Higher Medical Expenditures Research Articles

Impact of dialysis dependence on prognosis in patients with myocardial infarction: An 11-year population-based study.

In this study we aimed to directly compare the short and long-term prognosis of nondialysis patients with chronic kidney disease (CKD), dialysis patients, and patients with preserved renal function after acute myocardial infarction (AMI).AMI in patients with CKD is a catastrophic event associated with high medical expenditures and dismal survival. However, there is little research comparing post-AMI outcomes between patients with CKD who were and were not receiving dialysis.The retrospective cohort study included patients with AMI (n = 158,125) in the Taiwan's National Health Insurance Research Database who were treated March 1998 and December 2009. Patients were classified into a nondialysis CKD group (n = 6300), dialysis group (n = 5140), and a control group (n = 146,685). The clinical characteristics, in-hospital events, and long-term outcomes of these 3 groups were compared separately using a multivariable Cox proportional hazard model.The risks of in-hospital death and 2-year all-cause mortality were the highest in the dialysis group, followed by the nondialysis CKD group, and were the lowest in the control group. The 1-year risk of myocardial infarction did not differ among the 3 study groups, but the 2-year risk of myocardial infarction was higher in the dialysis group than in the control group (hazard ratio, 1.13; 95% confidence interval, 1.03-1.24; P = .010).Patients with CKD experienced adverse short- and long-term outcomes after acute myocardial infarction. Patients with CKD, especially those who are dialysis dependent, may require more intensive management to improve their post-AMI clinical outcomes.

Predictors of Smartphone Uses for Health Information Seeking in the Korean Elderly

ABSTRACTThe purpose of this research is to examine the predictors of smartphone uses for health information–seeking (SHIS) in the Korean elderly. This research applies the comprehensive model of information seeking as a theoretical framework. Data reported in this study are from the 2016 Dementia Literacy Survey, and 235 elderly smartphone users were included in logistic regression model. SHIS was significantly predicted by younger age, higher education levels, having a regular exercise, higher medical expenditures, and health literacy. The findings of this study can help social workers understand the specific features of health information seeking in the Korean elderly.

New semiparametric method for predicting high-cost patients.

Motivated by the Medical Expenditure Panel Survey containing data from individuals' medical providers and employers across the United States, we propose a new semiparametric procedure for predicting whether a patient will incur high medical expenditure. Problems of the same nature arise in many other important applications where one would like to predict if a future response occurs at the upper (or lower) tail of the response distribution. The common practice is to artificially dichotomize the response variable and then apply an existing classification method such as binomial regression or a classification tree. We propose a new semiparametric prediction rule to classify whether a future response occurs at the upper tail of the response distribution. The new method can be considered a semiparametric estimator of the Bayes rule for classification and enjoys some nice features. It does not require an artificially dichotomized response and better uses the information contained in the data. It does not require any parametric distributional assumptions and tends to be more robust. It incorporates nonlinear covariate effects and can be adapted to construct a prediction interval and hence provides more information about the future response. We provide an R package plaqr to implement the proposed procedure and demonstrate its performance in Monte Carlo simulations. We illustrate the application of the new method on a subset of the Medical Expenditure Panel Survey data.

Factors associated with outpatient experience of Chinese public hospitals: a cross-sectional study

