Balancing financial incentives during COVID-19: A comparison of provider payment adjustments across 20 countries

The dynamics of international health system reforms: Evidence of a new wave in response to the 2008 economic crisis and the COVID-19 pandemic?

Global economic and health shocks, such as the 2008 global financial crisis and the COVID-19 pandemic typically impact healthcare financing and delivery. Cutler found that profound societal changes in the 20th century induced three waves of healthcare reform across seven major OECD countries. Our study investigates whether major crises in the 21st century induced similar reform waves. Through thematic analysis, we systematically compared health system changes in response to these shocks, using data from the Observatory on Health Systems and Policies and the OECD. Our analysis reveals similar overarching reform trends across countries in response to the 2008 economic crisis: a tendency toward re-centralization of health system governance to control and leverage the efficient rationalization of public health resources. This, to some extent, countered the effects of the market-based reforms of the previous wave. The reforms induced by the 2008 crisis were mediated by its repercussions on the countries' economies. In contrast, reforms in response to the pandemic aimed primarily to address the direct impact of the shock on the health system. Despite its negative economic impact, the pandemic resulted in a substantial but temporary increase in public health spending. A better understanding reform dynamics and their impact on overarching conflicting health system objectives may prevent unintended consequences and enhance health systems' resilience in response to future shocks.

Unveiling the truth: is COVID-19 reimbursement in Colombia a flawed design? A cost-of-illness analysis for moderate, severe and critical infections

PURPOSE

This study examines the financial impact of the COVID-19 pandemic on the Colombian Health System, focusing on the adequacy of reimbursement rates for inpatient stays. The study, based on a cost of illness analysis, aims to evaluate the effectiveness of the reimbursement scheme and identify potential economic losses within the health system.

PATIENTS AND METHODS

The study protocol outlines the inclusion criteria for patients >18 years with confirmed COVID-19 infection and moderate to critical disease. Patients hospitalised between June 2020 and June 2021 for at least 24 hours were included. Exclusion criteria involved pregnant patients and those initially hospitalised for non-COVID-19.

RESULTS

The study included 781 patients contributing to 790 hospitalisations. Demographic and clinical characteristics were analysed, with critical illness being the most prevalent category (61%). The overall mortality rate was 20.3%, primarily observed in critically ill patients. In the general ward for moderate cases, the reimbursement rate saw a substantial increase from US$3237 in 2020 to US$6760 in 2021, surpassing median resource utilisation. However, for severe cases in the intermediate care unit, reimbursement rates decreased, indicating potential insufficiency in covering costs. In the intensive care unit for critical cases, despite improved reimbursement rates, median resource utilisation still exceeds the 2021 rate, suggesting financial insufficiency in reimbursement rates.

CONCLUSION

Our study underscores the inadequacies of the previous reimbursement system in addressing the varying resource utilisation and costs associated with COVID-19 inpatient care. Our analysis reveals substantial discrepancies between estimated costs and actual resource utilisation, particularly for severe and critical cases. We advocate for government flexibility in revising reimbursement baskets, supported by pilot studies to assess effectiveness. The use of real-world evidence forms a crucial basis for informed adjustments to reimbursement levels in preparation for future pandemics. This proactive approach ensures alignment between reimbursement policies and the actual costs associated.

Comparison of diagnosis-related groups (DRG)-based hospital payment system design and implementation strategies in different countries: The case of ischemic stroke

Diagnosis-related groups (DRG) based hospital payment systems are gradually becoming the main mechanism for reimbursement of acute inpatient care. We reviewed the existing literature to ascertain the global use of DRG-based hospital payment systems, compared the similarities and differences of original DRG versions in ten countries, and used ischemic stroke as an example to ascertain the design and implementation strategies for various DRG systems. The current challenges with and direction for the development of DRG-based hospital payment systems are also analyzed. We found that the DRG systems vary greatly in countries in terms of their purpose, grouping, coding, and payment mechanisms although based on the same classification concept and that they have tended to develop differently in countries with different income classifications. In high-income countries, DRG-based hospital payment systems have gradually begun to weaken as a mainstream payment method, while in middle-income countries DRG-based hospital payment systems have attracted increasing attention and increased use. The example of ischemic stroke provides suggestions for mutual promotion of DRG-based hospital payment systems and disease management. How to determine the level of DRG payment incentives and improve system flexibility, balance payment goals and disease management goals, and integrate development with other payment methods are areas for future research on DRG-based hospital payment systems.

