Universal National Health Insurance Research Articles

Sickly, Idle and Risky Minorities: Race and Diabetes under Singapore’s Emergent “Insurantial Imaginary”

This article highlights the role of the “insurantial imaginary”, defined as a social context in which profitable, useful and necessary uses can be found for insurance technology, as a condition that shaped the articulation of the sickly, idle and risky racial minorities within Singapore’s public health discourse on diabetes. Focusing on parliamentary speeches relating to diabetes between 1965 to 2020 as well as healthcare financing policy documents, I argue that the narrative of sickly, idle and risky minorities bodies tied to broader notions of racialized responsibility and accountability emerged sharply under a universal national health insurance system. Where parliamentary discussions on diabetes as a public health issue before the institution of universal health insurance circa 2014 utilized racial categories in the classificatory or administrative sense, these very categories became endowed with new meanings and moral imperatives, where Malays and Indians were urged to lead healthier lifestyles to reduce the national insurantial burden. This study builds on the literature on race in medicine by underlining the role of healthcare financing as a technology of racial biopolitics.

Taiwan renal data report system: Framework, function, and development.

The world healthcare system is actively seeking possible solutions for the rapid growth of kidney disease threats. The Taiwan Renal Data System (TWRDS) was central in assisting kidney health and care policymaking to reduce end-stage kidney disease incidence and mortality. This article summarizes the TWRDS framework, recent applications, and developments to provide new insights for some international researchers to promote planetary kidney health. The TWRDS originated in 1987 for the accreditation and quality monitoring of dialysis units and was connected with enriched health claim databases after the implementation of universal national health insurance in Taiwan in 1995. As a healthcare information centre, TWRDS has published annual reports forming indispensable instructions for renal care improvement since 2014. The TWRDS possesses three main functions: (1) kidney disease surveillance; (2) offering rich materials for research purposes; (3) achieving precision prevention and care through complex algorithms. In the new era, TWRDS can help build a more resilient society against communicable disease threats by integrating remote sensor techniques for developing future remote healthcare structures, as well as identifying kidney health inequity populations and promoting healthcare resources distributed equity. The global healthcare system is facing escalating burdens of non-communicable disease care due to the rapidly growing elderly population. Therefore, a considerable-scale data system is an essential decision-supportive tool in promoting an evidence-based, resilient, sustainable, equity care environment. Undoubtedly, TWRDS experience is a practical example of leveraging healthcare providers' decisions, care outcomes, and renovation.

Treaties for "offshoring" hospital treatment of Asian patients from Christmas Island, 1963-1985: a racist chapter in the history of Australian medical care.

Treaties for "offshoring" hospital treatment of Asian patients from Christmas Island, 1963-1985: a racist chapter in the history of Australian medical care.

The impact of informal patient navigation initiatives on patient empowerment and National Health Insurance responsiveness in Indonesia

BackgroundIndonesia introduced a universal National Health Insurance (NHI) programme Jaminan Kesehatan Nasional (JKN) in 2014. However, challenges in timely consultation and access to health services resulted in the introduction of...

Pregnancy loss and Income in the Republic of Korea using National Health Insurance Service Data, 2008\u20132014

BackgroundAlthough unintentional pregnancy loss is common, national representative statistics are lacking in high-income East Asian countries undergoing rapid demographic changes. It is necessary to confirm the income inequality of pregnancy loss even in universal national health insurance.MethodUsing National Health Insurance Service data between 2008 and 2014, the annual prevalence of pregnancy loss was enumerated, and differences in pregnancy loss according to age and income levels were assessed by multivariable Poisson regression. Joint-point regression was used to examine the trend of pregnancy loss.ResultOn average, there was a 15.0% annual pregnancy loss among 3,941,020 pregnancy cases from 2008 to 2014. Pregnancy loss inequality increased stepwise with income levels except for the highest income group. After adjusting for income levels, the annual percent change of age-standardized prevalence significantly increased by 2.6% every year since 2011.ConclusionEven in high-income countries with universal national health insurance, income inequality in pregnancy loss is observed. Further appraisal is needed to explain the increasing trend of pregnancy loss between 2011 and 2014 even after adjusting income.

