University of Macau / Institute of Chinese Medical Sciences

The first chapter of this dissertation tests for addiction to food. This is the first empirical study using nationally representative data to do so. Data show that many common foods are addictive, suggesting that prices play a larger role in food consumption than previously thought. The finding of significant addiction also suggests that targeted food taxes may provide effective instruments for reducing the prevalence of overweight and obesity. The second chapter of this dissertation investigates the determinants of childhood obesity. This research improves upon previous economic research on the topic by incorporating controls for biological relationships of mothers and fathers and examining the entire child weight distribution using quantile regression. I find evidence of genetic weight transmission though the behavioral influence of mothers appears to be dominant. Furthermore, I find that the commonly cited influences on childhood weight do little to explain the most extreme weights. The third chapter of this dissertation studies the contract choice effect. Though frequently discussed, the impact of changes in insurance contract on utilization in response to a change in the expected cost of care has not been explicitly studied in an empirical setting. The analysis identifies a significantly negative contract choice effect, implying that individuals choose better insurance plans in response to increases in the expected cost of care. / text

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Ongoing research in the fields of genetics and biotechnology hold the promise of improved diagnosis and treatment of genetic diseases, and potentially the development of individually tailored pharmaceuticals and gene therapies. Difficulty, however, arises in determining how these services are to be evaluated and integrated equitably into public health care systems such as Canada's. The current context is one of increasing fiscal restraint on the part of governments, limited financial resources being dedicated to health care, and rising costs for new health care services and technologies. This has led to increasing public debate in the last few years about how to reform public health care, and whether we should prohibit, permit or perhaps even encourage private purchase of health care services. In Canada, some of these concerns have crystallized around the issue of gene patents and commercial genetic testing, in particular as illustrated by the case of Myriad Genetics' patented BRACAnalysis test for hereditary breast and ovarian cancer. While most Canadians who currently access genetic services do so through the public health care system, for those with the means, private purchase is becoming an option. This situation raises serious concerns - about justice in access to health care; about continued access to safe and reliable genetic testing supported by unbiased patient information; and about the broader effects of commercialization for ongoing research and the Canadian public health care system. Commercial genetic testing presents a challenge to health care professionals, policy analysts, and academics concerned with the social, ethical and policy implications of new genetic technologies. Using the Myriad case as an exemplar, tools from moral philosophy, the social sciences, and health policy and law will be brought to bear on the larger issues of how as a society we should regulate commercial research and product development, and more coherently decide which services to cover under public health insurance and which to leave to private purchase. Generally, the thesis is concerned with the question of "how best to bring capital, morality, and knowledge into a productive and ethical relationship" (Rabinow 1999, 20).