The Israeli health system's rapid responses during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic posed numerous challenges to health systems around the world. In addressing many of those challenges, Israel responded quite rapidly. While quick action is not an end in it itself, it can be important in responding to disease outbreaks. Some of Israel's rapid responses to the pandemic contributed significantly to population health and provided important learning opportunities for other countries.

MAIN BODY

Some of the most prominent Israeli rapid responses were related to vaccination. Israel led the world in the pace of its initial vaccine rollout, and it was also the first country to approve and administer booster vaccines to broad segments of the population. In addition, Israeli scholars published a series of timely reports analyzing vaccination impact, which informed policy in Israel and other countries. Israel was a rapid responder in additional areas of public health. These include the partial closure of its borders, the adoption of physical distancing measures, the use of digital surveillance technology for contact tracing, the use of wastewater surveillance to monitor viral spread, and the use of vaccine certificates ("green passes") to facilitate a return to routine in the face of the ongoing pandemic. Many factors contributed to Israel's capacity to repeatedly respond rapidly to a broad array of COVID-19 challenges. These include a national health insurance system that promotes public-private coordination, a system of universal electronic health records, a high level of emergency preparedness, a culture of focusing on goal attainment, a culture of innovation, and the presence of a strong scientific community which is highly connected internationally. In addition, some of the rapid responses (e.g., the rapid initial vaccination rollout) facilitated rapid responses in related areas (e.g., the analysis of vaccination impact, the administration of boosters, and the adoption of green passes). While rapid response can contribute to population health and economic resilience, it can also entail costs, risks, and limitations. These include making decisions and acting before all the relevant information is available; deciding without sufficient consideration of the full range of possible effects, costs, and benefits; not providing enough opportunities for the involvement of relevant groups in the decision-making process; and depleting non-renewable resources.

CONCLUSIONS

Based on our findings, we encourage leaders in the Israeli government to ensure that its emergency response system will continue to have the capacity to respond rapidly to large-scale challenges, whether of a military or civilian nature. At the same time, the emergency response systems should develop mechanisms to include more stakeholders in the fast-paced decision-making process and should improve communication with the public. In addition, they should put into place mechanisms for timely reconsideration, adjustment, and-when warranted-reversal of decisions which, while reasonable when reached, turn out to have been ill-advised in the light of subsequent developments and evidence. These mechanisms could potentially involve any or all branches of government, as well as the public, the press, and professional organizations. Our findings also have implications for health system leaders in other countries. The Israeli experience can help them identify key capacities to develop during non-emergency periods, thus positioning themselves to respond more rapidly in an emergency. Finally, health system leaders in other countries could monitor Israel's rapid responses to future global health emergencies and adopt selected actions in their own countries.

Adjustments in purchasing arrangements to support the COVID-19 health sector response: evidence from eight middle-income countries

The COVID-19 pandemic has triggered several changes in countries' health purchasing arrangements to accompany the adjustments in service delivery in order to meet the urgent and additional demands for COVID-19-related services. However, evidence on how these adjustments have played out in low- and middle-income countries is scarce. This paper provides a synthesis of a multi-country study of the adjustments in purchasing arrangements for the COVID-19 health sector response in eight middle-income countries (Armenia, Cameroon, Ghana, Kenya, Nigeria, Philippines, Romania and Ukraine). We use secondary data assembled by country teams, as well as applied thematic analysis to examine the adjustments made to funding arrangements, benefits packages, provider payments, contracting, information management systems and governance arrangements as well as related implementation challenges. Our findings show that all countries in the study adjusted their health purchasing arrangements to varying degrees. While the majority of countries expanded their benefit packages and several adjusted payment methods to provide selected COVID-19 services, only half could provide these services free of charge. Many countries also streamlined their processes for contracting and accrediting health providers, thereby reducing administrative hurdles. In conclusion, it was important for the countries to adjust their health purchasing arrangements so that they could adequately respond to the COVID-19 pandemic, but in some countries financing challenges resulted in issues with equity and access. However, it is uncertain whether these adjustments can and will be sustained over time, even where they have potential to contribute to making purchasing more strategic to improve efficiency, quality and equitable access in the long run.

