A dissertation presented to the Faculty of Health, Durban University of Technology, for the Masters Degree in Technology: Chiropractic, 2009. / Background: The International Classification of Diseases (ICD) provides codes to classify diseases in such a manner, that every health condition is assigned to a unique category. Some of the most common diagnoses made by chiropractors are not included in the ICD-10 coding system, as it is mainly medically orientated and does not accommodate these diagnoses. This can potentially lead to reimbursement problems for chiropractors in future and create confusion for medical aid schemes as to what conditions chiropractors actually diagnose and treat. Aim: To determine the level of compliancy of chiropractors, in South Africa, to the ICD-10 coding procedure and the factors that may influence the use of correct ICD-10 codes. As well as to determine whether the ICD-10 diagnoses chiropractors commonly submit to the medical aid schemes, reflect the actual diagnoses made in practice. Method: The study was a retrospective survey of a quantitative nature. A self-administered questionnaire was e-mailed and posted to 380 chiropractors, practicing in South Africa. The electronic questionnaires were sent out four times at two week intervals for the duration of eight weeks; and the postal questionnaires sent once. A response rate of 16.5% (n = 63) was achieved. Raw data was received from the divisional manager of the coding unit of Discovery Health (Pty) Ltd. in the form of an excel spreadsheet containing the most common ICD-10 diagnoses made by chiropractors in South Africa, for the period June 2006 to July 2007, who had submitted claims to the Medical Scheme. The spreadsheet also contained depersonalised compliance statistics of chiropractors to the ICD-10 system from July 2006 to October 2008. SPSS version 15 was used for descriptive statistical data analysis (SPSS Inc., Chicago, Ill, USA). Results: The age range of the 63 participants who responded to the questionnaire was 26 to 79 years, with an average of 41 years. The majority of the participants were male (74.6%, n = 47). KwaZulu-Natal had 25 participants (39.6%), Gauteng 17 (26.9%), Western Cape 12 (19%), Eastern Cape four (6.3%), Free State and Mpumalanga two (3.1%) each and North West one (1.5%). The mean knowledge score for ICD-10 coding was 43.5%, suggesting a relatively low level of knowledge. The total percentage of mistakes for electronic claims was higher for both the primary and unlisted claims (3.93% and 2.18%), than for manual claims iv (1.57% and 1.59%). The total percentage of mistakes was low but increased marginally each year for both primary claims (1.43% in 2006; 1.99% in 2007; 2.33% in 2008) and unlisted claims (0% in 2006; 2.61% in 2007; 3.07% in 2008). CASA members were more likely to be aware of assistance offered, in terms of ICD-10 coding through the medical schemes and the association (p = 0.131), than non-members. There was a non-significant trend towards participants who had been on an ICD-10 coding course (47.6%; n = 30), having a greater knowledge of the ICD-10 coding procedures (p = 0.147). Their knowledge was almost 10% higher than those who had not been on a course (52.4%; n = 33). Most participants (38.1%; n = 24) did not use additional cause codes when treating cases of musculoskeletal trauma, nor did they use multiple codes (38.7%; n = 24) when treating more than one condition in the same patient. Nearly 70% of participants (n = 44) used the M99 code in order to code for vertebral subluxation and the majority (79.4%; n = 50) believed the definition of subluxation used in ICD-10 coding to be the same as that which chiropractors use to define subluxation. According to the medical aid data, the top five diagnoses made by chiropractors from 2006 to 2007 were: Low back pain, lumbar region, M54.56 (8996 claims); Cervicalgia, M54.22 (6390 claims); Subluxation complex, cervical region, M99.11 (2895 claims); Other dorsalgia, multiple sites in spine, M54.80 (1524 claims) and Subluxation complex, sacral region, M99.14 (1293 claims). According to the questionnaire data, the top five diagnoses (Table 4.24) were: Lumbar facet syndrome, M54.56 (25%); Lumbar facet syndrome, M99.13 (23.3%); Cervical facet syndrome, M99.11 (21.7%); Cervicogenic headache, G44.2 (20%) and Cervicalgia, M54.22 (20%). Conclusion: The sample of South African chiropractors were fairly compliant to the ICD-10 coding system. Although the two sets of data (i.e. from the medical aid scheme and the questionnaire) regarding the diagnoses that chiropractors make on a daily basis correlate well with each other, there is no consensus in the profession as to which codes to use for chiropractic specific diagnoses. These chiropractic specific diagnoses (e.g. facet syndrome) are however, the most common diagnoses made by chiropractors in private practice. Many respondents indicated that because of this they sometimes use codes that they know will not be rejected, even if it is the incorrect code. For more complicated codes, the majority of respondents indicated that they did not know how to or were not interested in submitting the correct codes to comply with the level of specificity required by the medical aid schemes. The challenge is to make practitioners aware of the advantages of correct coding for the profession.

