Public Health Insurance System Research Articles

Development of a practical framework and indicators for monitoring integrated long-term health and care needs and service use

This case study presents an evidence-building approach to support policy planning for integrated health and care delivery for older adults. We developed an integrated needs-assessment framework to monitor the complex long-term medical and care needs of older individuals, using routinely collected, standardized needs-assessment and utilization data from the public health and long-term care (LTC) insurance systems in South Korea. We also developed a set of misuse indicators and analyzed service utilization patterns, while accounting for their varying types of needs. Approximately 11 % of older Koreans were identified as having complex long-term medical and care needs, which were categorized into four distinct need groups. More than one-third of those in the higher-medical/lower-care needs group stayed in LTC hospitals for six months or more during the year, and about one-third of those in the higher-medical/higher-care needs group inappropriately resided in LTC facilities, where medical services are limited. The newly developed integrated needs-assessment framework and misuse indicator set provide practical tools for monitoring the extent and nature of complex needs, as well as patterns of over- or under-utilization of health and care services over time. The empirical evidence gathered here highlights the need for reforms in South Korea's health and LTC systems.

Japanese Public Health Insurance System's new genomic strategic action to shorten the "diagnostic odyssey" for patients with rare and intractable diseases.

In June 2024, the Japanese government introduced a new genomic strategic action to shorten the "diagnostic odyssey" for patients with rare and intractable diseases: Six groups of rare diseases, (i) Muscle weakness group, (ii) Growth retardation, intellectual disability, and characteristic facial features group, (iii) Intellectual disability/epilepsy group, (iv) Cardiomyopathy group (mainly adult onset) (v) Proteinuria group, (vi) Fever, inflammation, skin rash, osteoarthritis group, have been newly recognized as "difficult-to-differentiate disorders" and comprehensive genomic testing can be reimbursed when patients belong to one of the six groups and certain requirements are met. The introduction of comprehensive genomic testing will improve the diagnosis rate of diseases and have significant potential to enhance Japan's rare and intractable disease policy. The new strategy in Japan and its rationale will be a reference for insurance reimbursement of comprehensive genomic testing in other countries that have universal health coverage supported by the public health insurance system.

Preliminary outcomes of boron neutron capture therapy for head and neck cancers as a treatment covered by public health insurance system in Japan: Real-world experiences over a 2-year period.

Since June 2020, boron neutron capture therapy (BNCT) has been a health care service covered by health insurance in Japan to treat locally advanced or recurrent unresectable head and neck cancers. Therefore, we aimed to assess the clinical outcomes of BNCT as a health insurance treatment and explore its role among the standard treatment modalities for head and neck cancers. We retrospectively analyzed data from patients who were treated using BNCT at Kansai BNCT Medical Center, Osaka Medical and Pharmaceutical University, between June 2020 and May 2022. We assessed objective response rates based on the Response Evaluation Criteria in Solid Tumors version 1.1, and adverse events based on the Common Terminology Criteria for Adverse Events, version 5.0. Additionally, we conducted a survival analysis and explored the factors that contributed to the treatment results. Sixty-nine patients (72 treatments) were included in the study, with a median observation period of 15 months. The objective response rate was 80.5%, and the 1-year locoregional control, progression-free survival, and overall survival rates were 57.1% (95% confidence interval [CI]: 43.9%-68.3%), 42.2% (95% CI: 30.1%-53.8%), and 75.4% (95% CI: 62.5%-84.5%), respectively. Locoregional control was significantly longer in patients with earlier TNM staging and no history of chemotherapy. BNCT may be an effective treatment option for locally advanced or recurrent unresectable head and neck cancers with no other definitive therapies. If definitive surgery or radiation therapy are not feasible, BNCT should be considered at early disease stages.

