of patient benefit is essential. Cost-effectiveness is likely to gain importance in future.

Cross-country comparisons of costs: the use of episode-specific transitive purchasing power parities with standardised cost categories

International comparisons of healthcare costs are growing in importance for a number of different applications. The use of common approaches to converting costs such as GDP purchasing power parities (PPPs) often does not reflect price differences in healthcare in an appropriate manner. This means that new approaches need to be explored. The objective of this paper is to demonstrate the feasibility of using episode-specific PPPs (ESPPPs) to facilitate cross-country comparisons of healthcare costs and to compare this approach with other common approaches to conversion. Costs for five care episodes from hospitals in eight European countries were obtained from the EU HealthBASKET project. ESPPPs were created by using Fisher-type PPPs in combination with the Eltetö-Köves-Szulc method at the episode level. Differences in ESPPPs among the five care episodes were discussed and compared with other common conversion approaches. We found that ESPPPs-reflected prices and resource use more accurately than conventional conversion approaches such as GDP PPPs and medical care PPPs. This was particularly evident for labour-intensive care episodes in which other conversion approaches revealed problems in the way that labour input had not been considered appropriately. The results demonstrate that ESPPPs are preferable to other common conversion approaches when international healthcare cost comparisons are performed.

Methods to determine reimbursement rates for diagnosis related groups (DRG): a comparison of nine European countries

Over the past 20 years, most European countries have introduced DRGs or similar grouping systems as instruments for hospital reimbursement. This paper compares and analyzes the methods used to determine prices for inpatient care within DRGs or similar grouping systems employed in nine EU member states (i.e., Denmark, France, Germany, Hungary, Italy, Tthe Netherlands, Poland, Spain and England). It categorizes the systems of patient classification used in these nine countries and compares them according to the three steps necessary in order to set prices: 1.) definition of a data sample, 2.) use of trimming methods and plausibility checks and 3.) definition of prices. It concludes with a discussion on the typical development path of DRG systems and the role of additional reimbursement components in this context.

Editorial: Hospital case payment systems in Europe

Since the introduction of the system of diagnosis related groups (DRGs) for USA Medicare patients in 1983, case payment mechanisms have gradually become the principal means of reimbursing hospitals in most developed countries. The use of case payments nevertheless poses severe technical and policy challenges, and there remain many unresolved issues in their implementation. This paper introduces a special issue of the journal that describes and compares experience with the use of case payments for reimbursing hospitals in nine European countries. The editorial sets the policy scene, and argues that DRG systems must be seen both as a technical reimbursement method and as a fundamental incentive mechanism within the health system.