Analyzing whether physicians use cesarean sections (c-sections) as defensive medicine (DM) has proven difficult. Using natural experiments arising out of Oregon court decisions overturning a state legislative cap on non-economic damages in tort cases, we analyze the impact of patient conditions on estimates of DM. Consistent with theory, we find heterogeneous impacts of tort laws across patient conditions. When medical exigencies dictate a c-section, tort laws have no impact on physician decisions. When physicians have latitude in their decision making, we find evidence of DM. When we estimate a model combining all women and not accounting for patient conditions (such as models estimated in previous studies) we obtain a result which is the opposite of DM, which we call offensive medicine (OM). The OM result appears to arise out of a bias in the difference-in-differences estimator associated with changes in the marginal distributions of patient conditions in control and treatment groups. The changes in the marginal distributions appear to arise from the impact of tort law on the market for midwives (substitutes for physicians for low-risk women). Our analysis suggests that not accounting for theoretically expected heterogeneity in physician reactions to changes in tort laws may produce biased estimates of DM.

The privatisation of provision and the emerging privatisation of funding, manifested in the rapid rise of private health insurance, are the most obvious signs that the universal, Swedish health system is gradually weakened. Meanwhile, the private welfare industry creates a neoliberal Newspeak where the burdening effects of the private insurance system on public healthcare are said to be unburdening, and where every step away from the principles of a universal welfare model is said to be in line with the principles of a universal welfare model. The language spoken by the private welfare industry spills over into authorities, journalists and scholars. In this article, I discuss, problematise and partially reject two research questions – Does VHI unburden the public health care system? and Are VHI holders less supportive of funding public health care? – where the authors fail to place development in the context of increased inequality and declining tax ratio, and where they use the welfare industry's definitions invented to blur the consequences of a parallel health system.

On 31st January 2020, the Italian cabinet declared a 6-month national emergency after the detection of the first two COVID-19 positive cases in Rome, two Chinese tourists travelling from Wuhan. Between then and the total lockdown introduced on 22nd March 2020 Italy was hit by an unprecedented crisis. In addition to being the first European country to be heavily swept by the COVID-19 pandemic, Italy was the first to introduce stringent lockdown measures. The SARS-CoV-2 outbreak and related COVID-19 pandemic have been the worst public health challenge endured in recent history by Italy. Two months since the beginning of the first wave, the estimated excess deaths in Lombardy, the hardest hit region in the country, reached a peak of more than 23,000 deaths. The extraordinary pressures exerted on the Italian Servizio Sanitario Nazionale (SSN) inevitably leads to questions about its preparedness and the appropriateness and effectiveness of responses implemented at both national and regional levels. The aim of the paper is to critically review the Italian response to the COVID-19 crisis spanning from the first early acute phases of the emergency (March–May 2020) to the relative stability of the epidemiological situation just before the second outbreak in October 2020.

This paper explores the factors that influence citizens' attitudes toward the alternative provision of health care services, leading them to be willing to make extra, informal payments within the public health care system. We question whether these attitudes depend primarily on inherent normative preferences, such as beliefs about the government's responsibility to its citizens, or on certain aspects of the reality that they experience, such as satisfaction with the quality and quantity of services as well as the fairness of public systems. Analyzing the findings from a national survey, the paper shows that practical considerations and real-world conditions strongly relate to attitudes more than normative perceptions do.

The cost of clinical negligence claims continues to rise, despite efforts to reduce this now ageing burden to the National Health Service (NHS) in England. From a welfarist perspective, reforms are needed to reduce avoidable harm to patients and to settle claims fairly for both claimants and society. Uncertainty in the estimation of quanta of damages, better known as financial settlements, is an important yet poorly characterised driver of societal outcomes. This reflects wider limitations to evidence informing clinical negligence policy, which has been discussed in recent literature. There is an acute need for practicable, evidence-based solutions that address clinical negligence issues, and these should complement long-standing efforts to improve patient safety. Using 15 claim cases from one NHS Trust between 2004 and 2016, the quality of evidence informing claims was appraised using methods from evidence-based medicine. Most of the evidence informing clinical negligence claims was found to be the lowest quality possible (expert opinion). The extent to which the quality of evidence represents a normative deviance from scientific standards is discussed. To address concerns about the level of uncertainty involved in deriving quanta, we provide five recommendations for medico-legal stakeholders that are designed to reduce avoidable bias and correct potential market failures.

