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PubMed2002

Social security reform ideas in Japan.

Japan has a complex social security system. This article discusses the demographic and economic situation in Japan as background for understanding the setting in which the social security system functions. Japan has a three-pillar system for retirement income. The first pillar is the social security pension plan; the second pillar is the voluntary occupational pension plan; and the third pillar is personal savings, including the personal pension plan. The most important part of the retirement income system is the social security pension plan, which paid benefits accounting for 64% of the total income of elderly households in 1998. The five Employees' Pension Plans are established on a compulsory social insurance basis. Most large Japanese employers have a mandatory retirement age. Over 90% of all employees, including public sector ones, must retire from their career jobs at age 60.

Aged↗
PubMed2003

Gender's effect on willingness-to-pay for community-based insurance in Burkina Faso.

The purpose was to study gender's effect on willingness-to-pay (WTP) for community-based insurance (CBI) in order to provide information for deciding enrolment unit and setting premium in Burkina Faso. A two-stage cluster sampling was used in the household survey, with each household having the same probability of being selected. One thousand one hundred and seventy-eight men and 1236 women in the 800 households were interviewed. The bidding game approach was used to elicit WTP. We found that compared to male, female had less education, lower income and expenditure, less episodes of diseases and lower ratio of becoming household head, but higher marriage rate. These characteristics influenced the WTP difference between men and women. Men were willing to pay 3666 CFA ($4.89) to join CBI, 928 CFA higher than women were. Education and economic status positively influenced WTP, implying higher years of schooling and economic status and higher WTP. Age and distance to health facility negatively influenced WTP, thus higher age and longer distance and less WTP. Based on the results from this study, we suggest that CBI should be enrolled on the basis of households or villages in order to protect vulnerable persons, such as the aged, women and the poor. In setting premium a policy-maker needs to take into account costs of the CBI benefits package, possible subsidies from government and other agencies and WTP information. WTP should never be taken as a premium because it only provides some information for the respondents' financial acceptability for a certain benefits package.

Adult↗
PubMed1994

Self-referral and self-payment in Danish primary care.

This study aims at characterizing the group of people who want to have the right to consult any general practitioner or practising specialist without referral on condition of part self-payment, as opposed to the group of people who choose to be registered with a general practice that offers free services but controls further access to the health care system. All adults or a 10% sample of those listed in nationwide Danish registers were examined cross-sectionally for social and demographic factors and utilization of primary and secondary health care. A minority, which totals 3% of the population, chose free choice of doctor and part self-payment. On average, this group is older and has a higher income. Its mortality and its utilization of general practice and hospital services are lower, and its use of practising specialists is higher, than the majority. Among the persons who chose free choice and self-payment, the pattern of utilization is more likely to be due to a wish for free choice and for specialized medical care than to high morbidity. Dissatisfaction caused by restrictions on self-referral to specialists can be met by offering an option of a parallel system of free choice of doctor on condition of part self-payment.

Age Distribution↗
PubMed2001

Reconciling medical expenditure estimates from the MEPS and the NHA, 1996.

This article compares 1996 estimates of national medical care expenditures from the Medical Expenditure Panel Survey (MEPS) and the National Health Accounts (NHA). The MEPS estimate for total expenditures in 1996 was $548 billion; whereas, the NHA estimate for personal health care (PHC) in 1996 was $912 billion. Much of this apparent difference, however, arises from differences in scope between MEPS and NHA--rather than from differences in estimates for comparably-defined expenditures. We adjusted the NHA for differences in included populations and types of services covered, finding a much smaller difference between MEPS and a comparably-defined NHA.

Family Characteristics↗
PubMed2004

Out-of-pocket healthcare expenditures of older Americans with depression.