How COVID-19 has changed the utilization of different health care services in Poland

BACKGROUND

The COVID-19 pandemic has affected health care systems in many ways, including access to and the use of non-COVID services. The aim of the study was to assess the impact of the pandemic on the utilization of different public health care services in Poland.

METHODS

The aggregated data on health care users and provided services for the years 2015/2016-2021 were used to analyse the changes in health care utilization during the pandemic and deviations from pre-pandemic utilization trends. Quantitative analysis was complemented with qualitative descriptions of the changes in principles of health care provision during the pandemic.

RESULTS

The results show a considerable drop in the provision of most health care services in 2020 that in some cases disturbed pre-pandemic utilization trends and was not made up for in 2021. The most significant decrease has been observed in the field of preventive and public health services, as well as rehabilitation. The provision of these services was put on hold during the pandemic.

CONCLUSIONS

The accumulated COVID-19-related "health debt" urgently calls for government actions to strengthen disease prevention and health promotion in Poland.

Health financing policies during the COVID-19 pandemic and implications for universal health care: a case study of 15 countries

BACKGROUND

The COVID-19 pandemic was a health emergency requiring rapid fiscal resource mobilisation to support national responses. The use of effective health financing mechanisms and policies, or lack thereof, affected the impact of the pandemic on the population, particularly vulnerable groups and individuals. We provide an overview and illustrative examples of health financing policies adopted in 15 countries during the pandemic, develop a framework for resilient health financing, and use this pandemic to argue a case to move towards universal health coverage (UHC).

METHODS

In this case study, we examined the national health financing policy responses of 15 countries, which were purposefully selected countries to represent all WHO regions and have a range of income levels, UHC index scores, and health system typologies. We did a systematic literature review of peer-reviewed articles, policy documents, technical reports, and publicly available data on policy measures undertaken in response to the pandemic and complemented the data obtained with 61 in-depth interviews with health systems and health financing experts. We did a thematic analysis of our data and organised key themes into a conceptual framework for resilient health financing.

FINDINGS

Resilient health financing for health emergencies is characterised by two main phases: (1) absorb and recover, where health systems are required to absorb the initial and subsequent shocks brought about by the pandemic and restabilise from them; and (2) sustain, where health systems need to expand and maintain fiscal space for health to move towards UHC while building on resilient health financing structures that can better prepare health systems for future health emergencies. We observed that five key financing policies were implemented across the countries-namely, use of extra-budgetary funds for a swift initial response, repurposing of existing funds, efficient fund disbursement mechanisms to ensure rapid channelisation to the intended personnel and general population, mobilisation of the private sector to mitigate the gaps in public settings, and expansion of service coverage to enhance the protection of vulnerable groups. Accountability and monitoring are needed at every stage to ensure efficient and accountable movement and use of funds, which can be achieved through strong governance and coordination, information technology, and community engagement.

INTERPRETATION

Our findings suggest that health systems need to leverage the COVID-19 pandemic as a window of opportunity to make health financing policies robust and need to politically commit to public financing mechanisms that work to prepare for future emergencies and as a lever for UHC.

FUNDING

Bill & Melinda Gates Foundation.

Lessons from health insurance responses in counteracting COVID-19: a qualitative comparative analysis of South Korea and three influential countries

BACKGROUND

The COVID-19 pandemic has caused delays and restrictions in providing medical services. In response to the medical surge, countries with social insurance systems provided financial incentives to medical institutions. This study aimed to present the directions for health insurance support by comparing countries in terms of the domains and contents of COVID-19 health insurance support to ensure timely support in case of future pandemics.