France is one of the European countries hardest hit by the Covid-19 pandemic. The pandemic brought into light structural weaknesses of the health system, including its governance and decision-making process, but also provoked changes that helped to improve its resilience. We analyse the French experience of Covid-19 in 2020 by critically reviewing major policy measures implemented during the first two waves of the pandemic. France has struggled to find the right balance between the rock of economic and social damage caused by containment measures and the hard alternative of a rapidly spreading pandemic. The response to the first wave, including a full lock-down, was an emergency response that revealed the low level of preparedness for pandemics and the overly hospital-centred provision of health care in France. During the second wave, this response evolved into a more level strategy trying to reconcile health needs in a broader perspective integrating socio-economic considerations, but without fully managing to put in place an effective health strategy. We conclude that to achieve the right balance, France will have to strengthen health system capacity and improve the cooperation between actors at central and local levels with greater participatory decision-making that takes into account local-level realities and the diversity of needs.

Chronic diseases are highly important for the future level and distribution of health and well-being in western societies. Consequently, it seems pertinent to assess not only efficiency of chronic care but also its impact on health equity. However, operationalisation of health equity has proven a challenging task. Challenges include identifying a relevant and measurable evaluative space. Various schools of thought in health economics have identified different outcomes of interest for equity assessment, with capabilities as a proposed alternative to more conventional economic conceptualisations. The aim of this paper is to contribute to the conceptualisation of health equity evaluation in the context of chronic disease management. We do this by firstly introducing an equity enquiry framework incorporating the capabilities approach. Secondly, we demonstrate the application and relevance of this framework through a content analysis of equity-related principles and aims in national chronic disease management guidelines and the national diabetes action plan in Denmark. Finally, we discuss how conceptualisations of equity focused on capabilities may be used in evaluation by scoping relevant operationalisations. A promising way forward in the context of chronic care evaluation may emerge from a combination of concepts of capabilities developed in economics, health sciences and psychology.

Voluntary private health insurance (VHI) has generally been of limited importance in national health service-type health care systems, especially in the Nordic countries. During the last decades however, an increase in VHI uptake has taken place in the region. Critics of this development argue that voluntary health insurance can undermine support for public health care, while proponents contend that increased private funding for health services could relieve strained public health care systems. Using data from Sweden, this study investigates empirically how voluntary health insurance affects the public health care system. The results of the study indicate that the public Swedish health care system is fairly resilient to the impact of voluntary health insurance with regards to support for the tax-based funding. No difference between insurance holders and non-holders was found in willingness to finance public health care through taxes. A slight unburdening effect on public health care use was observed as VHI holders appeared to use public health care to a lesser extent than those without an insurance. However, a majority of the insurance holders continued to use the public health care system, indicating only a modest substitution effect.

The scarcity of medical resources is widely recognized, and therefore priority setting is inevitable. This study examines whether Portuguese healthcare professionals (physicians vs nurses): (i) share the moral guidance proposed by ethicists and (ii) attitudes toward prioritization criteria vary among individual and professional characteristics. A sample of 254 healthcare professionals were confronted with hypothetical prioritization scenarios involving two patients distinguished by personal or health characteristics. Descriptive statistics and parametric analyses were performed to evaluate and compare the adherence of both groups of healthcare professionals regarding 10 rationing criteria: waiting time, treatment prognosis measured in life expectancy and quality of life, severity of health conditions measured in pain and immediate risk of dying, age discrimination measured in favoring the young over older and favoring the youngest over the young, merit evaluated positively or negatively, and parenthood. The findings show a slight adherence to the criteria. Waiting time and patient pain were the conditions considered fairer by respondents in contrast with the ethicists normative. Preferences for distributive justice vary by professional group and among participants with different political orientations, rationing experience, years of experience, and level of satisfaction with the NHS. Decision-makers should consider the opinion of ethicists, but also those of healthcare professionals to legitimize explicit guidelines.

