Discrepancies Between the Cost of Advanced Lung Cancer Treatment and How Much Is Reimbursed by the Brazilian Public Healthcare System

OBJECTIVE

Lung cancer is the leading cause of cancer-related death worldwide, and most patients are diagnosed of advanced disease. Molecular-targeted therapy and immunotherapy increase survival among these patients. In this study, we compared the cost of the best treatments available with the amount reimbursed by the Brazilian public healthcare system (Sistema Único de Saúde [SUS]) to treat advanced lung cancer.

METHODS

The authors divided lung cancer into 10 subtypes according to histology and molecular profile. A panel of experts defined the best treatment sequencing for each subtype. The authors considered only drug costs retrieved from the Brazilian Health Regulatory Agency official data. The progression-free survival of each regimen was considered as treatment duration. The cost estimate included all postprogression therapies weighted by each subtype proportional frequency. The amount reimbursed by SUS was the sum of the monthly budget accumulated during the estimated treatment duration and then for the proportional frequency of each subtype.

RESULTS

The budget reimbursed by SUS for treating each advanced lung cancer case in Brazil is R$8000.00 in average whereas the cost estimate for the best treatment available is R$729 454.00 per case, which represents a difference of 9118%. The budget impact to ensure the reimbursement needed to acquire the best treatments available was estimated in near R$13 billion annually.

CONCLUSIONS

The cost estimate of the best treatment available for advanced lung cancer in Brazil is much higher than the amount reimbursed by SUS. This budgetary gap leads to a major access barrier that may compromise the survival outcomes of SUS users.

Establishing a research informatics program in a public healthcare system: a case report with model documents

While much is known about governance models for research informatics programs in academic medical centers and similarly situated cancer centers, community and public health systems have been less well-characterized. As part of implementing an enterprise research governance framework, leaders in the Los Angeles County Department of Health Services established a research informatics program, including research data warehousing. The strategy is focused on high-priority, patient-centered research that leverages the investment in health IT and an efficient, sustained contribution from 2 affiliated Clinical Translational Sciences Institutes. This case study describes the foundational governance framework and policies that were developed. We share the results of several years of planning, implementation, and operations of an academically funded research informatics service core embedded in a large, multicenter county health system. We include herein a Supplementary Appendix of governance documents that may serve as pragmatic models for similar initiatives.

Publicly versus privately funded cardiac rehabilitation: access and adherence barriers. A cross-sectional study

BACKGROUND

Cardiac rehabilitation (CR) barriers are well-understood in high-resource settings. However, they are under-studied in low-resource settings, where access is even poorer and the context is significantly different, including two-tiered healthcare systems and greater socioeconomic challenges.

OBJECTIVE

To investigate differences in characteristics of patients attending publicly versus privately funded CR and their barriers to adherence.

DESIGN AND SETTING

Observational, cross-sectional study in public and private CR programs offered in Brazil.

METHODS

Patients who had been attending CR for ≥ 3 months were recruited from one publicly and one privately funded CR program. They completed assessments regarding sociodemographic and clinical characteristics and the CR Barriers Scale.

RESULTS

From the public program, 74 patients were recruited, and from the private, 100. Participants in the public program had significantly lower educational attainment (P < 0.001) and lower socioeconomic status (P < 0.001). Participants in the private program had more cognitive impairment (P = 0.015), and in the public program more anxiety (P = 0.001) and depressive symptoms (P = 0.008) than their counterparts. Total barriers among public CR participants were significantly higher than those among private CR participants (1.34 ± 0.26 versus 1.23 ± 0.15/5]; P = 0.003), as were scores on 3 out of 5 subscales, namely: comorbidities/functional status (P = 0.027), perceived need (P < 0.001) and access (P = 0.012).

CONCLUSION

Publicly funded programs need to be tailored to meet their patients' requirements, through consideration of educational and psychosocial matters, and be amenable to mitigation of patient barriers relating to presence of comorbidities and poorer health status.

Satisfaction With Patient Engagement and Self-Reported Depression Among Hospitalized Patients: A Propensity-Score Matching Analysis

BACKGROUND

Depression is common among hospitalized patients and poses a significant threat to their quality of life. Patient engagement (PE) in healthcare has been shown to be associated with positive health outcomes. However, the relationship between PE and depression among hospitalized patients, with and without chronic conditions, has not yet been explored. This study aimed to investigate the association between patients' satisfaction with PE and self-reported depression in Chinese public hospitals.