METHODS

An analysis framework was developed to compare health insurance policy interventions for COVID-19 and non-COVID-19 domains, and detailed policy interventions were divided into sub-domains (space, staff, and stuff) for each domain. Data were collected by country from the websites of the Ministry of Health and Social Insurers, Organisation for Economic Co-operation and Development, and European Observatory on Health Systems and Policies and were analyzed using qualitative comparative analysis.

RESULTS

The countries provided comprehensive support for both the COVID-19 and non-COVID-19 domains. In the COVID-19 domain, overall support was provided in all three sub-domains. Additional cost support was provided to prevent infection and provide secure facilities to treat confirmed patients. Outpatient services were mainly supported, and an intensive intervention was developed in the staff sub-domain for the non-COVID-19 domain. The point of policy intervention was the surge of the first confirmed case. Continuous revisions were subsequently made. The government provided financial support through health insurance.

CONCLUSIONS

Regarding where policy support through health insurance should be focused, the workload of medical personnel increased according to the change in the service provision environment due to the pandemic, and the medical service delivery system changed to prevent further infection. Consequently, incentives should be provided to aid the provision of stable services to patients and should be an auxiliary means to implement the national quarantine policy more effectively via a health insurance response system that promptly provides additional financial support in case of future crises.

Trajectories of quality of life and mental health during the Covid-19 lockdown and six months after in Italy. A longitudinal exploration

Aim

Covid-19 pandemic and its relative containment measures have affected populations' quality of life and psychological well-being worldwide. The fear related to the pandemic and the imposed containment measures has acted as a trigger causing a global increase in negative mental health states. Thus, we aimed to explore the relationship between fear of covid-19 and mental health via QoL (the first and the second lockdown in Italy, 2020).

Subject and methods

Through a quantitative cross-lagged path model research design, the study investigates people's fear of Covid-19, quality of life, and negative mental states in a population of 444 Italian adults (Mean=40.7; Standard Deviation=16.9; 80% women), in the period between the first and the second waves of the pandemic.

Results

Results show that participants' Covid-19 fear decreased between waves, contributing to a decrease in negative mental states (stress, anxiety and depression), thus improving the perceived quality of life. Furthermore, quality of life emerged as able to buffer the impact of fear of Covid on people's psychological distress in short and medium terms, confirming its central role in regulating mental distress.

Conclusion

The study suggests important guidelines for developing interventions to support the populations' well-being and mental health.

Can COVID-19 response inform future health system reforms? Lessons learned from Finland

The COVID-19 pandemic has plagued health systems in an unprecedented way and challenged the traditional ways to respond to epidemics. It has also revealed several vulnerabilities in countries’ health systems and preparedness. In this paper we take the Finnish health system as an example to analyse how pre-COVID-19 preparedness plans, regulations, and health system governance were challenged by the pandemic and what lessons can be learned for the future. Our analysis draws on policy documents, grey literature, published research, and the COVID-19 Health System Response Monitor. The analysis shows how major public health crises often reveal weaknesses in health systems, also in countries which have been ranked highly in terms of crisis preparedness. In Finland, there were apparent regulative and structural problems which challenged the health system response, but in terms of epidemic control, the results appear to be relatively good. The pandemic may have long-term effects on the health system functioning and governance. In January 2023, an extensive health and social services reform has taken place in Finland. The new health system structure needs to be adjusted to take on board the legacy of the pandemic and a new regulatory frame for health security should be considered.

Trend in the admissions of patients with non-COVID-19 respiratory symptoms during COVID-19 pandemic and its impact on hospital finances in surabaya, Indonesia

Background

COVID-19 cases surge, it has a crucial impact on healthcare systems, with rapidly increasing demand for healthcare resources in hospitals and intensive care units (ICUs) in Indonesia and worldwide. It is necessary to quantify the extent to which the effects of the COVID-19 pandemic on the hospital admissions, and clinical and financial outcomes of patients with non-COVID-19 respiratory symptoms.

Objective

To determine whether the COVID-19 pandemic changed the hospitalisation of child and adult patients with non-COVID-19 respiratory conditions and whether these changes affected the patient's disease condition, clinical outcomes, and hospital finances.