한국의 의료 공공성에 대한 인식 격차*

Medical care is an essential social service that supports other valued goods, such as life, health, safety, and the guarantee of social opportunities. In many countries, access to medical care is provided through public health insurance systems. South Korea’s medical insurance system, which has expanded at an unprecedented rate in recent decades, performs very well by several internationally recognized indicators. However, excessive government regulations, a private-centered supply of medical resources, and overuse of the system by patients have led to a misallocation of medical resources. This article examines the supply and use of medical care by the Korean government, the medical community, patients, and citizens, highlighting awareness gaps in the public value and nature of medical care. Recognizing this issue is the first step in building a sustainable medical system that ensures that medical resources are appropriately allocated and utilized.

Real-world outcome of rTMS treatment for depression within the Japanese public health insurance system: Registry data from Kansai TMS network

This study registered consecutive cases to elucidate the efficacy of rTMS treatment for depression within the Japanese public health insurance system. Of the 102 patients with depression who received rTMS over the left dorsolateral prefrontal cortex, 44 (43.1 %) patients reached remission and 14 (13.7 %) patients did not reach remission but responded to treatment. No serious adverse events occurred. Low baseline HAMD-17 score was associated with remission after rTMS treatment. Favorable outcomes of rTMS treatment were shown in this cohort within the Japanese public insurance system. Our results provide insights into rTMS treatment for depression in real-world clinical setting.

Financial Toxicity in Japanese Patients with Metastatic Renal Cell Carcinoma: A Cross-Sectional Study.

Information on the financial toxicity experienced by Japanese patients with metastatic renal cell carcinoma (mRCC) is lacking, even though Japan has its own unique public health insurance system. Thus, a web-based survey was conducted to evaluate the financial toxicity experienced by Japanese mRCC patients using the COmprehensive Score for financial Toxicity (COST) tool. This study enrolled Japanese patients who underwent, or were undergoing, systemic therapy for mRCC. The outcomes evaluated were the distribution of COST scores, the correlation between COST and quality of life (QOL) assessed by the Functional Assessment of Cancer Therapy-General (FACT-G) scale, and demographic factors associated with financial toxicity. The median (range) COST score was 19.0 (3.0-36.0). The Pearson correlation coefficient for COST and FACT-G total scores was 0.40. Univariate analysis revealed that not having private health insurance and lower household income per year were significantly associated with lower COST scores. Multivariate analyses showed that age < 65 years and not having private health insurance were significantly associated with lower COST scores. This study revealed that Japanese mRCC patients experience adverse financial impacts even under the universal health insurance coverage system available in Japan, and financial toxicity negatively affects their QOL.

What do people know and think about medical overuse? an online questionnaire study in Germany.

Medical overuse is defined as health care services that exceed the individual needs of patients and when the potential harms of medical interventions exceed their benefits. It has impacts on patients as well as on health care resources. To address medical overuse, it is important to understand the knowledge and experiences of overuse on the side of patients. What is the citizens' understanding of overuse? How do they assess its relevance, causes, consequences and potential solutions? A quantitative online survey was conducted. The participants were asked to state what they understand by medical overuse. Statements on causes, consequences and possible solutions were evaluated. Recruitment was carried out via a panel of a market research institute (Schlesinger Group). The survey was completed by 406 participants. In terms of age and gender, the sample corresponded to the distribution in the German population. The majority had never heard of medical overuse (58%). About 60% assumed that medical overuse means "too much medicine including overtreatment and overtesting". Medical overuse was mainly suspected for services not covered by the public health insurance system (56%), surgical interventions (45%) and medication prescriptions (37%). Reasons for medical overuse were seen in uncoordinated care and financial incentives, but also in the expectations of patients. The main problem with medical overuse was seen in rising health care costs, while harmful physical and mental consequences for patients were mentioned less often. In order to reduce medical overuse, little importance was attributed to a primary care based system or higher financial contribution of patients. Instead, stricter cost control on the side of physicians and better coordination between care providers were suggested as solutions. Differences in socio-demographic characteristics hardly showed any differences in response behavior. More than half of the respondents had never heard of medical overuse. Overuse was mainly associated with financial causes and consequences. It was not seen that overuse can be harmful for patients directly. The limited awareness of the problem of overuse probably is a barrier to tackling it effectively. Communicating the topic to the public might therefore be an effective start to mitigate medical overuse. Many citizens seem not to be familiar with the concept of medical overuse, especially not with the fact that it may directly cause harm to patients. Informing citizens about the harms of medical overuse might be helpful in mitigating it.