New Obligations of Health Insurance Review and Assessment Service: Taking Full-fledged Action Against the COVID-19 Pandemic.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented disruptions to global health systems. The Korea has taken full-fledged actions against this novel infectious disease, swiftly implementing a testing-tracing-treatment strategy. New obligations have therefore been given to the Health Insurance Review and Assessment Service (HIRA) to devote the utmost effort towards tackling this global health crisis. Thanks to the universal national health insurance and state-of-the-art information communications technology (ICT) of the Korea, HIRA has conducted far-reaching countermeasures to detect and treat cases early, prevent the spread of COVID-19, respond quickly to surging demand for the healthcare services, and translate evidence into policy. Three main factors have enabled HIRA to undertake pandemic control preemptively and systematically: nationwide data aggregated from all healthcare providers and patients, pre-existing ICT network systems, and real-time data exchanges. HIRA has maximized the use of data and pre-existing network systems to conduct rapid and responsive measures in a centralized way, both of which have been the most critical tactics and strategies used by the Korean healthcare system. In the face of new obligations, our promise is to strive for a more responsive and resilient health system during this prolonged crisis.

The Longitudinal Impact of Private Health Insurance on the Usage of Outpatient Services Among Aging Koreans

South Korea has a universal national health insurance system; however, its coverage is only about 65%. Consequently, many Koreans have supplemental private health insurance. This study aims to examine 1) how utilization of health care services and out-of-pocket expenditure of outpatient services varies by private health insurance status and 2) whether this relationship changes for these individuals over time. We analyze six waves of the Korean Longitudinal Study of Aging (KLoSA) from 2006 to 2016. Our primary outcomes of interest are the total number of outpatient visits and total out-of-pocket spending on outpatient services per year. Our independent variable of interest is private health insurance holding status. We use simple OLS regressions for each year to test if differences exist and change over time, controlling for age, sex, education, income, and various indicators of health conditions. The difference between those who never had private health insurance and those who always or sometimes had private health insurance becomes larger over time. When comparing total out-of-pocket expenditure, those who always had private health insurance have the lowest spending at the beginning of the study period (2006); however, their spending increases sharply by 2010 and remains higher than the other groups for the rest of the study period. Findings suggest that those who always had supplemental insurance use outpatient services more frequently and spend more out-of-pocket for services as a result. In addition, discrepancies become larger over time. As private health insurance holders age, the risk of higher utilization of outpatient services grows.

Spatial accessibility to hospital facilities: the case of Kumasi, Ghana

ABSTRACT Despite official introduction of the universal national health insurance scheme (NHIS) and Community-based Health Planning and Services (CHPS) in Ghana since 2003, most Ghanaians still don’t seem to have spatial access to healthcare. Based on a case study of Kumasi, this paper discusses spatial accessibility to health facilities in Ghana using the Generalized Two-Step Floating Catchment Area Method. Overall, the results showed that most people in the study area could reach a hospital within 20 minutes, but those in peri-urban areas have very limited spatial access to health facilities. The paper concludes with a discussion of the policy implications of the findings.

Internet survey on the provision of complementary and alternative medicine in Japanese private clinics: a cross-sectional study

