Determinants of hospital loss in Thailand: experience from the first year of a universal coverage health insurance program

The objective of this study was to examine determinants of hospital loss in Thailand. Administration national data for 640 public hospitals of fiscal year 2002 from Ministry of Public Health were analyzed. Results showed that various managerial, service mix, and market variables were significantly associated with the likelihood of the hospital being unprofitable. Hospital characteristics were associated with the amount of loss. The results also suggested that managing the number of hospital employees, inventory, and patient hospitalization could control the amount of loss. In conclusion, most of identified factors associated with hospital loss were manageable. The ramification of this study was to help policy makers understand the hospital loss situation in Thailand after implementing the UC scheme and design policy to resolve the hospital loss problems.     

Increasing health insurance costs and the decline in insurance coverage

OBJECTIVE: To determine the impact of rising health insurance premiums on coverage rates. DATA SOURCES & STUDY SETTING: Our analysis is based on two cohorts of nonelderly Americans residing in 64 large metropolitan statistical areas (MSAs) surveyed in the Current Population Survey in 1989-1991 and 1998-2000. Measures of premiums are based on data from the Health Insurance Association of America and the Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits. STUDY DESIGN: Probit regression and instrumental variable techniques are used to estimate the association between rising local health insurance costs and the falling propensity for individuals to have any health insurance coverage, controlling for a rich array of economic, demographic, and policy covariates. PRINCIPAL FINDINGS: More than half of the decline in coverage rates experienced over the 1990s is attributable to the increase in health insurance premiums (2.0 percentage points of the 3.1 percentage point decline). Medicaid expansions led to a 1 percentage point increase in coverage. Changes in economic and demographic factors had little net effect. The number of people uninsured could increase by 1.9-6.3 million in the decade ending 2010 if real, per capita medical costs increase at a rate of 1-3 percentage points, holding all else constant. CONCLUSIONS: Initiatives aimed at reducing the number of uninsured must confront the growing pressure on coverage rates generated by rising costs.     

The dynamics of health insurance coverage: identifying trigger events for insurance loss and gain

By linking consecutive years of the 1996–2004 Current Population Survey (CPS), we create new estimates of annual transitions into and out of health insurance coverage. Using the matched CPS panel data, we explore the dynamic factors—including job loss, changes in hours or weeks worked, and movement between firm sizes—associated with health insurance loss and gain. Job loss is strongly associated with losing insurance, whereas becoming reemployed is only weakly associated with gaining insurance. Movement down (up) in employment size is associated with insurance loss (gain), but movement to employers with fewer than 10 employees is associated with especially high rates of loss. Changes in hours or weeks worked and employment type are also strongly associated with insurance transitions.

Health insurance coverage within sibships: Prevalence of mixed coverage and associations with health care utilization

An increasing proportion of children in the United States lives in families with complicated family structures and a mix of immigrant and US-born family members. Eligibility rules for health insurance coverage, however, were not designed with these families in mind. The result can be complicated insurance patterns among siblings within families, with some “sibships” only being partially-insured, and other sibships having both private and public coverage. We hypothesize that mixed coverage among siblings causes confusion and logistical difficulties for parents and may lead to less access to appropriate health care for their children. In this article, we use data from the 2009–2011 National Health Interview Survey (n = 51,418 children in 20,478 sibships) to present estimates of the prevalence of mixed health insurance coverage among siblings and describe the predictors of such coverage. We also use linked data from the 2001–2005 National Health Interview Survey and 2002–2007 Medical Expenditure Panel Survey (n = 17,871) to show how mixed coverage is related to health care utilization. We find that although few sibships are characterized by different health insurance coverage types, mixed coverage among siblings is far more common among families with mixed nativity status, and blended families with step- and half-siblings. In terms of outcomes, children living in sibships with mixed coverage have significantly lower odds of having a usual source of health care. We also consider whether the association between mixed insurance coverage and health care outcomes differs across particular combinations of insurance coverage. We find that both publicly-insured children who have uninsured siblings and privately-insured children with publicly-insured siblings are less likely to have a usual source of care than similar children with uniformly-insured siblings. Because a usual source of care is associated with better health care outcomes, we argue that policymakers should consider ways to reduce mixed coverage among children and families.     

