Irene Papanicolas and colleagues consider the potential of alternatives to quality-based pay-for-performance systems and the remaining challenges

Over the past two decades most healthcare systems have modified the way they pay providers to attach financial incentives directly to quality of care. This type of payment, often referred to as pay for performance, gained momentum in the early 2000s, following several studies highlighting concerns about the quality and safety of healthcare systems.1 However, the evidence suggests they have been largely ineffective in improving quality. In response, health payers in various countries have introduced alternative payment models that encourage more effective, efficient, and integrated healthcare. We examine the early evidence on these alternative models and consider what they can realistically achieve.

Comparing health policy measures before elections and identifying potential gaps in the health policy debate can be challenging. We explored the use of the Health System Performance Assessment for Universal Health Coverage framework to analyse health policy proposals by classifying health policy measures outlined in political manifestos into four health system functions: governance, financing, resource generation and service delivery. As a case study, we analysed the political manifestos of all Portuguese parties with parliamentary representation ahead of the election in March 2024. We calculated the share of measures per health system function for individual political manifestos and identified potential gaps in the health policy debate. When required, we used additional classification criteria and local expertise on political and institutional knowledge.

Wealth-related inequalities in self-reported health status are strong and persistent across countries. Our results suggest that there is meaningful variation across high-income countries in health-wealth dynamics that merits further investigation to better understand whether certain health or welfare systems are more equitable. They also highlight the need to consider social policy and wealth redistribution mechanisms as strategies for improving population health among the less wealthy, in the United States and elsewhere.

The articles in this issue highlight the importance of regular health systems performance assessment to inform policies that advance progress on health system objectives globally, and offer insights on associated data, methods and applications.

Using satisfaction ratings without nuanced approaches in value-based purchasing programmes may mask poor-quality interpersonal services, particularly for historically marginalized patients. Surveys should be designed to accurately capture true levels of dissatisfaction, ensuring that patient concerns are not hidden.

Heterogeneity in national SARS-CoV-2 infection surveillance capabilities may compromise global enumeration and tracking of COVID-19 cases and deaths and bias analyses of the pandemic’s tolls. Taking account of heterogeneity in data completeness may thus help clarify analyses of the relationship between COVID-19 outcomes and standard preparedness measures. Results support the pre-pandemic hypothesis that countries with greater pandemic preparedness capacities have larger SARS-CoV-2 infection and mortality data completeness rates and lower COVID-19 disease burdens. More high-quality data of COVID-19 impact based on direct measurement are needed.

Researchers and policy-makers have long compared health system performance. International comparisons raise awareness of health systems’ relative strengths and shortcomings, prompting policy debates and informing policy decisions. Yet determining how these international comparisons can be used to improve health system performance is challenging. Health systems can differ in many ways, including how they are governed, how they are funded, how they generate and deploy resources, and how they deliver services. While the international health community widely agrees that these functions influence health system performance, understanding of how much they matter, which ones matter most, and how they are affected by the context in which they operate remains limited. To gain relevant and meaningful insights from health systems comparisons that offer lessons for policy, we must agree on how to compare health systems. In this article, we argue that doing so requires collecting better, more granular data on a broad range of health system characteristics and using those data to choose the most appropriate health system comparators.

Analysis of interhospital variation highlights important outcome differences that are not explained by known patient or hospital characteristics. Targeting variation is therefore a promising strategy to improve cardiovascular care. Considering their treatment in multidisciplinary teams, policy makers, and managers should prioritize heart failure, hypertension, cardiac arrest, and angina pectoris improvements by targeting guideline implementation outside the cardiology department.

In their Letter to the Editor, Olivença and colleagues question the benefit of adopting health technology assessment (HTA) in the US, and suggest it could result in fewer drugs being available to patients. They raise 3 main critiques of our study.1

First, Olivença et al note that patients in countries with HTA have voiced concerns about inadequate access to new therapies, citing 5 media reports from negative coverage decisions in England. The extent to which these reports represent the broader views of society is unclear. Recent decades have seen global consensus that universal health coverage is desirable for health care systems. Achieving universal coverage requires decisions about which services should be made available to maximize population health. As many new drugs offer little or no added therapeutic value,2 no coverage may be acceptable unless pharmaceutical companies offer reasonable prices (otherwise, funds would not be available to pay for other health services). In our study, we observed good coverage in all countries of high-value drugs following HTA review.

Total hip arthroplasty (THA) is among the most commonly performed elective surgeries in high-income countries, and wait times for THA have frequently been cited by US commentators as evidence that countries with universal insurance programs or national health systems “ration” care. This novel qualitative study explores processes of care for hip replacement in the United States and 6 high-income countries with a focus on eligibility, wait times, decision-making, postoperative care, and payment policies. We found no evidence of rationing or government interference in decision-making across high-income countries. Compared with the 6 other high-income countries in our study, the United States has developed efficient care processes that often allow for a same-day discharge. In contrast, THA patients in Germany stay in the hospital 7–9 days and receive 2–3 weeks of inpatient rehabilitation. However, the payment per THA in the United States remains far above other countries, despite far fewer inpatient days.

The choice of price index has major implications for comparative analysis. Despite their widespread use internationally, general price indices likely underestimate the contribution of price growth to overall health expenditure growth. We find that in addition to its reputation for having high health price levels compared to other high-income countries, the United States also faces health price growth for goods and services paid for by government and households in excess of general price growth. Furthermore, US households are exposed to greater health price growth than households in comparator countries.

