Professor Francesco Paolucci

© 2017, Springer International Publishing Switzerland. The aims of this paper are to evaluate the risk equalisation (RE) arrangement in Australia¿s private health insurance against practices in other countries with similar arrangements and to propose ways of improving the system to advance economic efficiency and solidarity. Possible regulatory responses to insurance market failures are reviewed based on standard economic arguments. We describe various regulatory strategies used elsewhere to identify essential system features against which the Australian system is compared. Our results reveal that RE is preferred over alternative regulatory strategies such as premium rate restrictions, premium compensation and claims equalisation. Compared with some countries¿ practices, the calculated risk factors in Australia should be enhanced with further demographic, social and economic factors and indicators of long-term health issues. Other coveted features include prospective calculation and annual clearing of equalisation payments. Australia currently operates with a crude mechanism for RE in which the scheme incentivises insurers to select on risk rather than focusing on efficiency and equity-promoting actions. System changes should be introduced in a stepwise manner; thus, we propose an incremental reform.

© 2017, Springer International Publishing AG. Health technology assessment (HTA) is widely viewed as an essential component in good universal health coverage (UHC) decision-making in any country. Various HTA tools and metrics have been developed and refined over the years, including systematic literature reviews (Cochrane), economic modelling, and cost-effectiveness ratios and acceptability curves. However, while the cost-effectiveness ratio is faithfully reported in most full economic evaluations, it is viewed by many as an insufficient basis for reimbursement decisions. Emotional debates about the reimbursement of cancer drugs, orphan drugs, and end-of-life treatments have revealed fundamental disagreements about what should and should not be considered in reimbursement decisions. Part of this disagreement seems related to the equity-efficiency tradeoff, which reflects fundamental differences in priorities. All in all, it is clear that countries aiming to improve UHC policies will have to go beyond the capacity building needed to utilize the available HTA toolbox. Multi-criteria decision analysis (MCDA) offers a more comprehensive tool for reimbursement decisions where different weights of different factors/attributes can give policymakers important insights to consider. Sooner or later, every country will have to develop their own way to carefully combine the results of those tools with their own priorities. In the end, all policymaking is based on a mix of facts and values.

© 2017 The Author(s). Background: There is a traditional tension in public policy between the maximization of welfare from given resources (efficiency) and considerations related to the distribution of welfare among the population and to social justice (equity). The aim of this paper is to measure the relative weights of the efficiency- and equity-enhancing criteria in the preferences of health policy-makers in Israel, and to compare the Israeli results with those of other countries. Methods: We used the criteria of efficiency and equity which were adopted in a previous international study, adapted to Israel. The equity criteria, as defined in the international study, are: severity of the disease, age (young vs. elderly), and the extent to which the poor are subsidized. Efficiency is represented by the criteria: the potential number of beneficiaries, the extent of the health benefits to the patient, and the results of economic assessments (cost per QALY gained). We contacted 147 policy-makers, 65 of whom completed the survey (a response rate of 44%). Using Discrete Choice Experiment (DCE) methodology by 1000Minds software, we estimated the relative weights of these seven criteria, and predicted the desirability of technologies characterized by profiles of the criteria. Results: The overall weight attached to the four efficiency criteria was 46% and that of the three equity criteria was 54%. The most important criteria were "financing of the technology is required so that the poor will be able to receive it" and the level of individual benefit. "The technology is intended to be used by the elderly" criterion appeared as the least important, taking the seventh place. Policy-makers who had experience as members of the Basket Committee appear to prefer efficiency criteria more than those who had never participated in the Basket Committee deliberations. While the efficiency consideration gained preference in most countries studied, Israel is unique in its balance between the weights attached to equity and efficiency considerations by health policy-makers. Discussion: The study explored the trade-off between efficiency and equity considerations in the preferences of health policy-makers in Israel. The way these declarative preferences have been expressed in actual policy decisions remains to be explored.

