Although many studies examining whether NHI mitigates the inequality in health care utilization have been con- ducted and have provided solid evidence that NHI does lessen the socio-demographic and regional disparity, few studies have focused on testing how equitable the financ- ing scheme of Taiwan health care system is. Neither have the changes in relative out-of-pocket expenditures during the pre- and post-NHI period been compared. Since a national insurance program should spread risks over large population groups and reduce medical costs for all patients, particularly the poor, it is important to under- stand how the health care reform (NHI) reduces and to what extent it reduces out-of-pocket expenditures for medical care. The financial burden from out-of-pocket medical expenditures is regressive financing in developed countries such as USA  or in developing countries such as Thailand , where financial burden is heavier for the poor. That is, the poor pay a larger share of their income for out-of-pocket medical expenditures than the rich in most countries; only a few, including Colombia and Viet- nam, have implemented healthcare reforms capable of remedying regressivity and reducing medical costs for the poor [9,10]. No studies, however, have assessed the impact of Taiwan's NHI on out-of-pocket medical expenditures.
This study considers total and out-of-pocket spending attributable to having chronic conditions among all adults in comparison to having no chronic conditions, in an ef- fort to highlight the big picture and support the hypoth- esis that total medical expenditures, including hospital, physician office, and prescription drug costs, are higher among individuals with chronic conditions compared to those with no chronic conditions. Results of the study would further emphasize the need for equitable health policy to target care provision for people with chronic conditions across the life course. This is crucial, as add- itional resources and support may be necessary to ensure that this vulnerable group has access to affordable, appropriate, and adequate health care. It has been re- ported that the unique needs of vulnerable populations such as those with chronic conditions have not been adequately reflected in local planning, policy/decision making and service provision . Concerted efforts to fight chronic diseases can advance health equity and de- velopment, both nationally and globally .
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Background: Studies indicate a relationship between cost and quality of life (QOL) in diabetes care, however, the interaction is complex and the relationship is not well understood. The aim of this study was to 1) examine the relationship of quartiles of QOL on cost amongst U.S. adults with diabetes, 2) investigate how the relationship may change over time, and 3) examine the incremental effect of QOL on cost while controlling for other relevant covariates. Methods: Data from 2002 – 2011 Medical Expenditure Panel Survey (MEPS) was used to examine the association between QOL and medical expenditures among adults with diabetes (aged ≥ 18 years) N = 20,442. Unadjusted means were computed to compare total healthcare expenditure and the out-of-pocket expenses by QOL quartile categories. QOL measures were Physical Component Summary (PCS) and Mental Component Summary (MCS) derived from the Short-Form 12. A two-part model was then used to estimate adjusted incremental total healthcare expenditure and out-of-pocket expenses adjusting for relevant covariates.
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Our results have significant health policy relevance. The speed of processing intervention was able to reduce pre- dicted medical expenditures by 3.2% ($223/$6,929) between baseline and the first annual follow-up. Moreo- ver, we emphasize here the fact that ACTIVE participants were only allowed ten 1-hour training sessions at base- line, unless they had been randomized, conditioned upon completing at least 8 of the ten baseline intervention ses- sions, to receive up to four additional standardized ses- sions one-month prior to the first and third annual follow-ups. Because the receipt of booster training was conditioned on participant adherence, however, we can- not address the "dosing" question (i.e., the separation of the basic intervention effect [up to 10 hours] from the booster effect [up to 8 additional hours for those so rand- omized]) in an intent-to-treat format. Nonetheless, when we have explored the "dosing" issue from an effectiveness standpoint for other outcomes, the results have been what one would expect–greater effects for those randomized to basic and booster speed of processing training, than for those randomized to just basic speed of processing (Wolinsky FD, et al., Speed of processing training improves self-rated health in older adults: enduring effects observed in the multi-site ACTIVE study, submitted; (Wolinsky FD, et al., Cognitive training improves internal locus of control among older adults, submitted).
