Home care reimbursement,long-term care utilization,and health outcomes

Using a substantial change in Medicare reimbursement policy to study the market for home health care, I find that the introduction of tightly binding average per-patient reimbursement caps led to a large drop in the provision of home care, particularly to the least healthy beneficiaries. This decline in home health utilization was not offset by increases in institutional long-term care or other medical care and there were no associated adverse health consequences. However, approximately one-quarter of the decline in Medicare spending was offset by increases in out-of-pocket expenditures for home health care, with the offset concentrated in higher income populations.     

Living arrangements of the elderly in China: evidence from the CHARLS national baseline

Declining fertility in China has raised concerns about elderly support, especially when public support is inadequate. Using rich information from the nationally representative China Health and Retirement Longitudinal Study (CHARLS) baseline survey, we describe the patterns of current living arrangements of the Chinese elderly and investigate their determinants and correlation with intergenerational transfers. We find that roughly 41% of Chinese aged 60 and over live with an adult child; living with a male adult child being strongly preferred. However another 34% have an adult child living in the same immediate neighborhood and 14% in the same county; only 5% have an adult child with none of them living in the same county. At the same time, a large fraction of the elderly, 45% in our sample, live alone or with only a spouse. In general, women, those from western provinces, and those from rural areas are more likely to live with or close to their adult children than their corresponding counterparts, but different types of intergenerational transfers play a supplementary role in the unequal distribution of living arrangements. Among non-co-resident children, those living close by visit their parents more frequently and have more communications by other means. In contrast, children who live farther away are more likely to send financial and in-kind transfers and send larger amounts.     

中国城镇老年人的居住意愿对空巢居住的影响

实证研究发现,超过半数的中国城镇老年人在居住意愿上选择空巢居住,而近十年来,中国城镇老年人空巢的比例也呈现明显的增长趋势,且越来越倾向于与子女分开居住,中低龄老年人愿意空巢居住的比例更高。就2000年至2010年中国城镇老年人的居住意愿对实际居住方式的影响进行了研究。老年人的居住意愿对其居住方式有重要影响,不愿意与子女同住、经济状况好、有配偶、没有儿子、生活能完全自理的老年人更倾向于空巢居住。与十年前相比,生活自理能力对居住方式的影响增强。未来不愿意与子女同住的老人将越来越多,老年空巢家庭的比例将会继续增加。为了更好地适应老年人空巢居住的变化趋势,应尽快完善社会养老服务体系。     

The incidence of Medicare

The Medicare program transfers nearly $300 billion annually from taxpayers to beneficiaries. This paper considers the incidence of such transfers in the context of a life cycle model with uncertainty about future health care expenditures. We find the distributional consequences of the Medicare program are roughly neutral in dollar terms; households living in high income neighborhoods pay more in taxes, but they also receive more in benefits. These dollar flows, however, ignore the insurance value of the Medicare system. Given the incomplete insurance coverage of lower income elderly households prior to the Medicare program, the money-metric benefits to lower income groups exceed the dollar flows, suggesting that Medicare redistributes more than a simple accounting exercise would suggest.     

老年人居住方式及影响因素分析——以贵阳市为例

利用调查数据对贵阳市老年人居住方式及其影响因素进行分析。贵阳市老年人以居住在三代及以上户为主,夫妇户也占较大比重;老年人与子女居住的比重略高于不与子女居住的比重。在控制其他变量的情况下,住房条件、经济收入和与子女的关系状况三个因素对老年人的居住方式具有显著性影响。     

The Effect of State Tax Preferences on the Living Arrangements of Elderly Individuals

The United States is in the midst of profound demographic changes. The proportion of the elderly population (65+) in the country is projected to increase from a current 13% of the population to just over 20% of the population by 2030. Considering that the decision regarding living arrangements is of great consequence to the well-being of the elderly and their families, understanding the factors that influence this decision is of great value. In this paper, we exploit the changes in state income tax preferences over time to examine the impact of such tax policies on the living arrangements of the elderly population.     

Estimating the monetary benefits of medicare eligibility for reducing the symptoms of dementia

We adopt a three-component method based on the idea of cost-saving for estimating the monetary benefits of Medicare eligibility for reducing dementia symptoms. The method involves Medicare eligibility lowering dementia symptoms, which reduces the need for dependent living, which in turn lowers caregiving costs. We use the Regression Discontinuity approach to establish a causal link between Medicare eligibility and dementia. The novel aspect of the study comes from using a quality-of-life proxy measure for the utility function to derive the marginal rate of substitution between dementia symptoms reduction and dependent living arrangements.     

DO DOCTORS INDUCE DEMAND?

This paper examines supply‐induced demand in medicine using an exogenous income shock to obstetricians and gynaecologists caused by a declining number of births in their practice location from 1989 to 1999. The results of the present study indicate some evidence of induced demand. A 4.1 percentage point increase in Caesarean section procedures is found for a one unit decline in the birth rate per 100 population. Interestingly, people commence prenatal care statistically significantly earlier with fertility decline and, subsequently, the total number of prenatal care visits has been increased. However, I found no evidence of declining fertility inducing excessive prenatal care visits.     