BackgroundPatient experience is an important indicator of health-care quality from the patient's view and has a better evidence-based characteristic than patient satisfaction. In this study, we compared the experience among different outpatient groups and explored the influencing factors of the outpatient experience to improve outpatient experience and the health-service quality of public hospitals in China. MethodsSix comprehensive public hospitals in Hubei, China, were chosen by typical sampling method and including three tertiary hospitals and three secondary hospitals. In each hospital, 100 outpatients were invited to participate in the survey when they ended their visits. The questionnaire had good reliability and validity (the Cronbach's α coefficient of the overall questionnaire was 0·948). The inclusion criteria of participants were: (1) aged ≥18 years; (2) visit procedure were completed; and (3) ability to describe their experience accurately. A five-point Likert scale was used in the questionnaire. Outpatient experience score was calculated by transforming the five-point into hundred-marked system (score 5=100 points; score 4=75 points; score 3=50 points; scorer 2=25 points; score 1=0 points. 100 points means best experience, 0 points means worst experience. The cross-sectional survey was done by data collection. One-way Anova and independent t-test were used to assess the difference between demographic variables in outpatient experience. Multiple linear regression was used to assess how those demographic variables affected the experience. This study was approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (IORG number IORG0003571). FindingsOf the 600 participants who were eligible for inclusion, 17 were excluded because of missing data in the questionnaires and logical errors, and 583 eligible questionnaires were included for further analysis. 176 respondents had a poor experience (score<50) when they visited hospitals. The mean score of medical cost experience was the lowest (61·16 [SD 0·86]), whereas health information got the highest experience score (71·37 [0·79]). Age (β=0·213, p<0·0001), type of payment (β=0·159, p<0·0001), and the self-rated health status (β=0·261, p<0·0001) were associated with outpatient experience. Outpatients older than 65 years had the highest experience score (74·25 [1·88]), whereas outpatients paying out-of-pocket had the lowest experience score (64·68 [0·81]) among all participants. Outpatients with good self-rated health status had the highest experience score (72·63 [0·99]) among different self-rated health status groups. No association was found between sex, education, average income, residence, and marital status and experience score (p<0·0001). InterpretationYoung outpatients (younger than 45 years) who paid entirely out-of-pocket and who had poor self-rated health status should be particularly focused on to improve the outpatient experience. Outpatients with poor self-rated health status are more prone to discomfort, anxiety, fear, and other negative emotions when they visit hospitals, resulting in lower experience scores than outpatients with good self-rated health status when they receive the same health service. High medical expenditure results in the financial burden of patients and their family. Thus, expanding medical insurance coverage and reimbursement ratio can improve the outpatient experience effectively. Additionally, strengthening referral policy is warranted, which makes it possible for doctors to spend more energy on patients to improve their experience. FundingFundamental Research Funds for the Central Universities (2017WKYXQY004). The funders did not participate in study design, data collection, and analysis.

Medical costs in patients with heart failure after acute heart failure events: one-year follow-up study

Aims: This study investigated annual medical costs using real-world data focusing on acute heart failure.Methods: The data were retrospectively collected from six tertiary hospitals in South Korea. Overall, 330 patients who were hospitalized for acute heart failure between January 2011 and July 2012 were selected. Data were collected on their follow-up medical visits for 1 year, including medical costs incurred toward treatment. Those who died within the observational period or who had no records of follow-up visits were excluded. Annual per patient medical costs were estimated according to the type of medical services, and factors contributing to the costs using Gamma Generalized Linear Models (GLM) with log link were analyzed.Results: On average, total annual medical costs for each patient were USD 6,199 (±9,675), with hospitalization accounting for 95% of the total expenses. Hospitalization cost USD 5,904 (±9,666) per patient. Those who are re-admitted have 88.5% higher medical expenditure than those who have not been re-admitted in 1 year, and patients using intensive care units have 19.6% higher expenditure than those who do not. When the number of hospital days increased by 1 day, medical expenses increased by 6.7%.Limitations: Outpatient drug costs were not included. There is a possibility that medical expenses for AHF may have been under-estimated.Conclusion: It was found that hospitalization resulted in substantial costs for treatment of heart failure in South Korea, especially in patients with an acute heart failure event. Prevention strategies and appropriate management programs that would reduce both frequency of hospitalization and length of stay for patients with the underlying risk of heart failure are needed.

Complementary traditional Chinese medicine use in Children with cerebral palsy: a nationwide retrospective cohort study in Taiwan

