Health shocks, health and labor market dynamics, and the socioeconomic-health gradient in older Singaporeans.

Health disparities by socioeconomic status (SES) are potentially shaped by how an individual's health status and work capacity are affected by the incidence of illness, and how these effects vary across SES groups. We examine the impact of illness on the dynamics of health status, work activity and income in older Singaporeans to gain new insights on how ill health shapes the socioeconomic health gradient. Our data comprise of 60 monthly waves (2015-2019) of panel survey data containing 445,464 person-observations from 11,827 unique respondents from Singapore. We apply a matched event-study difference-in-differences research design to track how older adults' health and work changes following the diagnosis of heart disease and cancer. Our focus is how the dynamics of health and work differ for different SES groups, which we measure by post-secondary education attainment. We find that the dynamics of how self-assessed health recovers following the diagnosis of a new heart disease or cancer do not vary significantly across SES groups. Work activity however varies significantly, with less well-educated males and females being significantly less likely to be in active employment and have income from work, and are marginally more likely to be in retirement following the onset of ill health. By contrast, more well-educated males work more, and earn more a year after the health shock than they did before they fell ill. Occupational differences likely played a role in how work activity of less well-educated men decline more after an acute health event compared with more well-educated men. Understanding the drivers of the socioeconomic health gradient necessitates a focus on individual-level factors, as well as system-level influences, that affect health and work.

Loss ratio of the capitation payment unit of the health-promoting entities in Colombia between 2017 and 2021: a financial-actuarial approach.

BACKGROUND: Because of a change of government, the Colombian Ministry of Health and Social Protection is in the process of presenting a structural reform for the General System of Social Security in Health (GSSSH), in order to implement a 'preventive and predictive health model'. However, it will always be relevant to review and analyze the fiscal implications of any proposed public policy program, to protect financial sustainability and to promote the better functioning of the system in question. METHODS: To contribute to this topic, we have calculated, using a financial-actuarial approach, the loss ratio for the years 2017 to 2021 for the Capitation Payment Unit (CPU) for all the Health-Promoting Entities (HPE) for both contributory and subsidized schemes. This information, derived from public reports available on the official website of the National Health Superintendency, allows us to estimate the financial burden of the institutions that guarantee access to and provision of health services and technologies in Colombia. RESULTS: The study shows that close to half of the HPEs in Colombia (which represent 11.6 million affiliates) have CPU loss ratios of more than 100% for the year 2021, evidencing insufficient resources for the operation of health insurance. CONCLUSIONS: Finally, we propose some policy recommendations regarding the strengthening of informed decision-making to allow the healthy financial sustainability of the Colombian GSSSH.

The relationship between hospital ownership, in-hospital mortality, and medical expenses: an analysis of three common conditions in China.

BACKGROUND: Private hospitals expanded rapidly in China since 2009 following its national health reform encouraging private investment in the hospital sector. Despite long-standing debates over the performance of different types of hospitals, empirical evidence under the context of developing countries remains scant. We investigated the disparities in health care quality and medical expenses among public, private not-for-profit, and private for-profit hospitals. METHODS: A total of 64,171 inpatients (51,933 for pneumonia (PNA), 9,022 for heart failure (HF) and 3,216 for acute myocardial infarction (AMI)) who were admitted to 528 secondary hospitals in Sichuan province, China, during the fourth quarters of 2016, 2017, and 2018 were selected for this study. Multilevel logistic regressions and multilevel linear regressions were utilized to assess the relationship between hospital ownership types and in-hospital mortality, as well as medical expenses for PNA, HF, and AMI, after adjusting for relevant hospital and patient characteristics, respectively. RESULTS: The private not-for-profit (adjusted OR, 1.69; 95% CI, 1.08, 2.64) and for-profit (adjusted OR, 1.67; 95% CI, 1.06, 2.62) hospitals showed higher in-hospital mortality than the public ones for PNA, but not for AMI and HF. No significant differences were found in medical expenses across hospital ownership types for AMI, but the private not-for-profit was associated with 9% higher medical expenses for treating HF, while private not-for-profit and for-profit hospitals were associated with 10% and 11% higher medical expenses for treating PNA than the public hospitals. No differences were found between the private not-for-profit and private for-profit hospitals both in in-hospital mortality and medical expenses across the three conditions. CONCLUSION: The public hospitals had at least equal or even higher healthcare quality and lower medical expenses than the private ones in China, while private not-for-profit and for-profit hospitals had similar performances in these aspects. Our results added evidences on hospitals' performances among different ownership types under China's context, which has great potential to inform the optimization of healthcare systems implemented among developing countries confronted with similar challenges.

Circulating Biomarkers for Prediction of Immunotherapy Response in NSCLC.

Non-small cell lung cancer (NSCLC) constitutes the majority of the lung cancer population and the prognosis is poor. In recent years, immunotherapy has become the standard of care for advanced NSCLC patients as numerous trials demonstrated that immune checkpoint inhibitors (ICI) are more efficacious than conventional chemotherapy. However, only a minority of NSCLC patients benefit from this treatment. Therefore, there is an unmet need for biomarkers that could accurately predict response to immunotherapy. Liquid biopsy allows repeated sampling of blood-based biomarkers in a non-invasive manner for the dynamic monitoring of treatment response. In this review, we summarize the efforts and progress made in the identification of circulating biomarkers that predict immunotherapy benefit for NSCLC patients. We also discuss the challenges with future implementation of circulating biomarkers into clinical practice.

