Public involvement in service change has been identified as a key facilitator of health care transformation (Foley et al., 2017) but little is known about how health policy influences whether and how organisations involve the public in change processes. This qualitative study compares policy and practice for involving the public in major service changes across the UK's four health systems (England, Northern Ireland, Wales and Scotland). We analysed policy documents, and conducted interviews with officials, stakeholders, NHS staff and public campaigners (total number of interviewees = 47). Involving the public in major service change was acknowledged as a policy challenge in all four systems. Despite ostensible similarities, there were some clear differences between the four health systems' processes for involving patients and the public in major changes to health services. The extent of central Government oversight, the prescriptiveness of Government guidance, the role for intermediary bodies and arrangements for independent scrutiny of contentious decisions all vary. We analyse how health policy in the four systems has used ‘sticks’ and ‘sermons’ to promote particular approaches, and conclude that both policy and the wider system context within which health care organisations try to effect change are significant, and understudied aspect of contemporary practice.

Explanations of the state of ‘crisis’ in the English National Health Service (NHS) generally focus on the overall level of health care funding rather than the way in which funding is distributed. Describing systematic patterns in the way different areas are experiencing crisis, this paper suggests that NHS organisations in older, rural and particularly coastal areas are more likely to be ‘failing’ and that this is due to the historic underfunding of such areas. This partly reflects methodological and technical shortcomings in NHS resource allocation formulae. It is also the outcome of a philosophical shift from horizontal (equal access for equal needs) to vertical (unequal access to equalise health outcomes) principles of equity. Insofar as health inequalities are determined by factors well beyond health care, we argue that this is an ineffective approach to addressing health inequalities. Moreover, it sacrifices equity in access to health care by failing to adequately fund the health care needs of older populations. The prioritisation of vertical over horizontal equity also conflicts with public perspectives on the NHS. Against this background, we ask whether the time has come to reassert the moral and philosophical case for the principle of equal access for equal health care need.

The strong and positive relationship between gross domestic product (GDP) and health expenditure is one of the most extensively explored topics in health economics. Since the global financial crisis, a variety of theories attempting to explain the slow recovery of the global economy have predicted that future economic growth will be slower than in the past. Others have increasingly questioned whether GDP growth is desirable or sustainable in the long term as evidence grows of humanity's impact on the natural environment. This paper reviews recent data on trends in global GDP growth and health expenditure. It examines a range of theories and scenarios concerning future global GDP growth prospects. It then considers the potential implications for health care systems and health financing policy of these different scenarios. In all cases, a core question concerns whether growth in GDP and/or growth in health expenditure in fact increases human health and well-being. Health care systems in low growth or ‘post-growth’ futures will need to be much more tightly focused on reducing overtreatment and low value care, reducing environmental impact, and on improving technical and allocative efficiency. This will require much more concerted policy and regulatory action to reduce industry rent-seeking behaviours.

This article studies the implementation of the European Union (EU)’s Patients’ Rights Directive in Germany and Norway. The objective of the Directive was to allow EU member states to have a say in the regulatory work, ensure predictability and uniformity in the application of EU rules on cross-border care, and enhance a move towards EU harmonisation in this area. So far, the implementation processes in Norway and Germany have mixed results regarding the likelihood of achieving uniformity and harmonisation. Although the Directive has had convergent effects on certain areas of cross-border care, such as setting up National Contact Points and providing patients with the basic right to treatment abroad, implementation also shows divergent patterns. In both countries, adapting to EU rules has strengthened patients’ rights to choose freely among health-service providers in a wider European health-service market. However, due to legal discretion and country-specific institutions within which the new rules are applied, divergent patterns prevail.

Using dual-entitlement theory as the guide, we conducted a survey of economists from the National Bureau of Economic Research asking them a series of questions about the fairness of drug prices in the United States. Public opinion surveys have repeatedly shown that the public perceives drug prices to be unfair, but economists trained in laws of supply and demand may have different perceptions. Three hundred and ten senior economists responded to our survey. Forty-five percent agreed that drug prices were unfair when people, specifically low-income individuals, could not afford their prescription medications. Sixty-five percent oppose a dollar threshold, or upper limit, on drug prices. The economists recommend the most promising policy change would be to provide the government additional negotiating power and price controls would moderately impact investment in pharmaceutical research and development.

