Health care provider choice and utilization among the elderly in a state in Brazil: a structural model.

OBJECTIVES: Current demographic trends point to the need for understanding the health challenges facing the elderly in Latin America today. This study assessed whether health care provider choice and household income impact utilization and health among the elderly in Brazil. METHODS: Using a sample taken in 1995 in southern Brazil, a structural model was used to estimate the parameters of a function that represents the choice of health care provider, controlled for health care services utilization and a health production function. The dependent variable for the production function was self-assessed health. These two functions were structurally linked by introducing the probability of choosing a private over a public provider in the health production function as an added explanatory variable. With this structural linkage, the production function assessed how much the selection of a public versus a private provider affects health, while controlling for the possibility that individuals with poorer health have a tendency to prefer one or other health care provider. RESULTS: Health care services utilization by the elderly was constrained by two factors: the number of providers at the municipality level and household income. The elderly who live in municipalities with a greater number of public, outpatient clinics and providers were more likely to use the public system. Patients who used the public health care system had lower self-assessed health status than those using the private system. This result is valid even after controlling for demographic variables and morbidity. CONCLUSIONS: Brazil's public health system does not adequately provide for the health needs of the elderly population. Policy recommendations include further investments in the public health care infrastructure, full implementation of the National Plan for Elderly Health, and developing new programs for effective geriatric consultations at the primary care level.     

Users of home‐care services in a Nordic welfare state under marketisation: the rich,the poor and the sick

Stricter access to public services, outsourcing of municipal services and increasing allocation of public funding for the purchase of private services have resulted in a marketisation wave in Finland. In this context of a Nordic welfare state undergoing marketisation, this paper aims to examine the use of Finnish care services among older people and find out who are using these new kinds of private services. How wide is their use and do the users of private care services differ from those who are using public services? How usual is it to mix both public and private care services? The questionnaire survey data set used here was gathered in 2010 among the population aged 75 and over in the cities of Jyväskylä and Tampere (N = 1436). The methods of analysis used include cross‐tabulation, chi‐square tests and multinomial logistic regression. The findings showed that among those respondents who used care services (n = 681), 50% used only public services, 24% utilised solely private services and the remaining 26% used both kinds of services. Users of solely private services had significantly higher income and education as well as better health than those using public services only. The users of public services had the lowest education and income levels and usually lived in rented housing. The third group, those mixing both public and private services, reported poorer health than others. The results increase concerns about the development towards a two‐tier service system, jeopardising universalistic Nordic principles, and also suggest that older people with the highest needs do not receive adequate services without complementing their public provisions with private services.     

中国老年人就医行为及其影响因素研究

目的了解我国老年人就医行为及其影响因素。方法基于安德森医疗服务利用模型框架,利用中国健康与养老追踪调查(CHARLS)2015年数据建立Heckman样本选择模型和Probit模型,从倾向特征、使能资源、医疗需要等方面分析老年人就医行为影响因素。结果共调查老年人10172例,其门诊、住院比例分别为32.41%、17.68%;门诊、住院中选择公立医疗机构的比例分别为72.93%、92.18%,选择基层医疗机构比例分别为57.63%、17.00%。女性、低龄、城镇、中西部地区、有医保、自评健康不好和ADL受损的老人的门诊和住院服务利用较高,女性、高龄、居住在农村、自评健康不好、ADL受损的老人更依赖于民营或基层医疗机构。安德森模型中倾向特征、使能资源和医疗需要对老年人的就医行为解释较好,交通方式、医疗费用及自付比例、疾病的紧急程度等也与医疗机构的选择相关。当前的基本医疗保险制度提高了老年人的就诊率,但对就诊机构选择影响不明显。结论老年人门诊、住院时选择公立医疗机构较多,选择民营机构较少,门诊时在基层医疗机构略多,住院机构选择集中于高级别医疗机构。其就医行为出发于医疗需要,也受到使能资源的制约和倾向特征的影响。应致力于提高老年人的医疗可及性和公平性,在进一步完善现有高等级、公立医疗机构建设的同时,还应充分发挥基层及民营医疗机构的作用,满足不同老年群体的医疗需求。     