Methods

A retrospective cohort study was conducted from May 1, 2018 (before the COVID-19 pandemic) until December 31, 2021. Total sampling was done to compare hospital admission of patients with non-COVID-19 respiratory symptoms before versus during the COVID-19 pandemic. The results were analyzed using SPSS 26.0 and SmartPLS.v.3.2.9.

Results

There was a reduction in hospitalisations for respiratory disorders unrelated to COVID-19 during the pandemic by 55.3% in children and 47.8% in adult patients. During the pandemic, the average hospital revenue per patient of child and adult patients increased significantly, but the profit per patient decreased. Pathway analysis showed that in children, the COVID-19 Pandemic changed disease severity and complexity (β = 0.132, P < 0.001), as well as clinical outcomes (β = 0.029, P < 0.05). In adults, the COVID-19 pandemic improves disease severity and complexity (β = -0.020, P < 0.001), as well as clinical outcomes (β = -0.013, P < 0.001). COVID-19 pandemic increases care charges (in children with β = 0.135, P < 0.001; and in the adult patients with β = 0.110, P < 0.001), worsens hospital financial outcomes relating to child (β = -0.093, P < 0.001) and adult patient (β = -0.073, P < 0.001). In adult patients, seasonal variations moderate the impact of the COVID-19 pandemic on improving disease conditions (β = -0.032, P=<0.001). The child structural model effectively predicted clinical outcomes (Q² = 0.215) and financial outcomes (Q² = 0.462). The adult structural model effectively predicted clinical outcomes (Q² = 0.06) and financial outcomes (Q² = 0.472).

Conclusion

The conclusions are that the number of non-COVID respiratory patients decreased during the COVID-19 pandemic (47.8% in adult patients, 55.3% in child patients). Disease severity and complexity increased in child patients but decreased in adult patient. Costs of care and insurance payments increased. Since the insurance payments did not increase as much as the cost of care, hospital profit decreased.

Hospital quality reporting in the pandemic era: to what extent did hospitals' COVID-19 census burdens impact 30-day mortality among non-COVID Medicare beneficiaries?

OBJECTIVES

Highly visible hospital quality reporting stakeholders in the USA such as the US News & World Report (USNWR) and the Centers for Medicare & Medicaid Services (CMS) play an important health systems role via their transparent public reporting of hospital outcomes and performance. However, during the pandemic, many such quality measurement stakeholders and pay-for-performance programmes in the USA and Europe have eschewed the traditional risk adjustment paradigm, instead choosing to pre-emptively exclude months or years of pandemic era performance data due largely to hospitals' perceived COVID-19 burdens. These data exclusions may lead patients to draw misleading conclusions about where to seek care, while also masking genuine improvements or deteriorations in hospital quality that may have occurred during the pandemic. Here, we assessed to what extent hospitals' COVID-19 burdens (proportion of hospitalised patients with COVID-19) were associated with their non-COVID 30-day mortality rates from March through November 2020 to inform whether inclusion of pandemic-era data may still be appropriate.

DESIGN

This was a retrospective cohort study using the 100% CMS Inpatient Standard Analytic File and Master Beneficiary Summary File to include all US Medicare inpatient encounters with admission dates from 1 April 2020 through 30 November 2020, excluding COVID-19 encounters. Using linear regression, we modelled the association between hospitals' COVID-19 proportions and observed/expected (O/E) ratios, testing whether the relationship was non-linear. We calculated alternative hospital O/E ratios after selective pandemic data exclusions mirroring the USNWR data exclusion methodology.

SETTING AND PARTICIPANTS

We analysed 4 182 226 consecutive Medicare inpatient encounters from across 2601 US hospitals.

RESULTS

The association between hospital COVID-19 proportion and non-COVID O/E 30-day mortality was statistically significant (p<0.0001), but weakly correlated (r²=0.06). The median (IQR) pairwise relative difference in hospital O/E ratios comparing the alternative analysis with the original analysis was +3.7% (-2.5%, +6.7%), with 1908/2571 (74.2%) of hospitals having relative differences within ±10%.

CONCLUSIONS

For non-COVID patient outcomes such as mortality, evidence-based inclusion of pandemic-era data is methodologically plausible and must be explored rather than exclusion of months or years of relevant patient outcomes data.