A tale of two counties: expanding health insurance coverage for children in California

During difficult economic times, many California counties have expanded health insurance coverage for low-income children. These Children's Health Initiatives (CHIs) enroll children in public programs and provide new health insurance, Healthy Kids, for those ineligible for existing programs. This article describes the policy issues in implementing the Santa Clara and San Mateo County CHIs, as well as the children's enrollment levels and utilization of services. These CHIs are among the first of the thirty California counties planning or implementing such initiatives. Their success depends on leadership from county agencies that have not traditionally worked closely together, as well as the development of a diverse public and private funding base. This effort to provide universal coverage for all children is important to national policymakers desiring similar goals.     

Assessing incentives for service-level selection in private health insurance exchanges

Even with open enrollment and mandated purchase, incentives created by adverse selection may undermine the efficiency of service offerings by plans in the new health insurance Exchanges created by the Affordable Care Act. Using data on persons likely to participate in Exchanges drawn from five waves of the Medical Expenditure Panel Survey, we measure plan incentives in two ways. First, we construct predictive ratios, improving on current methods by taking into account the role of premiums in financing plans. Second, relying on an explicit model of plan profit maximization, we measure incentives based on the predictability and predictiveness of various medical diagnoses. Among the chronic diseases studied, plans have the greatest incentive to skimp on care for cancer, and mental health and substance abuse.     

Worker preferences, sorting and aggregate patterns of health insurance coverage

To assess the performance of the employment-based health insurance system, it is necessary to understand how well workers sort into jobs that offer their desired mix of cash wages relative to benefits. However, few studies directly measure the extent of sorting. We quantify the prevalence of mismatches between workers’ preferences and firms’ insurance offerings by considering two types of mismatch: (1) workers who appear to desire coverage through their employer, but work for firms that do not offer coverage, and; (2) workers who appear not to desire coverage through their employer, but work for firms that offer coverage. Most workers (79.6%) enjoy labor market matches that appear consistent with their preferences. The remaining 20.4% of workers appear to be mismatched. For most of these mismatches, the primary consequence is lower wages than would be earned if individuals were better matched in the labor market. However, a minority of the identified mismatches appear to be “involuntarily uninsured” workers who would gain insurance if they were to find a better match. Extrapolating from the analysis sample, these involuntarily uninsured workers and their uninsured dependents may represent up to one in six uninsured individuals in the United States. This work was supported by a grant from the Economic Research Initiative on the Uninsured (ERIU) at the University of Michigan, funded by the Robert Wood Johnson Foundation.     

The validity of hospital discharge register data on coronary heart disease in Finland

We studied the validity of the Finnish hospital discharge register data on coronary heart disease (CHD) for the purposes of epidemiologic studies and health services research. The Finnish nationwide hospital discharge register (HDR) was linked with the FINMONICA acute myocardial infarction (AMI) register for the years 1983–1990. The frequency of errors in the HDR was assessed separately. Between 8% and 13% of hospitalized AMI events registered in the AMI Register were not found in the HDR with an ICD code for CHD. Problems with the register linkage and the use of some ICD code other than one of the codes for CHD explained these missing events. The frequency of errors in the personal identification number was about 5% in the early 1980s. After 1986 errors were found only occasionally. The diagnosis recorded in the HDR was the same as that in the discharge sheet in about 95% of hospitalizations. The positive predictive value of the ICD code 410 (AMI), compared with the FINMONICA definite+possible AMI category, was very high and stable, about 90% in all areas and all hospitals, but it sensitivity varied from 50% at local hospitals to 80% at central hospitals. In summary, data on CHD obtained from the Finnish hospital discharge register give, on average, a correct picture on changes in the occurrence of AMI in Finland and can, with necessary caution, be used in epidemiological studies and health services research. However, the classification of individual cases is not standardized in the HDR, but varies over time, between geographical areas and the levels of care. Therefore, these data should not be used without confirmation in studies where correct classification of individual outcomes is of crucial importance, such as follow-up studies and case-control studies.     

The effects of child-only insurance coverage and family coverage on health care access and use: recent findings among low-income children in California

OBJECTIVE: To compare the extent with which child-only and family coverage (child and parent insured) ensure health care access and use for low income children in California and discuss the policy implications of extending the State Children's Health Insurance Program (California's Healthy Families) to uninsured parents of child enrollees. DATA SOURCES/SETTING: We used secondary data from the 2001 California Health Interview Survey (CHIS), a representative telephone survey. STUDY DESIGN: We conducted a cross-sectional study of 5,521 public health insurance-eligible children and adolescents and their parents to examine the effects of insurance (family coverage, child-only coverage, and no coverage) on measures of health care access and utilization including emergency room visits and hospitalizations. DATA COLLECTION: We linked the CHIS adult, child, and adolescent datasets, including the adolescent insurance supplement. FINDINGS: Among the sampled children, 13 percent were uninsured as were 22 percent of their parents. Children without insurance coverage were more likely than children with child-only coverage to lack a usual source of care and to have decreased use of health care. Children with child-only coverage fared worse than those with family coverage on almost every access indicator, but service utilization was comparable. CONCLUSIONS: While extending public benefits to parents of children eligible for Healthy Families may not improve child health care utilization beyond the gains that would be obtained by exclusively insuring the children, family coverage would likely improve access to a regular source of care and private sector providers, and reduce perceived discrimination and breaks in coverage. These advantages should be considered by states that are weighing the benefits of expanding health insurance to parents.     