anemia treatment and general severity of illness in the follow-up period, there is no other association between persistent anemia and medical costs, or it is too small to detect. Except β 1 , all asso- ciations on paths from persistent anemia to medical cost are sig- nificant (all p-values are 0.0001). The model was rerun with β 1 = 0. The model fits the data very well. The R-square for logged PPPM is 0.812; Goodness of Fit Index = 0.976, Normed Fit Index = 0.91, Root Mean Square Error Approximation = 0.057. Table 4 summarizes findings from structural equation models
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Background: The occurrence of multimorbidity (i.e., the coexistence of multiple chronic diseases) increases with age in older adults and is a growing concern worldwide. Multimorbidity has been reported to be a driving factor in the increase of medical expenditures in OECD countries. However, to the best of our knowledge, there is no published research that has examined the associations between multimorbidity and either long-term care (LTC) expenditure or the sum of medical and LTC expenditures worldwide. We, therefore, aimed to examine the associations of multimorbidity with the sum of medical and LTC expenditures for older adults in Japan. Methods: Medical insurance claims data for adults ≥ 75 years were merged with LTC insurance claims data from Kashiwa city, a suburb in the Tokyo metropolitan area, for the period between April 2012 and September 2013 to obtain an estimate of medical and LTC expenditures. We also calculated the 2011 updated and reweighted version of the Charlson Comorbidity Index (CCI) scores. Then, we performed multiple generalized linear regressions to examine the associations of CCI scores (0, 1, 2, 3, 4, or ≥ 5) with the sum of annual medical and LTC expenditures, adjusting for age, sex, and household income level.
In this study, the impact of home and community-based services on hospitalisation and institutionalisation of individuals certified as being eligible for LTCI benefits for the first time was analysed after adjusting for demo- graphic variables and outpatient medical expenditures. The results showed that users of home and community- based services were less likely than non-users to be hos- pitalised or institutionalised. Among the types of home and community-based services, users of respite care and rental services for assistive devices were less likely to be hospitalised or institutionalised than non-users. When subjects were limited to individuals certified as having light need for long-term care, hospitalisation and institu- tionalisation were also less likely for users of day care than for non-users. Therefore, respite care, rental ser- vices for assistive devices and day care were effective in preventing hospitalisation and institutionalisation. Our results suggest home and community-based services contribute to the goal of the LTCI system of encoura- ging individuals certified as being eligible for LTCI ben- efits to live independently at home for as long as possible.
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The health of the rural elderly arouses great concern. The huge number of rural elderly and their deepening health problems (e.g., growing threats of infectious dis- eases and chronic diseases) place enormous pressure on health security for the elderly in rural China . The subsidization of healthcare costs through insurance schemes is crucial in overcoming financial barriers to healthcare and avoiding high medical expenditures for patients in China . In 2003, the Chinese central gov- ernment launched a policy in rural areas called the ‘New Cooperative Medical System’ (NCMS). This scheme aims to safeguard farmers’ access to basic health services and alleviate the financial burden caused by sickness and poverty with a focus on inpatient services and cata- strophic outpatient services . Farmers were actively encouraged to enroll in the scheme as over 70% of the NCMS fund was contributed by the government and individual contributions were relatively small. The par- ticipants are entitled to reimbursements in designated hospitals and regulated by lower reimbursement rates in higher-level hospitals.
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To further probe the relationship between household smoking and Medicaid expenditures, we present results from the two-part and aggregate models of expenditures in Table 3. For overall expenditures, there was no rela- tionship between the presence of smoking in the home and overall Medicaid expenditures for either the two- part or aggregate models. Because inpatient and emer- gency expenditures are so rare, their two-part models did not converge and we were not able to separately assess the two components contributing to aggregate expenditures for the services. For prescription drug expenditures, the two-part model highlighted a signifi- cant increase in the likelihood of any expenditures among children living with smokers. However, this slight increase did not carry through to the conditional or aggregate models. On the other hand, for dental expenditures, there was no difference in the likelihood of any dental expenditures, but there was a significant increase in conditional expenditures for children living with smokers. Again, this did not carry through to the aggregate model. There was no evidence that ambula- tory care expenditures exclusive of well-child care were related to the number of smokers in the home. The trend towards lower well-child expenditures among chil- dren living with smokers was driven almost entirely by lower medical expenditures among those who had non- zero expenditures.
As mentioned earlier, the major goal of this study was to evaluate whether we can possibly control medical expenditures without degrading the quality of medical treatments. In the case of this disease, the answer seems to be yes: medical expenditures for educational hospitalization could be reduced significantly by reducing LOS without degrading the effects of hospitalization. The total medical expenditures for diabetes hospitalization in Japan were 320 billion yen in FY 2012 . Our dataset shows that 21% of these expenditures went to educa- tional hospitalization, and the analysis revealed that the medical expenditures for educational hospitalization were mainly determined by the LOS. Therefore, if we could reduce the ALOS by half (from 14 to 7 days), we would be able to reduce the medical expenditures by more than 30 billion yen. For that purpose, 1) introduction of critical path, and 2) improvement and standardization of educational programs including accountability and quality of trainers  are important, especially for hospitals with a long ALOS. The patient-centered diabetes care and education currently practiced in the United Kingdom   might be a good example of such mod- ifications. Reducing ALOS (and improving educational programs) can also benefit patients. A shorter ALOS reduces costs of hospitalization (including opportunity costs) for patients, and more (potential) patients can join educational programs if costs are reduced. As pointed out earlier, the risk of type 2 diabetes can be controlled through lifestyle improvements. Incentives to improve the efficiency of hospitals must be considered in the fu- ture revision of the medical payment system.