Cost-benefit analysis of Intensive Care Unit with Activity-Based Costing approach in the era COVID-19 pandemic: A case study from Iran

BACKGROUND

Providing intensive care to acute patients is a vital part of health systems. However, the high cost of Intensive Care Units (ICU) has limited their development, especially in low-income countries. Due to the increasing need for intensive care and limited resources, ICU cost management is important. This study aimed to analyze the cost-benefit of ICU during COVID-19 in Tehran, Iran.

METHODS

This cross-sectional study is an economic evaluation of health interventions. The study was conducted in the COVID-19 dedicated ICU, from the provider's point of view and within one-year horizon. Costs were calculated using a top-down approach and the Activity-Based Costing technique. Benefits were extracted from the hospital's HIS system. Benefit Cost ratio (BCR) and Net Present Value (NPV) indexes were used for cost-benefit analysis (CBA). A sensitivity analysis was performed to evaluate the dependence of the CBA results on the uncertainties in the cost data. Analysis was performed with Excel and STATA software.

RESULTS

The studied ICU had 43 personnel, 14 active beds, a 77% bed occupancy rate, and 3959 occupied bed days. The total costs were $2,372,125.46 USD, of which 70.3% were direct costs. The highest direct cost was related to human resources. The total net income was $1,213,314.13 USD. NPV and BCR were obtained as $-1,158,811.32 USD and 0.511 respectively.

CONCLUSION

Despite operating with a relatively high capacity, ICU has had high losses during the COVID-19. Proper management and re-planning in the structure of human resources is recommended due to its importance in the hospital economy, provision of resources based on needs assessment, improvement of drugs management, reduction of insurance deductions in order to reduce costs and improve ICU productivity.

Infection control and radiation safety practices in the radiology department during the COVID-19 outbreak

RATIONALE AND OBJECTIVES

Radiology personnel must have good knowledge, experience and adherence to radiation protection and infection control practices to ensure patient safety and prevent the further spread of the COVID-19 virus. This study analysed compliance and adherence to radiation protection and infection control during COVID-19 mobile radiography.

METHODS

A cross-sectional using online survey was conducted from September to December 2021. Data on demographic characteristics, adherence to radiation protection and infection control practice were collected during mobile radiography for COVID-19 patients in the study. A random sample of the radiographers working in COVID-19 centres in the United Arab Emirates.

RESULTS

Responses were received from 140 participants, with a response rate of 87.5%. Females were the predominant participants (n = 81; 58%). Participants aged ages between 18-25 years (n = 46; 33%) and 26-35 years (n = 42; 30%), (n = 57; 41%) had less than five years of experience, followed by participants who had more than 15 years (n = 38; 27%). Most participants (n = 81; 57.9%) stated that they performed approximately 1-5 suspected or confirmed COVID-19 cases daily. The participants had moderate to high adherence to radiation protection, with a mean and standard deviation of 42.3 ± 6.28. Additionally, infection control adherence was high, with 82% of the participants showing high adherence.

CONCLUSION

Continuous guidance, training and follow-up are recommended to increase adherence and compliance to radiation protection and infection control compliance. Educational institutions and professional organisations must collaborate to provide structured training programmes for radiology practitioners to overcome the practice and knowledge gap.

Medical Staff Shortages and the Performance of Outpatient Clinics in Poland during the COVID-19 Pandemic

Unlike many industries, healthcare was simultaneously affected by the COVID-19 pandemic in two opposite ways. On the one hand, the industry faced shortages and overload of many medical representatives such as nurses and infectious disease professionals, but on the other, many medical professionals such as dentists were left with considerably reduced demand. The objective of this paper is to study the efficiency of medical staff allocation and the performance of small and medium sized outpatient clinics in Poland during the COVID-19 pandemic. Owing to the contemporaneity of this problem, we have employed a multiple case study approach. Our sample comprises 5 small and medium-sized outpatient clinics located in Poland in the 3-year period 2019-2021. The results indicate a considerable percentage of medical staff employed in small and medium-sized outpatient clinics remained outside the pandemic, despite their potential provision of healthcare services. Four of the five clinics studied remained passive towards the pandemic. In view of future pandemics, the indications we provide have practical implications for outpatient clinics executives and public health policymakers.