© 2016 Foundation for the Sociology of Health & Illness. Time can be thought of as a resource that people need for good health. Healthy behaviour, accessing health services, working, resting and caring all require time. Like other resources, time is socially shaped, but its relevance to health and health inequality is yet to be established. Drawing from sociology and political economy, we set out the theoretical basis for two measures of time relevant to contemporary, market-based societies. We measure amount of time spent on care and work (paid and unpaid) and the intensity of time, which refers to rushing, effort and speed. Using data from wave 9 (N = 9177) of the Household, Income and Labour Dynamics of Australia Survey we found that time poverty (> 80 h per week on care and work) and often or always rushing are barriers to physical activity and rushing is associated with poorer self-rated and mental health. Exploring their social patterning, we find that time-poor people have higher incomes and more time control. In contrast, rushing is linked to being a woman, lone parenthood, disability, lack of control and work-family conflicts. We supply a methodology to support quantitative investigations of time, and our findings underline time's dimensionality, social distribution and potential to influence health.

© 2016, Copyright © Taylor & Francis Group, LLC. Although Recovery-oriented approaches to delivering mental health services are now promoted in health services across the globe, there is an ongoing need to adapt these approaches to meet the unique needs of consumers with a diagnosis of borderline personality disorder. The lived experience of borderline personality disorder includes emotional dysregulation, intense and unstable relationships, self-harming behaviours, fear of abandonment, and a limited capacity to cope with stress. These experiences present a range of challenges for those who deliver Recovery-oriented services and advocate the principles of empowerment and self-determination. This paper describes a novel crisis intervention program, ¿Open Borders,¿ which has been established to meet the unique needs of people with a borderline personality disorder diagnosis. Open Borders is a Recovery-oriented model that is run at a public, state-wide residential facility for mental health consumers in Western Australia, and offers alternative pathways to achieving mental health Recovery, including self-referral and short-term admission to a residential facility. The aims of the program are to break the cycle of hospital admission, reduce rates of self-harm, and support the complex Recovery journey of consumers with a diagnosis of borderline personality disorder. Open Borders provides an exemplar for other health service organisations seeking to establish Recovery-oriented crisis intervention alternatives.

© 2016 The International Association for the Study of Insurance Economics. Efforts are currently under way in Cambodia to expand the population coverage of social health protection schemes (health equity funds and voluntary insurance). Aligning the benefit packages for members of such schemes poses particular challenges in relation to the insurance component, as the financing of direct benefits in the insurance relies largely on the collection of voluntary premiums. This paper develops the concept of a targeted "risk-adjusted subsidy" approach to address this issue. Data on the health-seeking behaviour of insured households from Kampong Thom district over the course of one year (2010) are used to illustrate the concept. To retain the currently applied community rating and set incentives for cost effectiveness in administrative costs, as well as to avoid cream skimming (focusing on "good risks"), a risk-adjustment mechanism is proposed that would provide ex ante subsidies to insurance schemes according to the expected additional cost of a person joining the scheme. Although the concept is developed using the example of Cambodia, it is equally applicable to all developing countries facing fragmented risk pools while aiming for universal health coverage.

© 2015, Springer-Verlag Berlin Heidelberg. Background: In addition to cost-effectiveness, national guidelines often include other factors in reimbursement decisions. However, weights attached to these are rarely quantified, thus decisions can depend strongly on decision-maker preferences. Objective: To explore the preferences of policymakers and healthcare professionals involved in the decision-making process for different efficiency and equity attributes of interventions and to analyse cross-country differences. Method: Discrete choice experiments (DCEs) were carried out in Austria, Hungary, and Norway with policymakers and other professionals working in the health industry (N¿=¿153 respondents). Interventions were described in terms of different efficiency and equity attributes (severity of disease, target age of the population and willingness to subsidise others, potential number of beneficiaries, individual health benefit, and cost-effectiveness). Parameter estimates from the DCE were used to calculate the probability of choosing a healthcare intervention with different characteristics, and to rank different equity and efficiency attributes according to their importance. Results: In all three countries, cost-effectiveness, individual health benefit and severity of the disease were significant and equally important determinants of decisions. All countries show preferences for interventions targeting young and middle aged populations compared to those targeting populations over 60. However, decision-makers in Austria and Hungary show preferences more oriented to efficiency than equity, while those in Norway show equal preferences for equity and efficiency attributes. Conclusion: We find that factors other than cost-effectiveness seem to play an equally important role in decision-making. We also find evidence of cross-country differences in the weight of efficiency and equity attributes.

