Quality-based benefit design in health insurance : the impact of a product benefit design change on the utilisation of oral health services by members of a private health insurance fund in regional and rural New South Wales, Australia

Objective: To examine the impact on dental utilisation following the introduction of a participating provider scheme (Regional and Rural Oral Health Program {RROHP)). In this model dentists receive higher third party payments from a private health insurance fund for delivering an agreed range of preventive and diagnostic benefits at no out-ofpocket cost to insured patients. Data source/Study setting: Hospitals Contribution Fund of Australia (HCF) dental claims for all members resident in New South Wales over the six financial years from l99811999 to 200312004. Study design: This cohort study involves before and after analyses of dental claims experience over a six year period for approximately 81,000 individuals in the intervention group (HCF members resident in regional and rural New South Wales, Australia) and 267,000 in the control group (HCF members resident in the Sydney area). Only claims for individuals who were members of HCF at 31 December 1997 were included. The analysis groups claims into the three years prior to the establishment of the RROHP and the three years subsequent to implementation. Data collection/Extraction methods: The analysis is based on all claims submitted by users of services for visits between 1 July 1988 and 30 June 2004. In these data approximately 1,000,000 services were provided to the intervention group and approximately 4,900,000 in the control group. Principal findings: Using Statistical Process Control (SPC) charts, special cause variation was identified in total utilisation rate of private dental services in the intervention group post implementation. No such variation was present in the control group. On average in the three years after implementation of the program the utilisation rate of dental services by regional and rural residents of New South Wales who where members of HCF grew by 12.6%, over eight times the growth rate of 1.5% observed in the control group (HCF members who were Sydney residents). The differences were even more pronounced in the areas of service that were the focus of the program: diagnostic and preventive services. Conclusion: The implementation of a benefit design change, a participating provider scheme, that involved the removal of CO-payments on a defined range of preventive and diagnostic dental services combined with the establishment and promotion of a network of dentists, appears to have had a marked impact on HCF members' utilisation of dental services in regional and rural New South Wales, Australia.

Incentivising private health insurance through the income tax regime : Capitalising on behavioural models

The Australian income tax regime is generally regarded as a mechanism by which the Federal Government raises revenue, with much of the revenue raised used to support public spending programs. A prime example of this type of spending program is health care. However, a government may also decide that the private sector should provide a greater share of the nation's health care. To achieve such a policy it can bring about change through positive regulation, or it can use the taxation regime, via tax expenditures, not to raise revenue but to steer or influence individuals in its desired direction. When used for this purpose, tax expenditures steer taxpayers towards or away from certain behaviour by either imposing costs on, or providing benefits to them. Within the context of the health sector, the Australian Federal Government deploys social steering via the tax system, with the Medicare Levy Surcharge and the 30 percent Private Health Insurance Rebate intended to steer taxpayer behaviour towards the Government’s policy goal of increasing the amount of health provision through the private sector. These steering mechanisms are complemented by the ‘Lifetime Health Cover Initiative’. This article, through the lens of behavioural economics, considers the ways in which these assorted mechanisms might have been expected to operate and whether they encourage individuals to purchase private health insurance.

Early users of fertility treatment with hormones and IVF : women who live in major cities and have private health insurance

Objective: To identify early users (women aged <34 years) of fertility treatment with hormones and in vitro fertilisation (IVF). Methods: A cross-sectional survey of infertile women from fertility clinics (n=59) and from the community (Australian Longitudinal Study on Women's Health participants) who had (n=121) or had not (n=110) used hormones/IVF as treatment for infertility. Associations between socio-demographic, reproductive and lifestyle factors, medical conditions and recurrent symptoms and using treatment (or not) were analysed using multivariable logistic regression. Results: Among infertile women who had used treatment (community vs clinic), women from clinics had lower odds of living outside major cities, using hormones only, i.e., not IVF, or recurrent headaches/migraines, severe tiredness, or stiff/painful joints; and higher odds of recent diagnoses of urinary tract infection or anxiety disorder. Compared to infertile women who had not used treatment, women from clinics had lower odds of living outside major cities, recurrent allergies or severe tiredness; and higher odds of having private health insurance for hospital or ancillary services, recent diagnosis of polycystic ovary syndrome or recurrent constipation. Conclusions: Compared to infertile women in the community, living in major cities and having private health insurance are associated with early use of treatment for infertility at specialist clinics by women aged <34 years. Implications: These results provided evidence of inequity of services for infertile women.

