Public Insurance Schemes Research Articles

Cost of shifting from healthcare to long-term care in later life across major diseases: analysis of end-of-life care during the last 24 months of life.

Aim: To evaluate the costs associated with healthcare and long-term care during the last 24 months before death according to major disease groups.Methods: Individual data regarding healthcare and long-term care costs according to public insurance schemes during the last 24 months before death among all decedents older than 75 years reported in a city in Japan between April 1, 2010 and March 31, 2014 were identified; the data for nine major diseases were then analyzed.Results: For the 2149 decedents studied, the average healthcare costs per capita in the last 24 months of life for moderately-old (75 to 84 years) and extremely-old (85 years and older) decedents was 4,135,467 JPY and 2,493,001 JPY, respectively, while the average long-term care costs per capita for 24 months was 1,300,710 JPY and 2,723,239 JPY, respectively. The total costs (healthcare and long-term care combined) ranged from 9,169,547 JPY for chronic kidney disease to 5,023,762 JPY for ischemic heart disease. In all the diseases studied, the moderately-old decedents incurred higher healthcare costs while the extremely-old decedents incurred higher long-term care costs. However, for the care costs of chronic lower respiratory diseases, this pattern was not observed.Conclusion: A shift in expenditure from healthcare to long-term care as the decedents’ age increased was observed in major diseases, with some exceptions.

Deportation of non-citizen military veterans: A critical analysis of implications for the right to health

ABSTRACTMilitary personnel are commonly exposed to health-harming conditions during their service, resulting in higher rates of physical and mental health conditions compared with the general population. In an era of mass deportations, it is notable that non-citizen military veterans are not exempt from deportation. We utilised a human rights framework to conduct a critical analysis of potential health consequences of deportation for U.S. military veterans, identifying three ways in which veterans’ rights to health may be constrained through deportation. First, honourably discharged deported veterans may be denied access to free or subsidised Veterans Affairs health services to which they would likely otherwise be entitled. Second, availability of and access to healthcare may be limited for reasons including barriers to enrolling in public insurance schemes, challenges navigating unfamiliar health systems and stigma and discrimination towards deported migrants. Finally, quality of available care may be sub-optimal due to limited expertise in service-related health issues and lack of evidence-based treatment for some health conditions (e.g. substance abuse/dependence). Binational multi-sectoral efforts are necessary to ensure that the rights to health of deported military veterans are adequately protected.

Comparing Strategies for Providing Child and Youth Mental Health Care Services in Canada, the United States, and The Netherlands.

This paper reviews how child and youth mental health care services in Canada, the United States, and the Netherlands are organized and financed in order to identify systems and individual-level factors that may inhibit or discourage access to treatment for youth with mental health problems, such as public or private health insurance coverage, out-of-pocket expenses, and referral requirements for specialized mental health care services. Pathways to care for treatment of mental health problems among children and youth are conceptualized and discussed in reference to health insurance coverage and access to specialty services. We outline reforms to the organization of health care that have been introduced in recent years, and the basket of services covered by public and private insurance schemes. We conclude with a discussion of country-level opportunities to enhance access to child and youth mental health services using existing health policy levers in Canada, the United States and the Netherlands.

Uncertain altruism and the provision of long term care

When family assistance is uncertain, benefits cannot be conditioned on family aid. We study the role of private and public LTC insurance in this environment and compare the properties and optimality of the topping up versus opting out public insurance schemes. Under topping up, the required LTC is less than full insurance and should be provided publicly unless private insurance market for dependency is fair. With an opting out scheme, there will be three possible equilibria depending on the children's degree of altruism. These imply: full LTC insurance with no aid from children, less than full insurance just enough to induce aid, and full insurance with aid. Fair private insurance can support only the first equilibrium. Opting out policies are self-targeted and dominate topping up schemes when the degree of children's altruism is sufficiently large. However, when the degree of altruism is small the dominance goes in the opposite direction.