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Le calcul des coûts des séjours et des pathologies peut être abordé selon différentes perspectives :les coûts à charge des systèmes sociaux, des patients ou des hôpitaux. La thèse est centrée sur cette dernière approche.<p>Les DRGs représentent la tentative la plus récente de maîtriser la croissance des dépenses des hôpitaux en introduisant une médicalisation partielle des mécanismes de financement.<p>La connaissance des coûts des pathologies peut permettre aux hôpitaux de participer à l’élaboration des tarifs par pathologie en faisant partie d’un échantillon de référence des coûts hospitaliers. En cas de financement basé sur les pathologies, les hôpitaux doivent pouvoir comparer le coût des séjours au chiffre d’affaires octroyé et s’y adapter. Cet intérêt s’accroît en cas de financement forfaitaire, évolution qui semble se profiler en Belgique tout comme dans d’autres pays. En décrivant une méthodologie de calcul des coûts par pathologie et en indiquant la manière dont ceux-ci pourraient contribuer à la création d’une échelle de cost-weights, notre thèse incite les hôpitaux à adopter une politique proactive dans le domaine du financement des hôpitaux. <p>Les comparaisons de coûts hospitaliers pour évaluer la gestion sont pratiquées depuis de nombreuses années. Cependant, ce « benchmarking » est imparfait car il ne prend pas en compte la lourdeur des patients pris en charge. La standardisation des coûts sur base du case-mix de l’hôpital suppose un préalable important :l’existence d’une échelle de cost-weights issue d’un échantillon représentatif d’hôpitaux. Si cette situation n’est pas encore totalement rencontrée en Belgique, il est néanmoins possible de suggérer une voie de réflexion. La simulation inspirée de la méthodologie suisse à partir d’un échantillon de quatre hôpitaux belges présentée dans le cadre de cette thèse, est une première avancée en ce sens. <p>Un des problèmes majeurs de la gestion hospitalière est d’intéresser les prescripteurs et les prestataires à un contrôle de gestion essentiellement financier. Depuis quelques années, de nombreux efforts visent à intégrer de nouveaux indicateurs de performance dans les tableaux de bord. L’analyse des coûts des pathologies et de la variabilité des cas permet d’entamer un dialogue entre gestionnaire et corps médical. En abordant différentes études (apport des nomenclatures dans le calcul des coûts par pathologie, mesure des coûts associés aux bactériémies nosocomiales, analyse des facteurs médico-sociaux expliquant les surcoûts des patients outliers, analyse de la relation entre le coût et la sévérité des cas, comparaison des coûts de production et des pratiques médicales), nous avons voulu montrer l’importance d’associer une approche médicalisée à des raisonnements économiques. Si elle se développe, cette approche est susceptible de représenter un moyen de communication idéal entre le personnel médical et soignant et le monde de la gestion. <p>Comme nous le rappelions au début de cette thèse, les concepteurs des DRGs (Fetter et Thompson) ont regretté le manque d'intérêt manifesté par les gestionnaires d'hôpitaux pour l'utilisation de leur concept dans le management hospitalier. Au terme de cette thèse, nous pensons que, si l'analyse des coûts par pathologie reste encore d'un abord difficile, elle peut rendre d'importants services en associant médecins et managers à l'élaboration d'un contrôle de gestion enfin adapté à la spécificité de leurs institutions.<p> / Doctorat en Sciences de la santé publique / info:eu-repo/semantics/nonPublished

Ongoing research in the fields of genetics and biotechnology hold the promise of improved diagnosis and treatment of genetic diseases, and potentially the development of individually tailored pharmaceuticals and gene therapies. Difficulty, however, arises in determining how these services are to be evaluated and integrated equitably into public health care systems such as Canada's. The current context is one of increasing fiscal restraint on the part of governments, limited financial resources being dedicated to health care, and rising costs for new health care services and technologies. This has led to increasing public debate in the last few years about how to reform public health care, and whether we should prohibit, permit or perhaps even encourage private purchase of health care services. In Canada, some of these concerns have crystallized around the issue of gene patents and commercial genetic testing, in particular as illustrated by the case of Myriad Genetics' patented BRACAnalysis test for hereditary breast and ovarian cancer. While most Canadians who currently access genetic services do so through the public health care system, for those with the means, private purchase is becoming an option. This situation raises serious concerns - about justice in access to health care; about continued access to safe and reliable genetic testing supported by unbiased patient information; and about the broader effects of commercialization for ongoing research and the Canadian public health care system. Commercial genetic testing presents a challenge to health care professionals, policy analysts, and academics concerned with the social, ethical and policy implications of new genetic technologies. Using the Myriad case as an exemplar, tools from moral philosophy, the social sciences, and health policy and law will be brought to bear on the larger issues of how as a society we should regulate commercial research and product development, and more coherently decide which services to cover under public health insurance and which to leave to private purchase. Generally, the thesis is concerned with the question of "how best to bring capital, morality, and knowledge into a productive and ethical relationship" (Rabinow 1999, 20). / Graduate and Postdoctoral Studies / Graduate