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Korea, high psychiatric inpatient MEs among AID benefi- ciaries are partially due to the inpatients ’ prolonged stay because of the defects in the health care system. For AID beneficiaries, both providers (medical institutions) and consumers (patients and their families) tend to delay patients’ discharges. From the standpoint of providers, inadequate oversight of quality of care, lack of coordina- tion of mental health care and a low per-diem rate may result in prolonging admissions [7,10,45]. Per-diem rates are typically low, but cover the average production costs (fixed costs plus variable costs) of most Korean medical institutions. Therefore, medical institutions, which must bear the burden of fixed costs associated with unoccu- pied beds, tend to admit psychiatric patients and keep them for long periods of time in order to minimize their fixed cost burdens, especially because AID beneficiaries are cared for under no or very low cost sharing structures . Consumers are also often reluctant to be dis- charged. In Korea, psychiatric day care and non-medical services (like residential service and vocational rehabilita- tion) for AID beneficiaries are not subsidized by the Table 3 Inpatient characteristics associated with inpatient medical expenditures, univariate and bivariate analyses: public insurance (NHI) beneficiaries versus public aid (AID) beneficiaries (N = 160,465).
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medical expenditures abroad and OOP expenditures on health among Maldivian medical travellers were similar between the poor and the rich. We conclude mixed evi- dence on the linkages between public financing of med- ical travel and impoverishment. Despite the fact that they bear the highest cost of treatment abroad, very low levels of impoverishment were observed among patients seeking treatment for neoplasms, for which more than 85 % of the patients received the government subsidy. In comparison, other disease groups had high levels of impoverishment where the number of beneficiaries was comparatively low. However, the proportion of subsi- dised travellers suffering from impoverishment was higher than that of the non-subsidized group which calls for more evidence to identify reasons why people do not seek the public subsidy for medical travel and the health seeking behaviours of the subsidized and the non- subsidized traveller. There is need for further research to examine differences in impoverishment levels between households with and without medical travel and investi- gate the relationship between public subsidy for medical travel and impoverishment.
People reporting multiple types of insurance in the March 1993 Current Population Survey were assumed to have been covered by both private insurance and Medicaid. We used 2 sets of as- sumptions to estimate expenditures for these people. Under the first assumption, people reporting multiple sources of insurance were assumed to have been covered by both insurers for the whole year. Under this assumption, expenditures were the same as they would have been for people with private insurance only, because for dually covered enrollees, Medicaid pays only premiums and copayments, which are unaffected by individual utilization. Un- der the second assumption, people reporting multiple insurance were assumed to have no overlap in insurance but to have been covered by each type of insurer for half of the year. In this case, the average of the per-capita reimbursement amount for private in- surance and for Medicaid was calculated for each type of service, and these averages were used in the calculation of expenditures. To provide a more current expression of medical expenditures for otitis media, we inflated the 1992 expenditure estimates to 1998 dollars using the Consumer Price Index published by the US Bureau of Labor Statistics. We used US city average inflation estimates for prescription drugs and medical supplies, hospital and related services, and professional services to inflate each component of expenditures we estimated.
We used sequential explanatory linear models to investi- gate whether functional limitations explain the differ- ence in medical expenditures between patients with arthritis and joint pain and those without. For each model, we ran a generalized linear model (GLM) using gamma distribution with total expenditures as the dependent variable and reporting joint pain or arthritis as the main independent variable. We then added vari- ables in blocks according to the Anderson model for healthcare use categories of predisposing variables, enab- ling variables, and need variables. Finally, we ran a final fully adjusted model and added any functional limitation. After each GLM, we determined the marginal effects using the margins command in Stata 14.0 statistical soft- ware (StataCorp, College Station, TX, USA). In order to generalize our study findings to the U.S. population, the complex sampling design of the MEPS dataset was taken into account by using sampling weight, variance estima- tion stratum, and primary sampling unit in all regression models and sample demographic estimates.