ObjectiveAlthough the use of complementary and alternative medicine (CAM) by the general population has been surveyed previously, the provision of CAM by Japanese physicians in private clinics has not been studied. Universal health insurance system was established in Japan in 1961, and most CAMs are not on the drug tariff. We aimed to clarify the current status of CAM provided by physicians at private clinics in Japan. MethodsWe conducted an internet survey on 400 directors/physicians of private clinics nationwide on the provision of CAM from February 6 to February 10, 2017. Survey items included attributes of subjects, presence/absence of sections or facilities for provision of CAM, proportions of health insurance coverage for medical practices, and source of information. Private clinic was defined as a clinic run by one physician, with less than 20 beds. ResultsCommonly provided CAMs were Kampo (traditional Japanese herbal) medicines (34.8%) and supplements/health foods (19.3%). CAMs on the drug tariff were provided in 46.5% of cases at the clinics, but only 16.5% of cases were provided CAMs which were not on the drug tariff, at different neighboring facilities. Among different specialties, Kampo medicines were prescribed at obstetrics/gynecology (54.0%), orthopedics (44.4%), and dermatology (43.0%). Clinics not providing any CAM accounted for 53.5%. With regard to health insurance coverage, 96.8% of the clinics provided only or mainly health services on the universal national health insurance tariff (29.8% and 67.0%, respectively). ConclusionKampo medicines represent the most commonly used CAM in private clinics in Japan, and universal national health insurance coverage is considered to be the reason for the high rate of their use.

Association of preterm birth and small for gestational age with metabolic outcomes in children and adolescents: A population-based cohort study from Taiwan

Previous studies have identified preterm birth and/or small for gestational age (SGA) as risk factors for features of the metabolic syndrome, including high blood pressure, insulin sensitivity and atherosclerosis, occurring later in life, with controversial results. We conducted this population-based cohort study to investigate metabolic outcomes in those with former preterm birth and/or SGA status in Taiwan. Data were obtained from Taiwan's universal National Health Insurance Research Database. From 1996 to 2004, 37,119 preterm infants, 3386 SGA infants, and 162,020 matched controls were included. We investigated the risk of the metabolic disease, including hypertension, diabetes, and hyperlipidemia, which had been recorded by the end of 2008. The preterm and SGA cohort, combined into one, had a significantly increased risk of developing metabolic disorders when compared with the comparison cohort (HR=2.46, 95% CI=2.02-3.01). We observed that children with former preterm and SGA status in Taiwan had a higher risk of developing hypertension (HR=3.24, 95% CI=1.58-6.67), Type 1 diabetes mellitus (HR=1.80, 95% CI=1.05-3.07), Type 2 diabetes mellitus (HR=2.49, 95% CI=1.98-3.14), and hyperlipidemia (HR=2.14, 95% CI=1.29-3.52). Our study revealed the risk of metabolic disease in those with preterm birth and/or SGA. Further studies with a longer duration of follow-up are required to confirm if there is a tendency for the metabolic syndrome to develop in this study cohort.

Social gradient in the cost of oral pain and related dental service utilisation among South African adults.

BackgroundOral pain affects people’s daily activities and quality of life. The burden of oral pain may vary across socio-economic positions. Currently, little is known about the social gradient in the cost of oral pain among South Africans. This study therefore assessed the social gradient in the cost of oral pain and the related dental service utilisation pattern among South African adults.MethodsData were obtained from a nationally representative cross-sectional survey of South African adults ≥16 year-old (n = 2651) as part of the South African Social Attitudes Survey conducted by the South African Human Sciences Research Council. The survey included demographic data, individual-level socio-economic position (SEP), self-reported oral health status, past six months’ oral pain experience and cost. The area-level SEP was obtained from the 2010 General Household Survey (n = 25,653 households) and the 2010/2011Quarterly Labour Force Survey conducted in South Africa. The composite indices used for individual-level SEP (α = 0.76) and area-level SEP (α = 0.88) were divided into tertiles. Data analysis was done using t-tests and ANOVA. Significance was set at p < 0.05.ResultsThe prevalence of oral pain among the adult South Africans was 19.4 % (95 % CI = 17.2–21.9). The most commonly reported form of oral pain was ‘toothache’ (78.9 %). The majority of the wealthiest participants sought care from private dental clinics (64.7 %), or from public dental clinics (19.7 %), while the poorest tended to visit a public dental clinic (45 %) or nurse/general medical practitioner (17.4 %). In the poorest areas, 21 % responded to pain by ‘doing nothing’. The individual expenditure for oral pain showed a social gradient from an average of ZAR61.44 spent by those of lowest SEP to ZAR433.83 by the wealthiest (national average ZAR170.92). Average time lost from school/work was two days over the six-month period, but days lost was highest for those living in middle class neighbourhoods (3.41), while those from the richest neighbourhood had lost significantly fewer days from oral pain (0.64).ConclusionsThere is a significant social gradient in the burden of oral pain. Improved access to dental care, possibly through carefully planned universal National Health Insurance (NHI), may reduce oral health disparities in South Africa.