Private choices,public costs: Evaluating cost-shifting between private and public health sectors in New Zealand

New Zealand’s dual public-private health system allows individuals to purchase health services from the private sector rather than relying solely upon publicly-funded services. However, financial boundaries between the public and private sectors are not well defined and patients receiving privately-funded care may subsequently seek follow-up care within the public health system, in effect shifting costs to the public sector. This study evaluates this phenomenon, examining whether cost-shifting between the private and public hospital systems is a significant issue in New Zealand.We used inpatient discharge data from 2013/14 to identify private events with a subsequent admission to a public hospital within seven days of discharge. We examined the frequency of subsequent public admissions, the demographic and clinical characteristics of the patients and estimated the direct costs of inpatient care incurred by the public health system.Approximately 2% of private inpatient events had a subsequent admission to a public hospital. Overall, the costs to the public system amounted to NZ$11.5 million, with a median cost of NZ$2800. At least a third of subsequent admissions were related to complications of a medical procedure.Although only a small proportion of private events had a subsequent public admission, the public health system incurred significant costs, highlighting the need for greater understanding and discussion around the interface between the public and private health systems.     

社区居家养老意愿下居住方式和子女支持对老年人基层卫生服务需求的影响

目的:探讨居住方式和子女支持对老年人基层卫生服务需求的影响,使基层卫生服务更具针对性,以满足不同居家类型老年人的卫生服务需求.方法:利用2016年中国老年社会追踪调查数据,采用负二项Hurdle回归模型(NBH模型)分析.结果:与子女同住会显著提高城乡居家老年人对基层卫生服务的需求(P<0.05),子女经济支持则会显著...     

Inpatient and outpatient health care demand in Cairo,Egypt

This paper uses the results of a household survey conducted in Cairo, Egypt in 1992 to examine the factors that influence the demand for inpatient and outpatient health services. Multi-stage discrete choice models of the demand for health care, which identify the importance of individual, household, and facility level variables on each treatment decision, are estimated separately for outpatients and inpatients. Consumers are assumed to decide whether to seek any treatment and then choose between three categories of providers: a large public hospital (Embaba Hospital), all other public providers, and private/charitable providers. The results confirm that more affluent consumers prefer the higher cost, higher quality private and charitable hospitals. Age, sex, education, and insurance are also found to strongly impact the use of medical services. The results are suggestive but do not conclusively show that inpatient care is less price responsive than outpatient care. Price responsiveness of inpatient and outpatient demand are imprecisely estimated because price is highly correlated with quality, and the available data on facility quality do not permit us to adequately control for quality variations across facilities.     

D��terminants du recours aux soins dans la ville de Cotonou (B��nin).

Households in Contonou show a clear preference for modern medicine. Self-medication is the first choice, followed by use of private practices, which are growing in importance in Benin as treatment options. This preference for private medicine seems to meet a demand that is not covered by the public services, which occupy the third place among treatment options. The hospital and the practitioner of traditional medicine are the last resort where the other choices have not produced the expected outcome. The choice of self-medication is determined by the patient''s assessment that the illness is not serious, by the habit of using a certain treatment in response to a familiar symptomatology, and by the desire to avoid the expense of a consultation. The recourse to other options is connected with the geographical accessibility of the places of consultation, the cost of care and treatment, the reception accorded to patients at the place of consultation, the seriousness of the illness and, to a lesser degree, the relations of kinship with the health personnel in the services visited. The choice between the available health services lies principally between private clinics and public health centres. There is therefore a need to consider the operation of public health centres and the quality of the care they provide since this would enable those responsible for health service organization and planning to make better informed choices. At the same time, the state should encourage its research bodies to study the operation of the private sector in the light of the importance of this type of care in the treatment chosen by households.     

The dually entitled elderly Medicare and Medicaid population living in the community.

This study shows that the elderly living in the community and covered by Medicare and Medicaid have a higher proportion of older persons, of minority races, and of women and are in poorer health than other aged persons covered only by Medicare. The noninstitutionalized poor elderly population use more health care services (especially inpatient hospital care) and have much higher per capita health care expenses compared to those covered by Medicaid. There were also large disparities in education and income. The study indicates that the Medicare program provides substantially more financial protection for all elderly persons living in the community than for the total elderly population.     