Participation of Foreigners in Public Health Insurance in the Czech Republic

Abstract Foreigners from third countries are not entitled to participate in the Czech public health insurance system unless they have either permanent residence in the Czech Republic or a Czech employer. This article aims to analyse the economic impact of the possible inclusion of such foreigners into the public health insurance system in the Czech Republic. First, we estimate the size of the group of foreigners concerned and follow with the estimation of contributions paid and the cost involved. The analysis is based on publicly available data that entail simplifications. The conducted research shows that the inclusion of foreigners from third countries into the public health system of the Czech Republic would positively impact the economic balance of the system in that the estimated contributions would surpass the estimated costs.

Relationship between nurses' perceptions and financial toxicity management in the public health insurance system.

Aims: To describe nursing practices for financial toxicity management based on nurses' perceptions. Materials & methods: A survey was conducted with 615 oncology nurses in Japan, focusing on nurses' perspectives on the importance of financial toxicity, nursing practices to manage financial toxicity and factors inhibiting its management. Results: A total of 521 participated, of whom 266 respondents (51.1%) considered nurses' role important, and they engaged in a significantly higher proportion of nursing practices. Participants with greater perceptions of their role included certified or specialized nurses and nurses responsible for outpatient care. Conclusion: Interventions leveraging the expertise of certified or specialized nurses and nurses involved in outpatient care could help to spread proactive nurse practices addressing financial toxicity.

Survival Rate of Metal Crowns Covered by Public Health Insurance System in Japan: A Quality-of-Care Perspective

Survival Rate of Metal Crowns Covered by Public Health Insurance System in Japan: A Quality-of-Care Perspective

Cost-effectiveness of combination therapy of polatuzumab vedotin plus rituximab, cyclophosphamide, doxorubicin, and prednisolone for previously untreated diffuse large B-cell lymphoma in Japan

AimThe POLARIX trial showed that Pola + R-CHP (polatuzumab vedotin plus rituximab, cyclophosphamide, doxorubicin, and prednisolone) prolongs progression-free survival (PFS) in patients with previously untreated diffuse large B-cell lymphoma (DLBCL) compared with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone), the conventional standard of care, with a similar safety profile. However, Pola + R-CHP has not been evaluated from the viewpoint of health economics in Japan. This study evaluates the cost-effectiveness of Pola + R-CHP for previously untreated DLBCL from a Japanese public healthcare payer’s perspective.MethodsA partitioned survival analysis model was constructed to estimate lifetime costs and effectiveness of Pola + R-CHP and R-CHOP in previously untreated DLBCL who had an International Prognostic Index score (IPI) score of ≥2. A parametric survival model was applied to data analyzed in the POLARIX trial to estimate the lifetime overall survival (OS) and PFS for each treatment. The parameters required for the model were based on the results of a literature search and expert opinion.ResultsThe incremental cost-effectiveness ratio (ICER) of Pola + R-CHP vs. R-CHOP was JPY2,710,238 per quality-adjusted life year (QALY), less than the ICER of JPY7.5 million per QALY that is considered to be cost-effective based on the threshold of the Japanese cost-effectiveness evaluation system. One-way sensitivity analysis showed that the parameters influencing the results of the analysis were median PFS and the total cost per regimen of salvage chemotherapy, patient weight, and patient age. Probabilistic sensitivity analysis showed that the probability of Pola + R-CHP having superior cost-effectiveness was 99.2% when the reference value was JPY7.5 million. The results of scenario analysis suggested that prolongation of PFS was an important factor in the evaluation of cost-effectiveness in previously untreated DLBCL with or without prolongation of OS.ConclusionsThis study suggests that Pola + R-CHP is a cost-effective treatment for previously untreated DLBCL in Japan under the public health insurance system.