ISQUA16-2073IMPLEMENTING EXTERNAL ELECTRONIC MEDICATION RECORDS TO PROMOTE EFFECTIVE HOSPITAL MEDICATION RECONCILIATION

Lack of accurate information among health professionals and patients about pre-admission medications can lead physicians inadvertently adding or duplicating medications, resulting in unintended harms and costs. PharmaCloud is an electronic based system, consisted of prescription claims covered by the universal National Health Insurance program for all insured in Taiwan. This study is to report the process and outcome related to the implementation of national electronic medication records (EMR) in a medical center aims to support effective medication reconciliations. A cross-sectional study was conducted at a tertiary medical center in Taiwan, using quantitative and …

Medical utilization by liver cancer patients under the National Health Insurance program in Taiwan: A population-based cross-sectional study

Aims Taiwan implemented a comprehensive and universal National Health Insurance (NHI) program to cover all inhabitants. This study aimed to assess the medical utilization by liver cancer patients under the NHI. Methods This retrospective cross-sectional study used a sampled NHI research database, which contained 1 million beneficiaries. The claims of liver cancer patients in 2009 were analyzed. The other beneficiaries without liver cancer who used medical services in 2009 served as the control patients. Results Among the 2335 identified liver cancer patients, 2178 (93.3%) patients used outpatient services and 1193 (51.1%) patients used inpatient services. Liver cancer accounted for 1.8% of the NHI's total cost. The cost per visit was United States dollars (US$)59.30 for outpatient care and US$2070.30 for inpatient care. The annual cost per patient was US$4746.60; US$1951.00 were for outpatient care and US$2795.60 for inpatient care. Patients who were female, in their 60s, had a lower income, and lived in southern Taiwan had a higher cost per patient (p < 0.0001). Fees for consultation, treatment, and medical supplies (57.3%) accounted for the highest portion of outpatient costs, followed by drug fees (30.0%) and diagnosis fees (11.2%). Ward fees accounted for the highest portion of inpatient costs (19.0%), followed by drug fees (18.7%) and X-ray fees (14.9%). Private hospitals were visited more frequently than public hospitals. The cost per visit and cost per patient with liver cancer were 206.0% and 666.8%, respectively, of the cost of the control patients. Conclusion The cost of liver cancer care is substantial and varies by sex, age, income, and geographic distribution. It is critical to reduce the incidence of liver cancer and identify cost-effective treatment strategies.

Trend and factors associated with healthcare use and costs in type 2 diabetes mellitus: a decade experience of a universal health insurance program.

Little is known about how a universal National Health Insurance program with cost-containment strategies affect costs and quality of diabetes care. To examine the trends of healthcare use and costs for patients with type 2 diabetes mellitus (T2DM) in Taiwan over the last decade, and to identify factors associated with high healthcare cost and poor diabetes care. We delineated the pattern of healthcare use and costs for T2DM in 2000-2010. Generalized linear and logistic regression models were used to identify factors associated with medical costs and diabetes care. Representative adult T2DM patients and age-matched and sex-matched nondiabetes individuals were selected from the 2000, 2005, and 2010 National Health Insurance Research Databases. Healthcare use included physician visits, hospital admissions, and antidiabetic drug prescriptions. Indicators of diabetes management included completeness of recommended diabetes tests and medication adherence, assessed using medication possession ratio. The total healthcare cost per diabetes patient was approximately 2.8-fold higher than that for nondiabetes individual. The growth of healthcare cost per diabetes patient was significantly contained by about 3694 New Taiwan dollars (3.6%) between 2005 and 2010, but diabetes care improved over the decade. Diabetes duration, income, place of residence, continuity of care, and enrollment to a pay-for-performance program were associated with healthcare costs and diabetes management. Some public health measures implemented to support diabetes care were also discussed. Healthcare costs could be controlled without sacrificing the quality of diabetes care by implementing pay-for-performance programs and effective health policies favorable for diabetes care.

