Multiple-race mortality data for California, 2000-2001

OBJECTIVES: To examine mortality rates and quality of race reporting for multiple-race individuals in California using the new multiple-race data available on the death certificate. METHODS: Death date were drawn from California vital statistics for 2000 and 2001. Denominator data were drawn from the 2000 census Modified Race Data Summary File. The authors calculated mortality rates and relative standard errors for multiple-race individuals as a whole and by county, and for the three largest reported multiple-race groups (African American and white, American Indian/Alaska Native and white, and Asian and white). RESULTS: Decedents reported to be of more than one race were disproportionately young, Hispanic, male, and never-married. Age-adjusted mortality rates for multiple-race groups were approximately one-sixth as high as rates for single-race individuals. There was substantial variability in rates for multiple-race decedents according to county of residence. CONCLUSIONS: Mortality rates for multiple-race people were implausibly low, and death certificates for multiple-race individuals were geographically clustered. Race reporting on death certificates will need to be improved before accurate death rates can be calculated for those of multiple races.     

The determinants of private medical insurance prevalence in England, 1997-2000

OBJECTIVE: The aim of this paper is to identify the factors that determine the prevalence of private medical insurance (PMI) in England. DATA SOURCES/STUDY SETTING: Secondary data sources are the British Household Panel Survey (BHPS) 1997-2000, Laing's Healthcare Market Review 1999-2000, the United Kingdom (U.K.) Department of Health's National Health Service Waiting Times Team, and the Work Force Statistics Branch of the Department of Health. STUDY DESIGN: Logistic regression models for panel data were used to compare non-PMI subscribers with individual subscribers and those with employer-provided PMI. DATA COLLECTION/EXTRACTION METHODS: The BHPS data are collected by the Institute for Social and Economic Research at the University of Essex. Other data used were collected by Laing and Buisson and the U.K. Department of Health. PRINCIPAL FINDINGS: Individual PMI is more prevalent among the well-educated and healthy. Income, age, sex, and political preference are key determinants of PMI prevalence for both individual and employer paid PMI. Individuals are also likely to reflect on information with regard to waiting times in deciding whether or not to purchase PMI cover. The withdrawal of the tax subsidy in 1997 to PMI subscribers over 60 years of age did not impact on their rate of withdrawal from PMI coverage relative to the rate among all PMI subscribers, but may have discouraged potential new subscribers. CONCLUSIONS: Current trends in the PMI market suggest that, over time, individually purchased PMI is likely to be partially displaced by PMI purchased as part of a company-based plan. However, having PMI is linked to economic factors in both groups, suggesting a similar segment of the population valuing the responsiveness that PMI provides. Geographic factors relating to waiting times and supply-side factors are associated with both individual and company-based PMI. The withdrawal of the tax subsidy to individual subscribers older than age of 60 resulted in a significant decline in the demand for PMI. In particular, the number of new subscribers in this group declined substantially.     

Incentives for voluntary health insurance in a national health system: Evidence from Italy

ObjectivesThe paper evaluates the extent to which the government's policy to encourage the purchase of voluntary health insurance (VHI) may have led to income-related horizontal inequity in access to health care in a universal health care system (NHS).MethodsAd hoc tax return data for the universe of Italian taxpayers for years 2009-2016 are used to estimate the tax benefits granted to taxpayers who hold VHI, the redistributive impact, and the public budget effect. The income elasticity of tax benefits is estimated using tax return data and considering some taxpayers’ characteristics (income class, gender, age, and geographic area). Standard inequality indices are computed to assess income-related horizontal inequity in access to health care.ResultsTax incentives, especially those granted to employer-paid health insurance, have a sizeable impact on tax revenue and introduce into the Italian NHS significant income-related horizontal and vertical inequity in access to health care. The results suggest a distributional profile of tax incentives that is highly concentrated in favor of wealthier taxpayers.ConclusionOur analysis adds novel evidence that may contribute to the current debate on whether and to what extent countries in which all citizens have access to free healthcare and equal standards of healthcare services should subsidize VHI, especially when the coverage doubles the healthcare services provided by universal public insurance. We show that VHI reduces tax revenues and introduces disparities among citizens in terms of access to healthcare services.     