Biologic Therapy in Inflammatory Bowel Disease - Results from a Single Tertiary Care Center in North Macedonia.

Medical therapies used for Inflammatory Bowel Disease (IBD) include conventional (e.g. 5-aminosalicylates, steroids, immunomodulators) and biologic (e.g. inhibitors of tumor necrosis factor - alpha, integrin inhibitors, interleukin inhibitors) medications. Biologics, due to their high cost, were unfortunately not covered by the public health insurance system in North Macedonia until 2019 and, therefore, not widely utilized for our IBD patients. In 2019, the University Clinic of Gastroenterology and Hepatology in Skopje developed a biologic therapy supply, provided by the National Health Insurance Fund, making this therapy available for a larger number of patients. This report presents the initial results of our prospective, single tertiary-care center study on the effects of biologic therapy in patients with IBD in North Macedonia. The study is focused on the evaluation of clinical outcomes after anti-tumor necrosis factor alpha (anti TNF-alpha) therapy in IBD patients with prior inadequate response to conventional medications.

THE RED FLAG OF EMERGENCY USE AUTHORIZATION (EUA)

The Emergency Use Authorization (EUA) policy, a representative biodefense policy, was legislated in the United States in 2001 based on lessons learned from Amerithrax, whereas Korea's EUA policy was based on lessons learned from the Middle East Respiratory Syndrome outbreak in 2015. Due to these divergent origins, the U.S. EUA's homeland security objectives were specialized to deal with highly pathogenic biological agents that could be exploited for bioterrorism, whereas the Korean EUA pursues disease containment purposes to strengthen mass‐testing practices. During the early phase of the COVID‐19 pandemic, the U.S. EUA revealed limitations in its integration with public health surveillance, laboratory partnerships, and insurance systems, which hampered the rapid expansion of testing capacities. Thereafter, once the limitations of the EUA were circumvented, the testing capacity of the United States began to catch up with that of South Korea, and later skyrocketed after solving these issues.

Regular Dental Check-Ups Are Associated with Choosing Uninsured Dental Restoration/Prosthesis Treatment in Japan.

Since Japan has implemented Universal Health Coverage (UHC), most dental treatments are covered by public health insurance. Therefore, when receiving fixed dental restoration/prosthesis (FDRP) treatment, such as inlays, crowns, and bridges, the patient can choose whether or not it is covered by insurance. This study aimed to evaluate whether those who receive dental check-ups regularly chose uninsured FDRP treatment. Data were collected from 2088 participants, who had undergone FDRP treatment, via a web-based survey and analyzed. Among them, 1233 (59.1%) had received regular dental check-ups (RDC group) and 855 (40.9%) had not (non-RDC group). The multivariate logistic regression model showed that compared to the non-RDC group, those in the RDC group were statistically significantly associated with higher rates of good oral health behaviors (brushing teeth ≥ 3 times daily, odds ratios (OR):1.46; practiced interdental cleaning habitually, OR: 2.22) and received uninsured FDRP treatment more often (OR: 1.59), adjusted for socioeconomic factors. These results suggest that health policy interventions to promote access to RDC among individuals may improve the oral health of people and reduce the financial burden on the public health insurance system.

Multiregional Population-Based Cohort Study for Evaluation of the Association Between Herpes Zoster and mRNA Vaccinations for Severe Acute Respiratory Syndrome Coronavirus-2: The VENUS Study.