Medical crowdfunding is a key source of finance for individuals facing high out of pocket costs, including organ transplant candidates. However, little is known about racial disparities in campaigning activity and outcomes, or how these relate to access to care. In this exploratory nationwide cross-sectional study, we examined racial disparities in campaigning activity across states and the association between U.S. campaigners’ race and ethnicity and crowdfunding outcomes using a novel database of organ-transplant related campaigns, and an algorithm to identify race and ethnicity based on name and geographic location. This analysis suggests that there are racial disparities in individuals’ ability to successfully raise requested funds, with Black and Hispanic campaigners fundraising lower amounts and less likely to achieve their monetary goals. We also find that crowdfunding among White, Black, and Hispanic populations exhibit different patterns of activity at the state level, and in relation to race specific uninsurance and wait list additions, highlighting potential differences in fundraising need across the three groups. Policy efforts should consider not only how inequalities in fundraising ability for associated costs influences accessibility to care, but also how to identify clinical need among minorities.

Most high-income countries except the US rely on health technology assessment (HTA) to ensure that prices paid for new medicines reflect the value they provide.1,2 Health technology assessment bodies assess the relative clinical or economic impact of new drugs to guide pricing and coverage decisions. These assessments usually occur after marketing authorization by a medicines regulatory body (eg, European Medicines Agency), and patients may have little or no access to therapies not assessed favorably by HTA bodies. As Medicare considers using comparative effectiveness data to negotiate drug prices, examining HTA decisions abroad can inform US policymakers about how HTA affects the availability and coverage of new medicines.3 We analyzed HTA outcomes and review times in 6 countries (Australia, Canada, England, France, Germany, and Switzerland) for novel therapeutic agents approved by the US Food and Drug Administration (FDA).

In low- and middle-income countries, many believe that telehealth services could significantly expand access to doctors by offering remote access at low cost. Yet, despite its convenience, telehealth care is limited by the absence of physical examination, point-of-care testing, or immediate treatment. Hence it is unclear how individuals value such options compared to standard face-to-face care. We study this issue in South Africa with general practitioners who today mostly practice in the private sector and are geographically located in wealthier areas with higher health insurance coverage. We use an incentive-compatible method to elicit robust measures of willingness-to-pay (WTP) for telehealth and face-to-face consultations with general practitioners in a sample of uninsured individuals. We find that only 36% of respondents are willing to pay the prevailing market price for a telehealth consultation. We find average WTP for in-person consultations is only 10% higher than that of telehealth. Additionally, individuals with higher health needs are willing to pay a premium for face-to-face consultations, while others are indifferent. Our findings suggest that private telehealth services are better suited for more minor health needs, but are unlikely to expand access to a majority unless cheaper models are introduced.

The COVID-19 pandemic was associated with increased mental health visits for parents of young children. This raises concerns about mental health impacts and highlights the need to address these concerns.

Study results raise concerns over prolonged high rates of mental health use during the pandemic, particularly in female adolescents and young women, and highlights the need to better monitor and identify mental health outcomes associated with COVID-19 containment measures and to develop policies to address these concerns.

Report identifies striking lack of progress relative to peer countries.

Jonathan Cylus and colleagues argue that inflationary pressures mean the NHS may have reached the limit on its ability to contain costs for goods and staff without affecting care.

The need for cardiac transplantation (CT) in eligible patients with advanced heart failure has continued to grow, with a substantial mismatch between organ availability and demand. As the demand for transplantable organs has risen in the United States,1 so has the prevalence of major cardiometabolic risk factors, including diabetes mellitus (DM), among the current and emerging pool of potential donors.2 Although the cardiovascular complications of DM are well recognized, donor DM status has not been shown to adversely impact post-CT outcomes in older analyses.3 However, this has not been evaluated in the contemporary era or over longer-term follow-up.

One of the most pressing challenges facing most health care systems is rising costs. As the population ages and the demand for health care services grows, there is a growing need to understand the drivers of these costs across systems. This paper attempts to address this gap by examining utilization and spending of the course of a year for two specific high-need high-cost patient types: a frail older person with a hip fracture and an older person with congestive heart failure and diabetes. Data on utilization and expenditure is collected across five health care settings (hospital, post-acute rehabilitation, primary care, outpatient specialty and drugs), in six countries (Canada (Ontario), France, Germany, Spain (Aragon), Sweden and the United States (fee for service Medicare) and used to construct treatment episode Purchasing Power Parities (PPPs) that compare prices using baskets of goods from the different care settings. The treatment episode PPPs suggest other countries have more similar volumes of care to the US as compared to other standardization approaches, suggesting that US prices account for more of the differential in US health care expenditures. The US also differs with regards to the share of expenditures across care settings, with post-acute rehab and outpatient speciality expenditures accounting for a larger share of the total relative to comparators.

Although there are cross-country differences in the availability and structure of data sources, countries had the ability to effectively identify comparable HNHC personas for international study. This work serves as the methodological paper for six accompanying papers examining differences in spending, utilization, and outcomes for these personas across countries.

Across seven countries, we find important variations in end-of-life care for patients who sustained a hip fracture, with some differences explained by sex and age. Our work sheds important insights that may help ongoing health policy discussions on equity, efficiency, and reimbursement in health care systems.

Distribution of health care consumption in different settings varies within countries, but there are also some common treatment patterns across all countries. Clinicians and policy makers need to look into these differences in care utilization by sex and care setting to determine whether they are justified or indicate suboptimal care.

Across 11 countries, there are meaningful differences in health system outcomes for two types of patients.