海南省医院费用定额包干补偿方式个案研究

作者通过对海南省医疗保险改革的调查，探讨当地正在实践的医院费用补偿办法，并与其他城市采取的补偿方式进行比较，认为海南的医疗费用定额包干支付办法有明显的优点，提供了一种可供选择的新的医疗资源分配方式。     

Hips and hearts: The variation in incentive effects of insurance across hospital procedures

The separate identification of effects due to incentives, selection and preference heterogeneity in insurance markets is the topic of much debate. In this paper, we investigate the presence and variation in moral hazard across health care procedures. The key motivating hypothesis is the expectation of larger causal effects in the case of more discretionary procedures. The empirical approach relies on an extremely rich and extensive dataset constructed by linking survey data to administrative data for hospital medical records. Using this approach we are able to provide credible evidence of large moral hazard effects but for elective surgeries only.     

Cor pulmonale and pneumoconiotic lung disease: An investigation using hospital discharge data

Cor pulmonale has been reported in the past to be associated with pneumoconiosis as an end-stage complication. However, whether the association can be demonstrated among cases of pneumoconiosis acquired in more recent decades is not clear. We examined the relation between these conditions using data summarized in hospital records in Ontario for males discharged between 1979 and 1990 with a diagnosis of chronic cor pulmonale or one of the pneumoconioses. Based on the age-specific frequency rates, cor pulmonale was diagnosed 17 (95% confidence interval 13–22) times more frequently than expected among men diagnosed with pneumoconiosis than among other men admitted to hospital. Our investigation indicates that cor pulmonale still appears to be associated with dust exposure in the workplace, and it demonstrates the usefulness of hospital discharge information in addressing questions in occupational health. However, we recommend that hospital medical records be examined to confirm the diagnoses and to determine the smoking histories of these men. © 1993 Wiley-Liss, Inc.     

The adequacy of household survey data for evaluating the nongroup health insurance market

OBJECTIVE: To evaluate the accuracy of household survey estimates of the size and composition of the nonelderly population covered by nongroup health insurance. DATA SOURCES/STUDY SETTING: Health insurance enrollment statistics reported to New Jersey insurance regulators. Household data from the following sources: the 2002 Current Population Survey (CPS)-March Demographic Supplement, the 1997 and 1999 National Surveys of America's Families (NSAF), the 2001 New Jersey Family Health Survey (NJFHS), a 2002 survey of known nongroup health insurance enrollees, a small 2004 survey testing alternative health insurance question wording. STUDY DESIGN: To assess the extent of bias in estimates of the size of the nongroup health insurance market in New Jersey, enrollment trends are compared between official enrollment statistics reported by insurance carriers to state insurance regulators with estimates from three general population household surveys. Next, to evaluate possible bias in the demographic and socioeconomic composition of the New Jersey nongroup market, distributions of characteristics of the enrolled population are contrasted among general household surveys and a survey of known nongroup subscribers. Finally, based on inferences drawn from these comparisons, alternative health insurance question wording was developed and tested in a local survey to test the potential for misreporting enrollment in nongroup coverage in a low-income population. DATA COLLECTION/EXTRACTION METHODS: Data for nonelderly New Jersey residents from the 2002 CPS (n=5,028) and the 1997 and 1999 NSAF (n=6,467 and 7,272, respectively) were obtained from public sources. The 2001 NJFHS (n=5,580 nonelderly) was conducted for a sample drawn by random digit dialing and employed computer-assisted telephone interviews and trained, professional interviewers. Sampling weights are used to adjust for under-coverage of households without telephones and other factors. In addition, a modified version of the NJFHS was administered to a 2002 sample of known nongroup subscribers (n=1,398) using the same field methods. These lists were provided by four of the five largest New Jersey nongroup insurance carriers, which represented 95 percent of all nongroup enrollees in the state. Finally, a modified version of the NJFHS questionnaire was fielded using similar methods as part of a local health survey in New Brunswick, New Jersey, in 2004 (n=1,460 nonelderly). PRINCIPAL FINDINGS: General household sample surveys, including the widely used CPS, yield substantially higher estimates of nongroup enrollment compared with administrative totals and yield estimates of the characteristics of the nongroup population that vary greatly from a survey of known nongroup subscribers. A small survey testing a question about source of payment for direct-purchased coverage suggests than many public coverage enrollees report nongroup coverage. CONCLUSIONS: Nongroup health insurance has been subject to more than a decade of reform and is of continuing policy interest. Comparisons of unique data from a survey of known nongroup subscribers and administrative sources to household surveys strongly suggest that the latter overstates the number and misrepresent the composition of the nongroup population. Research on the nongroup market using available sources should be interpreted cautiously and survey methods should be reexamined.     