Private health insurance status and utilisation of dental services in Australia

This article focuses on the relationship between private insurance status and dental service utilisation in Australia using data between 1995 and 2001. This article employs joint maximum likelihood to estimate models of time since last dental visit treating private ancillary health insurance (PAHI) as endogenous. The sensitivity of results to the choice between two different but related types of instrumental variables is examined. We find robust evidence in both 1995 and 2001 that individuals with a PAHI policy make significantly more frequent dental consultations relative to those without such coverage. A comparison of the 1995 and 2001 results, however, suggests that there has been an increasing role of PAHI in terms of the frequency of dental consultations over time. This seems intuitive given the trends in the price of unsubsidised private dental consultations. In terms of policy, our results suggest that while government measures to increase private health insurance coverage in Australia has been successful to a significant degree, it may have come at some cost in terms of socio-economic inequality as the privately insured are provided much better access to care and financial protection.

The determinants of demand for private health insurance under Medicare

Since the introduction of Medicare in 1984, the proportion of the Australian population with private health insurance has declined considerably. Insurance for health care consumption is compulsory for the public health sector but optional for the private health sector. In this paper, we explore a number of important issues in the demand for private health insurance in Australia. The socio-economic variables which influence demand are examined using a binary logic model. A number of simulations are performed to highlight the influence and relative importance of various characteristics such as age, income, health status and geographical location on demand. A number of important policy issues in the private health insurance market are highlighted. First, evidence is provided of adverse selection in the private health insurance pool, second, the notion of the wealthy uninsured is refuted, and finally it is confirmed that there are significant interstate differences in the demand for private health insurance.

Trends in demographic, health behaviour factors, and self-perceived weight status : influences on obesity in Australia from 1995 to 2005

Overweight and obesity are two of the most important emerging public health issues in our time and regarded by the World Health Organisation [WHO] (1998) as a worldwide epidemic. The prevalence of obesity in the USA is the highest in the world, and Australian obesity rates fall into second place. Currently, about 60% of Australian adults are overweight (BMI „d 25kg/m2). The socio-demographic factors associated with overweight and/or obesity have been well demonstrated, but many of the existing studies only examined these relationships at one point of time, and did not examine whether significant relationships changed over time. Furthermore, only limited previous research has examined the issue of the relationship between perception of weight status and actual weight status, as well as factors that may impact on people¡¦s perception of their body weight status. Aims: The aims of the proposed research are to analyse the discrepancy between perceptions of weight status and actual weight status in Australian adults; to examine if there are trends in perceptions of weight status in adults between 1995 to 2004/5; and to propose a range of health promotion strategies and furth er research that may be useful in managing physical activity, healthy diet, and weight reduction. Hypotheses: Four alternate hypotheses are examined by the research: (1) there are associations between independent variables (e.g. socio -demographic factors, physical activity and dietary habits) and overweight and/or obesity; (2) there are associations between the same independent variables and the perception of overweight; (3) there are associations between the same independent variables and the discrepancy between weight status and perception of weight status; and (4) there are trends in overweight and/or obesity, perception of overweight, and the discrepancy in Australian adults from 1995 to 2004/5. Conceptual Framework and Methods: A conceptual framework is developed that shows the associations identified among socio -demographic factors, physical activity and dietary habits with actual weight status, as well as examining perception of weight status. The three latest National Health Survey data bases (1995 , 2001 and 2004/5) were used as the primary data sources. A total of 74,114 Australian adults aged 20 years and over were recruited from these databases. Descriptive statistics, bivariate analyses (One -Way ANOVA tests, unpaired t-tests and Pearson chi-square tests), and multinomial logistic regression modelling were used to analyse the data. Findings: This research reveals that gender, main language spoken at home, occupation status, household structure, private health insurance status, and exercise are related to the discrepancy between actual weight status and perception of weight status, but only gender and exercise are related to the discrepancy across the three time point s. The current research provides more knowledge about perception of weight status independently. Factors which affect perception of overweight are gender, age, language spoken at home, private health insurance status, and diet ary habits. The study also finds that many factors that impact overweight and/or obesity also have an effect on perception of overweight, such as age, language spoken at home, household structure, and exercise. However, some factors (i.e. private health insurance status and milk consumption) only impact on perception of overweight. Furthermore, factors that are rel ated to people’s overweight are not totally related to people’s underestimation of their body weight status in the study results. Thus, there are unknown factors which can affect people’s underestimation of their body weight status. Conclusions: Health promotion and education activities should provide education about population health education and promotion and education for particular at risk sub -groups. Further research should take the form of a longitudinal study design ed to examine the causal relationship between overweight and/or obesity and underestimation of body weight status, it should also place more attention on the relationships between overweight and/or obesity and dietary habits, with a more comprehensive representation of SES. Moreover, further research that deals with identification of characteristics about perception of weight status, in particular the underestimation of body weight status should be undertaken.