Minority Response to Health Insurance Coverage for Mental Health Services

BACKGROUND: To promote access to mental health services, policy makers have focused on expanding the availability of insurance and the generosity of mental health benefits. Ethnic minority populations are high priority targets for outreach. However, among persons with private insurance, minorities are less likely than whites to seek outpatient mental health treatment. Among those with Medicaid coverage, minorities continue to be less likely than whites to use services. AIMS OF THE STUDY: The present study sought to determine if public insurance is as effective in promoting outpatient mental healthtreatment as private coverage for ethnic minority groups. METHODS: The analysis uses data from the 1987 National Medical Expenditure Survey to model mental health expenditures as a function of minority status and private insurance coverage. An interaction term between the two highlights any differences in response to private and public insurance coverage. The analysis uses a two stage least squares method to account for endogeneity of insurance coverage in the model. RESULTS: Minorities are less responsive to private insurance than whites in two ways. First, minorities are less responsive to private insurance than to public insurance whereas whites do not show this difference. Second, minorities are less responsive to private insurance than whites are to private insurance. DISCUSSION: Results suggest that there is a difference in the effectiveness of public and private health insurance to encourage use of mental health services. Among minorities but not among whites, those with private coverage used fewer mental health services than those with public coverage. Minorities were not only less responsive to private insurance than public insurance, but among those who were privately insured, minorities used fewer mental health services than whites. These results imply that insurance may not be as effective a mechanism as hoped to encourage self-initiated treatment seeking particularly among minority and other low income populations. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These results suggest that increasing private insurance coverage to minority populations will not eliminate racial and ethnic gaps in professional help-seeking for outpatient mental health care. Although the total number of people receiving treatment might increase, these results suggest that whites would seek care in greater numbers than minorities and the size of the minority-white differential might grow. IMPLICATIONS FOR FURTHER RESEARCH: Areas for further research include the impacts of alternative definitions of mental health services, the dynamics of the substitution of inpatient for outpatient mental health care, elucidation of nonfinancial barriers to care for minorities, and determinants of timely help-seeking among minorities.     

Do the more educated utilize more health care services? Evidence from Vietnam using a regression discontinuity design

In 1991, Vietnam implemented a compulsory primary schooling reform that provides this study a natural experiment to estimate the causal effect of education on health care utilization with a regression discontinuity design. This paper finds that education causes statistically significant impacts on health care utilization, although the signs of the impacts change with specific types of health care services examined. In particular, education increases the inpatient utilization of the public health sector, but it reduces the outpatient utilization of both the public and private health sectors. The estimates are strongly robust to various windows of the sample choice. The paper also discovers that the links between education and the probability of health insurance and income play essential roles as potential mechanisms to explain the causal impact of education on health care utilization in Vietnam.     

Evaluation of immunization knowledge, practices, and service-delivery in the private sector in Cambodia

A study of private-sector immunization services was undertaken to assess scope of practice and quality of care and to identify opportunities for the development of models of collaboration between the public and the private health sector. A questionnaire survey was conducted with health providers at 127 private facilities; clinical practices were directly observed; and a policy forum was held for government representatives, private healthcare providers, and international partners. In terms of prevalence of private-sector provision of immunization services, 93% of the private inpatient clinics surveyed provided immunization services. The private sector demonstrated a lack of quality of care and management in terms of health workers' knowledge of immunization schedules, waste and vaccine management practices, and exchange of health information with the public sector. Policy and operational guidelines are required for private-sector immunization practices that address critical subject areas, such as setting of standards, capacity-building, public-sector monitoring, and exchange of health information between the public and the private sector. Such public/private collaborations will keep pace with the trends towards the development of private-sector provision of health services in developing countries.     