The objective of this study was to estimate mean annual out-of-pocket (OOP) healthcare expenditures of Americans aged 65 and older with self-reported depression and compare these expenditures with the OOP expenditures of older Americans with hypertension, heart disease, diabetes mellitus, and arthritis. Data from the 1999 Medical Expenditure Panel Survey, which employs a nationally representative stratified random sample of households in the United States, were used to estimate mean OOP expenditures for health care during 1999. The data were limited to observations on individuals aged 65 and older living in households in the United States included in the 1999 Medical Expenditure Panel Survey sample (N=2,730). Mean OOP expenditures for older Americans with depression were $1,835 in 1999. Most of the spending ($1,090) was for prescription drugs in this population. For patients with depression, only 8% of total OOP spending was for depression-specific services and treatments. Mean OOP spending was greater for persons with depression than it was for older Americans with hypertension ($1,181) and arthritis ($1,190), whereas OOP spending for depression was similar to spending of older Americans with heart disease ($1,412) and diabetes mellitus ($1,527). Older Americans with depression have high OOP expenditures, with most of this spending for health services and drugs to treat general medical conditions.

Age Factors↗
PubMed2002

Statistical comparison of consumer drug expenditures and discretionary purchases to assess drug affordability.

BACKGROUND: Affordability may be defined as the absence of economic barriers to a good or service. There are 2 frequently observed measures of affordability: a consumer's ability to pay and his or her physical access to a good or service. Thus, most programs designed to subsidize consumers' health care costs, especially state programs that address prescription drug expenditures for people aged > or =65 years, base eligibility on measures of income as a proxy for a consumer's ability to pay. These measures do not explicitly include a consumer's willingness to pay for medications. For example, it is possible that some Medicare beneficiaries may be resistant to paying for medication because other major health care expenditures are typically covered by insurance. This resistance could be exacerbated by the keen awareness among the general population of the rising costs of medications. Because medications are considered a necessity, expenditure levels are usually compared with expenditures for other necessities, such as housing and medical services. OBJECTIVE: In an attempt to assess consumers' potential willingness to pay for medications, this article draws on data from the US Bureau of Labor Statistics' Consumer Expenditure Surveys to compare pharmaceutical expenditures with out-of-pocket expenditures for discretionary purchases, such as dining outside the home. RESULTS: Personal out-of-pocket expenditures for medications have ranged from 0.8% to 1.0% of consumer unit income since 1985. These expenditures are relatively small compared with those for necessities, such as housing (33%) and food (13.5%). They are also less than the share of income dedicated to many nonessentials. CONCLUSION: Assessing inability versus unwillingness to pay for medication remains a problem for both researchers and health care policy makers attempting to determine the affordability of medications.

Aged↗
PubMed2002

The impact of outcome orientation and justice concerns on tax compliance: the role of taxpayers' identity.

Previous research has yielded inconsistent evidence for the impact of justice perceptions on tax compliance. This article suggests a more differentiated view on the basis of 2 congenial theories of procedural and distributive justice. The group-value model and a categorization approach argue that taxpayers are more concerned about justice and less about personal outcomes when they identify strongly with the inclusive category within which procedures and distributions apply. Regression analyses of survey data from 2,040 Australian citizens showed that 2 forms of tax compliance (pay-income reporting and tax minimization) were determined by self-interest variables. For 2 other forms (nonpay income and deductions), inclusive identification had an additional effect and moderated the effects of self-interest and justice variables as predicted.

Adolescent↗
PubMed2006

Willingness-to-pay for a population program aimed at reducing dietary salt in Denmark.

BACKGROUND: High intake of salt increases blood pressure and the risk of cardiovascular disease. Population programs aimed at reducing dietary salt may be cost-effective, but little is known about people's valuation of such programs. METHODS: A random sample (n = 924) of Danish people aged 20-74 was interviewed in-person in year 2000. They were asked how much they would be willing to contribute in additional tax for a population program that would half the intake of salt. The respondents were randomized to presentation of effectiveness format (number-needed-to-treat (NNT), relative risk reduction (RRR), avoided cases of heart attack or increase in longevity). RESULTS: In total, 57% were unwilling to contribute to the program (63%, 51%, 51% and 63% in the NNT-, RRR-, case- and longevity-groups, respectively). The mean willingness-to-pay among the remaining 43% was $30 per person per month. While in Denmark, the annual net program cost would be $148 millions in the most unfavorable scenario, the aggregate willingness-to-pay was $468 millions. CONCLUSIONS: A public health program may be worthwhile even though only a minority of the population is willing to contribute towards it. People's valuation is moderately sensitive to format of the program information.