Health promotion

The ‘promotion of health’ has become everybody’s business: from the marketers of ‘healthy’ products and lifestyles, and gym memberships; government media campaigns to ‘Go for 2&5®’ (fruit and vegetables every day), special ‘extra’ benefits for joining a private health insurance fund and workplace ‘wellness’ programs that include yoga and pilates. For consumers, the list is endless. Health professionals need to understand the background to this growth in the promotion of ‘health’ and the place health promotion plays in public health. We begin this chapter with a discussion on health education, we then trace the evolution of health promotion from health education, the strategies and settings for health promotion, and conclude with challenges for health promotion. Case studies, activities and reflections on the material are presented to assist you.

The emerging role of private health care provision in China : a critical analysis of the current health system

China continues to face great challenges in meeting the health needs of its large population. The challenges are not just lack of resources, but also how to use existing resources more efficiently, more effectively, and more equitably. Now a major unaddressed challenge facing China is how to reform an inefficient, poorly organized health care delivery system. The objective of this study is to analyze the role of private health care provision in China and discuss the implications of increasing private-sector development for improving health system performance. This study is based on an extensive literature review, the purpose of which was to identify, summarize, and evaluate ideas and information on private health care provision in China. In addition, the study uses secondary data analysis and the results of previous study by the authors to highlight the current situation of private health care provision in one province of China. This study found that government-owned hospitals form the backbone of the health care system and also account for most health care service provision. However, even though the public health care system is constantly trying to adapt to population needs and improve its performance, there are many problems in the system, such as limited access, low efficiency, poor quality, cost inflation, and low patient satisfaction. Currently, private hospitals are relatively rare, and private health care as an important component of the health care system in China has received little policy attention. It is argued that policymakers in China should recognize the role of private health care provision for health system performance, and then define and achieve an appropriate role for private health care provision in helping to respond to the many challenges facing the health system in present-day China.

Private hospital emergency departments in Australia : challenges and opportunities

BACKGROUND: Public hospital EDs in Australia have become increasingly congested because of increasing demand and access block. Six per cent of ED patients attend private hospital EDs whereas 45% of the population hold private health insurance. OBJECTIVES: This study describes the patients attending a small selection of four private hospital EDs in Queensland and Victoria, and tests the feasibility of a private ED database. METHODS: De-identified routinely collected patient data were provided by the four participating private hospital and amalgamated into a single data set. RESULT: The mean age of private ED patients was 52 years. Males outnumbered females in all age groups except > 80 years. Attendance was higher on weekends and Mondays, and between 08.00 and 20.00 h. There were 6.6% of the patients triaged as categories 1 and 2, and 60% were categories 4 or 5. There were 36.4% that required hospital admission. Also, 96% of the patients had some kind of insurance. Furthermore, 72% were self-referred and 12% were referred by private medical practitioners. Approximately 25% arrived by ambulance. There were 69% that completed their ED treatment within 4 h. CONCLUSION: This study is the first public description of patients attending private EDs in Australia. Private EDs have a significant role to play in acute medical care and in providing access to private hospitals which could alleviate pressure on public EDs. This study demonstrates the need for consolidated data based on a consistent data set and data dictionary to enable system-wide analysis, benchmarking and evaluation

Beyond the hospital door : a retrospective, cohort study of associations between birthing in the public or private sector and women’s postpartum care

Background In Australia, maternity care is available through universal coverage and a parallel, competitive private health insurance system. Differences between sectors in antenatal and intrapartum care and associated outcomes are well documented but few studies have investigated differences in postpartum care following hospital discharge and their impact on maternal satisfaction and confidence. Methods Women who birthed in Queensland, Australia from February to May 2010 were mailed a self-report survey 4 months postpartum. Regression analysis was used to determine associations between sector of birth and postpartum care, and whether postpartum care experiences explained sector differences in postpartum well-being (satisfaction, parenting confidence and feeling depressed). Results Women who birthed in the public sector had higher odds of health professional contact in the first 10 days post-discharge and satisfaction with the amount of postpartum care. After adjusting for demographic and postpartum contact variables, sector of birth no longer had an impact on satisfaction (AOR 0.95, 99% CI 0.78-1.31), but any form of health professional contact did. Women who had a care provider’s 24 hour contact details had higher odds of being satisfied (AOR 3.64, 95% CI 3.00-4.42) and confident (AOR 1.34, 95% CI 1.08- 1.65). Conclusion Women who birthed in the public sector appeared more satisfied because they had higher odds of receiving contact from a health professional within 10 days post-discharge. All women should have an opportunity to speak to and/or see a doctor, midwife or nurse in the first 10 days at home, and the details of a person they can contact 24 hours a day.