BackgroundComplementary traditional Chinese medicine (TCM) has been used to treat patients with cerebral palsy (CP). However, large-scale surveys examining its use in the treatment of CP and associated disorders are lacking.MethodsWe enrolled 11,218 patients ≤ 18 years of age with CP in the Taiwanese National Health Insurance Research Database from 1995 to 2011. Patients were categorized as TCM users (n = 6,997; 62.37%) and non-TCM users (n = 4,221; 37.63%) based on the inclusion of TCM in their treatment plan.ResultsChildren with higher proportions of complementary TCM use were male, younger, and lived in urbanized areas. Most TCM users (n = 5332, 76.2%) visited TCM outpatient departments more than 20 times per year. In both groups, the three most common reasons for clinical visits were problems of the nervous system, respiratory system, and digestive system. Acupuncture was commonly used in problems of injury, musculoskeletal system and connective tissue, and nervous system. Chinese herbal medicine was used to improve the primary symptoms of CP in patients, as well as its associated disorders. The incidence rate ratios in allergic rhinitis, dyspepsia, menstrual disorders, and musculoskeletal system and connective tissue diseases among TCM users were significantly higher than non-TCM users. Although patients receiving complementary TCM therapies had higher medical expenditure for utilizing outpatient clinical consultations, their medical costs for visiting ER and hospitalization were significantly lower than that of non-TCM user within one year of the diagnosis of CP.ConclusionThis study was a large-scale survey to characterize patterns of complementary TCM use among children with CP. The complementary use of TCM in children with CP was considerably high. Future clinical trials and basic researches can be developed based on the findings of this study.

Abstract 045: Incremental Medical Expenditures Attributable to Hypertension in China’s Middle-aged and Elderly Population

Background: Hypertension is a prevalent and costly health condition in China. We sought to estimate the inpatient and outpatient expenditures attributable to hypertension among China’s middle-aged and elderly population. Methods: Data for this study was from the China Health and Retirement Longitudinal Survey (CHARLS) 2011 and 2013, a comprehensive and nationally representative survey of Chinese residents aged 45 and older. We selected our study sample among respondents who had complete information on biomarker blood pressure measures and had not developed hypertension in 2011. Hypertension in 2013 was identified in the following steps: (a) He/she had an average systolic blood pressure of ≥ 140 mmHg, and/or an average diastolic blood pressure of ≥ 90 mmHg and/or (b) He/she was currently taking anti-hypertensive medications. The outcome measures were total inpatient expenditures in the past year and outpatient expenditures in the last month. We used a difference-in-difference approach, by classifying those with hypertension as treatment group, and those without hypertension as control group. A propensity score weighting approach was applied to balance out the population characteristics between the treatment and control groups. Linear regression was used to examine the incremental medical expenditures attributable to hypertension. Results: The final sample contained 7827 observations. For those who developed hypertension between 2011 and 2013, their inpatient expenditure increased faster and on average, the hypertension-attributable inpatient expenditures were¥129.5 ($20.9) per person in a year. When we restricted the sample to those with only positive inpatient expenditures, the incremental expenditure reached ¥1526.2 ($246.2) a year. On average, the hypertension-attributable outpatient expenditures were ¥31.0 ($5) per person each month. When we only considered the sample with positive outpatient expenditures, the incremental outpatient expenditures reached ¥276.1 ($44.5) in a month. Conclusions: Having hypertension was associated with substantially higher medical expenditures for both inpatient and outpatient care services. Given that the prevalence of hypertension among adults aged 45 and older was 33% (180 million) in China), the estimated national medical expenditures attributable to hypertension would be as high as ¥90.3 billion ($14.6 billion) per year.

Diagnosis, prevention, and management of bronchiolitis in children: review of current controversies.

Viral bronchiolitis is a common and costly condition among young children worldwide, contributing to high medical expenditures in industrialized countries and significant mortality in low-income countries. Much research has focused on therapy for this disease entity, though the standard of care remains merely supportive. Current areas of active research include the nuances of defining bronchiolitis, a deeper exploration of causative viruses, the role and development of preventive strategies, and associated long-term outcomes. This review aims to explore relevant recent literature, and particularly to focus on active areas of uncertainty and controversy.

Over-reaching beyond disease activity: the influence of anxiety and medical economic burden on health-related quality of life in patients with inflammatory bowel disease.