The effect of Health Savings Accounts on group health insurance coverage

This paper presents new empirical evidence on the impact of tax subsidies for Health Savings Accounts (HSAs) on group insurance coverage. HSAs are tax-free health care expenditure savings accounts. Coupled with high deductible health insurance plans (HDHPs), they together represent new health insurance options. The tax advantage of HSAs expands the group health insurance market by making health care more affordable. Using individual level data from the Current Population Survey and exploiting policy variation by state and year from 2004 to 2012, I find that HSA tax subsidies increase small-group coverage by a statistically significant 2.5 percentage points, although not coverage in larger firms. Moreover, if the tax price of HSA contribution decreases by 10 cents, small-group insurance coverage increases by almost 2 percentage points. I also find that for older workers or less-educated workers, HSA subsidies are associated with 2–3 percentage point increase in their group insurance coverage.     

医疗保险制度对降低我国居民灾难性卫生支出的效果分析

目的：2008年中国的医保制度已经覆盖87.9%的居民,接近全民医保覆盖的目标。然而,仍存在部分居民现金卫生支出比例过高的现象,导致家庭由于支付医疗卫生费用而陷入经济困境。本文通过计算中国灾难性卫生支出发生率和致贫率,来探究中国医疗保险制度的保障力度与水平。方法：本文利用第四次卫生服务调查的数据,通过世界卫生组织推荐的方法计算灾难性卫生支出和致贫率。结果：灾难性卫生支出发生率为13.0%,且发生率随着家庭经济水平的提高而降低;总体致贫率为7.5%;家庭中含有住院病人、慢性病人、肺结核病人及60岁以上老人,其发生灾难性卫生支出的风险高。结论与建议：通过分析脆弱人群发生灾难性卫生支出风险及影响因素,为今后完善医疗保险制度设计提供具有可操作性的政策建议,增强其对居民抵御疾病经济风险的保障能力。     

Dynamics of social health insurance development: examining the determinants of Chinese basic health insurance coverage with panel data

Social health insurance (SHI) is gaining popularity in many developing countries, but there are few systematic empirical studies on the dynamics of SHI development. This study investigates the determinants of coverage of the Basic Healthcare Insurance for Urban Employees (BHI) in China. Using a panel database ranging from 1999 to 2007, the study finds that: (1) economic development plays a valuable role in BHI development; (2) strong financial capacity and administrative capacity in the government contributes to BHI progress; (3) higher trade union density is closely related to more rapid BHI expansion; and (4) taxation agencies are better at collecting SHI premiums. These findings provide evidence-based lessons for new and ongoing SHI programs. In addition, this article aims to make a more general contribution to the study of social policy development by expanding the scope of current theories on social policy development.     

A discrete choice decomposition analysis of racial and ethnic differences in children's health insurance coverage

This paper presents a multivariate decomposition analysis of racial and ethnic differences in children's health insurance using the 2004-2005 Medical Expenditure Panel Survey. We present two methodological contributions. First, we adapt a recently-developed matching decomposition method for use with sample-weighted data. Second, we develop a fully nonparametric approach that implements decomposition through weight adjustments. Accounting for the black-white wealth gap: a nonparametric approach. Journal of the American Statistical Association 97, 663-673]. Differences in observed characteristics explain large percentages of racial and ethnic coverage differences. Important contributors include poverty levels, parent education, family structure (for black children), and immigration-related factors (for Hispanic children). We also examine racial and ethnic differences in parent offers of employer-sponsored insurance and in children's coverage conditional on having a parent offer. Comparison of our linear, nonlinear, and nonparametric results suggests researchers may face a trade-off between robustness and precision when selecting among decomposition methodologies for discrete outcomes.