Insurance discrimination on the basis of health status: an overview of discrimination practices, federal law, and federal reform options

AI-Assisted Decision-making in Healthcare: The Application of an Ethics Framework for Big Data in Health and Research

Artificial intelligence (AI) is set to transform healthcare. Key ethical issues to emerge with this transformation encompass the accountability and transparency of the decisions made by AI-based systems, the potential for group harms arising from algorithmic bias and the professional roles and integrity of clinicians. These concerns must be balanced against the imperatives of generating public benefit with more efficient healthcare systems from the vastly higher and accurate computational power of AI. In weighing up these issues, this paper applies the deliberative balancing approach of the Ethics Framework for Big Data in Health and Research (Xafis et al. 2019). The analysis applies relevant values identified from the framework to demonstrate how decision-makers can draw on them to develop and implement AI-assisted support systems into healthcare and clinical practice ethically and responsibly. Please refer to Xafis et al. (2019) in this special issue of the Asian Bioethics Review for more information on how this framework is to be used, including a full explanation of the key values involved and the balancing approach used in the case study at the end of this paper.

Commercial Health Care Financing: The Cause of U.S., Dutch, and Swiss Health Systems Inefficiency?

This article evaluates the performance of 3 industrialized nations that have pursued market-based financing models, focusing on equity in access to care, care quality, health status, and efficiency. It then assesses the consistency of the findings with those of different research teams. Using secondary data obtained from a semi-structured review of articles from 2000 to 2017, we discuss the hypothesis that commercial health care insurance is detrimental to accessing professional health care and to population health status. The results show that in 2010 the unmet care needs of both poor and rich Americans exceeded those of the poor in several industrial countries. The number of Dutch adults experiencing financial obstacles to health care quadrupled between 2007 and 2013, and 22% of Swiss adults reported skipping needed care in a 2016 survey. The most negative impacts of “managed care” on care quality are its tight constraints on physicians’ professional autonomy; a large reliance on the physicians’ material motivation; health service fragmentation; and the tendency to apply evidence-based medicine too rigidly. Countries with a commercial insurance monopoly generally remained above the maternal, infant, and neonatal mortality rates versus the health-spending regression line. We conclude that the most inefficient system is where the insurance market has achieved its maximal development and that care industrialization contributes to the comparatively poor performance of the U.S., Dutch, and Swiss health systems.

Off-target phenotypes in forensic DNA phenotyping and biogeographic ancestry inference: A resource

With recent advances in DNA sequencing technologies it has become feasible and cost effective to genotype larger marker sets for forensic purposes. Two technologies that make use of the larger marker sets have come into focus in forensic research and applications; inference of biogeographic ancestry (BGA) and forensic DNA phenotyping (FDP). These methods hold the promise to reveal information about a yet unknown perpetrator from a DNA sample. In contrast, DNA-profiling, that is a standard practice in case work, relies on matching DNA-profiles between crime scene material and suspects on a database of DNA-profiles. Markers for DNA-profiling were developed under the premise to reveal as little additional information about the human source of the profile as possible, the rationale being that personal privacy rights have to be balanced against the public interest in solving a crime. The same argument holds for markers used in BGA and FDP; these markers might also reveal information on off-target phenotypes (OTPs), that go beyond BGA and the phenotypes targeted in FDP. In particular, health related OTPs might shift the balance between privacy protection and public interest. However, to our knowledge, there is currently no convenient resource available to incorporate knowledge on OTPs in BGA and FDP assay design and application. In order to provide such a resource, we performed a systematic search for OTPs associated with a comprehensive set of markers (1766 SNPs) used or suggested to be used for BGA inference and FDP. In this set, we identified a relatively small number of 27 SNPs (1.53%) that convey information on diverse health related OTPs such as cancer risk, induced asthma, or risk of alcoholism. Some of these SNPs are commonly used for FDP and BGA across different marker sets. We conclude that the effects of SNP markers used in FDP and BGA on OTPs are currently limited, with few exceptions that should be considered in a balanced decision on assay design and application.

Societal Implications of Health Insurance Coverage for Medically Necessary Services in the U.S. Transgender Population: A Cost-Effectiveness Analysis

BACKGROUND

Recently, the Massachusetts Group Insurance Commission (GIC) prioritized research on the implications of a clause expressly prohibiting the denial of health insurance coverage for transgender-related services. These medically necessary services include primary and preventive care as well as transitional therapy.

OBJECTIVE

To analyze the cost-effectiveness of insurance coverage for medically necessary transgender-related services.

DESIGN

Markov model with 5- and 10-year time horizons from a U.S. societal perspective, discounted at 3% (USD 2013). Data on outcomes were abstracted from the 2011 National Transgender Discrimination Survey (NTDS).

PATIENTS

U.S. transgender population starting before transitional therapy.

INTERVENTIONS

No health benefits compared to health insurance coverage for medically necessary services. This coverage can lead to hormone replacement therapy, sex reassignment surgery, or both.

MAIN MEASURES

Cost per quality-adjusted life year (QALY) for successful transition or negative outcomes (e.g. HIV, depression, suicidality, drug abuse, mortality) dependent on insurance coverage or no health benefit at a willingness-to-pay threshold of $100,000/QALY. Budget impact interpreted as the U.S. per-member-per-month cost.

KEY RESULTS

Compared to no health benefits for transgender patients ($23,619; 6.49 QALYs), insurance coverage for medically necessary services came at a greater cost and effectiveness ($31,816; 7.37 QALYs), with an incremental cost-effectiveness ratio (ICER) of $9314/QALY. The budget impact of this coverage is approximately $0.016 per member per month. Although the cost for transitions is $10,000-22,000 and the cost of provider coverage is $2175/year, these additional expenses hold good value for reducing the risk of negative endpoints--HIV, depression, suicidality, and drug abuse. Results were robust to uncertainty. The probabilistic sensitivity analysis showed that provider coverage was cost-effective in 85% of simulations.

CONCLUSIONS

Health insurance coverage for the U.S. transgender population is affordable and cost-effective, and has a low budget impact on U.S. society. Organizations such as the GIC should consider these results when examining policies regarding coverage exclusions.

Assessing barriers to health insurance and threats to equity in comparative perspective: the Health Insurance Access Database

BACKGROUND

Typologies traditionally used for international comparisons of health systems often conflate many system characteristics. To capture policy changes over time and by service in health systems regulation of public and private insurance, we propose a database containing explicit, standardized indicators of policy instruments.

METHODS

The Health Insurance Access Database (HIAD) will collect policy information for ten OECD countries, over a range of eight health services, from 1990-2010. Policy indicators were selected through a comprehensive literature review which identified policy instruments most likely to constitute barriers to health insurance, thus potentially posing a threat to equity. As data collection is still underway, we present here the theoretical bases and methodology adopted, with a focus on the rationale underpinning the study instruments.

RESULTS

These harmonized data will allow the capture of policy changes in health systems regulation of public and private insurance over time and by service. The standardization process will permit international comparisons of systems' performance with regards to health insurance access and equity.

CONCLUSION

This research will inform and feed the current debate on the future of health care in developed countries and on the role of the private sector in these changes.