PurposeMany patients with inflammatory bowel disease (IBD) have impaired health-related quality of life (HRQOL). The influence of psychological and economic factors on HRQOL has not been fully elucidated in IBD. Therefore, we aimed to identify the predictors of HRQOL in an IBD cohort.Patients and methodsThis was a cross-sectional cohort study of patients presenting to our tertiary IBD center. HRQOL was measured using the 36-item Short Form Health Survey (SF-36) and the Inflammatory Bowel Disease Questionnaire (IBDQ). Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). Perceived stress and perceived social support were also assessed by standardized scales. Demographic, socioeconomic and clinical data were obtained from a prespecified questionnaire and patients’ medical records. Univariate analyses and multiple regression analysis were performed to identify predictors of HRQOL.ResultsA total of 242 IBD patients were recruited, and the questionnaire return rate was 90.5% (219/242). The prevalence rates of anxiety and depression were 24.7% and 17.4%, respectively. In all, 30.6% of the patients spent over half of their income to cover medical costs. Multivariate analysis revealed that anxiety symptoms (P<0.001), active disease (P<0.001) and higher medical expenditures (P=0.001) were strong and independent predictors of reduced HRQOL.ConclusionPsychological factors and costs of medical care strongly impair HRQOL in IBD, independent of the disease activity. Psychological counseling and socioeconomic support programs should be considered for integration into the management of IBD patients.

The Impacts of Persistent Behaviour and Cost-Sharing Policy on Demand for Outpatient Visits by the Elderly: Evidence from Taiwan’s National Health Insurance

Establishing how to reform the cost-sharing policy to reduce waste in health-care utilisation is an important issue, especially in an ageing society. Using a generalised method of moments (GMM) for the dynamic panel count model during the period 1997–2007 from the National Health Insurance (NHI) programme in Taiwan, this study examines the effects of persistent behaviour and the cost-sharing policy on outpatient medical utilisation for Taiwan’s elderly. Empirically, we find positive and negative coefficient estimations for persistent behaviour and price elasticity, respectively, thereby creating a clear trade-off effect of the cost-sharing policy on health-care utilisation. Furthermore, our study finds that the short-run price elasticity (−0.2561) is always smaller than long-run elasticity (−0.4052). Finally, the empirical results indicate that the price elasticity for females and patients with high medical expenditure, low income, high chronic diseases and good health is higher than that for males and patients with low medical expenditure, high income, low chronic diseases and bad health.

Research on 2041 Cases of High Inpatient Expenditure and Influence Factors during 3 Years in a Single Center.

Background:The study was to explore the causes of high inpatient expenditure through analyzing the distribution characteristics as well as the influence factors of high inpatient expenditure cases during 3 years within a Grade-A tertiary hospital through various aspects and multiple angles, thus identifying the major influence factors for high medical expenditure to develop further research.Methods:We retrospectively studied 2041 inpatient cases which cost more than RMB 100,000 Yuan per case in a Grade-A tertiary hospital from 2013 to 2015. We analyzed the compositions of the medical cost to evaluate the major factors that cause the high inpatient expenditure. All the data and materials were collected from medical record system, and the statistical methods included t-test, variance of analysis, and multivariate linear regression.Results:The average cost of the 2,041 cases was RMB 152,173 Yuan for medicines and materials of medical costs, which respectively accounted for 33.03% and 32.32% of the total cost; and the average length of hospital stay was 28.39 days/person. Diseases of skeletal and muscular system, circulatory system, and tumor were the top three disease categories of high inpatient expenditure, which accounted for 39.00%, 33.46%, and 18.03%, respectively. Complications, criticality of the disease, gender of the patients, the occurrence of death, and the excessive length of hospital stay all had great impacts on average medical expenditure, while age, hospital infection, and surgery showed no significant impact on average medical cost.Conclusions:The main factors for high inpatient expenditure included the inadequate use of high-value medicines and materials, lacking cost control measures within the hospital, the excessive length of hospital stay for inpatients, and the unnecessary treatment for the patients.

Regular Insulin Administered With the V-Go Disposable Insulin Delivery Device in a Clinical Diabetes Setting: A Retrospective Analysis of Efficacy and Cost.