METHOD

A multi-centered, cross-sectional survey was conducted in seven tertiary-level public hospitals in Guangdong province, China. Twelve items from a patient-centered care questionnaire and the Patient Health Questionnaire 2-item version were used were used to assess patients' satisfaction with PE and self-reported depression, respectively. Propensity score matching (PSM) approach was used to reduce selection bias and potential baseline differences between patients with and without chronic conditions. The relationship between satisfaction with PE and depression was assessed, using univariate and multivariate logistic regression analyses, respectively.

RESULTS

A total of 1,974 hospitalized patients participated in the survey. After the PSM procedure, 604 patients were assigned to the chronic condition group, and another 604 patients were successfully matched in the comparison group with no differences in sex, age, educational level, and PE-related characteristics. Univariate logistic regression analysis indicated that high satisfaction with PE-related approaches significantly decreased the probability of developing depressive status. Multivariate logistic regression analysis further indicated that, after adjusting all PE-related approaches, "patient education" and "involvement in discharge planning" could significantly decrease the probability of patients developing depression.

CONCLUSIONS

Our results indicate that encouraging PE and improving patients' satisfaction with PE interventions in clinical practice led to improved mental health outcomes among hospitalized patients in China.

Supplementary private health insurance: The impact of physician financial incentives on medical practice

In the French diagnosis-related group (DRG)-based payment system, both private and public hospitals are financed by a public single payer. Public hospitals are overcrowded and have no direct financial incentives to choose one procedure over another. If a patient has a strong preference, they can switch to a private hospital. In private hospitals, the preference does come into play, but the patient has to pay for the additional cost, for which they are reimbursed if they have supplementary private health insurance. Do financial incentives from the fees received by physicians for different procedures drive their behavior? Using French exhaustive data on delivery, we find that private hospitals perform significantly more cesarean deliveries than public hospitals. However, for patients without private health insurance, the two sectors differ much less in terms of cesareans rate. We determine the impact of the financial incentive for patients who can afford the additional cost. Affordability is mainly ensured by the reimbursement of costs by private health insurance. These findings can be interpreted as evidence that, in healthcare systems where a public single payer offers universal coverage, the presence of supplementary private insurance can contribute to creating incentives on the supply side and lead to practices and an allocation of resources that are not optimal from a social welfare perspective.

Informal Payments by Patients in Central and Eastern Europe during the COVID-19 Pandemic: An Institutional Perspective

Confronted with a global pandemic, public healthcare systems are under pressure, making access to healthcare services difficult for patients. This provides fertile ground for using illegal practices such as informal payments to gain access. This paper aims to evaluate the use of informal payments by patients during the COVID-19 pandemic and the institutions that affect the prevalence of this practice. Various measurements of formal and informal institutions are here investigated, namely the acceptability of corruption, the level of trust, transparency, and performance of the healthcare system. To do so, a logistic regression of 10,859 interviews with patients conducted across 11 Central and Eastern Europe countries in October-December 2020 is employed. The finding is that there are large disparities between countries in the prevalence of informal payments, and that the practice is more likely to occur where there are poorer formal and informal institutions, namely higher acceptability of corruption, lower trust in authorities, lower perceived transparency in handling the COVID-19 pandemic, difficult access to, and poor quality of, healthcare services, and higher mortality rates due to the COVID-19 pandemic. These findings suggest that policy measures for tackling informal payments need to address the current state of the institutional environment.

The effects of health spending on the propagation of infectious diseases

We explore the discontinuity in the allocation of the main federal grant to Brazilian municipalities to identify the local effects of health spending and the spillovers into the bordering jurisdictions. Fiscal reactions are asymmetric: small neighbors reduce health spending, while we do not find a significant budgetary response in the largest neighbor. Our results suggest a reduction in the spread of infectious diseases in the neighbors, with fewer residents hospitalized with gastrointestinal infections. In addition, the elderly demand less hospitalization in the largest bordering jurisdictions due to respiratory infectious diseases. Finally, we find a direct and significant reduction in infant mortality, consistent with the observed pediatricians' increase, while the spillover effects on neighbors' mortality rates are not conclusive.