Adult↗
PubMed1992

Medicare and Medicaid; charges to residents' funds in nursing homes--HCFA. Final rule.

This final rule protects the personal funds (including personal needs allowances) of residents in skilled nursing facilities (SNFs) and nursing facilities (NFs) whose care is paid for by Medicare and Medicaid. It sets forth the items and services that are included in program payment and those for which a facility may charge residents. The regulations are required by section 21(b) of the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977 and sections 4201 and 4211 of the Omnibus Budget Reconciliation Act of 1987.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1985

Use of ECT in California, 1977-1983.

The author examined the use of ECT in California from 1977 to 1983, a period during which its availability steadily declined. Approximately 1.12 persons per 10,000 population received ECT in 1977-1983, with little variation from year to year. Most ECT was paid for with nonpublic funds by white patients in nongovernmental facilities. The probability of receiving ECT increased with the age of the patient. ECT was quite safe: no fractures were reported, and the mortality rate was 0.2 deaths per 10,000 treatments. Despite restrictive regulation and limited availability, ECT continues to be used in California.

Adolescent↗
PubMed2000

Willingness to pay for obesity treatment.

OBJECTIVES: To estimate willingness to pay (WTP) for effective treatment in a sample of obese individuals and to examine whether WTP is associated with factors reflecting the severity of obesity as well as a number of other variables such as age, sex, education, and income. METHODS: WTP and data on the severity of obesity were collected from the study, Swedish Obese Subjects. Associations between WTP, income, and obesity-related factors were analyzed by linear regression. RESULTS: The mean age was 47 years (range, 37 through 59 years) and the mean body mass index (BMI) was 39.6 kg/m2 (n = 3,549). Average personal monthly income was SEK 13,000 (approximately US $1,585), average WTP was SEK 26,900 (approximately US $3,280) and the median value was SEK 10,900 (approximately US $1,330). A high WTP was associated with high personal and household income, high weight, high education, female sex, poor perceived health, low current age, and low age at onset of obesity. Over 50% of the patients deemed it necessary to borrow money to cover their WTP. When adding a loan to the regression analysis, the associations between WTP and perceived health, age, and gender disappeared. CONCLUSION: Obese patients are willing to pay approximately twice their monthly salary for effective treatment and a higher WTP is associated with higher weight and poorer perceived health.

Adult↗
PubMed2003

Costs of flexible sigmoidoscopy screening for colorectal cancer in the United Kingdom.

OBJECTIVES: Colorectal cancer is one of the most commonly occurring cancers in industrialized countries, yet appears to be amenable to screening. Amongst the many possible protocols is once-only screening by means of flexible sigmoidoscopy. This protocol is currently being investigated in a UK multicenter trial and the study provides estimates of the expected resource costs. METHODS: The direct health care costs of sigmoidoscopy and of all subsequent procedures were estimated from an audit of resource use of approximately 40,000 patients at thirteen centers. Patient-borne costs were estimated from the results of surveys conducted at twelve of these centers. RESULTS: The health service costs of a flexible sigmoidoscopy was estimated at pounds 56. The total costs of screening (including private costs) averaged pounds 82 per person screened, although costs varied by center. The total health service costs of screening and subsequent management averaged approximately pounds 91 per person screened, again with variations between centers. CONCLUSIONS: Even within a strict trial protocol, intercenter variation in costs can be detected, ascribable to variability in local management practices, local yield, and local patient-borne costs. Other recent estimates of flexible sigmoidoscopy costs vary widely. As these costs form the basis of technology assessment simulation models which, in turn, inform policy obtaining realistic cost estimates within the appropriate health care setting is of paramount importance.

Colorectal Neoplasms↗
PubMed1999

Application of experimental poverty measures to the aged.