The cost and efficiency of public and private health care facilities in Ogun state,Nigeria

During the 1980s, Nigeria faced difficult economic conditions resulting in a severely constrained budget for public health services. To assess more carefully the costs and efficiency of the public and private health sectors, the Federal Ministry of Health in Nigeria undertook a comprehensive survey of health care facilities in Ogun State in 1987, the analysis of which is presented in this study. The findings suggest that there is potential to increase service delivery within existing budgets by more cost-effective allocation of inputs. Many public and private providers are not operating at full technical capacity. It also appears that public facilities are not using cost-minimizing combinations of high and low-level health workers, in particular, too many low-level staff are being used to support high-level workers. The cost analysis indicates that there are short-run increasing returns to scale for inpatient and nearly constant returns to scale for outpatient services. Economies of scope for joint production of inpatient and outpatient services are not being realized. A major implication of such analysis is that improved resource allocation decisions heavily depend on the existence of information systems at the health facility level which carefully integrate financial information with other appropriate and adequate measures of service inputs, health care quality, facility utilization and ultimately health status.     

Changes in utilization of health services among poor and rural residents in Uganda: are reforms benefitting the poor?

Background

Uganda implemented health sector reforms to make services more accessible to the population. An assessment of the likely impact of these reforms is important for informing policy. This paper describes the changes in utilization of health services that occurred among the poor and those in rural areas between 2002/3 and 2005/6 and associated factors.

Methods

Secondary data analysis was done using the socio-economic component of the Uganda National Household Surveys 2002/03 and 2005/06. The poor were identified from wealth quintiles constructed using an asset based index derived from Principal Components Analysis (PCA). The probability of choice of health care provider was assessed using multinomial logistic regression and multi-level statistical models.

Results

The odds of not seeking care in 2005/6 were 1.79 times higher than in 2002/3 (OR = 1.79; 95% CI 1.65 - 1.94). The rural population experienced a 43% reduction in the risk of not seeking care because of poor geographical access (OR = 0.57; 95% CI 0.48 - 0.67). The risk of not seeking care due to high costs did not change significantly. Private for profit providers (PFP) were the major providers of services in 2002/3 and 2005/6. Using PFP as base category, respondents were more likely to have used private not for profit (PNFP) in 2005/6 than in 2002/3 (OR = 2.15; 95% CI 1.58 - 2.92), and also more likely to use public facilities in 2005/6 than 2002/3 (OR = 1.31; 95% CI 1.15 - 1.48). The most poor, females, rural residents, and those from elderly headed households were more likely to use public facilities relative to PFP.

Conclusion

Although overall utilization of public and PNFP services by rural and poor populations had increased, PFP remained the major source of care. The odds of not seeking care due to distance decreased in rural areas but cost continued to be an important barrier to seeking health services for residents from poor, rural, and elderly headed households. Policy makers should consider targeting subsidies to the poor and rural populations. Public private partnerships should be broadened to increase access to health services among the vulnerable.     

Across the health-social care divide: elderly people as active users of health care and social care

Several ways in which elderly people may assume an active role when using welfare services are discussed here. Selected findings are presented from a study that explored the experience and behaviour of elderly people on discharge from inpatient care with regard to criteria indicating user influence or control (namely participation, representation, access, choice, information and redress). Data were collected via semistructured interviews with service users (n = 30) soon after their return home from hospital. A number of differences were revealed between health care and social care in relation to users being provided with opportunities to assume an active role and in being willing and able to assume an active role. These differences were manifest in elderly service users accessing services, seeking information, exercising choice and acting independently of service providers. It appeared paradoxical that contact points were more easily defined with regard to health care yet users were more likely to exercise choice and act independently in securing social care. It is suggested that social care needs and appropriate service delivery are more easily recognised than making the link between perceived health care needs and appropriate services. In addition, it appeared that informal and private providers are more widely available and accessible for social care. If comprehensive continuing care is to be provided, incorporating both health and social care elements, greater uniformity appears to be required across the welfare sector. Lessons for social care provision from the delivery of health care suggest the clear definition of contact points to facilitate service use. Making health care more accessible, however, does not appear to be easily attainable due to the monopoly provision of health care and the lack of direct purchasing power by potential users.     

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.     