Supplemental insurance and mortality in elderly Americans. Findings from a national cohort

CONTEXT: As the burden of out-of-pocket health care expenditures for Medicare beneficiaries has grown, the need to assess the relationship between uncovered costs and health outcomes has become more pressing. OBJECTIVE: To assess the relationship between risk for out-of-pocket expenditures and mortality in elderly persons with private supplemental insurance. DESIGN: Retrospective cohort study using proportional hazards survival analyses to assess mortality as a function of health insurance, adjusting for sociodemographic, access, and case mix-health status measures. SETTING: The 1987 National Medical Expenditure Survey, a representative cohort of the US civilian population, linked to the National Death Index. PARTICIPANTS: A total of 3751 persons aged 65 years and older. MAIN OUTCOMES MEASURES: Five-year mortality rate. RESULTS: After 5 years, 18.5% of persons at low risk for out-of-pocket expenditures, 22.5% of those at intermediate risk, and 22.6% of those at high risk had died. After multivariate adjustment, a significant linear trend (P = .02) toward increasing mortality with increasing risk category was observed. Compared with the low-risk group, persons in the intermediate-risk group had an adjusted hazard ratio of 1.2 (95% confidence interval, 0.9-1.6), whereas those in the high-risk group had an adjusted hazard ratio of 1.4 (95% confidence interval, 1.0-1.9). CONCLUSIONS: Increasing risk for out-of-pocket costs is associated with higher subsequent mortality among elderly Americans with supplemental private coverage. Although research is needed to identify which specific components of out-of-pocket expenditures are adversely associated with health outcomes, findings support policies to decrease out-of-pocket health care expenditures to reduce the risk for premature mortality in elderly Americans.     

对建立老年人医疗保险制度的设想

随着人类生育率和死亡率的大幅度降低，21世纪的人口老龄化问题越来越突出，已成为世界关注的焦点。我国也同样面临人口老龄化的挑战。根据联合国规定，60岁及以上人口占总人口的比例超过10％或65岁及以上人口比重超过7％，即为老龄化社会。第五次全国人口普查结果显示：     

The association between health insurance coverage and diabetes care; data from the 2000 Behavioral Risk Factor Surveillance System

OBJECTIVE: To describe the association between type of health insurance coverage and the quality of care provided to individuals with diabetes in the United States. DATA SOURCE: The 2000 Behavioral Risk Factor Surveillance System. STUDY DESIGN: Our study cohort included individuals who reported a diagnosis of diabetes (n=11,647). We performed bivariate and multivariate logistic regression analyses by age greater or less than 65 years to examine the association of health insurance coverage with diabetes-specific quality of care measures, controlling for the effects of race/ethnicity, annual income, gender, education, and insulin use. PRINCIPAL FINDINGS: Most individuals with diabetes are covered by private insurance (39 percent) or Medicare (44 percent). Among persons under the age of 65 years, 11 percent were uninsured. The uninsured were more likely to be African American or Hispanic and report low incomes. The uninsured were less likely to report annual dilated eye exams, foot examinations, or hemoglobin A1c (HbA1c) tests and less likely to perform daily blood glucose monitoring than those with private health insurance. We found few differences in quality indicators between Medicare, Medicaid, or the Department of Veterans Affairs (VA) as compared with private insurance coverage. Persons who received care through the VA were more likely to report taking a diabetes education class and HbA1c testing than those covered by private insurance. CONCLUSIONS: Uninsured adults with diabetes are predominantly minority and low income and receive fewer preventive services than individuals with health insurance. Among the insured, different types of health insurance coverage appear to provide similar levels of care, except for higher rates of diabetes education and HbA1c testing at the VA.     

