An analysis of use of the health services by financing system: Brazil 1998-2008

This article analyzes the use of health services from the perspective of financing based on PNAD/IBGE micro-data related to 1998, 2003 and 2008. Among the main results, the following can be highlighted: 1) The Unified Health System (SUS) continues to be the major financing agent of most consultations and hospitalizations in Brazil; its participation increased significantly between 1998 and 2003 and remained almost stable between 2003 and 2008; 2) SUS participation in financing the use of the health services has been predominant in all Brazilian regions, especially in the North and North-East, which feature the most precarious socio-economic and health conditions; 3) SUS is the major financing agent of the two extreme levels of complexity of health care: primary care and high complexity services. 4) In spite of a significant rise in utilization rates of SUS services for consultations and hospitalizations, great inequities can still be observed between the population that exclusively uses SUS and that which has private health insurance; 5) There has been an increase in the use of SUS health services by part of the population with private health insurance plans.     

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.     

THE DEMAND FOR PRIVATE PSYCHIATRIC SERVICES IN A HEALTH INSURED POPULATION

This paper reports a study of the pattern of utilization of private psychiatric services by health insured persons who are members of a single large fund. The data show an increase in the average number of services per person consulting a psychiatrist with little change in the number of persons. There is a strong relation between private psychiatric contact rates and the socio-economic index of the LGA of patient residence. Contributor units containing a medical practitioner are examined as an example of the utilization pattern of a socially elite group. The financial and administrative significance of the findings is discussed. Very little information is available in Australia concerning the relationship between the demand for health services and the socioeconomic characteristics of the clients or potential clients of the health services. Since Australian governments have shown a substantial reliance on voluntary health insurance as a mechanism for financing health care, this lack of information is surprising. Studies in the United States of America and England suggest that the upper socio-economic classes receive more medical services than the lower, although these conclusions are not clear cut. It becomes a useful a priori hypothesis that a relationship between socio-economic status and the demand for medical services exists in Australia, even within a health insured population. In this paper we examine the utilization of private psychiatric services by persons who were members of a single large health insurance fund in New South Wales. Claim history and membership demographic data were obtained from the health fund computer record system for the years 1977, 1978 and the period January to June, 1979. Since this fund covers about onethird of all persons with private health insurance in that state, we believe that the study may rellect the relationships for health insured populations in Australia generally. Private psychiatric services have been examined, not only because the itemization of psychiatric services is simple and data analysis is easy, but also because there is ample anecdotal evidence that the demand for psychiatric services is determined partly by client status and education. This should help establish the existence or otherwise of some socioeconomic gradient with respect to the demand for services.     

Access to care and use of health services by low-income women

Data from the 1997 National Survey of America's Families (NSAF) are used to analyze access to care and use of health care services for low-income women. Three groups of women are examined: those with Medicaid coverage, those with private coverage, and those with no insurance. Findings show that uninsured women faced larger access barriers and utilized fewer services, particularly preventive care services, than women with either public or private coverage. Access and use did not differ greatly between Medicaid and privately covered women. The results suggest that expansions in coverage, either through Medicaid or through private options, could improve access to care for uninsured women.     

Health insurance and health services utilization in Ireland

The numbers buying private health insurance in Ireland have continued to grow, despite a broadening in entitlement to public care. About 40% of the population now have insurance, although everyone has entitlement to public hospital care. In this paper, we examine in detail the growth in insurance coverage and the factors underlying the demand for insurance. Attitudinal responses reveal the importance of perceptions about waiting times for public care, as well as some concerns about the quality of that care. Individual characteristics, such as education, age, gender, marital status, family composition and income all influence the probability of purchasing private insurance. We also examine the relationship between insurance and utilization of hospital in-patient services. The positive effect of private insurance appears less than that of entitlement to full free health care from the state, although the latter is means-tested, and may partly represent health status.     