Low-income senior citizens in the Municipality of São Carlos, São Paulo State, Brazil: an epidemiological survey

This study focuses on the health profile of the elderly population in Sao Carlos, Sao Paulo State, Brazil, in 2003. The study population consisted of a sample over 60 years of age (n = 523) registered with the Family Health Program and the Unified National Health System. Point and interval prevalence of disabilities and chronic non-communicable diseases and cognitive status were estimated (95%CI). The study population was predominantly female with low education; 24.8% lacked any kind of retirement pension; 43.6% presented a low level of social integration; 46.7% required some form of help for 1 to 3 routine activities; 74.9% presented 1 to 5 chronic non-communicable diseases; and 56.2% scored under 24 on a cognitive test. Some 87.0% had sought health care and 22.4% required some kind of inpatient care. The results confirmed the need for improved professional training, adequacy of health services, and effective public policy to provide qualified health care for the elderly population.     

THE DETERMINANTS OF HEALTH CARE EXPENDITURE TOWARD THE END OF LIFE: EVIDENCE FROM TAIWAN

This paper empirically investigates the relationship between the health care expenditure of end‐of‐life patients and hospital characteristics in Taiwan where (i) hospitals of different ownership differ in their financial incentives; (ii) patients are free to choose their providers; and (iii) health care services are paid for by a single public payer on a fee‐for‐services basis with a global budget cap. Utilizing insurance claims for 11 863 individuals who died during 2005–2007, we trace their hospital expenditures over the last 24 months of their lives. We find that end‐of‐life patients who are treated by private hospitals in general are associated with higher inpatient expenditures than those treated by public hospitals, while there is no significant difference in days of hospital stay. This finding is consistent with the difference in financial incentives between public and private hospitals in Taiwan. Nevertheless, we also find that the public–private differences vary across accreditation levels. Copyright © 2013 John Wiley & Sons, Ltd.     

Perceptions and utilization of primary health care services in Iraq: findings from a national household survey

Background

After many years of sanctions and conflict, Iraq is rebuilding its health system, with a strong emphasis on the traditional hospital-based services. A network exists of public sector hospitals and clinics, as well as private clinics and a few private hospitals. Little data are available about the approximately 1400 Primary Health Care clinics (PHCCs) staffed with doctors. How do Iraqis utilize primary health care services? What are their preferences and perceptions of public primary health care clinics and private primary care services in general? How does household wealth affect choice of services?

Methods

A 1256 household national survey was conducted in the catchment areas of randomly selected PHCCs in Iraq. A cluster of 10 households, beginning with a randomly selected start household, were interviewed in the service areas of seven public sector PHCC facilities in each of 17 of Iraq's 18 governorates. A questionnaire was developed using key informants. Teams of interviewers, including both males and females, were recruited and provided a week of training which included field practice. Teams then gathered data from households in the service areas of randomly selected clinics.

Results

Iraqi participants are generally satisfied with the quality of primary care services available both in the public and private sector. Private clinics are generally the most popular source of primary care, however the PHCCs are utilized more by poorer households. In spite of free services available at PHCCs many households expressed difficulty in affording health care, especially in the purchase of medications. There is no evidence of informal payments to secure health services in the public sector.

Conclusions

There is widespread satisfaction reported with primary health care services, and levels did not differ appreciably between public and private sectors. The public sector PHCCs are preferentially used by poorer populations where they are important providers. PHCC services are indeed free, with little evidence of informal payments to providers.     

Inmigración y demanda de seguros sanitarios

IntroductionThe wave of immigration in Spain in the last 10 years has had major consequences in the provision of key public services. In the present study, we examined the effect of this population shock on the demand for private health insurance.MethodsUsing data from the National Health Survey for 2001, 2003 and 2006, we estimated discrete choice models to analyze the demand for dual coverage (public and private insurance) and the demand for private coverage among civil servants.ResultsThe results suggest that both the percentage of immigrants and the increase in the population resulted in greater demand for private health insurance (social security sample), mainly in groups with a middle-to-high income and with children or with a greater choice of private healthcare provider (in the sample of civil servants). In both cases, private healthcare was sought to gain access to specialized and emergency services more rapidly. The marginal effect obtained by using the variable of the percentage of immigrants was much higher in the sample of civil servants (about 0.20) than in the social security sample (0.05).ConclusionsAlthough immigrants tend to enjoy better health and use health services (with the exception of emergencies) less frequently than Spaniards, this collective has led to a significant increase in the demand for healthcare and, especially, private health insurance.