Step therapy, also termed fail-first policy, describes a practice of insurance and pharmacy benefit management companies denying reimbursement for a specific treatment until after other treatments have first been found ineffective (i.e. failed). Laws to limit step therapy have been passed in 29 states of the United States. Using extrapolated data on fully insured employees, we find that except for New York and New Mexico, enacted State laws don't apply to even one-third of a state's population. Using the more robust Kaiser Family Foundation (KFF) data, which do not include fully insured employees, we find that only 2–10% of a state's population is covered. Advocating for these laws has been an expensive and time-consuming process, likely to become more so for the 21 states without such laws. The laws that have been enacted can be near impossible, to enforce, and loopholes exist. As a result, using KFF data, more than 90% of people in the United States with health insurance may still be unable to access the treatment chosen as most appropriate for them with their physician. Based on these data, we conclude federal step-therapy legislation is needed.

Singapore's health system generates similar levels of health outcomes as does Sweden's but for only 4.4% rather than 11.0% of gross domestic product, with Singapore's resulting health sector savings being re-directed to help fund both long-term care and retirement pensions for its elderly citizens. This paper contrasts the framework of financial risk-sharing and the configuration and management of health service providers in these two high-income, small-population countries. Two main institutional distinctions emerge from this country case comparison: (1) Key differences exist in the practical configuration of solidarity for payment of health care services, reflecting differing cultural roots and social expectations, which in turn carry substantial implications for financing long-term care and pensions. (2) Differing arrangements exist in the organization of health service institutions, in particular balancing public as against private sector responsibilities for owning, operating and managing these two countries' respective hospitals. These different structural characteristics generate fundamental differences in health sector financial and delivery outcomes in one developed country in Far East Asia as compared with a well-respected tax-funded health system in Western Europe. In the post-COVID era, as Western European policymakers find themselves forced to adjust their publicly funded health systems to (further) reductions in economic growth rates and overall tax receipts, and as the cost of the information revolution continues to rise while efforts to fund better coordinated social and home care services for growing numbers of chronically ill elderly remain inadequate, this two-country case comparison highlights a series of health system design questions that could potentially provide alternative health sector financing and service delivery strategies.

The Covid-19 pandemic has put policy systems to the test. In this paper, we unmask the institutionalized resilience of the Dutch health care system to pandemic crisis. Building on logics of crisis decision-making and on the notion of ‘tact’, we reveal how the Dutch government initially succeeded in orchestrating collective action through aligning public health purposes and installing socio-economic policies to soften societal impact. However, when the crisis evolved into a more enduring one, a more contested policy arena emerged in which decision-makers had a hard time composing and defending a united decision-making strategy. Measures have become increasingly debated on all policy levels as well as among experts, and conflicts are widely covered in the Dutch media. With the 2021 elections ahead, this means an additional test of the resilience of the Dutch socio-political and health care systems.

Using yearly panel data from 2011 to 2017 on New Zealand District Health Boards (DHBs), this study combines principal component analysis and data envelopment intertemporal analysis with the double-bootstrap approach to estimate the technical efficiency of health care providers along with the trend of efficiency performances. The results show that although most large DHBs have improved their level of technical efficiency between 2011 and 2017, the majority of medium- and small-sized DHBs have not seen any noticeable improvement in their level of technical efficiency. The results also show that large and tertiary DHBs operate at a high level of technical efficiency. In contrast, most of the medium- and small-sized DHBs posted some of the lowest technical efficiency scores. Furthermore, the results show that medium- and small-sized DHBs have a higher average length of hospital stays which is found to be associated with decreasing levels of technical efficiency scores.

Scholars and journalists have devoted considerable attention to understanding the circumstances in which Americans receive surprise medical bills. Previous research on this issue has focused on the scope of the problem, including the conditions that are most likely to lead to surprise bills. However, the existing literature has almost exclusively relied on claims data, limiting our understanding of consumer experiences and attitudes toward policy changes to address surprise billing. Using a survey administered to a nationally representative sample of 4998 Americans, we analyze consumer experiences with surprise billing, knowledge of the issue, how concerned Americans are about receiving surprise bills and how past experiences influence policy preferences toward federal action on surprise billing. Our analysis demonstrates that knowledge and concern about surprise billing are the highest among the educated and those who have previously received a surprise bill. These factors also predict support for federal policy action, with high levels of support for federal policy action across the population, including among both liberals and conservatives. However, more detailed federal policy proposals receive significantly less support among Americans, suggesting that stand-alone policy action may not be viable. Our results show bipartisan support among American consumers for federal action on surprise billing in the abstract but no consistent views on specific policy proposals.