Provider Behavior Under Global Budgeting and Policy Responses: An Observational Study on Eye Care Services in Taiwan.

Third-party payer systems are consistently associated with health care cost escalation. Taiwan’s single-payer, universal coverage National Health Insurance (NHI) adopted global budgeting (GB) to achieve cost control. This study captures ophthalmologists’ response to GB, specifically service volume changes and service substitution between low-revenue and high-revenue services following GB implementation, the subsequent Bureau of NHI policy response, and the policy impact. De-identified eye clinic claims data for the years 2000, 2005, and 2007 were analyzed to study the changes in Simple Claim Form (SCF) claims versus Special Case Claims (SCCs). The 3 study years represent the pre-GB period, post-GB but prior to region-wise service cap implementation period, and the post-service cap period, respectively. Repeated measures multilevel regression analysis was used to study the changes adjusting for clinic characteristics and competition within each health care market. SCF service volume (low-revenue, fixed-price patient visits) remained constant throughout the study period, but SCCs (covering services involving variable provider effort and resource use with flexibility for discretionary billing) increased in 2005 with no further change in 2007. The latter is attributable to a 30% cap negotiated by the NHI Bureau with the ophthalmology association and enforced by the association. This study demonstrates that GB deployed with ongoing monitoring and timely policy responses that are designed in collaboration with professional stakeholders can contain costs in a health insurance–financed health care system.

Anti-anxiety drugs use and cardiovascular outcomes in patients with myocardial infarction: A national wide assessment

ObjectiveAnti-anxiety medication in patients with anxiety may lessen the stress and thereby lower their risk for myocardial infarction (MI). The aim of current study is to examine an association between the use of anti-anxiety medication and long-term mortality risk in patients following MI. MethodsA universal national health insurance (NHI) program has been implemented in Taiwan since 1995. We used system sampling database from 1997 to 2008 with a total of 1,000,000 subjects. We included subjects with first episode of MI and were above 30 years old. Sudden death, cardiovascular mortality, and heart failure hospitalization were assessed in all included subjects. Anti-anxiety as well as other medications and risk factors were obtained. Cox regression analysis was used to evaluate the adjusted hazard ratio (HR) for all patients and subgroups. ResultsThe adjusted HRs of sudden death were significantly associated with increased benzodiazepam (BZD) dosage (HRs = 0.639, 1.003, 1.957 from Q2 to Q4 vs. Q1, p = .019 for trend) during approximately 4.8 years. For cardiac mortality and heart failure hospitalization, there was a J-curve dose–response relationship. The HRs for cardiac mortality were 0.255 (p < .001) and 0.385 (p < .001) for Q2 and Q3 vs. Q1, respectively. For patients receiving higher doses of daily BZDs (>5 mg), protective effects for cardiac mortality and heart failure hospitalization decreased and a J-curve dose–response relationship was seen. ConclusionAnti-anxiety medications are independent associated with a decreased risk of cardiac mortality and heart failure hospitalization in patients after a new MI.