Mexican immigrants and the utilization of U.S. health services: the case of San Diego

This paper examines survey data gathered from 2103 Mexican immigrants living or working in San Diego County, California, in order to explore four fundamental questions concerning the utilization of health services: (a) What type of health services do Mexican immigrants use? (b) When hospitals are used, do they tend to be emergency room services? (c) Do Mexican immigrants use preventive services? (d) To what extent do the utilization patterns of undocumented immigrants differ from their legally-immigrated counterparts? The socioeconomic profile of the sample is characterized through analysis of variables such as sex, age, length of residence in the U.S., occupation and income. Mexican immigrants, particularly the undocumented, are relatively young compared to the non-immigrant population, of short duration in the U.S. and earn low income. In addition, undocumented and legally-immigrated respondents are covered by medical insurance at rates far below the general population. Mexican immigrants, including the undocumented, use a variety of health services. Hospital services are not the primary source of care. However, when undocumented respondents did use hospital services, they were more likely to use emergency room care than their legally-immigrated counterparts, who were more likely to use out-patient services. Finally, undocumented respondents tended to neglect preventive services as evidenced by examination of the use of pre-natal care, general check-ups and dental services.     

The role of private medical insurance in socio-economic inequalities in cancer screening uptake in Ireland

Screening is seen by many as a key element in cancer control strategies. Differences in uptake of screening related to socio-economic status exist and may contribute to differences in morbidity and mortality across socio-economic groups. Although a number of factors are likely to underlie differential uptake, differential access to subsequent diagnostic tests and/or treatment may have a pivotal role. This study examines differences in the uptake of cancer screening in Ireland related to socio-economic status. Data were extracted from SLáN 2007 concerning uptake of breast, cervical, colorectal and prostate cancer screening in the preceding 12 months. Concentration indices were calculated and decomposed. Particular emphasis was placed in the decomposition upon the impact of private health insurance, evidenced in other work to impact on access to care within the mixed public-private Irish health system. This study found that significant differences related to socio-economic status exist with respect to uptake of cancer screening and that the main determinant of difference for breast, colorectal and prostate cancer screening was possession of private insurance. This may have profound implications for the design of cancer control strategies in countries where private insurance has a significant role, even where screening services are publicly funded and population based.     

Factors associated with parent report of access to care and the quality of care received by children 4 to 17 years of age in Georgia

We examined factors associated with health care access and quality, among children in Georgia. Data from the 2007 National Survey of Children's Health were merged with the 2008 Area Resource File. The medically underserved area variable was appended to the merged file, restricting to Georgia children ages 4-17 years (N = 1,397). Study outcomes were past-year access to care, defined as utilization of preventive medical care and no occasion of delay or denial of needed care; and quality of care received, defined as compassionate, culturally-effective, and family-centered care which was categorized as higher, moderate, or lower. Analysis included binary and multinomial logit modeling. In our study population, 80.8 % were reported to have access to care. The quality of care distribution was: higher (39.4 %), moderate (30.6 %), and lower (30.0 %). Younger age (4-9 years) was positively associated with having access to care. Compared to children who had continuous and adequate private insurance, children who were never/intermittently insured or who had continuous and inadequate private insurance were less likely to have access. Compared to children who had continuous and adequate private insurance, there were lower odds of perceiving received care as higher/moderate versus lower quality among children who were never/intermittently insured or who had continuous and inadequate/adequate public insurance. Being in excellent/very good health and living in safe/supportive neighborhoods were positively associated with quality; non-white race/ethnicity and federal poverty level were negatively associated with quality. Assuring continuous, adequate insurance may positively impact health care access and quality.     