© 2014 Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. Background Macroeconomic growth in China enables significant progress in health care and public health. It faces difficult choices regarding access, quality and affordability, while dealing with the increasing burden of chronic diseases. Policymakers are pressured to make complex decisions while implementing health strategies. This study shows how this process could be structured and reports the specific equity and efficiency preferences among Chinese policymakers. Methods In total, 78 regional, provincial and national level policymakers with considerable experience participated in a discrete choice experiment, weighting the relative importance of six policy attributes describing equity and efficiency. Results from a conditional logistic model are presented for the six criteria, measuring the associated weights. Observed and unobserved heterogeneities were incorporated and tested in the model. Findings are used to give an example of ranking health interventions in relation to the present disease burden in China. Results In general, respondents showed strong preference for efficiency criteria i.e. total beneficiaries and cost-effectiveness as the most important attributes in decision making over equity criteria. Hence, priority interventions would be those conditions that are most prevalent in the country and cost least per health gain. Conclusion Although efficiency criteria override equity ones, major health threats in China would be targeted. Multicriteria decision analysis makes explicit important trade-offs between efficiency and equity, leading to explicit, transparent and rational policy making.

© The Author(s) 2015. Moral hazard in public insurance for long-term care may be counteracted by strategies influencing supply or demand. Demand-side strategies may target the patient or the insurer. Various demand-side strategies and how they are implemented in four European countries (Germany, Belgium, Switzerland and the Netherlands) are described, highlighting the pros and cons of each strategy. Patient-oriented strategies to counteract moral hazard are used in all four countries but their impact on efficiency is unclear and crucially depends on their design. Strategies targeted at insurers are much less popular: Belgium and Switzerland have introduced elements of managed competition for some types of long-term care, as has the Netherlands in 2015. As only some elements of managed competition have been introduced, it is unclear whether it improves efficiency. Its effect will depend on the feasibility of setting appropriate financial incentives for insurers using risk equalization and the willingness of governments to provide insurers with instruments to manage long-term care.

© 2015 García-Goñi et al. Introduction: Access to ART and health services is guaranteed under universal coverage to improve life expectancy and quality of life for HIV patients. However, it remains unknown whether patients of different socioeconomic background equally use different types of health services. Methods: We use one-year (2010-2011) data on individual healthcare utilization and expenditures for the total population (N = 2262698) of the Basque Country. We observe the prevalence of HIV and use OLS regressions to estimate the impact on health utilization of demographic, socioeconomic characteristics, and health status in such patients. Results: HIV prevalence per 1000 individuals is greater the lower the socioeconomic status (0.784 for highest; 2.135 for lowest), for males (1.616) versus females (0.729), and for middle-age groups (26-45 and 46-65). Health expenditures are 11826¿ greater for HIV patients than for others, but with differences by socioeconomic group derived from a different mix of services utilization (total cost of 13058¿ for poorest, 14960¿ for richest). Controlling for health status and demographic variables, poor HIV patients consume more on pharmaceuticals; rich in specialists and hospital care. Therefore, there is inequity in health services utilization by socioeconomic groups. Conclusions: Equity in health provision for HIV patients represents a challenge even if access to treatment is guaranteed. Lack of information in poorer individuals might lead to under-provision while richer individuals might demand over-provision. We recommend establishing accurate clinical guidelines with the appropriate mix of health provision by validated need for all socioeconomic groups; promoting educational programs so that patients demand the appropriate mix of services, and stimulating integrated care for HIV patients with multiple chronic conditions.

