Improving hospital-based processes for effective implementation of Government funded health insurance schemes: evidence from early implementation of PM-JAY in India

Background Government-sponsored health insurance schemes (GSHIS) aim to improve access to and utilization of healthcare services and offer financial protection to the population. India’s Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one such GSHIS. This paper aims to understand how the processes put in place to manage hospital-based transactions, from the time a beneficiary arrives at the hospital to discharge are being implemented in PM-JAY and how to improve them to strengthen the scheme’s operation. Methods Guidelines were reviewed for the processes associated with hospital-based transactions, namely, beneficiary authentication, treatment package selection, preauthorization, discharge, and claims payments. Across 14 hospitals in Gujarat and Madhya Pradesh states, the above-mentioned processes were observed, and using a semi-structured interview guide fifty-three respondents were interviewed. The study was carried out from March 2019 to August 2019. Results Average turn-around time for claim reimbursement is two to six times higher than that proposed in guidelines and tender. As opposed to the guidelines, beneficiaries are incurring out-of-pocket expenditure while availing healthcare services. The training provided to the front-line workers is software-centric. Hospital-based processes are relatively more efficient in hospitals where frontline workers have a medical/paramedical/managerial background. Conclusions There is a need to broaden capacity-building efforts from enabling frontline staff to operate the scheme’s IT platform to developing the technical, managerial, and leadership skills required for them. At the hospital level, an empowered frontline worker is the key to efficient hospital-based processes. There is a need to streamline back-end processes to eliminate the causes for delay in the processing of claim payment requests. For policymakers, the most important and urgent need is to reduce out-of-pocket expenses. To that end, there is a need to both revisit and streamline the existing guidelines and ensure adherence to the guidelines.

Designing a Healthcare Technology Platform Framework for Purpose-Driven Oncology in a Developing Country Healthcare Context (Preprint)

UNSTRUCTURED The rising cases of cancer in India and the unequal care has given rise to large out-of-pocket expenses and late stage of detection of cares, leading to higher mortality rates in many states across rural India. Investing in digital health in resource-constrained countries could provide cancer diagnosis and treatment at affordable costs, improve availability and health outcomes for the citizens. This paper introduces the framework and features of a healthcare technology platform for a developing country to democratise oncology health care services. The framework relies on participatory systems, patient first algorithms and digital health exchange mechanisms. The proposed platform is built on three key pillars of Technology, Managed Healthcare and Advisory, each with a unique value proposition, yet will be complementary, and tries to address specific requirements across the healthcare delivery value chain, thereby, providing a comprehensive solution to the overall problem of the ecosystem. We discuss the application of the framework and usage of curated data and robust workflow and rules engine to enable seamless flow of information across all levels, while bringing close home care to people. We propose that a technology platform, build on a connected care ecosystem, could improve cancer care outcomes in a developing country healthcare context.

Attitudes toward Pursuing Genetic Testing among Parents of Children with Autism Spectrum Disorder in Taiwan: A Qualitative Investigation

Background: The diagnosis of autism spectrum disorder (ASD) cases is increasing in Taiwan. Genetic testing for children with ASD offers several potential benefits and is available with out-of-pocket expenses. Parents play a pivotal role in having their children with ASD tested; therefore, understanding their perceptions of, and perceived barriers to genetic testing is vital. Methods: Semi-structured interviews were conducted with 39 parents of children with ASD in Taiwan. Interviews were recorded and transcribed verbatim. NVivo 12 software (QSR International, Doncaster, Australia) was used to facilitate an inductive coding methodology. Results: The majority of participants (74.4%) supported ASD genetic testing for their children with ASD, citing reasons such as clarifying ASD etiology, well-informed family planning, contributing to ASD research, and early ASD detection and intervention. Others indicated that they were either against such testing (17.9%), or unsure (7.7%) about whether to take their children with ASD for genetic testing. Those who were opposed reported that their main concerns related to perceptions of no value of genetic testing, potential for family conflict, and financial difficulties. Conclusions: Most of the parents of children with ASD that we interviewed expressed favorable views of ASD genetic testing. There exists a need to increase parental access to education and counseling, and to include testing coverage in Taiwanese national health insurance.

Vision Payment Claims Analyses with Health Insurance

The purpose of this study was to identify associations between insurance type and costs and to investigate specified variables’ influence on individuals’ access to adequate coverage. This was a cross sectional study, using secondary data analyses. The study was completed at The Eye Institute (TEI) East Oak Lane Campus in Philadelphia, PA. The study population was all patients seen at TEI East Oak Lane Campus, specifically patients seen at TEI clinic from January 1st, 2019, - to December 31st, 2019, whose encounter generated an insurance claim (n=68,484). The exposure was insurance type and outcomes were patient total amount, billed amount, and pay amount by patient. Data analyses were performed using SAS, version 9.4. In all statistical analyses, p-values were one-sided and considered statistically significant if 0.05 or lower. The study protocol was approved by the Institutional Review Boards of Salus University. The sample represented an older population with an average age of about 55. There was a significant association found between financial class with patient total amount (p<0.0001), billed amount(p<0.0001), and pay amount (p<0.0001). People with managed PPO pay the least, while those on Medicaid and workers compensation pay the most out of pocket. The two Philadelphia zip codes which pay the most out of pocket have two of the lowest average household incomes in the Greater Philadelphia area. Insurance type and out of pocket expenses potentially have a negative effect on patient vision health and affordability of care as well as access to care. These findings contribute to the identification of variables that influence individual’s healthcare accessibility and evidence for opportunities to improve insurance coverage.