Hospital Contracting Reforms: The Lebanese Ministry of Public Health Experience

—Since 2009, the Ministry of Public Health (MoPH) in Lebanon has been going through a major reform initiative to improve its contracting system with private and public hospitals. The private sector is the main provider of hospital care in the country and the main contractor to the MoPH for the provision of curative care. As an “insurer of last resort,” the MoPH plays an important role in providing hospital coverage to 53% of the population who lack coverage by private or public insurance schemes, through contractual arrangements with the private sector. Historically, the MoPH used hospital accreditation as the basis for contracting and for determining the reimbursement rate. However, recent studies by the MoPH showed that reimbursing hospitals solely on accreditation results was not appropriate and led to an unfair and inefficient reimbursement system. The reform program included the development of several components, in particular, an automated billing system, a utilization review function, standardized admission criteria, and a hospital case mix index that accounts for case complexity. In 2014, the MoPH started implementing a new mixed-model contracting system with private and public hospitals. Preliminary evaluation of the new model suggests that the system incentivized hospitals to admit fewer inappropriate cases and more cases that are more complex/serious. This article shares one experience of how to introduce a merit-based system to face the common practice of political clientelism and confessional/religious-based favoritism in Lebanon. It highlights the importance of stakeholder engagement in a framework of networking and participatory governance that proved to be a key element behind the resilience of a diversified health system.

Determinants of Health Insurance Coverage among People Aged 45 and over in China: Who Buys Public, Private and Multiple Insurance.

BackgroundChina is reforming and restructuring its health insurance system to achieve the goal of universal coverage. This study aims to understand the determinants of public, private and multiple insurance coverage among people of retirement-age in China.MethodsWe used data from the China Health and Retirement Longitudinal Survey 2011 and 2013, a nationally representative survey of Chinese people aged 45 and over. Multinomial logit regression was performed to identify the determinants of public, private and multiple health insurance coverage. We also conducted logit regression to examine the association between public insurance coverage and demand for private insurance.ResultsIn 2013, 94.5% of this population had at least one type of public insurance, and 12.2% purchased private insurance. In general, we found that rural residents were less likely to be uninsured (Relative Risk Ratio (RRR) = 0.40, 95% Confidence Interval (CI): 0.34–0.47) and were less likely to buy private insurance (RRR = 0.22, 95% CI: 0.16–0.31). But rural-to-urban migrants were more likely to be uninsured (RRR = 1.39, 95% CI: 1.24–1.57). Public health insurance coverage may crowd out private insurance market (Odds Ratio = 0.55, 95% CI: 0.48–0.63), particularly among enrollees of Urban Resident Basic Medical Insurance. There exists a huge socioeconomic disparity in both public and private insurance coverage.ConclusionThe migrants, the poor and the vulnerable remained in the edge of the system. The growing private insurance market did not provide sufficient financial protection and did not cover the people with the greatest need. To achieve universal coverage and reduce socioeconomic disparity, China should integrate the urban and rural public insurance schemes across regions and remove the barriers for the middle-income and low-income to access private insurance.

After us, the deluge: German miners’ experience with pay‐as‐you‐go pensions and the intergenerational contract before the great inflation

Many public pension insurance schemes today use the pay‐as‐you‐go financing mechanism. This mechanism is vulnerable to an ageing population, which puts pressure on the intergenerational contract implicit in these schemes and raises the question as to how they might be eroded. This is not a new problem, and to put it into historical perspective, this article studies the intergenerational contract that formed the core of the Prussian miners’ invalidity insurance in the nineteenth and the early twentieth century (1861–1920). With the so‐called Knappschaften, miners relied on what was probably the most comprehensive and advanced occupational pension system existing in Germany around the time when Bismarckian social insurance was established. Financed via the pay‐as‐you‐go mechanism, the miners’ pension funds faced stress from their ageing memberships early on, and this potentially undermined their ability to maintain intergenerationally fair pensions. In order to examine whether or not the intergenerational contract among German miners showed signs of erosion, we look at the Knappschaftens’ profitability, as measured by actual and promised internal rates of return. This article shows that the intergenerational contract indeed weakened over time unless miners’ funds were large and continued to grow, and that a pension reform in 1906 served to stabilize generosity.