Inpatients' Perception of Patient-Centered Care in Guangdong Province, China: A Cross-Sectional Study

This study aimed to investigate the perceptions of patient-centered care (PCC) among inpatients in Guangdong Province (GD), China. Based on these perspectives, we sought to understand existing PCC practices in medical institutions and identify the impacts of inpatients’ sociodemographic status on their perceived PCC. A self-developed PCC questionnaire was used to investigate inpatients’ perceptions of PCC. A cross-sectional survey was conducted in nine tertiary-level hospitals across five cities in GD. Descriptive statistics was used to describe the levels of PCC in GD. The differences in PCC levels across different sociodemographic groups were assessed using analysis of variance and multivariate linear regression. Valid responses were provided by 1863 inpatients. The mean overall PCC score was 8.58 (standard deviation [SD] = 1.36); inpatients from the Pearl River Delta and eastern GD area reported significantly higher scores than those from western and northern GD area (P<.01). Inpatients from rural areas tended to report lower PCC scores than their urban counterparts. Among the PCC questionnaire sub-domains, inpatients scored highest and lowest in “patient experience” (mean = 8.96, SD = 1.34) and “medical insurance” (mean = 7.93, SD = 2.05), respectively. This study provided a comprehensive overview of inpatients’ perceptions of PCC in the public healthcare system in GD, China. Our findings highlighted that a majority of inpatients were satisfied with the PCC in public healthcare system; however, a significant discrepancy between inpatients with different sociodemographic status remained.

Can social firms contribute to alleviating the economic burden of psychiatric disabilities for the public healthcare system?

In a number of countries, unemployment rates for people with psychiatric disabilities are much higher than in the general population. On the one hand, the expenses for mental health reach 3.5% of the total public health and social services budget in Québec. On the other hand, social firms (SFs) receive government subsidies. The objective was to compare public healthcare expenses for people with psychiatric disabilities who work in SFs with those associated with people with a similar condition who are looking for a job in the competitive labour market. This study followed a retrospective comparative design and considered two groups, namely: 122 employees working in SFs and 64 individuals participating in a supported employment program as job-seekers. Two complementary datasets were used: a self-report questionnaire and public healthcare databases. The cost analysis was performed from the perspective of the public healthcare system and included outpatient visit fees to physicians, outpatient visits to health professionals other than physicians in public healthcare centres, inpatient expenses due to hospitalisations, emergency room visits and amounts reimbursed to patients for medication. Regression analyses using generalised linear models with a gamma distribution and log link were used. Our results revealed that when controlling for sociodemographic variables (gender, age, marital status, education, physical disability), global health (EuroQol EQ-5D-5L), the severity of psychiatric symptoms (18-item Brief Symptom Inventory) and self-declared primary mental health diagnosis, annual healthcare costs paid by the public insurance system were between $1,924 and $3,912 lower for people working in SFs than for the comparison group. An explanatory hypothesis is that working in SFs could act as a substitute for medical treatments such as outpatient visits and medication use. There might be a form of compensation between supporting SFs and financing the public healthcare system, which provides valuable insights for public decision-making.

Factors influencing the role of primary care providers as gatekeepers in the Malaysian public healthcare system

Primary care providers play an important gatekeeping role in ensuring appropriate referrals to secondary care facilities. This cross-sectional study aimed to determine the level, pattern and rate of referrals from health clinics to hospitals in the public sector, and whether the placement of resident family medicine specialist (FMS) had made a significant difference. The study was carried out between March and April in 2012, involving 28 public primary care clinics. It showed that the average referral rate was 1.56% for clinics with resident FMS and 1.94% for those without resident FMS, but it was not statistically significant. Majority of referred cases were considered appropriate (96.1%). Results of the multivariate analysis showed that no prior consultation with senior healthcare provider and illnesses that were not severe and complex were independently associated with inappropriate referrals. Severity, complexity or uncertain diagnosis of patients' illness or injury significantly contributed to unavoidable referrals. Adequate facilities or having more experienced doctors could have avoided 14.5% of the referrals. The low referral rate and very high level of appropriate referrals could indicate that primary care providers in the public sector played an effective role as gatekeepers in the Malaysian public healthcare system.