Background: Worldwide, there is a need for formalization of the priority setting processes in health. Recent research has used the term multicriteria decision analysis for methods that systematically include preferences for both equity and efficiency. The present study compares decision-makers' preferences at the country level for a set of equity and efficiency criteria according to a multicriteria decision analysis framework. Methods: Discrete choice experiments were conducted for Brazil, Cuba, Nepal, Norway, and Uganda. By using standardized methods, we elicited preferences for intervention attributes using a individual choice questionnaire. A multinomial logistic regression was applied to estimate the coefficients for all single-policy criteria, per country. Attributes were assigned to an equity group or to an efficiency group. After testing for scale variance, predicted probabilities for interventions with both types of attributes were compared across countries. Results: The Norway and Nepal groups showed considerable preferences for efficiency criteria over equity criteria with percent change in respective predicted sum probabilities of [10%, -84%] and [6%, -79%]. Brazil and Uganda also showed preference for the efficiency criteria though less convincingly ([-34%, -93%], [-18%, -63%], respectively). The Cuban group showed the strongest preferences with equity attributes dominating efficiency ([-52%, 213%]). Conclusions: Group preferences of policymakers show explicit but varying trade-offs of efficiency and equity in these diverse settings. This multicriteria decision analysis approach, using discrete choice experiments, indicates that systematic setting of health priorities is possible across a variety of countries. It may be a valuable tool to guide health reform initiatives. © 2012, International Society for Pharmacoeconomics and Outcomes Research (ISPOR).

Background: Priority setting in population health is increasingly based on explicitly formulated values. The Patients Rights Act of the Norwegian tax-based health service guaranties all citizens health care in case of a severe illness, a proven health benefit, and proportionality between need and treatment. This study compares the values of the country's health policy makers with these three official principles. Methods. In total 34 policy makers participated in a discrete choice experiment, weighting the relative value of six policy criteria. We used multi-variate logistic regression with selection as dependent valuable to derive odds ratios for each criterion. Next, we constructed a composite league table - based on the sum score for the probability of selection - to rank potential interventions in five major disease areas. Results: The group considered cost effectiveness, large individual benefits and severity of disease as the most important criteria in decision making. Priority interventions are those related to cardiovascular diseases and respiratory diseases. Less attractive interventions rank those related to mental health. Conclusions: Norwegian policy makers' values are in agreement with principles formulated in national health laws. Multi-criteria decision approaches may provide a tool to support explicit allocation decisions. © 2012 Defechereux et al; licensee BioMed Central Ltd.

Objective. To explore the potential effects of the global financial crisis (GFC) on the market for general practitioner (GP) services in Australia. Design. We estimate the impact of changes in unemployment rates on demand for GP services and the impact of lost asset values on GP retirement plans and work patterns. Combining these supply and demand effects, we estimate the potential effect of the GFC on the market for GP services under various scenarios. Results. If deferral of retirement increases GP availability by 2%, and historic trends to reduce GP working hours are halved, at the current level of ~5.2% unemployment average fees would decline by $0.23 per GP consultation and volumes of GP services would rise by 2.53% with almost no change in average GP gross earnings over what would otherwise have occurred. With 8.5% unemployment, as initially predicted by Treasury, GP fees would increase by $0.91 and GP income by nearly 3%. Conclusions. The GFC is likely to increase activity in the GP market and potentially to reduce fee levels relative to the pre-GFC trends. Net effects on average GP incomes are likely to be small at current unemployment levels. What is known about the topic? Although the broad directions of the impact of the global financial crisis on the demand for and supply of GP services have been the subject of public discussion, the overall impact on the GP market has not been formally assessed. What does this paper add? Drawing on existing supply and demand models, we estimate the likely effect of the global financial crisis on GP activity levels, GP earnings, and the fees to be faced by patients. What are the implications for practitioners? Practitioners on average are likely to work harder to recover losses in the investments they have made for their retirements. They may face lower fees than would have been the case due to the increasing supply of GPs as some defer retirement, but average incomes are likely to be minimally affected. © 2011 AHHA.