Physician participation in health insurance plans: evidence on Blue Shield

Various health insurance programs, including Blue Shield, have developed arrangements whereby the physician agrees to accept the insurer's reimbursement as payment in full. Incentives facing the physician to accept an arrangement of this type are reviewed in this study. The empirical work uses data on individual physicians from a 1973 survey. The results indicate that physician willingness to accept insurer reimbursement as payment in full is sensitive to the amount the insurer pays for specific procedures and to other insurance program characteristics. Physicians located in high patient income areas and/or with relatively prestigious credentials are less likely to accept insurer payments as payment in full. The empirical findings are used to generate policy implications pertaining to the Medicare and Medicaid programs, to medical care quality-access tradeoffs, and to national health insurance.     

Hospice costs and medicare reimbursement: an application of break-even analysis

The adequacy of Medicare reimbursement to cover hospice costs is examined using break-even analysis. Since hospice costs are high during the first few days after enrollment, a long period of enrollment is required for per diem reimbursement to cover costs. Under a variety of specifications, the length of stay required for the hospice to break even is greater than the median length of stay.     

Who's Getting Caught? An Analysis of the Australian Medicare Safety Net

The Medicare Safety Net (MSN) was introduced in March 2004 to provide financial relief for those who incur high out-of-pocket costs from medical services. The policy has the potential to improve equity. This study examines: (i) how the health and income profiles of small areas influence MSN expenditure; and (ii) the distribution of expenditure by medical service type. The results indicate that MSN expenditure is positively related to income and that patients who use private obstetricians and assisted reproductive services are the greatest beneficiaries. The MSN has possibly created greater inequities in Australia's health-care financing arrangements.     

新型农村合作医疗制度的农民满意度研究——对“新农合”试点县(电白县)的一项问卷调查

新型农村合作医疗制度从2003年试点至今,已处于全面覆盖状态。广东省电白县为实施该制度的一个试点县,2008年达到100%的参合率,但近年来参合率有所下降。文章通过实地走访谈话、设计并派发调查问卷等方式,找寻新型农村合作医疗的参合率下降的原因,通过调查数据整理,建立线性回归模型进行分析。分析结果显示,与新型农村合作医疗的满意度明显相关的因素是参合者的年龄、对新型农村合作医疗的了解度及对新型农村合作医疗的认可度。建议通过加强宣传力度、提高报销比例、扩大报销范围等进一步完善新型农村合作医疗制度。     

新型农村合作医疗制度的农民满意度研究——对＂新农合＂试点县（电白县）的一项问卷调查

新型农村合作医疗制度从2003年试点至今,已处于全面覆盖状态。广东省电白县为实施该制度的一个试点县,2008年达到100％的参合率,但近年来参合率有所下降。文章通过实地走访谈话、设计并派发调查问卷等方式,找寻新型农村合作医疗的参合率下降的原因,通过调查数据整理,建立线性回归模型进行分析。分析结果显示,与新型农村合作医疗的满意度明显相关的因素是参合者的年龄、对新型农村合作医疗的了解度及对新型农村合作医疗的认可度。建议通过加强宣传力度、提高报销比例、扩大报销范围等进一步完善新型农村合作医疗制度。     

民生支出的公平正义性分析——基于浙江各县教育和卫生支出的分析

文章基于1997～2008年浙江省教育支出和卫生支出的受益归宿分析表明,民生支出的最大受益者为人均收入最高地区居民,最大受损者为人均收入次低地区居民,民生支出具有累进性,距离公平正义的政策初衷仍有一定差距。但是,如果考虑不同收入组别生活成本、支出需求的差异,民生支出的公平程度将有所提高。通过建立因素法转移支付制度,提高民生支出比重,可以进一步提高民生支出的公平正义水平。     

ON THE LIVING ARRANGEMENTS OF ELDERLY WIDOWS*

Between 1970 and 1990, the share of elderly widows living alone grew by 23.2% in the United States, whereas those living with their children decreased by a similar amount. We pose a variety of models for determining the living arrangements in which living together increases consumption because of economies of scale and may also provide utility directly. We estimate these models using the 1970 data and obtain an excellent fit. The estimated models predict that changes in the incomes of both the widow and her offspring generate three‐quarters of the increase in the number of widows living alone.     

Healthcare utilization and costs associated with COPD among SEER-Medicare beneficiaries with NSCLC

Aim: To estimate the healthcare utilization and costs in elderly lung cancer patients with and without pre-existing chronic obstructive pulmonary disease (COPD).

Methods: Using Surveillance, Epidemiology and End Results (SEER)-Medicare data, this study identified patients with lung cancer between 2006–2010, at least 66 years of age, and continuously enrolled in Medicare Parts A and B in the 12 months prior to cancer diagnosis. The diagnosis of pre-existing COPD in lung cancer patients was identified using ICD-9 codes. Healthcare utilization and costs were categorized as inpatient hospitalizations, skilled nursing facility (SNF) use, physician office visits, ER visits, and outpatient encounters for every stage of lung cancer. The adjusted analysis was performed using a generalized linear model for healthcare costs and a negative binomial model for healthcare utilization.