Public health insurance and mortality in the older population: Evidence from the Irish Longitudinal Study on Ageing

Most developed countries provide publicly-financed insurance for many health services for their populations although there is considerable variation across countries in the types of services covered, eligible population groups and whether co-payments are levied. The Irish healthcare system, with a complex mix of public and private financing of healthcare services, offers a useful case study for an examination of the impact of type of health insurance cover on population health. In this paper, we investigate the extent to which type of health insurance cover is associated with all-cause, cause-specific, and amenable mortality using data on a representative survey of the population aged 50+ from the Irish Longitudinal Study on Ageing (TILDA) matched to administrative data on death registrations. The results show that those without public or private health insurance have a higher risk of all-cause and cancer mortality. However, there is no evidence that type of health insurance cover affects mortality risk from causes that are considered amenable to healthcare intervention, although this analysis was based on a much smaller sample size. This analysis provides important evidence for a country that is implementing reforms to its financing and delivery structures in order to move towards a system of universal healthcare.     

The demand for private health care under national health insurance

This study explores the demand for private health care and supplemental health insurance in Israel, where universal national health insurance provides all inhabitants with a standard package of medical care. Our theoretical model and empirical study follow research previously conducted in four other countries. It was found that the self-employed in Israel demand more private health services and supplemental health insurance than wage-earners. Income, age, education, health status, marital status, origin, and profession were found to play a part in explaining these demands.     

The poor pay more: Health-related inequality in Thailand

This paper examines the equality of utilization for equal need and equity of out-of-pocket expenditure for health services in a large urban area in Thailand. Data from a household health interview survey were used to explore patterns of perceived morbidity, utilization of various treatment sources, and out-of-pocket payment. Financial access to health care, as reflected in medical benefit/insurance cover, appeared to influence reported illness and hospitalization rates. Gross lack of access to health care amongst lower socio-economic groups was not the main problem in this densely populated urban area because people could choose and use alternative health services according to their ability and willingness to pay. The corollary, however, was an inequitable pattern of out-of-pocket health expenditure by income quintile and per capita. The underprivileged were more likely to pay out of their own pocket for their health problems, and to pay out of proportion to their household income when compared with more privileged groups. Furthermore, the underprivileged were least likely to be covered by government health benefit schemes, in contrast in particular to civil servants, who paid less out of pocket and did not contribute to their medical benefit fund. The private health sector (private clinics and private hospitals) was the major provider of health care to urban dwellers for both outpatient and inpatient services. Policy options for the short and long term to improve the equity of payment systems for health care are discussed.     

Choosing and paying for care

This paper presents data from before and after implementation of the 1990 NHS and Community Care Act in 1993. It shows the low proportions of the population who are covered by private health insurance and draws attention to the fact that, although some older people have considered private health insurance, few are covered. Comparing data for people aged <65 with those aged >65, the paper explores the preferred sources of help in a range of situations. The findings show that in most instances, statutory services are preferred. Data for older people aged >80 are presented comparing findings from 1990/91 and 1995, which show that use of services for which charges have been introduced appear to have fallen. Low take-up of dental and optician services are identified. The implications of the findings for social policy are considered and it is suggested: that insurance cover for long-term care should be organized at a national level; that greater attention should be given to service preferences of users and potential users; and, that the effectiveness of various health and social care services should be evaluated.     

The Effect of Medicaid Managed Care on Prenatal Care: The Case of Puerto Rico

Objectives From 1994 to the year 2000 the government of Puerto Rico implemented a health care reform which included the mandatory enrollment of the entire Medicaid eligible population under Medicaid managed care (MMC) plans. This study assessed the effect of MMC on the use, initiation, utilization, and adequacy of prenatal care services over the reform period. Methods Using the vital records of all infants born alive in Puerto Rico from the year 1995–2000, a series of bivariate and multivariate analyses were conducted to assess the effect of insurance status (traditional Medicaid, MMC, private insurance and uninsured) on prenatal care utilization patterns. In order to assess the potential influence of selection bias in generating the health insurance assignments, propensity scores (PS) were estimated and entered into the multivariate regressions. Results MMC had a generally positive effect on the frequency and adequacy of prenatal care when compared with the experience of women covered by traditional Medicaid. However, the PS analyses suggested that self-selection may have generated part of the observed beneficial effects. Also, MMC reduced but did not eliminate the gap in the amount and adequacy of prenatal care received by pregnant women covered by Medicaid when compared to their counterparts covered by private insurance. Conclusions The Puerto Rico Health Reform to implement MMC for pregnant women was associated with a general improvement in prenatal care utilization. However, continued progress will be necessary for women covered by Medicaid to reach prenatal care utilization levels experienced by privately insured women.     