People with diagnosed diabetes incur high average medical expenditures of ∼$13,700 per year, creating a cost burden for themselves and their health plan insurers (1). According to the American Diabetes Association (ADA), 97% of the $245 billion cost for diabetes care in the United States is provided by government and commercial insurance payers (2). The cost of diabetes therapy, including insulin, accounts for 12% of the total cost of diabetes care, and managing diabetes to prevent complications is becoming less affordable (2). Insulin is still considered the most potent glucose-lowering agent available. ADA and the European Association for the Study of Diabetes recently issued guidelines for the treatment of type 2 diabetes that identified insulin replacement therapy as a key component of effective diabetes management over the course of the disease (3). The use of rapid-acting insulin analogs (RAIs) has surpassed the use of regular human insulin (RHI) in the majority of basal-bolus and bolus-only therapy regimens (4). Ninety-six percent of patients with type 2 diabetes who take insulin in the United States now use an analog insulin for basal and/or prandial coverage—an increase from just 19% in 2000 (5). This increase in utilization may be the result of many factors, including the pharmacokinetic differences among the insulins, marketing developments, and formulary health plan coverage (6). Along with this increase in the utilization of RAIs, there has been an increase in costs to patients and health plans. This is especially apparent when the costs of RAIs are compared to those of RHI as a therapy alternative. The steep increase in the cost of RAIs has led many patients to partially or totally discontinue their insulin therapy because of affordability issues (1). Several studies have shown that low adherence to diabetes therapy is also associated with higher medication costs …

The financial burden and health care utilization patterns associated with amnestic mild cognitive impairment

IntroductionIndividuals with amnestic mild cognitive impairment (aMCI) are at elevated risk of developing Alzheimer's disease (AD) dementia. MethodsWith data from the Aging, Demographics, and Memory Study, we used the Clinical Dementia Rating Sum of Boxes classifications to conduct a cross-sectional analysis assessing the relationship between cognitive state and various direct and indirect costs and health care utilization patterns. ResultsPatients with aMCI had less medical expenditures than patients with moderate and severe AD dementia (P < .001) and were also significantly less likely to have been hospitalized (P = .04) and admitted to nursing home (P < .001). Compared to individuals with normal cognition, patients with aMCI had significantly less household income (P = .018). DiscussionPatients with aMCI had lower medical expenditures than patients with AD dementia. Poor cognitive status was linearly associated with lower household income, higher medical expenditures, higher likelihood of nursing and home care services, and lower likelihood of outpatient visits.

Medical Spending in France: Concentration, Persistence and Evolution before Death

AbstractThis paper studies medical spending in France from three perspectives: concentration, persistence, and evolution before death. We use claims data from a representative sample of over 500,000 individuals covered by the National Health insurance scheme, from 2008 to 2013. These data contain individual‐level information (gender, age, date of death), some clinical information and detailed information on each medical treatment (inpatient, outpatient, drugs). Medical spending in France is highly concentrated. In 2013, 10 per cent of the population accounted for 62 per cent of all health care spending. In addition, the concentration of medical expenditure increased between 2008 and 2013. The concentration of insurance reimbursement, however, is even greater, indicating that French social health insurance redistributes income from the healthy to the unhealthy. The serial correlation of health care expenditures appears relatively high between adjacent years, but not surprisingly decreases over time. Decedents have high medical expenditures – on average, eight times those of survivors – and resources devoted to health care in the last three years of life represent, on average, 22 per cent of lifetime medical spending. Decedents’ expenditures decrease with age after 55 years old.

Outcomes After Nonobstetric Surgery in Pregnant Patients: A Nationwide Study

ObjectiveTo evaluate outcomes after nonobstetric surgical procedures in pregnant patients. MethodsWe conducted a retrospective cohort study of 5591 pregnant women who underwent nonobstetric surgical procedures using Taiwan's National Health Insurance Research Database 2008-2012 claims data. Using a propensity score matching procedure, 22,364 nonpregnant women were selected for comparison. Logistic regression was used to calculate the odds ratios (ORs) and 95% CIs of postoperative complications and in-hospital mortality associated with pregnancy. ResultsPregnant women had higher risks of postoperative septicemia (OR=1.75; 95% CI, 1.47-2.07), pneumonia (OR=1.47; 95% CI, 1.01-2.13), urinary tract infection (OR=1.29; 95% CI, 1.08-1.54), and in-hospital mortality (OR=3.94; 95% CI, 2.62-5.92) compared with nonpregnant women. Pregnant women also had longer hospital stays and higher medical expenditures after nonobstetric surgical procedures than controls. Higher rates of postoperative adverse events in pregnant women receiving nonobstetric surgery were noted in all age groups. ConclusionSurgical patients with pregnancy showed more adverse events, with a risk of in-hospital mortality approximately 4-fold higher after nonobstetric surgery compared with nonpregnant patients. These findings suggest the urgent need to revise the protocols for postoperative care for this population.