Synergistic interaction of benign prostatic hyperplasia and prostatitis on prostate cancer risk

Background:The incidence of prostate cancer is much lower in Asian men than in Western men. This study investigated whether prostate cancer is associated with prostatitis, benign prostatic hyperplasia (BPH), and other medical conditions in the low-incidence population.Methods:From the claims data obtained from the universal National Health Insurance of Taiwan, we identified 1184 patients with prostate cancer diagnosed from 1997 to 2008. Controls comprised 4736 men randomly selected from a cancer-free population. Both groups were 50 years of age or above. Medical histories between the two groups were compared.Results:Multivariate logistic regression analysis showed that prostatitis and BPH had stronger association with prostate cancer than the other medical conditions tested. Compared with men without prostatitis and BPH, a higher odds ratio (OR) for prostate cancer was associated with BPH (26.2, 95% confidence interval (CI) 20.8–33.0) than with prostatitis (10.5, 95% CI=3.36–32.7). Men with both conditions had an OR of 49.2 (95% CI=34.7–69.9).Conclusion:Men with prostate cancer have strong association with prostatitis and/or BPH. Prostatitis interacts with BPH, resulting in higher estimated relative risk of prostate cancer in men suffering from both conditions.

Taiwan's Social Welfare System in Predicament after Expansion

Democratisation and highly competitive electoral politics in the past two decades have driven Taiwan's social welfare system to expand rapidly. Its universal national health insurance scheme is the most favoured social policy in Taiwan and the occupation-based pension programmes generally provide high income replacement rates. The expanded social welfare system has also generated an increasingly positive redistributive effect on income equality in Taiwan. However, financial sustainability is its largest challenge.

Health insurance coverage, medical expenditure and coping strategy: evidence from Taiwan

BackgroundThe health insurance system in Taiwan is comprised of public health insurance and private health insurance. The public health insurance, called “universal national health insurance” (NHI), was first established in 1995 and amended in 2011. The goal of this study is to provide an updated description of several important aspects of health insurance in Taiwan. Of special interest are household insurance coverage, medical expenditures (both gross and out-of-pocket), and coping strategies.MethodsData was collected via a phone call survey conducted in August and September of 2011. A household was the unit for survey and data analysis. A total of 2,424 households covering all major counties and cities in Taiwan were surveyed.ResultsThe survey revealed that households with smaller sizes and higher incomes were more likely to have higher coverage of public and private health insurance. In addition, households with the presence of chronic diseases were more likely to have both types of insurance. Analysis of both gross and out-of-pocket medical expenditure was conducted. It was suggested that health insurance could not fully remove the financial burden caused by illness. The presence of chronic disease and inpatient treatment were significantly associated with higher gross and out-of-pocket medical expenditure. In addition, the presence of inpatient treatment was significantly associated with extremely high medical expenditure. Regional differences were also observed, with households in the northern, central, and southern regions having less gross medical expenditures than those on the offshore islands. Households with the presence of inpatient treatment were more likely to cope with medical expenditure using means other than salaries.ConclusionDespite the considerable achievements of the health insurance system in Taiwan, there is still room for improvement. This study investigated coverage, cost, and coping strategies and may be informative to stakeholders of both basic and commercial health insurance.

Cohort profile: The QSkin Sun and Health Study

The QSkin Sun and Health Study comprises a cohort of 43 794 men and women aged 40-69 years randomly sampled from the population of Queensland, Australia in 2011. The cohort was established to study the development of skin cancer and melanoma in the population with the highest reported incidence of these diseases in the world. At baseline, besides demographic items and general medical history, information about standard pigmentary characteristics (including hair and eye colour, freckling tendency, tanning ability and propensity to sunburn), past and recent history of sun exposure and sunburns, sun protection behaviours, use of tanning beds and history of skin cancer was collected by self-completed questionnaire. Participants have given their consent for data linkage to the universal national health insurance scheme and for linkage to cancer registries and pathology databases, thus ensuring complete ascertainment of all future skin cancer and melanoma occurrences and medical treatments and other cancer events. Linkage to these registers will occur at predetermined intervals. Approval to access QSkin data can be obtained on application to the study investigators and submission of a formal research plan that has previous approval from the human research ethics committee of the applicant's institution.