Explaining regional variation in home care use by demand and supply variables

In the Netherlands, home care services like district nursing and personal assistance are provided by private service provider organizations and covered by private health insurance companies which bear legal responsibility for purchasing these services. To improve value for money, their procurement increasingly replaces fee-for-service payments with population based budgets. Setting appropriate population budgets requires adaptation to the legitimate needs of the population, whereas historical costs are likely to be influenced by supply factors as well, not all of which are necessarily legitimate. Our purpose is to explain home care costs in terms of demand and supply factors. This allows for adjusting historical cost patterns when setting population based budgets.Using expenses claims of 60 Dutch municipalities, we analyze eight demand variables and five supply variables with a multiple regression model to explain variance in the number of clients per inhabitant, costs per client and costs per inhabitant.Our models explain 69% of variation in the number of clients per inhabitant, 28% of costs per client and 56% of costs per inhabitant using demand factors. Moreover, we find that supply factors explain an additional 17–23% of variation. Predictors of higher utilization are home care organizations that are integrated with intramural nursing homes, higher competition levels among home care organizations and the availability of complementary services.     

Private payers of health care in Brazil: characteristics, costs and coverage

The private sector is the predominant provider of health care in Brazil, particularly for inpatient services, and financing is a mix of public (through a prospective reimbursement system) and private. Roughly a quarter of the population has private insurance coverage, reflecting rapid growth in the past decade fuelled by the crisis in the public reimbursement system and the perceived deterioration of publicly provided care. Four major forms of insurance exist: (1) prepaid group practice; (2) medical cooperatives, physician owned and operated preferred provider organizations; (3) company health plans where employers ensure employee access to services under various types of arrangements from direct provision to purchasing of private services; and (4) health indemnity insurance. Each type of plan includes a wide variety of subplans from basic individual/family coverage to comprehensive executive coverage. The paper discusses the characteristics, costs and utilization patterns of all types of privately financed care, as well as the major problems associated with private financing: the limited package of benefits and low payout ceilings, inadequate consumer information and virtually no regulation.     

Social class inequalities in the use of and access to health services in Catalonia, Spain: what is the influence of supplemental private health insurance?

OBJECTIVE: To analyse social class inequalities in the access to and utilization of health services in Catalonia (Spain), and the influence of having private health insurance supplementing the National Health System (NHS) coverage. DESIGN: 1994 Catalan Health Interview Survey, a cross-sectional survey conducted in 1994. SETTING: Catalonia (Spain). STUDY PARTICIPANTS: The participants were a representative sample of people aged over 14 years from the non-institutionalized population of Catalonia (n = 12,245). MAIN OUTCOME MEASURES: Health services utilization, perceived health, having only NHS or NHS plus a private health insurance, and social class. RESULTS: Although one-quarter of the population of Catalonia had a supplemental private health insurance, percentages were very different according to social class, ranging from almost 50% for classes I and II to 16% for classes IV and V in both sexes. No inequalities by social class were observed for the utilization of non-preventive health care services (consultation with a health professional in the last 2 weeks and hospitalization in the last year) among persons with poor self-perceived health status, i.e. those in most need. However, social inequalities still remain in the use of health services provided only partially by the NHS, and when characteristics of last consultation are taken into account. Subjects who paid for a private service waited an average of 18.8 minutes less than those attending the NHS. Within the NHS, social classes IV and V waited longer (35.5 minutes) than social classes I and II (28.4 minutes). CONCLUSION: The NHS in Catalonia, Spain, has reduced inequalities in the use of health services. Social inequalities remain in the use of those health services provided only partially by the NHS.     