The U.S. Census Bureau recently released new, experimental measures of poverty based on a National Academy of Sciences (NAS) panel's recommendations. This article examines the effects of the experimental measures on poverty rates among persons aged 65 or older in order to help inform policy debate. Policymakers and analysts use poverty rates to measure the successes and failures of existing programs and to create and defend new policy initiatives. The Census Bureau computes the official rates of poverty using poverty thresholds and definitions of countable income that have changed little since the official poverty measure was adopted in 1965. Amid growing concerns about the adequacy of the official poverty measure, a NAS panel undertook a study of the concepts, methodology, and data needed to measure poverty. The panel concluded in its 1995 report that the current measure no longer provides an accurate picture of relative rates of poverty for different groups in the population or of changes in poverty over time. The panel recommended changes in establishing the poverty thresholds, defining family resources, and obtaining the required data. The Census Bureau report shows how estimated levels of poverty would differ from the official level as specific recommendations of the NAS panel are implemented individually and how estimated trends would differ when many recommendations are implemented simultaneously. It computes nonstandardized and standardized poverty rates. (The latter constrains the overall poverty rate under the experimental measures to match the official rate.) This article reports poverty rates that have not been standardized and provides considerably more detail than the Census report about the effects of the experimental measures on poverty among the aged. It examines the effects of changing the poverty thresholds and the items included or excluded from the definition of available resources. It also explores the effects of the experimental measures on persons aged 65 or older by age group, gender, race and ethnicity, and marital status. Results indicate that: Poverty rates in 1997 for persons aged 65 or older under the experimental NAS poverty measure are 17.3 percent, compared with 10.5 percent under the official poverty measure. This 65-percent increase is largely driven by the NAS-based measure's subtraction of medical out-of-pocket (MOOP) expenses from resources. Under the NAS-based measures, poverty rates increase for all major groups of older persons, and increase the most for groups for whom the incidence of official poverty is the lowest. The experimental NAS poverty measure shows narrower differences between genders, racial and ethnic groups, and among persons of different marital statuses than the official poverty measure. For example, white Hispanic women aged 65 or older have poverty rates that are 450 percent higher than those for white non-Hispanic men under the official poverty measure and 181 percent higher under the NAS measure. The NAS-based measure's subtraction of MOOP expenses from resources has a disproportionate effect on poverty rates among non-Hispanic whites and men as compared with other groups. However, changes in relative poverty between groups appear to be most influenced by the NAS midpoint equivalence scale. Because this scale decreases poverty rates for persons who live alone or with unrelated individuals and increases them for persons who live with others, poverty rates differ meaningfully under the NAS and official measures among demographic groups. This article highlights issues concerning the elements of the experimental NAS poverty measure that are particularly important to the measurement of poverty among the aged population. Results suggest that the research community's future efforts to refine, enhance, and build upon the NAS panel's recommendations will yield important insights about poverty among the older population.

Aged↗
PubMed1991

Medicare program; grace period and termination for nonpayment of Supplementary Medical Insurance (Part B) premiums for insured and uninsured persons--HCFA. Final rule.

This final rule changes the termination date for Supplementary Medical Insurance (SMI) (Part B) enrollees who fail to pay their Medicare Part B premiums. Presently, there is a 90 day grace period for the enrollee during which he or she may pay all overdue premiums and continue Part B coverage uninterrupted. The grace period begins at different times depending on whether the individual is or is not eligible for monthly social security, railroad retirement or civil service retirement benefits. This final rule establishes a uniform timeframe for determining the 90 day grace period which precedes the termination of SMI enrollees who fail to pay their Medicare Part B premiums.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1983

Social and economic incentives for family caregivers.

The recent emphasis on developing programs and policies to support families who care for aged relatives makes it important to understand the families' receptivity to the specific social and economic incentives under consideration. The research reported in this paper draws on the experiences of 203 individuals identified as the primary caregiver to an aged frail relative currently receiving home care or day care services in New York City. As part of a larger study of caregiving behavior, respondents were asked to rank their preferences for various service and economic support programs. Findings indicate that family caregivers perceive service and social supports, specifically medical care and homemaker service, as more crucial than both direct and indirect financial incentives. Furthermore, the issue of economic incentives elicited an extremely negative reaction from a significant minority who refused to consider such support in their personal family situations. The analysis indicated that the caregiver's background characteristics were not critical in differentiating caregivers who select either a service or an economic incentive. Among the set of variables defining the current caregiving situation, only sex of the aged relative and utilization of home care services were significantly related to choice of program. Respondents caring for females and high service utilizers were more likely to prefer service supports. Relevance of findings to current policy initiatives regarding financial incentives to families are presented.