There is an increasing interest in assessing unmet need for health care services particularly in European countries. Despite this there has been relatively little analysis of unmet need in the European or wider international setting. It remains a challenge to pin down what types of unmet need can and should be addressed by health care policymakers, and how to go about identifying and quantifying those unmet needs. The objective of this paper is to propose a new way of thinking about unmet need for health care which can in turn guide analysis of unmet need in terms of potential data sources and analytic approaches. Unmet need is shown to be a complex multi-faceted concept that cannot be captured by a single indicator or measurement. To advance the literature in this field, this paper considers what happens to unmet need over time. By introducing a dynamic perspective, three alternative trajectories for health care needs are outlined: non-use of health care, delayed use of health care and sub-optimal use of health care. These trajectories are discussed with a view to improving the focus, and policy applicability, of empirical research in this field.

Since 1990, market mechanisms have occurred in the predominantly hierarchical National Health Service (NHS). The Health and Social Care Act 2012 led to concerns that market principles had been irrevocably embedded in the NHS and that the regulators would acquire unwarranted power compared with politicians (known as ‘juridification’). To assess this concern, we analysed regulatory activity in the period from 2015 to 2018. We explored how economic regulation of the NHS had changed in light of the policy turn back to hierarchy in 2014 and the changes in the legislative framework under Public Contracts Regulations 2015. We found the continuing dominance of hierarchical modes of control was reflected in the relative dominance and behaviour of the sector economic regulator. But there had also been a limited degree of juridification involving the courts. Generally, the regulatory decisions were consistent with the 2014 policy shift away from market principles and with the enduring role of hierarchy in the NHS, but the existing legislative regime did allow the incursion of pro market regulatory decision making, and instances of such decisions were identified.

This article proposes a classification of the different national health care systems based on the way the network of health care providers is organised. To this end, we present two rivalling models: on the one hand, the integrated model and, on the other, the separated model. These two models are defined based on five dimensions: (1) integration of insurer and provider; (2) integration of primary and secondary care; (3) presence of gatekeeping mechanisms; (4) patient's freedom of choice; and (5) solo or group practice of general practitioners. Each of these dimensions is applied to the health care systems of 24 OECD countries. If we combine the five dimensions, we can arrange the 24 national cases along a continuum that has the integrated model and the separated model at the two opposite poles. Portugal, Spain, New Zealand, the UK, Denmark, Ireland and Israel are to be considered highly integrated, while Italy, Norway, Australia, Greece and Sweden have moderately integrated provision systems. At the opposite end, Austria, Belgium, France, Germany, the Republic of Korea, Japan, Switzerland and Turkey have highly separated provision systems. Canada, The Netherlands and the United States can be categorised as moderately separated.

Parity in coverage for mental health services has been a longstanding policy aim at the state and federal levels and is a regulatory feature of the Affordable Care Act. Despite the importance and legislative effort involved in these policies, evaluations of their effects on patients yield mixed results. I leverage the Employee Retirement Income Security Act and unique claims-level data that includes information on employers’ self-insurance status to shed new light in this area after the implementation of two state parity laws in 2007 and federal parity a few years later. My empirics reveal evidence of strategic avoidance on behalf of insurers in both states prior to the passage of state parity, as well as positive increases in mental health care utilization after parity laws are implemented – but context matters. Policy heterogeneity across states and strategic behaviors by employers and commercial insurers substantively shape the benefits that ultimately flow to patients. Insights from this research have broad relevance to ongoing health policy debates, particularly as states retain great discretion over many health coverage decisions and as federal policy continues to evolve.

The Sustainable Development Goals set by the United Nations recognize the importance of making progress in the eradication and treatment of sexually transmitted deceases (STD). STD are among the most widespread diseases in the world and have the highest prevalence in Sub-Saharan Africa. The current study explored the associations between the allocation of the development assistance for health (DAH) in 54 African countries and key development indicators – STD incidence, Gross Domestic Product per capita, health expenditure, and life expectancy at birth. It employed descriptive statistical methods, the matrix scatter plot analysis and the Pearson correlation test for this purpose. The findings indicated that there was a considerable increase in the volume of the DAH given to control and prevent STD in Africa over the period of 2002–2011. A statistically significant positive association was detected between the STD incidence and the health aid allocations. At the same time, the imbalance in the distribution of the health aid between the major and minor aid recipients in the continent increased. The study concludes by discussing policy implications that can be drawn from these findings.