Treatment of Chronic Myeloid Leukemia in Rural Rwanda: Promising Early Outcomes.

PurposeThe burden of cancer is rising in low- and middle-income countries, yet cancer treatment requires resources that are often not available in these settings. Although management of chronic myeloid leukemia (CML) has been described in low- and middle-income countries, few programs involve patients treated in rural settings. We describe characteristics and early outcomes of patients treated for CML at rural district hospitals in Rwanda.MethodsWe conducted a retrospective review of patients with confirmed BCR-ABL–positive CML who were enrolled between July 1, 2009 and June 30, 2014. Types of data included patient demographics, diagnostic work up, treatment, clinical examination, laboratory testing, and death.ResultsForty-three patients were included, with a maximum follow-up of 58 months. Of 31 patients who were imatinib-naïve at enrollment, 54.8% were men and the median age at diagnosis was 36.9 years (interquartile range: 29-42 years). Approximately two-thirds of patients (67.7%) were on the national public insurance scheme. The imatinib dose was reduced for 16 patients and discontinued for five. Thirty-two of the 43 patients continued to have normal blood counts at last follow-up. Four patients have died and four are lost to follow-up.ConclusionOur experience indicates that CML can be effectively managed in a resource-constrained rural setting, despite limited availability of on-site diagnostic resources or specialty oncology personnel. The importance of model public-private partnerships as a strategy to bring high-cost, life-saving treatment to people who do not have the ability to pay is also highlighted.

Preventing Obesity in the USA: Impact on Health Service Utilization and Costs.

With more than two-thirds of the US population overweight or obese, the obesity epidemic is a major threat for population health and the financial sustainability of the healthcare service. Whether, and to what extent, effective prevention interventions may offer the opportunity to 'bend the curve' of rising healthcare costs is still an object of debate. This study evaluates the potential economic impact of a set of prevention programmes, including education, counselling, long-term drug treatment, regulation (e.g. of advertising or labelling) and fiscal measures, on national healthcare expenditure and use of healthcare services in the USA. The study was carried out as a retrospective evaluation of alternative scenarios compared with a 'business as usual' scenario. An advanced econometric approach involving the use of logistic regression and generalized linear models was used to calculate the number of contacts with key healthcare services (inpatient, outpatient, drug prescriptions) and the associated cost. Analyses were carried out on the Medical Expenditure Panel Survey (1997-2010). In 2010, prevention interventions had the potential to decrease total healthcare expenditure by up to $US2 billion. This estimate does not include the implementation costs. The largest share of savings is produced by reduced use and costs of inpatient care, followed by reduced use of drugs. Reduction in expenditure for outpatient care would be more limited. Private insurance schemes benefit from the largest savings in absolute terms; however, public insurance schemes benefit from the largest cost reduction per patient. People in the lowest income groups show the largest economic benefits. Prevention interventions aimed at tackling obesity and associated risk factors may produce a significant decrease in the use of healthcare services and expenditure. Savings become substantial when a long-term perspective is taken.

Organizing a national blood service with limited resources – developments in the South African National Blood Service

