Medical Utilization and Health Expenditure of the Elderly in Taiwan

The present analysis, based upon data from the 1989 Taiwan Labor Force Survey, includes two parts. First, the determinants of physician visits and hospitalization by the elderly are analyzed according to the behavioral systems approach, and, second, variation in health expenditures among the elderly are examined using the Tobit model with sample selection. Findings show that elderly with good or poor health conditions are less likely to use medical services than the frail elderly and that married elders are less likely than the non-married to use medical care. The higher the educational level, the lower the probability of using formal medical services, and elderly who have health insurance are more likely to use formal health care than those who have no health insurance. The elderly who live with their children are less likely to use formal medical services than those who do not live with their children. Finally, among the elderly who have used formal health care, individual health expenditures are influenced primarily by three factors: health condition, health insurance, and residential location. Implications for Taiwan's relatively newly established national health insurance program (effective April 1, 1995) are discussed based upon the findings of this research.     

Are There Differing Patterns of Health Care Access and Utilization Among Male Sexual Minorities in the United States?

Disparities in health care access and utilization among male sexual minorities in the United States were explored using data from the National Survey of Family Growth (N = 8,846). Bisexual men had a small disadvantage in health insurance coverage but no differences were found in health insurance or consistency of coverage between gay and heterosexual men. Gay men were more likely to have a usual place of care, but were not more likely to utilize services. The current study provides inconclusive evidence for systematic disparities in health care access and utilization among gay and bisexual men in the United States.     

Predisposing,Enabling, and Need Predictors of Community versus Institutional Long-Term Care

Abstract

This research explored characteristics of the elderly that are associated with the use of long-term care services. Using the 1999 National Long Term Care Survey, logistic regression was employed to examine the relationship of race with the use of formal and informal long-term care. This study also examined the relationship of health insurance with the use of formal and informal long-term care. The Andersen Model on health services utilization was used as the theoretical framework. The findings indicated that race was not associated with the use of long-term care but rather with predisposing, enabling, and need variables. Health insurance was found to be associated with the use of long-term care even after controlling for predisposing enabling and need variables.     

Use of Various Health Care Services by Students in Helsinki

Abstract

Review of the working of various health care schemes has revealed predominant use by a certain group of “large-scale consumers.” The concomitant use of various services (health, dental, and mental health care) was studied within the Helsinki Health Center of the Finnish Student Health Service from January 1, 1980 to August 31, 1980. The group consisted of 16,174 students. The characteristics of the groups of patients who used only the mental health care service and of those who used all three services were also studied. Within each sector, there were fewer patients than expected who did not use the services of other sectors. The number of patients visiting dental and health care services, mental health and health care services, and all three services were greater than expected. The groups of patients who used only the mental health care service and those who used all three services were surprisingly similar. The greatest difference between the groups probably lay in their need for somatic and dental care. The organization, which incorporates mental health, dental, and health care services in the same building offers improved possibilities for care of the patient as a whole. On the basis of this study, there is no reason to think that such an organization leads to misuse of the various services.     

Risk and selection processes between the general and the specialty mental health sectors

This paper examines risk, defined as the threat of danger or disruption, as a contextual concept important for understanding patterns of patient selection and referral. We explore the hypothesis that risks associated with mental disorder, as represented by factors such as thoughts about suicide or problems associated with drinking, increase the probability of referral of patients receiving mental health care from general medical practitioners to the specialty mental health sector. Interview and claims data from the RAND Health Insurance Experiment, a large experimental study of coinsurance, are used to examine referral processes over a five-year period. Risk, and especially a measure of suicide thoughts, increase the probability of referral to specialty care. Women and persons with higher education are more likely to use specialty services; older persons are less likely to use such services. Understanding referral requires attention to the behavioral contingencies and illness behavior surrounding the presentation of mental disorder.     

Health care reform and older adults: notes from the Polish experience

Poland enacted in 1997 legislation that founded a health care system in which health insurance societies contract with providers to deliver health services to the insured population. Through a review of the new statutes, interviews with key informants, analysis of public opinion polls and surveys of insurance administrators and health care workers, we examined the impact of reform on Poland's older citizens. The findings indicate that older adults are likely to be adversely affected by the inadequacies of insurance premiums as a source of finance, the lack of emergent private medical enterprise, and the failure to eradicate private health in its earlier, black market incarnation.     

