Out-of-pocket payment for medical care under Taiwan's National Health Insurance system

Income-related inequality in out-of-pocket health-care expenditures under Taiwan's national health insurance system: An international comparable estimation based on A System of Health Accounts

National estimates of out-of-pocket health-care expenditures (OOP-HCEs) that use comparable international guidelines based on A Systems of Health Accounts (SHA) are generally unavailable in Taiwan. International comparable OOP are essential for designing universal health-coverage (UHC) policy. We designed an SHA-based household OOP questionnaire. A nationally representative cross-sectional survey was then conducted from January to August 2022. The final questionnaire was completed by 657 households and 1969 individuals. The total OOPs were divided into expenditures related to curative care (HC.1), rehabilitative care (HC.2), long-term care (HC.3), ancillary services (HC.4), and medical goods (HC.5). National estimates were calculated by accounting for the complex survey design. Variance was estimated through Taylor series linearization. The concentration index was calculated using household income as the ranking variable. We then identified factors contributing to the inequality in OOP distribution by household income. National estimates revealed an OOP of NT$424 billion, which accounted for 29.6% of Taiwan's national health expenditure in 2021. Private health insurance (PHI) reimbursements accounted for 9.0% of the total OOP. The OOPs for curative care and medical goods accounted for 50.1% and 39.0% of the total OOP, respectively. The OOPs after PHI reimbursements were progressive (concentration index = 0.103, P = 0.012). The frequency of medical-care use and the number of medical visits negatively affected progressive OOPs. International comparable OOPs revealed that under the Taiwanese National Health Insurance (NHI), OOPs can still be high. However, the NHI might have caused OOPs to be progressive from the perspective of income but regressive from the perspective of health status. Countries striving for UHC should consider the redistribution effect of public health insurance and possible inequalities in health.

Out-of-pocket health spending among Medicare beneficiaries: Which chronic diseases are most costly?

Background

Little is known about the impact of different types of chronic diseases on older adults’ out-of-pocket healthcare spending and whether certain diseases trigger higher spending needs than others.

Methods

We use data from the 2014 Health and Retirement Study representing a weighted population of 35,939,270 Medicare beneficiaries aged 65+. Generalized linear models are applied to estimate the effect of different chronic diseases on total out-of-pocket expenditure, adjusted for demographics, socio-economic status, physical health, and other factors. We also decompose total spending by expenditure categories (inpatient, non-inpatient, and prescription drug spending). Sensitivity analysis is performed using a younger sample of older adults aged 50–64.

Results

Cardiovascular disease, diabetes, hypertension and cancer, induce significantly higher adjusted out-of-pocket spending among older adults than other conditions. These results hold regardless how the spending differences are assessed (absolute or percentage terms). For Medicare beneficiaries, cardiovascular disease is associated with an excess out-of-pocket spending of $317 per year, followed by diabetes ($237), hypertension ($150), and cancer ($144). Prescription drug spending is singularly the most important driver of additional expenses for cardiovascular disease, diabetes and hypertension, while non-inpatient services spending accounts for the bulk of increased spending among those with cancer.

Conclusions

Our finding that major noncommunicable diseases impact individuals’ out-of-pocket medical spending differentially–and that service drivers of increased spending may be heterogeneous across disease types–suggest that health professionals and policymakers should recognize that certain chronic diseases exert greater financial toll on the elderly. Interventions to promote more cost efficient healthcare services and consumer choices can help older adults better cope with these expensive long-lasting conditions and reduce the overall burden of noncommunicable diseases.

Combined Effects of Chewing Ability and Dietary Diversity on Medical Service Use and Expenditures

OBJECTIVES

To examine whether chewing ability affects healthcare use and expenditure and whether improving dietary quality alleviates any such effects.

DESIGN

Prospective cohort.

SETTING

The Elderly Nutrition and Health Survey in Taiwan (1999-2000), a nationwide community-based survey of people aged 65 and older.

PARTICIPANTS

Individuals aged 65 and older (N = 1,793; 903 men, 890 women).

MEASUREMENTS

Chewing ability (satisfactory or unsatisfactory) was assessed using a questionnaire, and dietary quality was assessed using a 24-hour dietary recall as a dietary diversity score. Data on annual medical use and expenditures from the interview date until December 31, 2006, were collected from National Health Insurance claims. Generalized linear models were used to assess the associations between chewing ability, dietary quality, and annual medical usage or expenditure.

RESULTS

After 8 years of follow-up, older adults with unsatisfactory chewing ability had considerably higher emergency, hospitalization, and total medical expenditures. Older adults with unsatisfactory chewing ability and a poor diet used fewer annual preventive care and dental services than those with satisfactory chewing ability but had longer hospital stays and higher expenditures. After adjusting for covariates, unsatisfactory chewing ability resulted in significantly longer hospital stays in participants with a poor diet (β = 2.34, 95% confidence interval = 2.02-2.71, P < .001).