Patient and public involvement (PPI) is framed as beneficial for individuals and for the health system. However, little is known about the extent of involvement, or of its impact. Based on data from Sweden, we show that apart from voting in regional elections (76%), more people reported involvement as individual patients (23%) than part of collective activities (5%) or activities relating to a citizen perspective (4%). There was no correlation between how many people participated and the estimated impact – which was generally low. More extensive involvement is thus not linked to the potential to influence decisions. We argue that to achieve the benefits associated with PPI it is crucial to understand more about people's motivation for being involved and what underlies low estimates of impact. This requires a more systematic approach to involvement, how it is evaluated and its results communicated to participants and the society. We also argue that a future challenge for the Swedish health system, and for other similar health systems, is to support long-term collective involvement in the midst of growing individualization of health services and involvement opportunities primarily intended for patients.

Health technology assessment is frequently credited with making difficult resource allocation decisions in health care fairer, more rational and more transparent. In Germany, a constitutional ‘right to health’ allows patients to challenge decisions by sickness funds to withhold reimbursement of treatment excluded from public funding because of insufficient evidence of effectiveness. The ability to litigate was qualified by the Constitutional Court in its 2005 ‘Nikolaus decision’ that sets out criteria to be applied to these cases. Treatment must be made available if (1) the condition is life-threatening, (2) no alternative treatment is available and (3) there is an indication that the treatment could benefit the patient. This paper examines how courts struggled to apply these criteria based on an analysis of cases of patients who sought treatment for cancer between 2005 and 2015, and explores the implications of applying a constitutional ‘right to health’ to treatment decisions.

While we know that upcoding of diagnosis-related groups (DRGs) regularly occurs, we have little knowledge of the role of the technical features of coding systems in inducing coding behaviour. This paper presents methods for investigating the financial structure of the Dutch DRG system, and more in particular the grouper software, to gain such insight. The paper describes a system for investigating the robustness of the reward structure, by simulating the response of the DRG system to small changes in individual coding. The results from these analyses are used to visualise some data on coding behaviour, and to investigate how this behaviour is affected by incentives in the technical features of the DRG system. A number of technical weaknesses in the system are also identified.

We use a reliable, intuitive and simple set of indicators to capture three dimensions of access – availability, affordability and acceptability. Data are from South Africa’s 2009 and 2010 General Household Surveys (n=190,164). Affordability constraints were faced by 23% and are more concentrated amongst the poorest. However, 73% of affordability constraints are due to travel costs which are aligned with findings of the availability constraints dimension. Availability constraints, involving distances and transport costs, particularly in underdeveloped rural areas, and inconvenient opening times, were faced by 27%. Acceptability constraints were noted by only 10%. We approximate acceptability with an indicator measuring the share of community members bypassing the closest health care facility, as we argue that reported health care provider choice is more reliable than stated preferences. However, the indicator assumes a choice of available and affordable providers, which may often not be an accurate assumption in rural areas. We recommend further work on the measurement of acceptability in household surveys, especially considering this dimension’s importance for health reform.

Concern has been expressed that human papillomavirus (HPV) vaccination programs might promote risky sexual behavior through mechanisms such as risk compensation, behavioral disinhibition, or perceived endorsement of sexual activity. This study assesses whether HPV vaccination status is associated with any differences in selected sexual behaviors among young sexually-active women in the US. Our dataset includes young, adult female respondents from questionnaire data collected in the National Center for Health Statistics' National Health and Nutrition Examination Survey from 2007 to 2014. The empirical approach implements a doubly robust estimation procedure, based on inverse probability of treatment weighting. For robustness, we implement several specifications for the propensity model and the outcomes model. We find no consistent association between HPV vaccination and condom usage or frequency of sex. Specifically, we find no evidence that HPV vaccination is associated with condom usage or with whether a person had sex more than 52 or more than 104 times per year. We find inconsistent evidence that HPV vaccination is associated with a person having sex more than 12 times per year. As in previous research, HPV vaccination does not appear to have a substantive effect on sexual behavior among young sexually-active women in the US.