This study was performed to assess the increased risk of herpes zoster (HZ) associated with mRNA vaccines for coronavirus disease 2019. This population-based cohort study was conducted in 4 municipalities in Japan. Individuals covered under public health insurance systems without a history of HZ were followed from October 1, 2020 to November 30, 2021. Incidence rates of HZ within 28 days of BNT162b2 or mRNA-1273 vaccination were compared. Adjusted incidence rate ratios (IRR) and 95% confidence intervals (CI) were estimated using a Poisson regression model, including vaccination status as a time-dependent covariate. Subgroup analyses by sex, age, and municipality were also conducted. A total of 339 548 individuals (median age, 74 years) were identified. During follow up, 296 242 individuals (87.2%) completed the primary series, among whom 289 213 and 7019 individuals received homologous BNT162b2 and mRNA-1273 vaccines, respectively. The adjusted IRRs of the first and second BNT162b2 vaccinations were 1.05 (95% CI, 0.84-1.32) and 1.09 (95% CI, 0.90-1.32), respectively. No cases of HZ were observed after mRNA-1273 vaccination. In subgroup analysis, the adjusted IRR of the second BNT162b2 vaccination was 2.94 (95% CI, 1.41-6.13) in individuals aged <50 years old. No increased risk of HZ was found after BNT162b2 vaccination in the overall study population. However, an increased risk was observed in the younger subgroup.

The Korea National Disability Registration System.

The Korea National Disability Registration System (KNDRS) was established in 1989 to provide social welfare benefits based on predefined criteria for disability registration and an objective medical assessment using a disability grading system. Disability registration requires (1) a medical examination by a qualified specialist physician and (2) a medical advisory meeting to review the degree of disability. Medical institutions and specialists for the diagnosis of disabilities are legally stipulated, and medical records for a specified period are required to support the diagnosis. The number of disability types has gradually expanded, and 15 disability types have been legally defined. As of 2021, 2.645 million people were registered as disabled, accounting for approximately 5.1% of the total population. Among the 15 disability types, disabilities of the extremities account for the largest proportion (45.1%). Previous studies have investigated the epidemiology of disabilities using data from the KNDRS, combined predominantly with data from the National Health Insurance Research Database (NHIRD). Korea has a mandatory public health insurance system that covers the entire Korean population, and the National Health Insurance Services manages all eligibility information, including disability types and severity ratings. In short, the KNDRS-NHIRD is a significant data resource for research on the epidemiology of disabilities.

Variation in Price of Cardiovascular and Diabetes Medicine in Indonesia, and Relationship with Quality: A Mixed Methods Study in East Java.

Lower-middle income Indonesia, the world's fourth most populous country, has struggled to contain costs in its mandatory, single-payer public health insurance system since the system's inception in 2014. Public procurement policies radically reduced prices of most medicines in public facilities and the wider market. However, professional associations and the press have questioned the quality of these low-cost, unbranded generic medicines. We collected 204 samples of four cardiovascular and one antidiabetic medicines from health facilities and retail outlets in East Java. We collected amlodipine, captopril, furosemide, simvastatin, and glibenclamide, sampling to reflect patients' likelihood of exposure to specific brands and outlets. We recorded sales prices and maximum retail prices and tested medicines for dissolution and percentage of labeled content using high-performance liquid chromatography. We conducted in-depth interviews with supply chain actors. All samples, including those provided free in public facilities, met quality specifications. Most manufacturers make both branded and unbranded medicines. Retail prices varied widely. The median ratio of price to the lowest price for an equivalent product was 5.1, and a few brands sold for over 100 times the minimum price. Prices also varied between outlets for identical products because retail pharmacies set prices to maximize profit. Because very-low-cost medicines were universally available and of good quality, we believe richer patients who chose to buy branded products effectively protected medicine quality for poorer patients in Indonesia because manufacturers cross-subsidize between branded and unbranded versions of the same medicine.