Health care consolidation and the changing health care marketplace. A review of the literature and issues

This Issue Brief examines the academic literature and issues in consolidation of the hospital sector in the context of responses to changes in the competitive environment. It analyzes the motivations for consolidation as well as its effects. Hospital merger activity has increased dramatically in recent years. The current wave of mergers is primarily a reaction to a competitive environment that is placing a greater emphasis on controlling costs and forcing high-cost providers out of the market. The growth of managed care has placed considerable pressure on providers of health care and, in particular, on hospitals. The evolution of insurance companies' behavior helps explain the recent hospital consolidation movement. As managed care has become the dominant type of coverage in the last decade, insurance companies have become more active in trying to control costs--a reversion to their previous practices before the advent of managed care. Insurance companies have placed cost constraints on providers, both in the early years of health insurance and currently, when there are strong competitive forces. Hospitals claim that their primary merger motives are improving efficiency and the quality of care. The empirical evidence on this claim is mixed. Vertical integration (between suppliers and buyers of health care services, such as between hospitals and physicians) has appealed to hospitals because of their need to obtain more patients. More research is needed to explore the effects of vertical integration in the health care sector. In one of the more significant recent legal rulings, the U.S. Justice Department lost a 1997 case challenging the merger of two hospitals in the New York City metropolitan area. This, along with other recent losses by the antitrust authorities, does not bode well for the government's ability to prevent hospital mergers in metropolitan areas. It is difficult to generalize on an appropriate antitrust policy for hospital mergers. Hospital consolidation is likely to continue at a rapid pace. Since some developments may reduce the cost of employee benefits while others may increase the cost of these benefits, the final effect on the provision of health care benefits by employers is uncertain. Employers must pay close attention to the hospital consolidation movement because it will lead to important changes in the provision of health care benefits.     

Health care reform: managed competition and beyond

Since the election, the health care reform debate has focused on three broad features: implementation of managed competition, changes in the tax treatment of health insurance, and the imposition of budget caps or targets. The basic element of managed competition is the creation of sponsors who act as collective purchasing agents for large groups of individuals. One of the potentially most politically difficult issues in implementing any health care reform proposal is likely to be defining the minimum standard benefit package. It will determine the costs society bears, the income of providers, the health of many individuals, and the attributes of a workable health care reform package. Managed competition is intended to foster competition among health plans on the basis of cost and quality. The measures of quality actually employed in the health care system will determine in large part the incentives faced by insurers, providers, and consumers. The problem of adverse selection is potentially the most important issue in reforming the health insurance market. If individuals can opt not to purchase health benefits, poorer risks will be more likely to purchase health insurance than good risks, and at minimum the price of these benefits will be higher than would otherwise be the case. Managed competition requires that individuals share at least some of the financial consequences of their choices among health plans. As a result, most managed competition proposals change the tax code by limiting the exclusion of employer contributions to health insurance from worker's taxable income. Changing the health insurance market, mandating employer health benefits, and changing the tax code may have significant effects on the health care delivery system, but they are unlikely to reduce health care cost inflation in the near term. One of the proposals for restraining the growth in health care costs is the imposition of a budget on the amount spent on health care services. The combination of the constraints placed on federal governmental action by the budget and the significant political problems involved in reaching a consensus on the important elements of health care reform may limit the ability of the federal government to implement national health care reform in the near term. As a result, individual states may be encouraged by the federal government to continue to experiment with their own health reform programs.     

Reforming the health care delivery system

The health care delivery system is evolving rapidly. There have been changes in the way health care is financed, the types of treatments available, the sites of care, and the physician patient relationship. These changes have resulted primarily from reactions to health care cost inflation. Health care reform is likely to accelerate some of these changes. The threat/promise of health care reform has already accelerated the consolidation of the health care services market. Health care reform is likely to reduce the number of insurers, increase the number of Americans in managed health care plans, increase the number of physicians in group practice, change provider income, and in general make the health care delivery system more concentrated and vertically integrated.     

The Effect of Long-Term Care Insurance on Home Care Use Among the Disabled Elders

Using the 1998?C2004 Health and Retirement Study, this study uses Cox??s model to explore the effects of private long-term care insurance ownership on first home care use among the disabled elderly. Results show that long-term care insurance ownership and Medicaid eligibility did not significantly increase the likelihood of using home care services, while income and homeownership lowered this likelihood. Functional limitation was the key determinant of home care use and those who lived with children were less likely to use home care services. Based on the findings, this study provides foundations for long-term care policies and long-term care planning programs.     