In the Dutch health care system, health insurers negotiate with hospitals about the pricing of hospital products in a managed competition framework. In this paper, we study these contract prices that became for the first time publicly available in 2016. The data show substantive price variation between hospitals for the same products, and within a hospital for the same product across insurers. About 27% of the contract prices for a hospital product are at least 20% higher or lower than the average contract price in the market. For about half of the products, the highest and the lowest contract prices across hospitals differ by a factor of three or more. Moreover, hospital product prices do not follow a consistent ranking across hospitals, suggesting substantial cross-subsidization between hospital products. Potential explanations for the large and seemingly random price variation are: (i) different cost pricing methods used by hospitals, (ii) uncertainty due to frequent changes in the hospital payment system, (iii) price adjustments related to negotiated lumpsum payments and (iv) differences in hospital and insurer market power. Several policy options are discussed to reduce variation and increase transparency of hospital prices.

The 2012 Supreme Court decision in National Federation of Independent Business v Sebelius gave states the option to adopt the Medicaid expansion as part of the Affordable Care Act. Many states, especially those under Republican control, have since grappled with their decision to implement the expansion. We conduct a comparative analysis of how Republican governors framed their stance on the Medicaid expansion. We analyze public statements on the Medicaid expansion published in two major in-state newspapers from all Republican governors from June 2012 through June 2018. In total we collected, coded and analyzed 3277 statements from 66 newspapers. Several key themes emerge from our analysis. While every Republican governor used oppositional framing as part of their rhetorical response to the Medicaid expansion, the policy had a destabilizing effect on the previously unified opposition to health reform. We find that Republican framing split after the results of the 2012 election and that overall Republican governors shifted towards more supportive framing prior to the 2016 presidential election. Republican governors transformed how they framed their stance towards Medicaid expansion after Donald Trump was elected in 2016, with both supportive and oppositional moral-based framing of expansion increasing. These findings inform how policymakers use rhetoric to support their stance on controversial policies in a hyper-partisan and polarized political environment.

Improving the ability of patients to make informed choices of health care provider can give providers more incentive to compete based on quality. Still, it is not evident to what extent and when people search for information when choosing a provider. The aim of this study is to identify under what circumstances individuals seek information when choosing a primary care provider. Research to date has mostly focused on individuals’ demographic and socio-economic characteristics and the poor availability of information as barriers to information-seeking and use. Our results highlight the importance of taking individuals’ personal motivations and situational context into account when studying information-seeking behavior. Overall, these results suggest that not even individuals who are likely to search for information since they switched or considered switching primary care provider, do so to any greater extent. However, those motivated to change providers by internal factors such as dissatisfaction or a belief that other providers may provide superior services actively sought out information to a greater extent than those motivated by external factors such as the closure of their current provider, or by moving house. Gender, employment status, place of residence and education level was also significantly associated with information-seeking.

Most hospital payment systems based on diagnosis-related groups (DRGs) provide payments for newly approved technologies. In Germany, they are negotiated between individual hospitals and health insurances. The aim of our study is to assess the functioning of temporary reimbursement mechanisms. We used multilevel logistic regression to examine factors at the hospital and state levels that are associated with agreeing innovation payments. Dependent variable was whether or not a hospital had successfully negotiated innovation payments in 2013 (n = 1532). Using agreement data of the yearly budget negotiations between each German hospital and representatives of the health insurances, the study comprises all German acute hospitals and innovation payments on all diagnoses. In total, 32.9% of the hospitals successfully negotiated innovation payments in 2013. We found that the chance of receiving innovation payments increased if the hospital was located in areas with a high degree of competition and if they were large, had university status and were private for-profit entities. Our study shows an implicit self-controlled selection of hospitals receiving innovation payments. While implicitly encouraging safety of patient care, policy makers should favour a more direct and transparent process of distributing innovation payments in prospective payment systems.

China has achieved nearly universal social health insurance (SHI) coverage by implementing three statutory schemes, but gaps and differences in benefit levels are apparent. There is wide agreement that China should merge the three schemes into a universal and uniform SHI. However, data on the medical expenses of all inpatients in 2014 at a public Tier-three hospital suggests that supply-induced demand (SID) is a serious concern and that, under the design of the current schemes, a higher benefit level has a greater impact on the total expenses of insured patients. Thus, if SID is not effectively controlled, a universal and uniform SHI may be more harmful than beneficial in China. Finally, we suggest that China should substitute the existing fee-for-service design with a suite of bundled provider payment methods; furthermore, China should replace its current system of pricing drugs that encourages hospitals and doctors to use costlier medications.