Medicare eligibles have the option of choosing from a menu of privately administered managed care plans, known as Medicare Advantage (MA) plans, in lieu of conventional fee-for-service Medicare coverage ("original Medicare"). These plans often provide extra benefits to enrollees, but may impose large switching costs as a result of restrictive provider networks, differences in coverage across plans, and learning and search costs. I propose a structural dynamic discrete choice model of how consumers who are persistently heterogeneous make the choice among MA plans and original Medicare based on the characteristics of the available MA plans. The model explicitly incorporates a switching cost and changes over time in choice sets and plan characteristics. I estimate the parameters of the model, including the switching cost, using the methods developed by Gowrisankaran and Rysman (2011). The estimates indicate that the switching cost is statistically and economically significant. Through a series of counterfactual analyses, I find that the share of consumers choosing MA plans in place of original Medicare would more than triple in the absence of switching costs, and nearly double if plan exit and quality changes were eliminated. I also find that when switching costs are accounted for the Medicare Advantage program only minimally increases consumer welfare.

The Academy of Nutrition and Dietetics and the Cooperative Extension System are organizations that serve the public and agricultural communities, respectively. Within these broad organizations are two groups of food systems professionals, registered dietitian nutritionists (RDNs) and Extension agents, who are utilizing communication as a critical point of access for health-related issues. Both groups of professionals negotiate organizational structure in order to construct their own health knowledge and, subsequently, communicate accurate information to their constituents. Understanding the ways that these professionals navigate their roles as health communicators are important for contributing to public discourse about how health knowledge is created and disseminated. Specifically, for the first article, I conducted semi-structured interviews with RDNs to analyze the ways in which they navigate both commercial and health messaging from industry groups at their largest organizational meeting. Industry affiliations have historically been a controversial aspect of Academy operations, yet little research has explored RDNs unique experiences with industry. Findings revealed RDNs have varied interpretations of industry messages and are utilizing strategies to negotiate interactions with industry. The spectrum of RDN interpretation suggests that formal dietetic training should address media literacy strategies in order to help RDNs navigate a complex message landscape. For the second article, through national focus groups with Extension professionals, I sought to understand how Extension is responding to healthcare reform changes and how this has translated into programming for their constituents. Extension participants reported a lack of available resources to improve their own health insurance knowledge, which has impacted their abilities to serve their constituents effectively. Findings emphasized a need for both collaborations both within Extension and across other agencies in order to improve health insurance access for agricultural communities. By researching these two organizations, I hope to contribute to new understandings about how professionals navigate and communicate knowledge related to public health. Both articles have practical implications for each group, and they also offer examples of opportunities to utilize leverage points for structural change within the food system.

The South African health care industry is characterised by strict regulation in the form of the Medical Schemes Act of 2000, high medical inflation, a deteriorating public health care system; and costly private health care schemes which are only available to the higher end of the market. Before 1992, medical inflation rose in double digits (over 20%) and medical aids traditionally responded by raising premiums considerably (Pile, 2004:19). Private health care was expensive, while the public health care system deteriorated. The financial sustainability of schemes depended on the number of young, healthy members remaining on the scheme as these members cross-subsidised the sick. For these members though, medical aids did not offer any incentive and/or reward to remain members of the scheme. The ‘use-it-or-lose-it’ principle of traditional schemes did not provide any value to members and led to young, healthy members leaving medical schemes. This tendency could potentially drive a health care industry to a meltdown (Pile, 2004:19). The South African health care environment is complex and dynamic, and within this environment, Discovery Health established itself as a successful and innovative company. The Discovery Health medical scheme is currently the largest open medical scheme in South Africa with 1.6 million members (Discovery A, 2004: on-line). Discovery is a specialist insurance company with four strong and distinct businesses (with a fifth business starting in partnership with UK insurance company Prudential in 2005). The businesses are Discovery Health, Discovery Life, Discovery Vitality and Destiny Health (US). Discovery Health is the first business of the group and was launched in 1992. Discovery listed on the JSE in 1999. The company’s strategy is to grow the business organically by building a strong foundation of innovation and engaging people in the management of their health in order to achieve better social and financial outcomes (Discovery A, 2004: on-line). While a medical aid would be an essential ‘commodity’ which consumers would not normally aspire to buy, Discovery positioned itself as a value-adding company that provides products and services that consumers want to buy. The Vitality HealthStyle programme for e.g., is similar to a loyalty programme, but with the aim of motivating members to improve their health. Members can earn points and move up different status levels by performing certain preventative activities for e.g. working out at the gym and having cholesterol and glaucoma screening tests done. Depending on their status, members can qualify for discounts on certain health and lifestyle benefits (Discovery A, 2004: on-line). The advantage of this is that while Vitality adds value to the Discovery product, it also improves the general health of members and in turn, decreases claiming from the medical scheme and assists in the overall management of the financial risk to the scheme. The company’s life assurance business was launched in 2000 and profits from this section of the business constituted 40% of operating profits in August 2004. The company succeeded in integrating the Discovery Health, Vitality, and Life product offerings through the Payback Benefit (Discovery A, 2004: on-line). This benefit allows Discovery Health members who are also Discovery Life policy holders to receive back a substantial percentage of their life assurance premiums, based on how they manage their health. / H.B. Klopper