Background Primary care practices in the United States (US) are currently constrained in their ability to deliver high quality care due to population aging, insurance expansion, and an increasing prevalence of chronically ill patients. The nurse practitioner (NP) workforce plays a critical role in meeting the growing demands for primary care, particularly in rural and underserved areas. NPs are also more likely to deliver care to clinically and socially complex populations such as high-need high-cost (HNHC) patients. HNHC patients are adults who suffer from multiple chronic conditions and experience additional functional, behavioral, or socioeconomic needs. Despite comprising only 5% of the US population, HNHC patients account for nearly half of total health care expenditures and over 90% of Medicare expenditures. HNHC patients with behavioral health diagnoses such as depression or substance abuse face heightened challenges managing their conditions and consequentially have higher preventable spending and emergency department (ED) utilization compared to the overall HNHC population. Significant policy attention has been placed on enhancing primary care practices as a strategy to improve outcomes and reduce costs in HNHC patients. Structural capabilities are features of primary care practices (e.g., after-hours care or care coordination) which are needed to deliver high quality primary care and chronic disease management. Yet, to date little research has been done on structural capabilities in primary care practices where NPs deliver care to HNHC patients. The overall purpose of this dissertation is to understand how to enhance primary care delivery and structural capabilities to improve outcomes for HNHC patients. We have achieved the following specific aims: (1) Establish a clear definition of HNHC patients, (2) Identify existing primary care and payment models used among HNHC patients and evaluate their impact on ED utilization and costs, (3) Evaluate structural capabilities in NP primary care practices located in Health Professional Shortage Areas (HPSAs), and (4) Analyze the association between NP practice structural capabilities and ED utilization among HNHC patients with behavioral health conditions. Dissertation Chapters and Key Findings Chapter One includes an introduction to the landscape of current primary care delivery, the role of the NP workforce in expanding access, and the unique challenges of delivering care to HNHC patients. This chapter also discusses the conceptual framework guiding the dissertation, the specific aims of each study, and how each study will fill a gap in the literature. Chapter Two (Aim 1) consists of a concept analysis of HNHC patients using the Walker and Avant framework. Three subgroups of HNHC patients were identified: adults over the age of 65 who suffer from multiple chronic conditions with functional or behavioral health needs, the frail elderly, and patients under 65 years old with a serious mental health condition or disability. Antecedents that predispose an individual to becoming a HNHC patient include challenges accessing timely care, low socioeconomic status, or unmet needs. Persistent high spending occurs as a result of poorly managed chronic diseases leading to acute exacerbations, preventable health service utilization, and fragmented care between the acute and primary care settings. Chapter Three (Aim 2) is a systematic review of studies conducted from 2000-2020 on primary care and payment models used with HNHC patients. About half of the primary care models evaluated in the systematic review (11 out of 21 studies) showed no significant difference in ED utilization among HNHC patients. Care coordination and care management (15 out of 21 studies) demonstrated both positive and negative associations with ED utilization and costs. Primary care models that demonstrated significant reductions in ED utilization had shared features, including frequent follow-up, multidisciplinary team-based care, enhanced access, and care coordination. Chapter Four (Aim 3) includes a cross-sectional study of NP survey data from 2018-2019 on practice structural capabilities linked with data on primary care shortages (i.e., HPSA designation). Bivariate analyses and multivariable regression models were used to compare NP characteristics and structural capabilities in HSPA practices compared to non-HPSA practices. The majority of NPs in our sample (61%) delivered care in HPSA practices. NP practices located in HPSAs were significantly more likely to deliver care coordination compared to non-HPSA practices. We found no significant difference in prevalence of registries, after-hours care, or shared communication systems. Chapter Five (Aim 4) is a study of cross-sectional NP survey data from 2018-2019 on practice structural capabilities linked with Medicare Part A and Part B claims to identify HNHC patients and ED utilization. Multivariable Poisson models were used to estimate the association between ED utilization and structural capabilities in practices serving HNHC patients with behavioral health conditions including depression, alcohol use, and substance use disorder. Care coordination was associated with decreased rates of ED utilization among the overall HNHC population and those with alcohol use, but not among HNHC patients with depression or substance use disorders. Shared communication systems were associated with decreased rates of all-cause and preventable ED utilization among HNHC patients with alcohol use and substance use disorders. Chapter 6 is a summary of findings across studies in this dissertation and will present the strengths, limitations, and contributions to science. This chapter will also discuss implications for policy, practice, and directions for future research. Conclusion HNHC patients face complex and wide-ranging medical, social, and behavioral health needs resulting in poor clinical outcomes and high costs. Enhancing primary care is an urgent goal for policymakers to improve disease management while reducing overall costs of care. Findings from these studies demonstrate that NPs practice in underserved areas and are significantly more likely to deliver care coordination in HPSA practices and to HNHC patients with behavioral health conditions. Care coordination has the potential to increase effectiveness of primary care delivery by tailoring models to target specific HNHC patients. Shared communication systems also show promise for improving primary care delivery and reducing ED utilization among HNHC patients with alcohol use and substance use disorders. Future research should continue to explore how structural capabilities may enable NPs to deliver timely, high quality, cost-effective primary care for HNHC patients.