Expanding Medical Surge Capacity to Counteract COVID-19: South Korea's Medical Fee Adjustment Through the National Health Insurance System

BACKGROUND

South Korea has utilized its National Health Insurance (NHI) system to adjust the medical fees payable for healthcare services, to financially support the frontline healthcare providers combating COVID-19. This study evaluated the composition of such adjustments to the medical fees-made to secure resource surge capacity against the pandemic-in South Korea.

METHODS

Descriptive statistics and schematization were employed to analyze 3,612,640 COVID-19-related NHI claims from January 1, 2020, to June 30, 2021. COVID-19 suspected and confirmed cases were evaluated based on the proportion of fees adjustment, classified into space, staff, or stuff (3S) using diagnosis codes. The proportion of fees adjustment was investigated in terms of the healthcare expenditure, number of patients, and number of healthcare services covered.

FINDINGS

First, in terms of cost, medical fee adjustments covered over 96% of the total costs arising from the increased demand for testing (stuff) and isolated spaces among patients suspected of having COVID-19. Second, medical fees were adjusted to cover over 80% of the cost attributable to COVID-19 confirmed cases, in relation to isolated spaces and medical staff support. Third, the adjustment of less than 10% of the various types of medical fees, if selected strategically, can effectively induce a surge in resource capacity.

INTERPRETATION

South Korea has improved its existing surge capacity by adjusting the medical fees payable through NHI to healthcare providers. Particularly, through the provider payment system of fee-for-service, the Korean government could prevent the spread of infection and protect the medical staff assigned to respond to COVID-19. However, additional studies on alternative payment systems are needed to control costs while maintaining an effective pandemic response system in the face of the prolonged COVID-19 outbreak.

How to Pay Primary Care Physicians for SARS-CoV-2 Vaccinations: An analysis of 43 EU and OECD Countries

Vaccinations are crucial to fighting SARS-CoV-2, and high coverage rates can in most countries probably only be achieved with the involvement of primary care physicians (PCPs). We aimed to explore how SARS-CoV-2 vaccination payment schemes in 43 countries differ with regard to the (i) type of payment scheme, (ii) amount paid, (iii) degree of bundling, and (iv) use of pay-for-performance elements.

We collected information on payments and health system characteristics, such as PCP income and employment status, in all EU and OECD countries over time. We regressed the payment amount on the income of PCPs for countries with activity-dependent schemes using a linear regression (OLS), and we interpreted the residuals of this regression as a vaccination payment index.

The majority of countries (30/43) had chosen payment schemes that reward PCPs for the activity they perform. Seventeen countries paid less per vaccination than the income-adjusted average, whereas 13 countries paid more. Twelve countries used pay-for-performance elements.

Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe☆

Countries with social health insurance (SHI) systems display some common defining characteristics - pluralism of actors and strong medical associations - that, in dealing with crisis times, may allow for common learnings. This paper analyses health system responses during the COVID-19 pandemic in eight countries representative of SHI systems in Europe (Austria, Belgium, France, Germany, Luxembourg, the Netherlands, Slovenia and Switzerland). Data collection and analysis builds on the methodology and content in the COVID-19 Health System Response Monitor (HSRM) up to November 2020. We find that SHI funds were, in general, neither foreseen as major stakeholders in crisis management, nor were they represented in crisis management teams. Further, responsibilities in some countries shifted from SHI funds to federal governments. The overall organisation and governance of SHI systems shaped how countries responded to the challenges of the pandemic. For instance, coordinated ambulatory care often helped avoid overburdening hospitals. Decentralisation among local authorities may however represent challenges with the coordination of policies, i.e. coordination costs. At the same time, bottom-up self-organisation of ambulatory care providers is supported by decentralised structures. Providers also increasingly used teleconsultations, which may remain part of standard practice. It is recommended to involve SHI funds actively in crisis management and in preparing for future crisis to increase health system resilience.