Thesis (Ph.D.)--University of the Witwatersrand, Faculty of Commerce, Law and Management, School of Law, 2014. / The proposed National Health Insurance (‘NHI’) is the most extensive health policy initiative proposed by the South African government since 1994, to bridge the divide between the private and public health sectors. It is intended that the NHI will fund health care services for the entire population. Yet, despite its laudable goals, the implementation of NHI might be stalled by litigation concerning its constitutionality. In this thesis, I construct a constitutional paradigm within which such challenges can be understood. Departing from the premise that the Constitution places a positive obligation on the state to implement redistributive policies in the health sector in order to progressively realise the right to have access to health care services, the thesis identifies the tensions underlying the proposed implementation of NHI and aligns these to liberty-based and equality-based understandings of the right to health, respectively. This analysis takes place after having considered the history of health care reform in South Africa and debates on the desirability of NHI. The thesis then investigates and sets out the constitutional principles, values and standards embodied by the rights to equality, freedom and security of the person, and access to health care services, and considers the extent to which current the formulation of the proposed NHI adheres to these principles. Potential constitutional challenges to NHI by private sector interest groups are identified. These challenges are primarily concerned with adverse effects that the implementation of NHI may cause to current beneficiaries of private sector health services. It is argued that these adverse consequences will, for the most part, not justify a finding that relevant features of NHI are unconstitutional. This is either because they will not amount to an infringement of the relevant constitutional rights or because such an infringement will be capable of reasonable justification in terms of the general limitations clause. Only where the impairment of existing rights is disportionate or is related to some extraneous purpose inconsistent with constitutional rights and values will NHI not pass constitutional muster. Ultimately, the constitutionality of different features of NHI will depend on how the rights of those who already have access to health care services under the current health financing system are balanced with those who currently lack such access.

This dissertation is a histo-graphic account of the origins and evolution of private health funding in South Africa. It commences with a history of medicine within the context of the provision of health care and health funding. The arrival of the Dutch and the influence of the different rulers are highlighted throughout the different eras, up to the formation of the first private medical scheme in 1889. From this point onward, the historical development of private health funding is recorded with due consideration of the appointed commissions of enquiry and legislative developments. The dissertation concludes with a review of the study.

Três modelos teóricos de negociação entre seguradores e provedores privados são desenvolvidos e seus resultados simulados e analisados. Os modelos procuram captar o que seria o encontro entre um segurador e um provedor vinculados entre si por um contrato de parceria e sentados à mesa para negociarem os preços do seguro-saúde e do bem/serviço médico. Na estrutura dos modelos está presente o problema de agente-principal característico da relação entre os dois atores, dadas as assimetrias informacionais inerentes ao campo da saúde. Tanto o segurador quanto o provedor estão restritos por considerações junto a seus consumidores. O processo de negociação em si baseia-se no modelo de Stackelberg para oligopólios, o que produz dois cenários: num primeiro cenário o líder da negociação é o provedor e num segundo cenário o líder da negociação é o segurador. / Three theoretical models about negotiation between private insurers and providers are developed and their results are simulated and analyzed. The models try to catch what would be a meeting between an insurer and a provider tied each other by an association contract bargaining the health insurance price and the medical good/service price. The main problem is the agent-principal relationship in an environment with asymmetric information. Both agents are restricted by consumer behavior. The basis for the bargain process is the Stackelberg model for oligopolies, which gives two scenes: one with insurer leadership and other with provider leadership.

The Diploma work "Health care reform in the United States of America" is the sequel of the Bachelor work of 2008 called "The liberal health care system of the United States of America". The work is focused on the financial means and changes which has been effective since singing The Patient Protection and Affordable Care Act (acronym PPACA) into the United States law on 23rd March 2010 by the democratic president Barack Obama. The special attention is drawn to permanently increasing health care costs and defrauding of money within the social heath care program Medicare that is designated for seniors 65 and over as well as handicapped people. This work deals with Massachusetts Mandatory Health Insurance Program of 2006, which has been used like a model for the new federal law PPACA. The practical part presents the particular changes brought by the new law, including their impact on the chosen social groups -- the uninsured, the employers, the families and their kids, the seniors and the people with "pre-existing conditions". Since the Health care reform is the political issue as well, at the end there are mentioned some pros and cons opinions.