© 2011 Ergas and Paolucci, publisher and licensee Dove Medical Press Ltd. This article focuses on the provision and financing of aged care in Australia. Demand for aged care will increase substantially as a result of population aging, with the number of Australians aged 85 and over projected to increase from 400,000 in 2010 to over 1.8 million in 2051. Meeting this demand will greatly strain the current system, and makes it important to exploit opportunities for increased efficiency. A move to greater beneficiary co-payments is also likely, though its extent may depend on whether aged care insurance and other forms of pre-payment can develop.

This paper capitalizes on a first set of experiences on the application of multi-criteria decision analysis (MCDA) in seven low- and middle-income settings. It thereby reacts to a recent paper by Peacock et al., highlighting the potential of MCDA to guide policy makers in highly specific decision-making contexts. We argue that MCDA also has a broader application in setting priorities in health, i.e. to indicate general perceptions on priorities without defining the allocation of resources in a precise fashion. This use of MCDA can have far-reaching and constructive influences on policy formulation. © 2010 Elsevier Ireland Ltd.

In April 2007, Australia introduced a risk equalisation (RE) scheme (de facto a claims equalisation scheme), which replaced an extant reinsurance scheme that had operated since 1976. This scheme is one of a number of policy measures that the Australian Government has instituted to support the voluntary private health insurance (PHI) market which is subject to mandatory community rating and the attendant problem of selection. The latter has been a persistent concern in the Australian PHI market since the introduction of Australia's universal, compulsory national health insurance scheme Medicare. This paper presents a brief overview of Australia's health care financing arrangements and, in particular, focuses on the history, structure and functioning of the RE scheme. It provides an exposition of the operation of the scheme and empirical evidence of the scheme's effects in its first full year of operation, 2007-08. The paper makes three contributions: first, it provides the only detailed overview of the functioning of the Australian RE scheme published to date; second, it presents the first empirical measures of the scheme's operation at the level of the 38 individual PHI funds; and third, it describes the systematic differences in the scheme's operation with respect to large and small funds. Thus, this paper provides a number of insights into the operation and outcomes of the Australian RE scheme following its first year of operation. © 2010.

The paper summarises the conclusions for health policy from the experience of three countries who have introduced risk equalisation subsidies, in their voluntary health insurance (VHI) markets. The countries chosen are Australia, Ireland and South Africa. All of these countries have developed VHI markets and have progressed towards introducing risk equalisation. The objective of such subsidies is primarily to make VHI affordable while encouraging efficiency in health care production.The paper presents a conceptual framework to understand and compare risk equalisation subsidies in VHI markets. The paper outlines how such subsidies are organised in each of the countries and identifies problems that arise in their implementation.We conclude that the objectives of risk equalisation, in VHI markets are no different to those in countries with mandatory insurance systems. We find that the introduction of risk equalisation subsidies is complex and that countries seeking to introduce risk equalisation in VHI markets must carefully consider how such subsidies advance their overall health policy goals. Furthermore, we conclude that such subsidies must be structured correctly as otherwise incentives exist for risk selection which may threaten affordability and efficiency.Our overall conclusion is that also in voluntary health insurance markets risk equalisation has a role in meeting the related public policy objectives of risk solidarity and affordability, and without it these objectives are severely undermined. © 2010 Elsevier Ireland Ltd.