Longer Delay From Chronic Pain to Spinal Cord Stimulation Results in Higher Healthcare Resource Utilization

A shorter delay time from chronic pain diagnosis to spinal cord stimulation (SCS) implantation may make it more likely to achieve lasting therapeutic efficacy with SCS. The objective of this analysis was to determine the impact of pain-to-SCS time on patients' post-implant healthcare resource utilization (HCRU). A retrospective observational study was performed using a real-world patient cohort derived from MarketScan(®) Commercial and Medicare Supplemental claims data bases from April 2008 through March 2013. The predictor variable was the time from the first diagnosis of chronic pain to permanent SCS implant. Using multivariable analysis, we studied the impact of pain-to-SCS time on HCRU in the first year post-implant. For some regression tests, patients were grouped into terciles by HCRU. A total of 762 patients met inclusion criteria, with a median pain-to-SCS time of 1.35 years (Q1: 0.8, Q3: 1.9). For every one-year increase in pain-to-SCS time, the odds increased by 33% for being in the high medical expenditures group (defined using the upper tercile: $4133 over above) over the low group (first lower: $603 or less). The odds increased by 39% for being in the high opioid prescriptions group (10-58 prescriptions) over the low group (0-1). The odds increased by 44% and 55%, respectively, for being in the high office visits (8-77) or hospitalizations (3-28) group over the low office visits (0-2) or hospitalizations (0) group. HCRU increased in the year following SCS implantation with longer pain-to-SCS time. These results suggest that considering SCS earlier in the care continuum for chronic pain may improve patient outcomes, with reductions in hospitalizations, clinic visits, and opioid usage.

Combined Effects of Chewing Ability and Dietary Diversity on Medical Service Use and Expenditures.

To examine whether chewing ability affects healthcare use and expenditure and whether improving dietary quality alleviates any such effects. Prospective cohort. The Elderly Nutrition and Health Survey in Taiwan (1999-2000), a nationwide community-based survey of people aged 65 and older. Individuals aged 65 and older (N=1,793; 903 men, 890 women). Chewing ability (satisfactory or unsatisfactory) was assessed using a questionnaire, and dietary quality was assessed using a 24-hour dietary recall as a dietary diversity score. Data on annual medical use and expenditures from the interview date until December 31, 2006, were collected from National Health Insurance claims. Generalized linear models were used to assess the associations between chewing ability, dietary quality, and annual medical usage or expenditure. After 8years of follow-up, older adults with unsatisfactory chewing ability had considerably higher emergency, hospitalization, and total medical expenditures. Older adults with unsatisfactory chewing ability and a poor diet used fewer annual preventive care and dental services than those with satisfactory chewing ability but had longer hospital stays and higher expenditures. After adjusting for covariates, unsatisfactory chewing ability resulted in significantly longer hospital stays in participants with a poor diet (β=2.34, 95% confidence interval=2.02-2.71, P<.001). Unsatisfactory chewing ability and a less-diverse diet together are associated with longer hospital stays and higher medical expenditures.

New cooperative medical scheme decreased financial burden but expanded the gap of income-related inequity: evidence from three provinces in rural China.