CONCLUSION

Unsatisfactory chewing ability and a less-diverse diet together are associated with longer hospital stays and higher medical expenditures.

Medical costs of a low skeletal muscle mass are modulated by dietary diversity and physical activity in community-dwelling older Taiwanese: a longitudinal study

Background

Age-related loss of skeletal muscle mass (SMM) and function (sarcopenia) are associated with poor health outcomes and an economic burden on health care services. An appropriate diet and physical activity have been proposed for prevention and treatment of sarcopenia. Nevertheless, the effects on medical service utilization and costs remain unclear. This study determined the effects of SMM in conjunction with diet quality and physical activity on medical service utilization and expenditure in community-dwelling older Taiwanese.

Methods

In total, 1337 participants from the Elderly Nutrition and Health Survey in Taiwan (1999–2000) were enrolled. An SMM index [SMMI, calculated by dividing SMM (kg) by height (m²)] was used as the marker of sarcopenia. Participants with the lowest SMMI quartiles (<11.4 kg/m² for men and 8.50 kg/m² for women) comprised the high-risk group, and the remainder comprised the low-risk group. Dietary information (dietary diversity: low and high) and physical activity (low and moderate) were obtained at baseline. Annual medical service utilization and expenditure were calculated from National Health Insurance claims until December 31, 2006. Generalized linear models were used to determine the association between the SMMI and annual medical service utilization and costs in conjunction with dietary diversity or physical activity.

Results

After 8 follow-up years, regardless of gender, participants in the high-risk group reported significantly more hospitalization (days and expenditure) and total medical expenditure. Participants in the high-risk group who had low dietary diversity made fewer annual outpatient (14%), preventive care (19%), and dental (40%) visits, but exhibited longer hospitalization (102%) than did those who had a low SMMI and high dietary diversity. Similar patterns were observed in the corresponding medical expenditures. The findings were similar when considering physical activity. Being in the low-risk group in conjunction with having high dietary diversity or more physical activity was associated with the lowest annual adjusted mean hospitalization days with expenditure, and also total expenditure.

Conclusions

A lower SMMI was associated with more hospitalization days and costs. However, high dietary diversity and more physical activity can attenuate the effects of lower SMMI on medical service utilization and expenditure.

Life Expectancy and Lifetime Health Care Expenditures for Type 1 Diabetes: A Nationwide Longitudinal Cohort of Incident Cases Followed for 14 Years

OBJECTIVES

To assess additional life expectancy (LE), expected years of life lost , and lifetime health care expenditures after type 1 diabetes diagnosis, stratified by sex and age of first diagnosis (early: 0-12 years; late: 13-40 years).

METHODS

A longitudinal cohort of patients with diabetes was constructed from Taiwan's National Health Insurance Research Database of 1999 to 2012. The survival functions for diabetic patients and age- and sex-matched general population were estimated by using a semiparametric extrapolation method with annual life tables. The average monthly health care expenditures were multiplied by the corresponding monthly survival rates and summed to calculate the lifetime health care expenditures. Cox proportional hazard models were constructed to corroborate the effects of sex and age, after being adjusted for comorbidities, complications, and calendar years.

RESULTS

A total of 2386 cases (45% early diagnosis, 49% males) were identified. An additional LE after diabetes diagnosis was 45.12 years, with an estimated 17.63 years of life lost. The predicted total and diabetes-related lifetime costs were $56,939 and $102,140, respectively. Early diagnosed patients had a longer LE and lower health care spending compared with those of late-diagnosed patients. Male patients had a shorter LE and a higher expected years of life lost than the female patients, which corresponded to lower lifetime costs for the former. The Cox model results for overall mortality corroborated these trends.

CONCLUSIONS

Early detection of type 1 diabetes and sex-specific strategies would probably improve long-term health outcomes and save on the cost of diabetes care.

Elderly Taiwanese who spend more on fruits and vegetables and less on animal-derived foods use less medical services and incur lower medical costs

A higher intake of fruits and vegetables (F&V) compared with animal-derived foods is associated with lower risks of all-cause-, cancer- and CVD-related mortalities. However, the association between consumption patterns and medical costs remains unclear. The effects of various food group costs on medical service utilisation and costs were investigated. The study cohort was recruited through the Elderly Nutrition and Health Survey in Taiwan between 1999 and 2000 and followed-up for 8 years until 2006. It comprised free-living elderly participants who provided a 24-h dietary recall. Daily energy-adjusted food group costs were estimated. Annual medical service utilisation and costs for 1445 participants aged 65-79 years were calculated from the National Health Insurance claim data. Generalised linear models were used to appraise the associations between the food group costs and medical service utilisation and costs. Older adults with the highest F&V cost tertile had significantly fewer hospital days (30%) and total medical costs (19%), whereas those in the highest animal-derived group had a higher number of hospital days (28%) and costs (83%) as well as total medical costs (38%). Participants in the high F&V and low animal-derived cost groups had the shortest annual hospitalisation stays (5·78 d) and lowest costs (NT$38,600) as well as the lowest total medical costs (NT$75,800), a mean annual saving of NT$45 200/person. Older adults who spend more on F&V and less on animal-derived foods have a reduced medical-care system burden. This provides opportunities for nutritionally related healthcare system investment strategies.