BackgroundSouth Africa has a population of 52 million people and is classified as a Middle Human Development Index (HDI) Country. Up until 1994, the majority Black population lived under discriminatory apartheid laws with resulting in significant socio‐economic disparities between the various population groups. The health system is two tier with Government funding health care in the public sector and medical insurance schemes funding health care in the private sector for those who can afford it. Fiscal allocation for health care in the public sector has been averaging at about 8·5% of the country's gross domestic product (GDP) and is utilized by 84% of the population as the majority of the population cannot afford medical insurance. There is inadequate value contribution due to high disease burden, increasing demand for services from previously disadvantaged groups and inefficiencies in service delivery. The blood services operate on a fee‐for‐service basis supplying about 60% of blood to public sector hospitals and about 40% to private health facilities. The South African National blood service (SANBS) supplies blood and blood products to 88% of the population in eight of the nine provinces and the Western Province Blood Transfusion Service (WPBTS) which operates independently in the Western Cape Province supplies the remaining 12%. Both blood services operate on a ‘vein to vein’ basis managing blood collections from 100% voluntary non‐remunerated donors, processing whole blood into various components, testing for viral markers and cross matching and issuing blood products to doctors on request. SANBS was formed as a National Blood Service in 2001 as a result of the amalgamation of 6 regional blood service organizations. The mission of SANBS is ‘to provide all patients with sufficient, safe, quality blood products and related medical services in a sustainable manner’. Blood safety and sufficiency are the most critical objectives of both blood establishments (BEs).AimTo present historical developments and achievements of SANBS in pursuit of its mandate over the last 12 years. The objective is to share outcomes of various strategies that enabled and strengthened delivery in the South African resource‐constrained environment and challenging socio‐economic context.MethodsA review of the strategic plans, governance framework, operational service delivery and efficiency, human resource management, financial efficiency and stakeholder management was performed to highlight the strategy, challenges and successes of organizing a national blood service.ResultsDespite significant socio‐economic challenges and limited resources SANBS has managed to effectively provide a low risk and sustainable blood supply to the patients that it serves.

Morocco's policy choices to achieve Universal health coverage.

Morocco's health system remains weak in spite of the improvement of other development indicators in the last ten years. Health remains one of the major challenges to lower the social disparities that are the priority for the authorities. Despite the goodwill of all stakeholders, significant reforms implemented respond only partially to the needs of the population. Morocco established several public insurance schemes, of which one focuses on the poorest, to achieve financial-risk protection for its population. Nevertheless, achieving universal health coverage through one of its dimensions is not sufficient, and all the effort being concentrated in one area has shown the deterioration of equity in access to and quality of health services. Moreover, the insurance schemes did not reach their objectives of protecting a majority of Moroccans from financial hardship.

Does Health Insurance Lead to Ex ante Moral Hazard? Evidence from China’s New Rural Cooperative Medical Scheme

This paper examines whether participating in the New Rural Cooperative Medical Scheme (NRCMS), a publicly subsidised health insurance programme in rural China, encourages individuals to engage in risky health behaviours. Despite its rapidly increasing coverage rate, relatively little attention has been paid to the impact of NRCMS on the lifestyle choices of its enrollees. On the basis of the 2000–2009 longitudinal data from the China Health and Nutrition Survey (CHNS), we find that NRCMS participation has a statistically significant (although quantitatively small) impact on people’s tendency towards smoking, heavy drinking (among males), spending time in sedentary activities, consuming high-calorie food and being overweight. The increase in these unhealthy lifestyles in turn leads to elevated disease risks, indicating that insurance-induced, “ex ante moral hazard” is present in rural China. The findings are robust to the variation in model specification and sample selection, as well as to the introduction of an instrumental variable that controls the endogeneity of insurance participation. Our results provide implications on reforming the pricing and administration practice of China’s largest health insurance campaign and on evaluating public insurance schemes in other developing countries.

The status and future challenges of tobacco control policy in Korea.

Tobacco use is the most important preventable risk factor for premature death. The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), the first international public health treaty, came into force in 2005. This paper reviews the present status of tobacco control policies in Korea according to the WHO FCTC recommendations. In Korea, cigarette use is high among adult males (48.2% in 2010), and cigarette prices are the lowest among the Organization for Economic Cooperation and Development countries with no tax increases since 2004. Smoke-free policies have shown incremental progress since 1995, but smoking is still permitted in many indoor public places. More than 30% of non-smoking adults and adolescents are exposed to second-hand smoke. Public education on the harmful effects of tobacco is currently insufficient and the current policies have not been adequately evaluated. There is no comprehensive ban on tobacco advertising, promotion, or sponsorship in Korea. Cigarette packages have text health warnings on only 30% of the main packaging area, and misleading terms such as "mild" and "light" are permitted. There are nationwide smoking cessation clinics and a Quitline service, but cessation services are not covered by public insurance schemes and there are no national treatment guidelines. The sale of tobacco to minors is prohibited by law, but is poorly enforced. The socioeconomic inequality of smoking prevalence has widened, although the government considers inequality reduction to be a national goal. The tobacco control policies in Korea have faltered recently and priority should be given to the development of comprehensive tobacco control policies.