BackgroundSubsidizing healthcare costs through insurance schemes is crucial to overcome financial barriers to health care and to avoid high medical expenditures for patients in China. The health insurance could decrease financial risk by less out-of-pocket (OOP) payment, but not promise the protection equity. With the growth of New Cooperative Medical Scheme (NCMS) financing and coverage since 2008, the protection effectiveness and equity of the modified NCMS policies on financial burden should be further evaluated.MethodsA cross-sectional household survey was conducted in Zhejiang, Hubei, and Chongqing provinces by multi-stage stratified random sampling in 2011. A total of 1,525 households covered by the NCMS were analyzed. The protection effectiveness and protection equity of NCMS was analyzed by comparing the changes in health care utilization and medical expenditures, and the changes in the prevalence of catastrophic health expenditure (CHE) and its concentration indices (CIs) between pre- and post-NCMS reimbursement, respectively.ResultsThe medical financial burden was still remarkably high for the low income rural residents in China due to high OOP payment, even after NCMS reimbursement. In Hubei province, the OOP payment of the poorest quintile was almost same as their households’ annual expenditures. Even it was higher than their annual expenditures in Chongqing municipality. Effective reimbursement ratio of both outpatient and inpatient services were far lower than nominal reimbursement ratio originally designed by NCMS plans. After NCMS reimbursement, the prevalence of CHE was considerably high in all three provinces, and the absolute values of CIs were even higher than those before reimbursement, indicating the inequity exaggerated.ConclusionPolicymakers should further modify NCMS policy in rural China. The high OOP payment could be decreased by expanding the drug list and check directory for benefit package of NCMS to minimize the gap between nominal reimbursement ratio and effective reimbursement ratio. And the increase in medical expenditures should be controlled by monitoring excess demand from both medical service providers and patients, and changing fee-for-service payment for providers to a prospective payment system. Service accessibility and affordability for vulnerable rural residents should be protected by modifying regressive financing in NCMS, and by providing extra financial aid and reimbursement from government.

A Difference in Copayment and the Physician Agency Problem: Empirical Evidence from Japan

I use two nationally representative sets of medical claim data from the Ministry of Health, Labour, and Welfare in Japan to examine how medical assistance system assignment affects beneficiary utilization of short-term inpatient health care. Since assignment of public assistance by local government is not random but is subject to means testing, I estimate instrumental variable models to control for this endogeneity. I find that monthly medical expenditure is significantly higher for medical assistance patients than that for universal public health insurance patients, but its implied price elasticity ranges from -0.158 to -0.081, which is equivalent to or slightly lower than the elasticity for the RAND health insurance experiment and for the recent Japanese studies. If the effect of patients with high medical expenditure is excluded, the price elasticity becomes more inelastic. However, there is no significant difference in length of hospital stay between medical assistance and health insurance patients. These findings imply that the medical assistance patients are provided with more intensive inpatient treatments than health insurance patients during short-term hospitalization.

Abstract 244: Sex-based Differences in Economic and Health-related Burden of Depression on Adults With Cardiovascular Disease

Background: Depression is commonly present in patients with cardiovascular disease (CVD). Among those with established CVD, depression is more common in women and associated with worse outcome. However, how depression affects overall health care expenditures, as well as whether depression among women has a greater impact on medical costs, has not been well studied, which is the aim of the present study. Methods: The 2012 Medical Expenditure Panel Survey was analyzed to explore this project. Variables of interest were defined as CVD (coronary artery disease, stroke, peripheral artery disease, dysrhythmias or heart failure) and depression diagnoses, ascertained by ICD-9-CM codes (410, 413, 433-437, 427-28, 440, 443, 447 and 296, 311, respectively). We restricted our study population to non-institutionalized adults ≥ 18 years of age. Two-part models were utilized to study cost data; a generalized linear model with gamma distribution and link log was used to assess the mean expenditure per capita for each sex/depression status. Results: 27,288 surveyed persons constituted our study population (mean age 67 ± 12.4, 46% female), translating to an approximate of 231 million people across the U.S. Overall, CVD was noted in 15.6 million, of which 18% were patients with depression (2.9 million). Of this nationally representative sample, those with CVD were 86% more likely to be diagnosed with depression (OR 1.86, 95% CI 1.51, 2.28, p&lt;0.001) than Non-CVD. Additionally, among CVD individuals, females were 66% more likely be diagnosed with depression than males (OR 1.66, 95% CI 1.23, 2.23, p=0.001). CVD diagnosis was independently associated with higher healthcare costs among individuals with depression. Moreover, on adjusted analysis, females with depression were also associated with $4,380.14 higher medical costs than those without depression (Table 1). When comparing female vs. males with CVD and depression diagnoses, adjusted mean expenditure per capita was $14,162 (95% CI 10,211 - 18,112) and $11,325 (95% CI 7,769 - 14,881), respectively. Conclusion: CVD patients, especially women, were more likely to have depression, and had considerable higher medical expenditures. The results reinforce the paramount importance of assessing and managing depression among those with CVD to favorably impact healthcare costs.