Aged↗
PubMed2005

Determinants of self-management strategies to reduce out-of-pocket prescription medication expense in homebound older people.

OBJECTIVES: To determine the extent to which homebound older people adopt strategies to reduce out-of-pocket prescription medication cost and the factors associated with level of cost-related medication management. DESIGN: Cross-sectional study. SETTING: Home-delivered meals programs in four North Carolina counties. PARTICIPANTS: Random sample of 222 home-delivered meal recipients aged 60 and older. MEASUREMENTS: The use of six different management strategies to reduce medication expenses was reported at the in-home assessment. Associations between level of cost-related medication management and sample characteristics, drug coverage, behaviors to cope with out-of-pocket medication expense, and payment difficulty were examined. RESULTS: Forty-five (20.3%) participants used one or more behaviors that restricted medication use; another 47 (21.2%) used one or more strategies to reduce out-of-pocket medication cost. Using medication restriction to reduce medication expense was more likely in older people who had difficulty paying for medications (odds ratio (OR)=8.2, 95% confidence interval (CI)=1.4-50.3), or used a strategy to cope with out-of-pocket expenses (choose food or medications (OR=5.1, 95% CI=1.7-15.7) or borrowed money or had another person pay for medications (OR=5.5, 95% CI=2.6-11.6)). Income, drug coverage, and medication use (prescribed and over-the-counter) increased the likelihood of having increased difficulty paying for medications. CONCLUSION: Clinicians should attempt to identify patients who are at risk for medication restriction and develop strategies for minimizing any unintended consequences of cost-related medication management behaviors. Provider-patient communication should include discussion of medication cost and appropriate medication management strategies.

Aged↗
PubMed2004

Do out-of-pocket health expenditures rise with age among older Americans?

PURPOSE: Relationships are examined between age and out-of-pocket costs for different health goods and services among the older population. DESIGN AND METHODS: Age patterns in health service use and out-of-pocket costs are examined by use of the 1990 Elderly Health Supplement to the Panel Study of Income Dynamics (N = 1,031, age 66+). Multivariate regression is used to examine how age effects are mediated by health, insurance, and socioeconomic variables. RESULTS: Although long-term care expenditures increased with age, out-of-pocket costs for most other services did not. Total out-of-pocket costs increased with age only when nursing home costs were included. Increases with age in hospital and prescription costs were explained by declining health. Patterns of service use suggested reduced access to discretionary care among the oldest old. IMPLICATIONS: Although expenditures did not increase with age for most services, the high personal cost for nursing home care among the oldest old underlines the need for increased efforts to support them in the community. Greater spending by those in poor health highlights the importance of preventing age-related health conditions and their complications. Improved access to discretionary care among the oldest old may help to reduce the need for care in higher cost settings. The high prevalence of out-of-pocket prescription spending across the age range provides impetus for current efforts to reduce these costs.

Age Factors↗
PubMed2004

Full disclosure of financial costs and options to patients: the roles of race, age, health insurance, and usual source for care.

The objective was to identify factors associated with financial discussions and financial disclosure of medical costs within a low-income urban community. The method used was a cross-sectional community-based survey in Allegheny County, Pennsylvania. The survey was conducted door-to-door and at area food pantries. Two hundred and twenty six adults were interviewed. Overall, 76.1% reported having a usual source for care and 73.0% had health insurance. Thirty nine and four tenths percent reported having been asked about their ability to pay for health services; this was more common among African Americans (OR 5.2; 95% CI 1.73-15.84), those with no health insurance (OR 4.3; 95% CI 1.01-17.89), and those less than 45 years old (OR:2.9; 95% CI 1.03-8.28). Only 10.6% reported being told how much a health visit would cost. Overall, 30.1% reported their provider made payment allowances for medical bills, with white respondents 2.5 times more likely and those persons identifying an ambulatory site for care 2.6 times more likely to report this. Overall, 30.5% reported being referred to a collection agency for unpaid medical bills; this was 2.4 times more common among those individuals identifying a non-ambulatory usual site for care. Significant race and socio-economic disparities exist in discussions about and access to financial resources to pay for medical care. Expanding the availability of financial assistance is critical to improving access to health care.

Adult↗