Use of Chinese medicine correlates negatively with the consumption of conventional medicine and medical cost in patients with uterine fibroids: a population-based retrospective cohort study in Taiwan

BACKGROUND

Chinese medicine is commonly used and covered by health insurance to treat symptoms of uterine fibroids in Taiwan. This retrospective cohort study compared the consumption of conventional western medicine and medical cost between Chinese medicine (CM) users and nonusers among patients with uterine fibroids.

METHODS

We extracted 44,122 patients diagnosed with uterine fibrosis between 1996 and 2010 from the National Health Insurance reimbursement database, which is a population-based database released by a government-run health insurance system. Multivariate linear regression models were used to find association between using Chinese medicine and the consumption of conventional medicine, and between using Chinese medicine and medical cost.

RESULTS

The total fibroid-related conventional western medicine consumed by CM users was less than that by nonusers (β = -10.49, P < 0.0001). Three categories of conventional medicines, including antianemics (-3.50 days/year/patient, P < 0.0001), hemostatics (- 1.89 days/year/patient, P < 0.0001), and hormone-related agents (-3.13 days/year/patient, P < 0.0001), were used less in patients who were CM users. Moreover, although using CM increased 16.9 USD per patient in CM users annually (P < 0.0001), the total annual medical cost for treating fibroid was 5610 USD less in CM users than in nonusers (P < 0.0001).

CONCLUSIONS

Our results suggested that CM reduced the consumption of conventional medicine, and might be a potential therapeutic substitute for conventional western medicines to treat uterine fibroids with low cost.

Incidence of cancer in children aged 0-14 years in Taiwan, 1996-2010

Studies have found lower risk of childhood cancer among Asian children. We aim to characterize the recent incidence and incidence-trend of childhood cancer in Taiwan after the National Health Insurance program was launched in March 1995. Data were extracted from the Taiwan Cancer Registry, a population-based database established in 1979. Cases diagnosed at age 0-14 from 1996 to 2010 were analyzed and categorized according to the International Classification of Childhood Cancer, Third Edition (ICCC-3). In total, 8032 childhood cancer cases were included, with a microscopic verification rate of 93.9%. The overall age-standardized rate (ASR) of incidence adjusted to the 2000 World Standard Population is 125.0 cases/million, with a male-to-female ratio of 1.3. The top five cancer types (ICCC-3 subgroup[s]; ASR per million) are acute lymphoblastic leukemia (Ia, 30.3), acute myeloid leukemia (Ib; 9.4), non-Hodgkin lymphoma (IIb,c,e, 9.0), extracranial germ cell tumor (Xb,c; 8.3), and neuroblastoma (IVa; 7.8). The median age of diagnosis was 6 years for both genders. During the study period, the ASR of childhood cancer has been increasing at a rate of 1.2% per year (95% confidence interval, 0.6-1.7%). In contrast to Western countries, China, Japan, and Taiwan have lower incidence of childhood cancer; however, Taiwan's incidence rates of childhood germ cell tumors and hepatic tumors are higher. In conclusion, this population-based study reveals that the incidence rate of childhood cancer in Taiwan is rising consistently. The high incidence of germ cell tumors warrants further investigation.

Use of chinese medicine and subsequent surgery in women with uterine fibroid: a retrospective cohort study

Background. Chinese medicine (CM) has been used to relieve symptoms relevant to uterine fibroids. Objective. This study investigated the association between the use of CM and the incidence of uterine surgery in women with uterine fibroids. Subjects and Methods. This retrospective cohort study extracted records for 16,690 subjects diagnosed with a uterine fibroid between 2000 and 2003 from the National Health Insurance reimbursement database. The risk factors for surgery were examined via Cox proportional hazard analysis, and the difference in incidence of surgery between CM users and nonusers was compared using incidence rate ratios (IRRs) derived from Poisson's models. Results. After an average follow-up period of 4.5 years, the cumulative incidence of uterine surgery was significantly lower in CM users than CM nonusers (P < 0.0001). Compared to CM nonusers, CM users were more unlikely to undergo uterine surgery (adjusted hazard ratio = 0.18, 95% confidence interval (CI) = 0.17, 0.19). The incidence of surgery in CM users was dramatically different from that for CM nonusers (IRR = 0.17, 95% CI = 0.16, 0.18). Conclusion. The risk of uterine surgery among fibroid patients who used CM was significantly decreased, implying an effective treatment of fibroid-related symptoms provided by CM.