Public health in Kosovo after five difficult years of independence

Kosovo is undergoing a rapid process of transformation to an independent state,which was formally proclaimed in 2008, after almost a decade under United Nationsadministration. Regarding the health status, five years after independence, compared with other European countries, post-war transitional Kosovo is still characterized by higher mortality rates including traditional public health problems pertinent to infant mortality and maternal deaths. In parallel, however, Kosovo is undergoing a rapid process of epidemiological transition characterized by an aging trend which is inevitably coupled with high cardiovascular and cancer mortality and morbidity along with an excess mortality in external causes of death and injuries among the adult population. Adoption of the new Health Law in December 2012 by the Kosovo Assembly aims the transition from centralized health care system established under emergency conditions of the post-war period towards a contemporary modern health care system with a clear purchaser-provider split based on a high transparency and accountability of the health care providers and their contractors. The health care reform, leading eventually to significant changes within the health sector in Kosovo, consists of two main pillars: (i) structural and functional reorganization of the health care system through establishment of Kosovo Health Service (an autonomous and non-for-profit public enterprise at central level of the health care sector), and; (ii) establishment for the first time of the public health insurance system with a Health Insurance Fund as its main body. Nevertheless, five years after declaration of independence, Kosovo, the newest state in Europe consisting of the youngest population, is currently facing a particularly difficult socioeconomic and political transition and is additionally struggling and mainstreaming all energies and efforts in order to get full international recognition.

Cost-effectiveness analysis of cardiac implantable electronic devices with reactive atrial-based antitachycardia pacing.

Reactive atrial-based anti-tachycardia pacing (rATP) in pacemakers (PMs) and cardiac resynchronization therapy defibrillators (CRT-Ds) has been reported to prevent progression of atrial fibrillation, and this reduced progression is expected to decrease the risk of complications such as stroke and heart failure (HF). This study aimed to assess the cost-effectiveness of rATP in PMs and CRT-Ds in the Japanese public health insurance system. We developed a Markov model comprising five states: bradycardia, post-stroke, mild HF, severe HF, and death. For devices with rATP and control devices without rATP, we compared the incremental cost-effectiveness ratio (ICER) from the payer's perspective. Costs were estimated from healthcare resource utilisation data in a Japanese claims database. We evaluated model uncertainty by analysing two scenarios for each device. The ICER was 763 729 JPY/QALY (5616 EUR/QALY) for PMs and 1,393 280 JPY/QALY (10 245 EUR/QALY) for CRT-Ds. In all scenarios, ICERs were below 5 million JPY/QALY (36 765 EUR/QALY), supporting robustness of the results. According to a willingness to pay threshold of 5 million JPY/QALY, the devices with rATP were cost-effective compared with control devices without rATP, showing that the higher reimbursement price of the functional categories with rATP is justified from a healthcare economic perspective.

Care-needs level prediction for elderly long-term care using insurance claims data

Background and objectiveOwing to an aging population, the increase in the number of elderly people certified as requiring long-term care has become a critical social issue in Japan. This study aimed to construct a machine learning model predicting the maximum care-needs level required for long-term care within the next three years for persons aged over 75 years. MethodsThe prediction model was constructed using features extracted from long-term care and healthcare insurance claims data. The study subjects were a total of 47,862 elderly individuals who had not received long-term care services in a large city in Japan. The prediction classes for outcome variable were categorized according to the criteria of the Japanese long-term care system: class 0 (no required), class 1 (support levels 1 and 2), class 2 (care levels 1 and 2), and class 3 (care levels 3–5). As explanatory variables, a total of 516 features were used, including age, sex, and 514 diseases classified under ICD-10. In this study, we focused on constructing a prediction model with the interpretability and adopted multinomial logistic regression (MLR) with L2 regularization as a machine learning algorithm. MLR allowed us to identify the characteristics influencing each prediction class of care-needs levels. ResultsIn terms of overall predictive performance, MLR achieved weighted average precision, recall, F-value, and lift scores of 0.694, 0.505, 0.567, and 1.333, respectively. Compared to other machine learning algorithms, MLR demonstrated comparable performance to Support Vector Machine (SVM) and Random Forest (RF). From the factor analysis based on the magnitudes of coefficients of the MLR model, the top three features influencing each prediction class were as follows: class1: female sex, hypertension, and gonarthrosis; class 2: age, Alzheimer-type dementia, and neuromuscular dysfunction of the bladder; class 3: age, Alzheimer-type dementia, and type 2 diabetes mellitus. ConclusionsIn practical terms, the care-needs level prediction can be applied by local governments to identify high-risk areas by comprehensively and routinely predicting insured persons under public health insurance and long-term care insurance systems.