Private medical insurance and saving: evidence from the British Household Panel Survey

This paper uses the British Household Panel Survey for the years 1996-2000 to investigate the relationship between saving and private medical insurance in the UK. Because the National Health Service (NHS) gives comprehensive health coverage and is generally free at source, one would not expect private medical insurance to crowd-out saving. However, the NHS being characterised by long waiting lists and generally poor quality, many people prefer to use private health services. In such circumstances, those individuals who are not covered by private medical insurance, and who are therefore more exposed to facing unexpected out-of-pocket private health care expenditures or income losses while waiting for public treatment might save more for precautionary reasons than those who are covered. According to our findings, which are based on a wide range of econometric specifications, there is a positive association between insurance coverage and saving, suggesting that private medical insurance does not generally crowd-out private saving. However, we found some evidence of crowding-out in those areas where the quality of medical facilities is perceived as poor, and in rural areas, characterised by fewer NHS providers.     

Respiratory illness in the Dominican Republic: what are the predictors for health services utilization of young children?

Respiratory illness and diarrhoea continue to be the leading causes of paediatric morbidity and mortality in the Dominican Republic. An important first step in alleviating this disease burden is to understand patterns and predictors of health services utilization for these conditions. This study examines the predictors of (a) health services utilization, and (b) public versus private sector use, for respiratory illness in the under-five population in the Dominican Republic. The DHS-2 dataset (1991) was utilized for analysis. Logistic regression models for predicting use and non-use, and for predicting private versus public sector use, were constructed using the Andersen Behavioural Model as the conceptual framework. Our findings indicate that sex, location and possession index quartile are factors that influence the decision to seek care or not for respiratory illness in under-fives. In contrast, the choice between the public and private sector is determined by location and insurance status. From the policy perspective, if the Dominican Republic were to undertake steps to increase private insurance coverage, our results indicate that this would lead to increased utilization of private sector providers for respiratory illness by children having private insurance, but would not have an impact on overall utilization (i.e. use vs. non-use). On the other hand, one of the ways to deliver cost-effective interventions by the publicly financed system would be to improve facilities in the rural areas.     

Health care services utilization and access inequalities in the Sao Paulo Metropolitan Region

This paper presents case study findings in five municipalities in the S?o Paulo Metropolitan Region. Inequalities in access to health care services and their utilization were described through advanced tabulation data from the 1998 SEADE Life Conditions Survey. The variables analyzed were: owning or not owning private health care insurance, income and age brackets. The health care service attributes studied were: health care services coverage by a health insurance plan, health services demands and average waiting time to receive health care. Compared with other studies, using the 1998 IBGE PNAD, the results allowed us to confirm interregional imbalances which can only be detected in shorter special scale studies: the municipalities. Despite showing the high private health insurances coverage the S?o Paulo Metropolitan Region has a great inner heterogeneity. The inequalities in private health care insurance, access, waiting time, and type of insurance coverage were observed through income quintiles and age classes analyses. Findings suggest that an expansion of the State's regulation capacity is necessary in order to empower the Brazilian Health Care System principles of universality and equity to be qualified to offer Brazilians the right to access health care services.     

Racial/ethnic disparities in adult preventive dental care use

Using the Behavioral Model of Health Services Utilization, this study examines whether adult preventive dental care utilization differs by ethnicity/race. Logistic regression results find that controlling only for predisposing characteristics (gender, age, education, and health status), African Americans, Mexican Americans, and Other race/ethnicity are less likely than whites to utilize dental services. However, the effects are no longer significant when enabling resource variables are included in the model (income level, insurance, census region, and metropolitan statistical area). Interactions between race/ethnicity and insurance status show that privately insured racial/ethnic minority groups do not differ from privately insured whites in their utilization of dental services. Similarly, the preventive dental care utilization of publicly insured African Americans and Other Hispanics does not differ significantly from privately insured whites. However, publicly insured whites, Mexican Americans, and individuals of Other race/ethnicity have significantly lower odds of utilizing dental services relative to whites with private insurance.