A survey of Colorado's migrant farmworkers: access to health care

This report utilizes data collected in a 1986 sample survey of 329 adult (18 to 50 years old) migrant farmworkers in Colorado to determine their health needs, health services utilization, and overall access to care. Health needs include selected indices of medical, dental, nutrition, and reproductive health. About 1/4 of the population had no usual source of health care. Upstream states such as Colorado are responsible as the primary providers of health services for those who either have no source of health care at their home base or experience a variety of barriers in their attempts to access services. Women are most likely to have had a medical visit over the past 12 months and are more likely to have experienced hospitalization. Unfortunately, although their contact with medical professionals is more frequent, the family planning needs of women are not being met. A large disparity exists between ideal family size and number of pregnancies and live births. The findings of this survey document the inferior health status of the migrant farmworker population in Colorado. Hunger, poverty, and environmental hazards increase the risk of illness, while at the same time, barriers to care often prevent migrants from accessing needed health services. Recommendations include 1) promoting and funding family planning and reproductive health services for migrant farmworker women and their partners, 2) incorporating trained family planning promoters in the migrant health delivery system, 3) maintaining successful models of restorative dental care for adults, 4) increasing access to services in nontraditional settings, 5) increasing use of ancillary personnel to provide services, especially dental services, 6) maintaining outreach programs in the available food programs, and 7) encouraging migrant health programs to provide leadership in the development of alternative food sources.     

Issues in mental health care benefits: the costs of mental health parity

This Issue Brief discusses issues in mental health care benefits. It describes the current state of employment-based mental health benefits and discusses studies and issues regarding full mental health parity. It also includes an analysis of the effect of full mental parity on the uninsured population and the effects of the limited mental health parity provision contained in the VA-HUD appropriations bill. The final section discusses the implications of mental health parity for health plans and health insurers. When employers began to provide health insurance benefits to their employees and their families, they extended coverage to include mental health benefits under the same terms as other health care services. Many employers continued to add mental health benefits through the 1970s and early 1980s until cost pressures required employers to re-examine all health care benefits that were offered. They quickly found that, while only a small proportion of the beneficiaries used mental health care services, the costs associated with this care were very high. As a result, employers placed limits on mental health benefits in an attempt to make the insurance risk more manageable. The general strategies employers have used to manage their health care costs are cost sharing, utilization review, managed care, and the packaging of provider services. Employers' cost management strategies may be restricted, however. Five states have mental health parity laws, but three of the states--Rhode Island, Maine, and New Hampshire--apply these laws only to the seriously mentally ill. In addition, 31 states mandate that mental health benefits be provided. However, state mandates apply only to insured plans, not to self-insured employer plans, which are exempt from state regulation of health plans under the Employee Retirement Income Security Act of 1974 (ERISA). A number of recent studies have examined the effect of mental health parity on health insurance premiums in a "typical" preferred provider organization and on the uninsured. In general, the studies concluded that mental health parity could increase health insurance premiums, decrease health insurance coverage for non-mental health related illnesses, and increase the number of uninsured individuals. All studies of mental health parity, and mandated benefits in general, assume that there is a strong likelihood that increased health benefit costs would be passed along to workers in the form of higher cost sharing for health insurance, lower wage growth, or lower growth in other employee benefits.     

Third party buying: the trend and the consequences

The trend toward more buying of health insurance, life insurance, and pension or annuity plans through employers brings up problems of consumer sovereignty , problems of the incentives of service providers, and problems of availability of the services of insurance which are only available through group buying. In order to specify what social indicators would be useful in this area, this paper analyzes the incentive systems for consumers, for service providers, and for employers as they are affected by the trend toward third party buying. It assesses the indicators that are available on the trend, and the literature in health economics which tried to analyze the impact of the trend on the provision of health services and health costs. On this basis, needed social indicators for policy assessment in the area of third party buying are suggested.     

Defined contribution health benefits

This Issue Brief discusses the emerging issue of "defined contribution" (DC) health benefits. The term "defined contribution" is used to describe a wide variety of approaches to the provision of health benefits, all of which have in common a shift in the responsibility for payment and selection of health care services from employers to employees. DC health benefits often are mentioned in the context of enabling employers to control their outlay for health benefits by avoiding increases in health care costs. DC health benefits may also shift responsibility for choosing a health plan and the associated risks of choosing a plan from employers to employees. There are three primary reasons why some employers currently are considering some sort of DC approach. First, they are once again looking for ways to keep their health care cost increases in line with overall inflation. Second, some employers are concerned that the public "backlash" against managed care will result in new legislation, regulations, and litigation that will further increase their health care costs if they do not distance themselves from health care decisions. Third, employers have modified not only most employee benefit plans, but labor market practices in general, by giving workers more choice, control, and flexibility. DC-type health benefits have existed as cafeteria plans since the 1980s. A cafeteria plan gives each employee the opportunity to determine the allocation of his or her total compensation (within employer-defined limits) among various employee benefits (primarily retirement or health). Most types of DC health benefits currently being discussed could be provided within the existing employment-based health insurance system, with or without the use of cafeteria plans. They could also allow employees to purchase health insurance directly from insurers, or they could drive new technologies and new forms of risk pooling through which health care services are provided and financed. DC health benefits differ from DC retirement plans. Under a DC health plan, employees may face different premiums based on their personal health risk and perhaps other factors such as age and geographic location. Their ability to afford health insurance may depend on how premiums are regulated by the state and how much money their employer provides. In contrast, under a DC retirement plan, employers' contributions are based on the same percentage of income for all employees, but employees are not subject to paying different prices for the same investment.     