Results: Inpatient admissions in the COPD group increased for each stage of non-small cell lung cancer (NSCLC) compared to the non-COPD group per 100 person-months (Stage I: 14.67 vs 9.49 stays, p?<?.0001; Stage II: 14.13 vs 10.78 stays, p?<?.0001; Stage III: 28.31 vs 18.91 stays, p?<?.0001; Stage IV: 49.5 vs 31.24 stays, p?<?.0001). A similar trend was observed for outpatient visits, with an increase in utilization among the COPD group (Stage I: 1136.04 vs 796 visits, p?<?.0001; Stage II: 1325.12 vs 983.26 visits, p?<?.0001; Stage III: 2025.47 vs 1656.64 visits, p?<?.0001; Stage IV: 2825.73 vs 2422.26 visits, p?<?.0001). Total direct costs per person-month in patients with pre-existing COPD were significantly higher than the non-COPD group across all services ($54,799.16 vs $41,862.91). Outpatient visits represented the largest cost category across all services in both groups, with higher costs among the COPD group ($41,203 vs $31,140.08).

Conclusion: Healthcare utilization and costs among lung cancer patients with pre-existing COPD was ～2–3-times higher than the non-COPD group.     

Treatment patterns,healthcare resource utilization,and costs in patients with acute myeloid leukemia in commercially insured and Medicare populations

Objective: To describe the setting, duration, and costs of induction and consolidation chemotherapy for adults with newly-diagnosed acute myeloid leukemia (AML), who are candidates for standard induction chemotherapy, in the US.

Methods: Adults newly-diagnosed with AML who received standard induction chemotherapy in an inpatient setting were identified from the Truven Health Analytics MarketScan (2006–2015) and SEER-Medicare (2007–2011) databases. Patients were observed from induction therapy start to the first of hematopoietic stem cell transplant, 180 days after induction discharge, health plan enrollment/data availability end, or death. Induction and consolidation chemotherapy were identified using Diagnosis-Related Group codes (chemotherapy with acute leukemia) or procedure codes for AML chemotherapy administration. AML treatment episode setting (inpatient or outpatient), duration, and costs (2015 USD, payers’ perspective) were described for commercially insured patients and Medicare beneficiaries.

Results: In total, 459 commercially insured patients and 563 Medicare beneficiaries (mean age?=?54 and 66 years; 53% and 54% male; respectively) were identified. For induction therapy, mean costs were $145,189 for commercially insured patients and $85,734 for Medicare beneficiaries, and median inpatient duration was 31 days (both). Following induction, 64% of commercially insured patients and 53% of Medicare beneficiaries had ≥1 consolidation cycle; 75% and 65% of consolidation cycles were in an inpatient setting, respectively. For consolidation cycles, in the inpatient setting, mean costs were $28,137 for commercially insured patients and $28,843 for Medicare beneficiaries, median cycle duration was 6 days (both); in the outpatient setting, mean costs were $11,271 for commercially insured patients and $5,803 Medicare beneficiaries, median duration was 5 days (both).

Limitations: Granular information on chemotherapy type administered was unavailable.

Conclusions: This is the first exploratory study providing a complete picture of recent AML treatment patterns and management costs among commercially insured patients and Medicare beneficiaries. There is substantial heterogeneity in the management and costs of AML.     

What did Medicare do? The initial impact of Medicare on mortality and out of pocket medical spending

We study the impact of the introduction of one of the major pillars of the social insurance system in the United States: the introduction of Medicare in 1965. Our results suggest that, in its first 10 years, the establishment of universal health insurance for the elderly had no discernible impact on elderly mortality. However, we find a substantial reduction in the elderly's exposure to out of pocket medical expenditure risk. Specifically, we estimate that the introduction of Medicare was associated with a 40% decline in out of pocket spending for the top quartile of the out of pocket spending distribution. A stylized expected utility framework suggests that the welfare gains from such reductions in risk exposure alone may be sufficient to cover almost two-fifths of the costs of Medicare. These findings underscore the importance of considering the direct insurance benefits from public health insurance programs, in addition to any indirect benefits from an effect on health.     

空巢老人的养老意愿及其影响因素——基于苏州的实证研究

以2008年苏州城乡老年空巢家庭养老状况的调查资料为基础,对城乡空巢老人的养老意愿及其影响因素进行了分析。超过半数的空巢老人不愿意与子女共同居住,而机构养老也并非空巢老人的最爱。在影响空巢老人是否愿意与子女共同居住的因素中,户籍因素最为重要,其次是与子女关系因素,最后是房屋建筑面积因素;而在影响空巢老人是否愿意入住养老机构的众多因素中,文化程度、儿子数量和养老金(养老补贴)数量这三个变量尤为重要。