The impact of the health insurance program on the near-poor in Vietnam

This thesis is a cross-sectional study of a health insurance scheme for a representative sample of the near-poor in Cao Lanh district, Dong Thap province, Vietnam. It examines insurance coverage, health service utilisation, out-of-pocket expenditures and their associated factors. The research findings contribute evidence for policy makers who seek to improve the health insurance scheme for socioeconomically disadvantaged people in Vietnam, which is an important component of national efforts to implement universal health insurance. This community-level research adds to the evidence-base needed to improve the insurance system and thereby influence the quality of health care services.

Predictors of physical activity in colorectal cancer survivors after participation in a telephone-delivered multiple health behavior change intervention

Purpose: Physical activity improves the health outcomes of colorectal cancer (CRC) survivors, yet few are exercising at levels known to yield health benefits. Baseline demographic, clinical, behavioral, and psychosocial predictors of physical activity at 12 months were investigated in CRC survivors. Methods: Participants were CRC survivors (n = 410) who completed a 12-month multiple health behavior change intervention trial (CanChange). The outcome variable was 12 month sufficient physical activity (≥150 min of moderate–vigorous physical activity/week). Baseline predictors included demographics and clinical variables, health behaviors, and psychosocial variables. Results: Multivariate linear regression revealed that baseline sufficient physical activity (p < 0.001), unemployment (p = 0.004), private health insurance (p = 0.040), higher cancer-specific quality of life (p = 0.031) and higher post-traumatic growth (p = 0.008) were independent predictors of sufficient physical activity at 12 months. The model explained 28.6 % of the variance. Conclusions: Assessment of demographics, health behaviors, and psychosocial functioning following a diagnosis of CRC may help to develop effective physical activity programs.

Qualitative study of patients' choice between public and private hospital emergency departments

Objective The aim of this study was to gather patients' perceptions regarding their choice between public and private hospital EDs for those who hold private health insurance. The findings of this study will contribute to knowledge regarding patients' decision-making processes and therefore may contribute to the development of evidence based public policies. Methods An in-depth semi-structured guide was used to interview participants at public and private hospital EDs. Questions sought to identify the issues that were considered by the participants to decide to attend that hospital ED, previous ED experience, expectations of ED services and perceived benefits and barriers to accessing services. Interviews were audio recorded, transcribed verbatim and analysed using content and thematic approaches. Results Four core themes emerged: prior good experience with the hospital, perceived quality of care, perceived waiting times and perceived costs that may explain patients' choice. Patients' choice between public and private EDs can be explained by the interaction of these core themes. The principal issues appear to be concern for gap payments at private hospital ED and waiting times at public hospital ED. Conclusions Patients who choose to attend public EDs appear to value financial concern over waiting time; those who choose to attend private EDs appear to value waiting time ahead of financial concerns.

Psychotherapy in Australia : clinical psychology and its approach to depression

In Australia, clinical psychology training is dominated by cognitive and behavioral treatments (CBTs), although there is exposure to other theoretical orientations. Since 2001, over 20% of general medical practitioners (GPs) have received training in CBT, and psychiatry training increasingly incorporates CBT elements. Psychotherapy by medical practitioners is financially supported by universal health care funding with supplementation by patients and their private health insurance. Federally funded health benefits for up to 12 psychology consultations per year are provided on referral from GPs and psychiatrists, and initial take up has been very strong. Mrs. A would be a typical patient for such a referral. However, she would not fulfil criteria for priority access from state-funded mental health services. Mrs. A would probably consult a GP and receive antidepressants, although she may also access a range of other community support programs. Access to and acceptance of psychotherapy would be greater in urban areas, and if she were of Anglo-Saxon and non- indigenous origin.

Differences in Treatment and Management of Indigenous and Non-Indigenous Patients Presenting with Chest Pain: Results of the Heart Protection Partnership (HPP) Study

BACKGROUND: Indigenous patients with acute coronary syndromes represent a high-risk group. There are however few contemporary datasets addressing differences in the presentation and management of Indigenous and non-Indigenous patients with chest pain. METHODS: The Heart Protection Project, is a multicentre retrospective audit of consecutive medical records from patients presenting with chest pain. Patients were identified as Indigenous or non-Indigenous, and time to presentation and cardiac investigations as well as rates of cardiac investigations and procedures were compared between the two groups. RESULTS: Of the 2380 patients included, 199 (8.4%) identified as Indigenous, and 2174 (91.6%) as non-Indigenous. Indigenous patients were younger, had higher rates hyperlipidaemia, diabetes, smoking, known coronary artery disease and a lower rate of prior PCI; and were significantly less likely to have private health insurance, be admitted to an interventional facility or to have a cardiologist as primary physician. Following adjustment for difference in baseline characteristics, Indigenous patients had comparable rates of cardiac investigations and delay times to presentation and investigations. CONCLUSIONS: Although the Indigenous population was identified as a high-risk group, in this analysis of selected Australian hospitals there were no significant differences in treatment or management of Indigenous patients in comparison to non-Indigenous.