Despite the adoption of the Doha Declaration on the TRIPS Agreement and Public Health in 2001, which unequivocally affirmed WTO members’ rights to use compulsory licences and other TRIPS flexibilities to access medicines, thirteen years on, developing countries and least developed countries are still grappling with access to medicines issues and a high disease burden. Despite some well researched and eloquent arguments to the contrary, it is a trite fact that patents remain an impediment to access to medicines by encouraging monopoly prices. The WTO TRIPS Agreement gives members room to legislate in a manner that is sympathetic to access to affordable medicines by providing for exceptions to patentability and the use of patents without the authorisation of the patent holder (TRIPS flexibilities). This study focuses on access to medicines under the TRIPS Agreement from a SADC comparative perspective by interrogating the extent of the domestication of TRIPS provisions promoting access to medicines in the SADC region with specific reference to Botswana, South Africa and Zimbabwe. After establishing that all SADC members, including Seychelles which is yet to be a WTO member have intellectual property (IP) laws in their statute books, this study confirms that while most of the IP provisions may be used to override patents, they are currently not being used by SADC members due to non-IP reasons such as lack of knowledge and political will. The study also engages in comparative discussions of topical occurrences in the context of access to medicines litigation in India, Thailand and Kenya and extracts useful thematic lessons for the SADC region. The study’s overall approach is to extract useful lessons for regional access to medicines from the good experiences of SADC members and other developing country jurisdictions in the context of a south-south bias. The study draws conclusions and recommendations which if implemented will in all likelihood lead to improved access to medicines for SADC citizens, while at the same time respecting the sanctity of patent rights. The study recommends the adoption of a rights-based approach, which will ultimately elevate patient rights over patent rights and urges the region to consider using its LDCs status to issue compulsory licences in the context of TRIPS Article 31 bis while exploring the possibility of local pharmaceutical manufacturing to produce generics, inspired by the experiences of Zimbabwe and current goings on in Mozambique and the use of pooled procurement for the region. The study embraces the rewards theory of patents which should be used to spur innovation and research into diseases of the poor in the SADC region. Civil society activity in the region is also identified as a potential vehicle to drive the move towards access to affordable medicines for all in the SADC region. / Mercantile Law / LL.D.

With the advent of the new National Health Act, health care in South Africa is at a critical point as this will be the first time in history that a National Health Insurance is being implemented in this country. Globally National Health Insurance has been around for more than a hundred years, however some countries with long established national health schemes are currently grappling with funding issues surrounding their health systems. South Africa should take note of these issues as it embarks on this journey. The objective of this study was to perform a literature review on how South Africa’s National Health Insurance can be funded taking cognisance of the history of the country and experiences of other countries. It is imperative for each country to achieve optimal health care funding to ensure the success and long-term sustainability of National Health Insurance. The analysis of the problems experienced by other countries revealed that balancing the three main funding options namely, allocated from the national revenue fund, user charges and or donations or grants from international organisations, is critical as the funds needed in a system to achieve coverage at an affordable cost is dependent on the current state of health care in a country. Considering South Africa’s history and current inequality in society and health care it is clear that the majority of funding for the National Health Insurance should be supplied by the national revenue fund. The required funds can either be raised by increasing existing taxes or introducing a new tax specifically aimed at financing the National Health Insurance. The use of user charges is important however, although not purely for a revenue collection point, but from a cost control point of view as well. Some studies have revealed that the lack of user charges results in a misuse of the system. / Financial Accounting / M. Phil. (Accounting Science)