Belgium is often seen as an outlier in the international experience with the coronavirus disease 2019. We summarize the unfolding of the pandemic in Belgium from February to December 2020, discuss the countermeasures that were implemented and provide some explanations why the numbers indicate a stronger pandemic in Belgium than in its neighbouring countries. To some extent, the seemingly poor performance of Belgium is a measurement artefact. Yet, there were indeed particular factors in Belgium that unnecessarily increased the toll of the pandemic. In the first wave insufficient priority was given to protect care homes. The second wave was larger than necessary due to a failure to timely implement restrictive measures. The latter can, at least partly, be explained by a unique political situation: a temporary, minority government in the middle of a major crisis.

There is currently a heightened need for transparency in pharmaceutical sectors. The inclusion of real-world (RW) evidence, in addition to clinical trial evidence, in decision-making processes, was an important step forward toward a more inclusive established value proposition. This advance has introduced new transparency challenges. Increasing transparency is a critical step toward accelerating improvement in type, quality, and access to data, regardless of whether these originate from clinical trials or from RW studies. However, so far, advances in transparency have been relatively restricted to clinical trials, and there remains a lack of similar expectations or standards of transparency concerning the generation and reporting of RW data. This perspective paper aims to highlight the need for transparency concerning RW studies, data, and evidence across health care sectors, to identify areas for improvement, and provide concrete recommendations and practices for the future. Specific issues are discussed from different stakeholder perspectives, culminating in recommended actions, from individual stakeholder perspectives, for improved RW study, data, and evidence transparency. Furthermore, a list of potential guidelines for consideration by stakeholders is proposed. While recommendations from different stakeholder perspectives are made, true transparency in the processes involved in the generation, reporting, and use of RW evidence will require a concerted effort from all stakeholders across health care sectors.

Wales is a small country, with an ageing population, high levels of population health need and an economy with a significant reliance on public services. Its health system attracts little attention, with analyses tending to underplay the differences between the four countries of the UK. This paper helps redress this via a case study of Welsh mental health policy, services and nursing practice. Distinctively, successive devolved governments in Wales have emphasised public planning and provision. Wales also has primary legislation addressing sustainability and future generations, safe nurse staffing and rights of access to mental health services. However, in a context in which gaps always exist between national policy, local services and face-to-face care, evidence points to the existence of tension between Welsh policy aspirations and realities. Mental health nurses in Wales have produced a framework for action, which describes practice exemplars and looks forward to a secure future for the profession. With policy, however enlightened, lacking the singular potency to bring about intended change, nurses as the largest of the professional groups involved in mental health care have opportunities to make a difference in Wales through leadership, influence and collective action.

Sweden's coronavirus disease 2019 (COVID-19) response, initially based largely on voluntary measures, has evoked strong reactions nationally and internationally. In this study, we describe Sweden's national policy response with regard to the general public, the community and the health care system, with a focus on how the response changed from March 2020 to June 2021. A number of factors contributed to Sweden's choice of policy response, including its existing legal framework, independent expert agencies and its decentralized, multi-level health care governance system. Challenges to the health- and elder care system during the pandemic, such as the need to increase intensive care- and testing capacity, and to ensure the safety of the elderly were addressed largely at the regional and local levels, with national authorities assuming a primarily coordinative role. Although the overall response based on voluntary compliance has persisted, the national government started to take a more prominent role in public messaging, and in enacting legally binding restrictions during subsequent waves of the pandemic. This study illustrates that not only policy responses, but also the fundamental structure of the health- and elder care system and its governance should be considered when evaluating the impact of the COVID-19 pandemic.

We investigated the impacts of Medicaid expansion on New York county total health spending and specifics of health spending, including health services, public health facilities and public health administration. Little research considered the financial effect of Medicaid expansion on local governments while well reported are its influences on uninsured rates and health services utilization. New York counties have contributed to health in their boundaries by providing or funding public health services, and supporting a part of the non-federal share of Medicaid expenditures and uncompensated care. Medicaid expansion can reduce the size of county expenditures for health by enrolling more previously uninsured population in the program and offering more generous federal funding for the expanded Medicaid. We offer empirical evidence that Medicaid expansion was associated with reduced county health spending.