The Patient Protection and Affordable Care Act: A Dissenting Opinion

This paper asks whether the Patient Protection and Affordable Care Act achieves its goals of significantly expanding health insurance coverage, while reducing costs and increasing the quality of the care provided. An examination of the early results and current future projections suggests that while PPACA will increase the number of Americans with health insurance, it will fall significantly short of universal coverage. In addition, PPACA fails to control health care costs, and will likely result in higher costs for government, as well as many businesses, and individuals. The author concludes that PPACA is not the most effective vehicle for achieving US health care reform, and that a more market-oriented approach offers a better alternative.     

Inequities in health outcomes and access to health care in South Africa: a comparison between persons with and without disabilities

Health is a fundamental human right and if health care is to be universal and equitable it should not be less accessible to some sectors of society than to others. The objective of this study was to compare health outcomes and access to health care between persons living with disabilities and their non-disabled counterparts. The research was based on secondary data analysis of wave 1 of the National Income Dynamic Survey. Results from the study indicated that people with disabilities reported a higher incidence of communicable and non-communicable diseases, lower access to medical insurance and greater use of public health care than their non-disabled counterparts. In conclusion, the findings highlight the inequities in health outcomes and access to health services for people with disabilities and emphasise the need for disability-friendly health care policies that reduce barriers to accessing health care.     

Expanding the focus of health insurance education for Medicare beneficiaries

Health insurance education plays an important role in helping consumers make informed decisions about their need for supplemental coverage. This article reviews findings on the knowledge of Medicare beneficiaries about their health insurance coverage. Then, current health insurance education programs are examined with regard to their ability to meet the needs of a competition-based public policy. Barriers outside the control of individuals that impede the growth of the long-term care insurance market are identified and the need for an alternative, broader form of health insurance education is suggested. Changes in the scope and content of health insurance education are proposed that would educate the elderly to their own needs as well as the larger policy issues. An expanded model of education based on the concept of the Swedish study circle is discussed to illustrate the possibility of combining individual knowledge and public debate about complex social issues.     

Expanding the Focus of Health Insurance Education for Medicare Beneficiaries

Health insurance education plays an important role in helping consumers make informed decisions about their need for supplemental coverage. This article reviews findings on the knowledge of Medicare beneficiaries about their health insurance coverage. Then, current health insurance education programs are examined with regard to their ability to meet the needs of a competition-based public policy. Barriers outside the control of individuals that impede the growth of the long-term care insurance market are identified and the need for an alternative, broader form of health insurance education is suggested. Changes in the scope and content of health insurance education are proposed that would educate the elderly to their own needs as well as the larger policy issues. An expanded model of education based on the concept of the Swedish study circle is discussed to illustrate the possibility of combining individual knowledge and public debate about complex social issues.     

An Examination of Older Immigrants' Use of Dental Services in the United States

The recent influx of immigrants aged 65 and older in the United States triggers an increasing need to understand older immigrants' dental services use. This paper uses data (n = 9,617) from the 2004 and 2006 waves of the Health and Retirement Study to examine the dental services use of older Americans. In particular, this study focuses on differences in dental services use between immigrants and natives and potential contributing factors. Multivariate logistic regression analyses showed, contrary to expectation, that older immigrants were more likely to use dental services than older natives despite numerous barriers (odds ratio = 1.30 in 2004). The results in 2006 confirmed these findings. The results from 2004 and 2006 analyses showed dental insurance coverage, sex, and marital status were associated differently with dental services use for immigrants and natives. Implications for current oral health policies and future research of older Americans are discussed, as well as methods for meeting older immigrants' growing dental services needs.     

Does Health Insurance Premium Exemption Policy for Older People Increase Access to Health Care? Evidence from Ghana

Aging in Sub-Saharan Africa causes major challenges for policy makers in social protection. Our study focuses on Ghana, one of the few Sub-Saharan African countries that passed a National Policy on Aging in 2010. Ghana is also one of the first Sub-Saharan African countries that launched a National Health Insurance Scheme (NHIS; NHIS Act 650, 2003) with the aim to improve access to quality health care for all citizens, and as such can be considered as a means of poverty reduction. Our study assesses whether premium exemption policy under the NHIS that grants non-payments of annual health insurance premiums for older people increases access to health care. We assessed differences in enrollment coverage among four different age groups (18–49, 50–59, 60–69, and 70+). We found higher enrollment for the 70+ and 60–69 age groups. The likelihood of enrollment was 2.7 and 1.7 times higher for the 70+ and 60–69 age groups, respectively. Our results suggest the NHIS exemption policy increases insurance coverage of the aged and their utilization of health care services.