Private Medical Insurance and Savings for Precautionary Reasons: Evidence from Sri Lanka

Medical insurance schemes are gaining popularity in many developing countries in recent decades due mainly to increasing out-of-pocket medical spending. Therefore, the study intended to explore individual preference towards medical insurance and savings concerning precautionary reasons in Sri Lanka and to estimate the effect of private medical insurance coverage on propensity to save. This study focuses 200 respondents whose age is between 18 and 55 year from Matara District of Sri Lanka. The results show that the private medical insurance coverage is positively and statistically significant with savings. This result suggests that the private medical insurance coverage does not crowd-out savings of individuals in Sri Lanka. Moreover, this study focused several explanatory factors that affect the savings behaviour of individuals and preference towards private medical insurance policy. Importantly, the savings tend to increase for individuals who expect the uncertain financial situation and financial situation worse than expected. It is also higher for individuals who have current financial situation as being good, who are not married, who have a higher education level, who have a higher income level, and who have no dependent children and one dependent child. On the hand, the savings tend to decrease for individuals who expect the financial situation to be improved, who have a current financial situation as being bad, and who have two dependent children or more. Therefore, these findings will benefit policy makers in developing an appropriate public or private medical insurance scheme and in formulating a better healthcare policy to ensure sufficient financial safeguard against medical emergencies for Sri Lankan citizens.

Environmental Regulation and Civil Liability under Causal Uncertainty: An Empirical Study of the French Legal System

The key question in this paper is to determine whether regulation and regulators information can help solving causal uncertainty problems in liability. A widely held view among Law & Economics scholars is that civil liability alone is not well-suited to cope with environmental accidents, especially where causation is uncertain or costly to establish. Instead of a simple civil liability rule, it is therefore advocated that a regulatory system be implemented combined with a public insurance scheme, or, alternatively, to go for a mix of regulation and civil liability. Such a mix of regulation and civil liability prevails in French law and this article presents an original analysis of French courts decisions concerning cases of environmental accidents for which causation was uncertain and regulators were not able to control for levels of organizational and human care. The dataset covers more than fifty years of trials outcomes from the highest civil and criminal court in France – Cour de Cassation. We found evidence that French judges apparently use the informational advantage of regulation (in showing that a particular activity may be of higher risk) to adopt a probabilistic approach to causation, thus increasing the effectiveness of the liability system. Claims that would (probably) be rejected in a liability regime (without regulation), given causal uncertainty are now accepted successfully in courts because the breach of regulation guides the judge (and hence cures his informational deficiency) in the difficulties in proving causation that normally arise in environmental liability cases.

Risk Taking, Principal Agent Problems and Breakdown of Corporate Social Responsibility (CSR): How to Reestablish Safe-Assets and Capital Funding for Social Security?

The breakdown of the financial markets in fall 2007 and the following debt crisis in the EU has produced an enormous mistrust in financial products and the monetary system. The paper describes the background of the crisis induced by functional failures in risk management and the multifold principal agent problems existing in the financial market structures. The innovated nontransparent financial products have mixed up different risk weights and puzzled, or even fooled formerly loyal customers. Contemporaneously abundant liquidity on the international financial market accompanied by easy money policies of the Fed in the US and the ECB in the euro zone have depressed the real interest rate to zero or even negative values. Desperate investors are seeking for safe-assets, but their demand remains unsatisfied. Low real interest rates and the consequently lacking compound interest effect in the same time jeopardize private as well as public insurance schemes being dependent on capital funding: the demographic crisis becomes gloomy. Therefore, the managers of the financial markets have to reestablish CSR and to divide the markets into safe-asset areas for the usual clients and “casino” areas for those who like to play with high risks. Only with transparency and risk adequate financial products can the lost commitment be regained.