Heterogeneous patterns of old-age vulnerability and loneliness from the cross-national comparative perspective

Loneliness has been extensively examined as a major risk factor for mortality and morbidity among older adults. In this research, we identified multi-dimensional patterns of old-age vulnerability in five countries (U.S., Korea, Sweden, Germany, Italy) guided by the welfare regime framework and examined how the patterns of vulnerability are associated with loneliness in old age in each country. Data were drawn from comparative national aging data: HRS for the U.S. (n=4331), KLOSA for Korea (n=3721), SHARE for Sweden (n=2746), Germany (n=2271), and Italy (n=2988). We used three vulnerability constructs: 1) material vulnerability (poverty, high out-of-pocket expenses for health care, unaffordability for housing), 2) health vulnerability (multiple chronic condition, depression), and 3) social vulnerability (living alone, contact with children and friend, social participation). Latent Class Analysis and regression analyses were used for data analysis. The relative proportion of the least vulnerable group varies substantially (from 11.88% in Italy to 59.33% in the U.S). In Sweden and Germany, around 7% of the sample belongs to the most vulnerable group, while in other countries the most vulnerable group was not found. Notably, in Italy, older people in the social vulnerable group were more likely to feel lonely when compared to least vulnerable, suggesting the country-specific significance of social supportive environment. This study is the first research to examine the empirical structure of the concept and how it may vary across countries related to their loneliness. A full discussion of country-specific discussion and policy implication will be presented.

Hereditary cancer panel testing challenges and solutions for the latinx community: costs, access, and variants

Hereditary breast and ovarian cancers (HBOCs) are common among the Latinx population, and risk testing is recommended using multi-gene hereditary cancer panels (HCPs). However, little is known about how payer reimbursement and out-of-pocket expenses impact provider ordering of HCP in the Latinx population. Our objective is to describe key challenges and possible solutions for HCP testing in the Latinx population. As part of a larger study, we conducted semi-structured interviews with key provider informants (genetic counselors, oncologist, nurse practitioner) from safety-net institutions in the San Francisco Bay Area. We used a deductive thematic analysis approach to summarize themes around challenges and possible solutions to facilitating HCP testing in Latinx patients. We found few financial barriers for HCP testing for the Latinx population due to laboratory patient assistance programs that cover testing at low or no cost to patients. However, we found potential challenges related to the sustainability of low-cost testing and out-of-pocket expenses for patients, access to cascade testing for family members, and pathogenic variants specific to Latinx. Providers questioned whether current laboratory payment programs that decrease barriers to testing are sustainable and suggested solutions for accessing cascade testing and ensuring variants specific to the Latinx population were included in testing. The use of laboratories with payment assistance programs reduces barriers to HCP testing among the US population; however, other barriers are present that may impact testing use in the Latinx population and must be addressed to ensure equitable access to HCP testing for this population.

Prescription Drugs Price Setting and Generic Drugs Prescription concerning Consumer Protection Law in Indonesia

<p>Health is one of the most important human rights in human life. Access to affordable prescription drugs is still a problem for people with out-of-pocket expenses. Generic prescription drugs that are much cheaper than non-generic drugs are still low, especially in non-government healthcare facilities. This research aims to provide suggestions of regulation on price control of prescription drugs and generic prescription drugs that will assure certainty and affordability for the public. The methodology is doctrinal legal research and is supported by empirical studies. The research finding consist of two things, namely the price of prescription drugs and the prescription of generic drugs. The first finding is that Highest Retail Price (HET) set by the manufacturer is potentially to be unlimited because there is no limit control. Currently, there are many drugs sold over HET with minimal supervision from the Government. The absence of law is found as the existing regulations are only for those listed in the National Formulary, while the rest have not been regulated. Therefore, the suggestion is to set ceiling prices for prescription drugs with comparison among generic drugs, branded generic drugs, and the originator; also create a refund mechanism for prices above HET to assure the consumers’ rights to get compensation under the Consumer Protection Law. The second finding is that only a few doctors prescribe generic drugs. Additionally, patients have not been involved in the treatment decisions.Therefore, the suggestion is to associate "the action of prescribing generic drugs" with the extension of doctor's license, namelythe Registration Certificate (STR); so that doctors will prescribe generic drugs without the need for close supervision due to their interests. With the increase of generic drugs’ prescription, the financing of health services, nationwide as well asindividually, can become more affordable.</p>