In our model we take into account two vectors of control variables per healthcare unit -X it ′ - and Regions -Z rt ′ - which, according to the literature on malpractice, could have some impact on the trend of malpractice premiums and on legal expenditures as well (e.g. Thorpe (2004)). 13 X it ′ groups structural characteristics of the healthcare providers. These include: 1) a set of dummies for the type of the healthcare provider (LHUs, IHs, THs and RHs), since different healthcare structures tend to have different management and organizational arrangements, which might affect insurance management and their bargaining power; 2) the amount of medical personnel payroll, given that medical liability insurance companies operating in Italy tend to set premiums according to a per- centage of the gross payroll; 3) two indexes to consider patients’ mobility that healthcare providers need to manage. These indexes control for qualitative differences, which could affect the number of medical errors or the probability of filing claims. Hence, we use: a) the ratio of revenues due to medical care provided to residents of other LHUs within the same Region (entry rate), being higher revenues potentially associated with higher quality; b) the ratio of expenditures due to ser- vices that resident patients received from other public healthcare structures within the same Regions (exit rate). 14 The latter is an approximation of poor quality. For example, if patients perceive that the hospitals managed directly by the LHU of their residency provide low quality care, they might decide to abandon the assigned healthcare providers. Mobility can be seen as a "defensive strategy" in the face of poor quality (Fabbri and Robone (2010)).
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For more than sixty years, our democracy has encouraged—and subsidized—profit-making businesses, researchers, and medical professionals, unleashing them to create wondrous medical innovations and make money by offering advanced health care— and by selling insurance for fortunate segments of the population, especially privileged employees and their families. But many in the working and middle class are falling into growing cracks, as more and more employers and families are being priced out of secure access to health care. No wonder that seven or eight out of every ten Americans have been consistently insisting that the health system needed fundamental change or needed to be completely rebuilt. The riches of health care beckon to frustrated and fearful people who need it, but it is as if growing portions of the American citizenry find themselves on rafts close to idyllic shores yet pulled outward by currents against which their oars, no matter how vigorously rowed, can make only limited headway. 91
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Now let us turn to the interaction terms at the top of table 1. First of all, relative income does not have a significant effect on the relationship between public sector size and well-being since the coefficient for the relevant interaction term is insignificant in models 2a, 5a, 6a and 7a. On the other hand, the interaction terms with regard to ideological preferences and expenditure decentralization are strongly significant and have the correct signs with respect to hypotheses 2 and 3. The former result shows that ideology and income need not be two congruent dimensions, while the latter result confirms previous evidence by Bjørnskov et al. (2008). Finally, the interaction term with regard to corruption has the expected negative sign and is significant at the 10% or 1% level, respectively. Model 7a additionally reveals a highly significant negative quadratic term for government expenditures. This suggests an inversely U-shaped relationship and diminishing returns to government size in terms of well-being.
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Furthermore, the result of our model demonstrated that large families spend more on healthcare. Indeed, holding all other variables constant in this model, more the size of the family increases the more health expenditures increases, but not necessarily with the same proportion. (p<0.001) Additionally, the variable area of residence is another major explanatory variable used in this analysis. Living in rural area increase significantly health expenditures by about 0.338 point higher than it is for person who live in urban area.
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It is important to acknowledge 3 limitations in the current study. 1) There may still be omitted-variable bias. For example, the race variables white, black, Hispanic, Asian, Native-American, and other race do not adequately capture the cultural and personal preferences of people who are categorized into these groups. Race and ethnicity in themselves may lead to prejudices that influence prescribing pattern and de- creased prescription drug spending; however, there are preferences and beliefs associated with race/ ethnicity that play an important role in being pre- scribed a medication and in getting a medication. 2) Another major category of variables that can signif- icantly influence prescription drug expenditure but is not included in our analysis is the group of vari- ables that specify prescription drug benefits within different insurance types. These variables are not available in the MEPS Household Component File for incorporation into our analysis. 3) This study does not address the question of whether those groups that had lower prescription drug expenditure were underprescribed or appropriately prescribed. This study also does not address the question of where the disparity occurs. Is it at the physician level (ie, prescribing pattern) or at the individual level (ie, preferences, compliance, etc.)? Undoubtedly, there is disparity in prescription drug expenditures as pre- sented earlier. However, the underlying causes of disparity remain to be identified.
Realizing that the direct economic damage from the emergency situation is expressed in the form of costs and losses caused by this disaster. The direct econom- ic damage to the state includes: the costs of rescue operations, one-time payments to the families of those killed and injured; the costs of purchasing (producing) the essential medical equipment and medicine; pay- ments to rescuers and specialists; restoration of resi- dential buildings; subsidies to firms; immediate elimi- nation of environmentally harmful effects.