Risk equalisation has been implemented in a number of countries as a means of providing explicit risk-adjusted transfers between health insurance undertakings to improve efficiency within the health insurance market, and make health insurance affordable. Two such countries are Australia and Ireland. In this article, a simulation exercise is carried out to compare the effectiveness of the two countries risk equalisation schemes in meeting the policy objectives of encouraging insurers to be efficient and discouraging them from engaging in risk selection. The results of the analysis show that the Australian scheme is less effective than the Irish scheme in reducing the incentive for risk selection and in encouraging insurers to be efficient. The results provide evidence that direct standardisation mechanisms (as used in Ireland) can lead to superior outcomes as compared to indirect standardisation mechanisms (as used in Australia) in terms of promoting efficiency and deterring risk selection. © 2010 The International Association for the Study of Insurance Economics.

¿ The current escalation in costs of Australia's health care system does not appear to be sustainable. ¿ Sustainable financing requires direct engagement of consumers - instead of the current political process driven by special interest groups, targeted at gaining a larger share of the federal and state governments' budgets. ¿ Reforms in the Netherlands, directed at achieving universal insurance with consumer choice of health fund, provide valuable lessons for Australia on how to design sustainable financing.

In this paper, we simulate several scenarios of the potential premium range for voluntary (supplementary) health insurance, covering benefits which might be excluded from mandatory health insurance (MI). Our findings show that, by adding risk-factors, the minimum premium decreases and the maximum increases. The magnitude of the premium range is especially substantial for benefits such as medical devices and drugs. When removing benefits from MI policymakers should be aware of the implications for the potential reduction of affordability of voluntary health insurance coverage in a competitive market. © Springer Science+Business Media, LLC 2009.

As the share of supplementary health insurance (SI) in health care finance is likely to grow, SI may become an increasingly attractive tool for risk-selection in basic health insurance (BI). In this paper, we develop a conceptual framework to assess the probability that insurers will use SI for favourable risk-selection in BI. We apply our framework to five countries in which risk-selection via SI is feasible: Belgium, Germany, Israel, the Netherlands, and Switzerland. For each country, we review the available evidence of SI being used as selection device. We find that the probability that SI is and will be used for risk-selection substantially varies across countries. Finally, we discuss several strategies for policy makers to reduce the chance that SI will be used for risk-selection in BI markets. © 2006 Cambridge University Press.

In this article we perform an economic analysis of different regulatory frameworks that aim at guaranteeing solidarity in competitive health insurance markets. Thereafter, we analyse the legal conformity of these intervention strategies with EC law. We find that risk compensation schemes are the first-best intervention strategy because they guarantee an 'acceptable level of solidarity' without hindering free trade and competition and without reducing efficiency. Second-best options are premium and excess-loss compensation schemes, which guarantee solidarity at the expense of some efficiency. Premium rate restrictions and open enrolment should be avoided because they reduce efficiency and are unnecessary, not proportional, and undesirable to the pursuit of the general good. These conclusions are relevant for EU countries that adopt premium rate restrictions and open enrolment in combination with a risk compensation scheme, such as Ireland and the Netherlands. In these countries policy makers should design the health insurance schemes in conformity with EC law, for example by replacing premium rate restrictions and open enrolment with premium and/or excess-loss compensation schemes.

Income-related horizontal inequity in hospital admissions is estimated in twelve European countries. Pooled data of the EHCS for five years (1994-1998) are used to estimate and compare inequity indices. In most EU member states, after standardizing for need differences, the better off are more likely to be admitted to hospitals than the poor, and significantly so in Portugal, Greece, Austria, Italy, Ireland, Germany and France. Regional disparities in hospital supply also plays a role in the measured degree of inequity, in particular, in Italy and Spain. For the former we studied more deeply this phenomenon by using the Multiscopo ISTAT survey. The analysis confirms that people living in the North of Italy have a higher probability of being hospitalized than their counterparts and enjoy better quality of care. To make it worse, in the South people tend more intensively to move to other regions to receive hospital care.