Este estudo constrói um modelo microeconômico estático baseado nas teorias do consumidor e da firma para sintetizar o funcionamento do mercado de saúde. O modelo envolve os três principais agentes no setor privado: o consumidor, o provedor e o segurador. O seu objetivo é representar simultaneamente os três problemas tradicionais do mercado de saúde: a seleção adversa, o perigo moral e a demanda induzida. Desses três problemas, o perigo moral é o que recebe a atenção mais completa. Não obstante, ao invés da usual distorção do preço da assistência médica observado pelo consumidor segurado, a explicação do modelo para o problema do perigo moral está no custo da cooperação entre os consumidores segurados de um fundo de seguro-saúde. Por sua vez, a seleção adversa aparece no modelo como um viés entre a porcentagem observada de doentes na população e a porcentagem esperada de doentes no fundo, na medida em que a porcentagem no fundo permanece acima da porcentagem na população antes de igualá-la. Por último, a demanda induzida surge como uma discriminação do preço da assistência médica entre os pacientes segurados e não segurados de um provedor. A aplicação do modelo é demonstrada por meio da simulação de um mercado de saúde com dados relativamente parcimoniosos sobre uma população, uma doença e a cura para essa doença. Dentre os resultados, destaca-se o efeito de uma melhor distribuição de renda em reduzir o preço do seguro-saúde e diminuir a distância entre pacientes segurados e não segurados. / This study constructs a static microeconomic model based on consumer and firm theories in order to synthesize the functioning of the health market. The model deals with the three main agents in the private sector: the consumer, the provider and the insurer. Its objective is to simultaneously represent the three traditional problems of the health market: adverse selection, moral hazard and induced demand. Of these three problems, moral hazard is the one which has received the most complete attention. However, instead of the usual distortion of the price of health care observed by the insured consumer, the model?s explanation for the moral hazard problem is the cooperation cost among the insured consumers of a health insurance fund. In turn, the adverse selection appears in the model as a bias between the observed percentage of sick persons in the population and the expected percentage of sick persons in the health insurance fund, since the fund?s percentage stays above that of the population?s percentage rather than equal to it. Finally, the induced demand comes out as a discrimination of the health care price between insured and uninsured patients of a medical provider. The model?s application is demonstrated through a simulation of a health market with relatively parsimonious data on a population, an illness and the cure for this illness. One can detach among the results the effect of a better income distribution in reducing the health insurance price and diminishing the distance between insured and uninsured patients.

La Tunisie connaît une progression notable de ses dépenses de santé et de l’espérance de vie des tunisiens. Mais ces résultats vont de pair avec des inégalités dans l’accès aux soins, motivant une réforme de l’assurance maladie mise en place en 2007. Les principaux changements visent une amélioration de la couverture pour les maladies chroniques et une généralisation de l’assurance pour l’offre de soins privée. Cette thèse de micro-économétrie appliquée examine l’impact de la réforme sur l’accès aux soins et le reste à charge des individus. Les évaluations sont réalisées sur des enquêtes visant plusieurs milliers d’individus en 2005 et 2010. On présente les motivations de la réforme, avant d’analyser le choix d’assurance et son influence sur le recours aux fournisseurs de soins publics ou privés en 2010, après la réforme. Une évaluation de cette réforme a été analysée à l’aide de l’approche de différences de différences. Au total, les résultats obtenus montrent que cette réforme semble avoir atteint plusieurs de ses objectifs : amélioration de l’accès aux soins pour les affiliés à la Caisse Nationale de Sécurité Sociale (CNSS), meilleur accès aux soins privés, baisse des restes à charges et des dépenses catastrophiques pour les personnes affectées d’une maladie chronique. / Tunisia experiences a noticeable growth in health expenditures and in Tunisians’ life expectancy. However, there are inequalities in health care access that motivated a reform of the health insurance which took place in 2007. The main changes were the improvement of the coverage for chronic diseases and the expansion of the access to insurance for care provided in the private sector. This PhD uses a micro econometric approach to examine the impact of this reform on access to health care and the out of pocket (OOP) born by individuals. The estimations are implemented on two surveys realized in 2005 and 2010 and relative to several thousand individuals. We first present the motivations of the reform. Then we analyze the individual insurance choice and its influence on the use of public or private care providers in 2010, i.e. after the reform. To evaluate this reform, we use a double difference approach. In total, our results show that the 2007 reform has attained many of its objectives: improvement of health care access for National Social Security Fund’s (NSSF) members, better access for private health care, decrease of OOP and catastrophic health expenses for individuals with chronic diseases.