发达国家医疗保险制度的经验借鉴

随着经济体制转型，我国的医疗保险制度也进行了一系列的改革。试图从发达国家医疗保险制度中存在的问题以及所进行的改革出发，分析和阐述发达国家医疗保险制度值得我国借鉴的经验。     

Preparation for palliative care: teaching about death,dying and bereavement in UK medical schools 2000-2001

AIM: To examine changes in formal teaching about death, dying and bereavement in undergraduate medical education in UK medical schools. METHODS: A short questionnaire based on one used in 2 previous surveys in 1983 and 1994 was sent to all UK medical schools. FINDINGS: All schools with clinical teaching provided teaching in this area. The amount of such teaching varied widely and appeared in the curriculum in a variety of manners, times and places. Specialists in palliative medicine, general practitioners and nurse specialists were most frequently involved in teaching, with decreased involvement of non-practitioners since 1983. Most schools covered a wide range of topics, with all addressing attitudes towards death and dying and symptom relief in advanced terminal illness. Some schools used terminally ill patients directly in their teaching and most included hospice participation. As the surveys conducted in 1983 and 1994 indicated, many schools do not address the evaluation of palliative care learning. ANALYSIS: Changes in undergraduate medical education, especially in terms of more integrated curricula, mean that for many schools, palliative care teaching is integrated into learning in other areas. This should help students apply their palliative care learning to other contexts. The increase in teaching about the management of physical symptoms that has occurred since the previous surveys seems to reflect the establishment of palliative medicine as a speciality and the current emphases within palliative care practice in the UK. CONCLUSION: The preparation for palliative care work provided for current undergraduate medical students appears to be of a better quality than that provided in 1983.     

资本新宠:医保事务信息处理系统

"在未来,医疗组织更有效地处理信息将会是一个要求……信息技术除了改进当前的护理和持续的医生、患者对话外,还能通过长期对症候、疾病和治疗的记录和分析提供改进护理的答案……商务启示:……数字系统能使您的专业人员在文书工作上花更少时间,而把更多时间花在病人身上吗?您的数字系统支持医生做医疗决策吗?"     

从医疗需求和医疗服务看医保制度改革的合理性

医保制度改革(以下简称医改)的根本目的是为了提高医疗保障能力，提高职工的健康水平。贯彻预防为主的方针，做到有病早治，通过提高卫生经济效益的方法，降低医疗费用的支出是一条基本的原则。通过合理的政策引导，调整职工对医疗服务的需求，同时，也调节医疗服务机构的服务供给，合理利用现有卫生资源，避免过度服务和资源浪费。在实际操作过程中，通过制定基本医疗保险服务范围和标准，包括基本医疗保险药品目录、诊疗项目和医疗服务设施标准，确定基金能够承付的医疗服务范围和标准，保证在满足基本医疗需求的同时确保医疗保险基金的收支平衡。这是以前公费医疗管理中一条成功的经验，也是国际上社会医疗保险的通常做法。有了这个基本医疗保险服务范围和标准，有利于合理控制医疗费用的支出，有效地保障大多数职工的基本医疗需求。     

Methods for identifying pregnancy-associated deaths: population-based data from Finland 1987-2000

To find maternal and pregnancy-related deaths, it is important that all pregnancy-associated deaths are identified. This article examines the effect of data linkages between national health care registers and complete death certificate data on pregnancy-associated deaths. All deaths among women of reproductive age (15-49 years) in Finland during the period 1987-2000 (n = 15 823) were identified from the Cause-of-Death Register and linked to the Medical Birth Register (n = 865 988 births), the Register on Induced Abortions (n = 156 789 induced abortions), and the Hospital Discharge Register (n = 118 490 spontaneous abortions) to determine whether women had been pregnant within 1 year before death. The death certificates of the 419 women thus identified were reviewed to find whether the pregnancy or its termination was coded or mentioned. In total, 405 deaths (96.7%) were identified in registers other than the Cause-of-Death Register. Without data linkages, 73% of all pregnancy-associated deaths would have been missed; the percentage after induced and spontaneous abortions was even higher. Data linkages to national health care registers provide better information on maternal deaths and pregnancy-associated deaths than death certificates alone. If possible, pregnancies not ending in a live birth should be included in the data linkages.