Analysis of a Payments Database Reveals Trends in Dental Treatment Provision

Use of fluoride has led to dramatic improvements in oral health; however, the impact of these improvements on the volume and mix of treatment provided in dental systems is largely unknown. The use of administrative data to analyze trends in treatment provision gives ‘real-life’ insight into the impact of changing levels of oral health on oral health services. The first aim of this study was to determine the extent to which useful data on temporal treatment patterns could be extracted from a public insurance database. The second aim, contingent on the first, was to investigate whether increased tooth retention and decreases in caries were reflected in the volume and types of treatment provided to adults within a public social insurance scheme between 1997 and 2008. Data were retrieved from the Dental Treatment Benefit Scheme databases, and new datasets were generated to analyze the distribution of treatments and mean treatments provided to 1,271,937 adults over the 12-year period. Provision of restorations, extractions, and dentures decreased, and the ratio of preventive/diagnostic to invasive treatments per dentist increased, which supports reported improvements in oral health. In conclusion, this paper illustrates the decline in invasive treatments, and increase in preventive treatments that accompanied improvements in oral health.

Pension Benefit Insurance and Pension Plan Portfolio Choice

Pension bene…t guarantee policies have been introduced in several countries to protect private pension plan members from the loss of income that would occur if a plan was underfunded when the sponsoring …rm terminates a plan. Most of these public insurance schemes face …nancial di¢ culty and consequently policy reforms are being discussed or implemented. Economic theory suggests that such schemes will face moral hazard and adverse selection problems. In this note we test a speci…c theoretical predic

Environmental Regulation and Civil Liability Under Causal Uncertainty: An Empirical Study of the French Legal System

The key question in this article is to determine whether regulation and regulator information can help to solve causal uncertainty problems in liability. A widely held view among Law and Economics scholars is that civil liability alone is not well-suited to cope with environmental accidents, especially where causation is uncertain or costly to establish. Instead of a simple civil liability rule, it is therefore advocated that a regulatory system be implemented combined with a public insurance scheme, or, alternatively, to institute a mix of regulation and civil liability. Such a mix of regulation and civil liability prevails in French law, and this article presents an original analysis of French court decisions concerning cases of environmental accidents for which causation was uncertain and in which regulators were not able to control for levels of organizational and human care. The dataset covers more than 50 years of trial outcomes from the highest civil and criminal court in France – Cour de Cassation. Our results seem to provide evidence that regulation provides a new way to address causal uncertainty at the liability stage. This may be due to a transfer of information from regulators to judges and to the adoption by judges of a probabilistic approach to causation.

Institutional Economics, Risk Management, and Breakdown of Corporate Social Responsibility: Towards a New Architecture of Financial Markets

The breakdown of the financial markets in fall 2007 and the following debt crisis in the EU have produced an enormous mistrust in financial products and the monetary system. The paper describes the background of the crisis induced by functional failures in risk management and the multifold principal agent problems existing in the financial market structures. The innovated nontransparent financial products especially by the so-called shadow banks have mixed up differential risk weights and puzzled or even fooled formerly loyal customers. Contemporaneously abundant liquidity on the international financial market accompanied by easy money policies of the Fed in the US and the ECB in the euro zone have depressed the real interest rate to zero or even negative values. Desperate investors are seeking for safe-assets but their demand remains unsatisfied. Low real interest rates and the consequently lacking compound interest effect in the same time jeopardize private as well as public insurance schemes being dependent on capital funding: the demographic crisis becomes gloomy. Therefore, the managers of the financial markets have to reestablish CSR and to separate the markets into safe-asset areas for the usual clients and “casino” areas for those who like to play with high risks. Only with transparency and risk adequate financial products the lost commitment can be regained.