Understanding online dual practice of public hospital doctors in China: a mixed-methods study.

Telemedicine and telehealth hold promise for reducing access barriers, improving quality and containing medical costs. As Internet companies enter the healthcare market, a rising number of online healthcare platforms have emerged worldwide. In some countries like China, public hospital doctors are providing direct-to-consumer telemedicine services on these commercial platforms as independent providers. Such online service provision creates a new form of dual practice, which we refer to as 'online dual practice' in this study. Using a mixed-methods design, this study aims to investigate the prevalence of online dual practice, doctors' time allocation and motivations for engaging in it and its potential impacts on the health system in China. We use the web-crawled data from four leading online health platforms to examine the prevalence of online dual practice in China. Then we conduct in-depth interviews with 38 active doctors on these platforms to investigate their time allocation, motivations and perception regarding online service provision. We find that the nationwide prevalence of online dual practice in China reaches at least 16.5% in 2020 and that it is more common among senior public hospital doctors. Public hospital doctors mainly use small pockets of time during working hours and after-hours to render services on the platforms The five most commonly cited motivations for their engagement in online dual practice are efficiency improvement, personal control, career development, financial rewards and serving the patients. Interviewed doctors believe that their online service provision is conducive to increasing healthcare access and improving efficiency, but some also express their concerns about the quality of care. Further analysis shows that the impact of online dual practice on health system performance remains an open question and regulatory policies on it should be health-system specific.

The effect of income-based mandates on the demand for private hospital insurance and its dynamics.

We examine the effect of an income-based mandate on the demand for private hospital insurance and its dynamics in Australia. The mandate, known as the Medicare Levy Surcharge (MLS), is a levy on taxable income that applies to high-income individuals who choose not to buy private hospital insurance. Our identification strategy exploits changes in MLS liability arising from both year-to-year income fluctuations, and a reform where income thresholds were increased significantly. Using data from the Household, Income and Labour Dynamics in Australia longitudinal survey, we estimate dynamic panel data models that account for persistence in the decision to purchase insurance stemming from unobserved heterogeneity and state dependence. Our results indicate that being subject to the MLS penalty in a given year increases the probability of purchasing private hospital insurance by between 2 to 3 percent in that year. If subject to the penalty permanently, this probability grows further over the following years, reaching 13 percent after a decade. We also find evidence of a marked asymmetric effect of the MLS, where the effect of the penalty is about twice as large for individuals becoming liable compared with those going from being liable to not being liable. Our results further show that the mandate has a larger effect on individuals who are younger.

How do gender differences in family responsibilities affect doctors' labour supply? Evidence from Australian panel data.

We use nine annual waves of a unique longitudinal dataset of Australian doctors to examine how children and family responsibilities influence the number of hours worked by female and male medical doctors. We exploit the longitudinal feature of the data to investigate how hours worked change in response to within-doctor changes in family circumstances over time. We find strong evidence of a 'carer effect' of having children for female doctors, whose working hours are significantly reduced by the presence of children, the number of children, and young children. The working hours by female doctors are also strongly influenced by the employment status of their spouses. In contrast, for male doctors, having children leads to a slight increase in hours worked. The effect of children in dual medical career households is highly asymmetric: female doctors reduce their hours worked by a very large margin, whereas male doctors report not changing their working hours. Finally we also find evidence of heterogeneous effects of how family circumstances affect hours worked across different quantiles of hours worked.

Monthly spending dynamics of the elderly following a health shock: Evidence from Singapore.

We use novel longitudinal data from 19 monthly waves of the Singapore Life Panel to examine the short-term dynamics of the effects health shocks have on household health and nonhealth spending and income by the elderly. The health shocks we study are the occurrence of new major conditions such as cancer, heart problems, and minor conditions (e.g., diabetes and hypertension). Our empirical strategy is based on an event study approach that exploits unanticipated changes in health status through the diagnosis of new health conditions. We find that major shocks have large and persistent effects whereas minor shocks have small and mainly contemporaneous effects. We find that household income reduces following a major shock for males but not females. Major health shocks lead to a decrease in households' nonhealth expenditures that is particularly pronounced for cancer and stroke sufferers, driven largely by reductions in leisure spending. The financial impact of major shocks on medical saving account balances occurs to those without private health insurance, whereas the impact is on cash balances for privately insured individuals.

DO YOU HAVE TO WIN IT TO FIX IT? A Longitudinal Study of Lottery Winners and Their Health-Care Demand.

We exploit lottery wins to investigate the effects of exogenous changes to individuals' income on the utilization of health care services, and the choice between private and public health care in the United Kingdom. Our empirical strategy focuses on lottery winners in an individual fixed effects framework and hence the variation of winnings arises from within-individual differences in small versus large winnings. The results indicate that lottery winners with larger wins are more likely to choose private health services than public health services from the National Health Service. The positive effect of wins on the choice of private care is driven largely by winners with medium to large winnings (win category > £500 (or US$750); mean = £1922.5 (US$2,893.5), median = £1058.2 (US$1592.7)). There is some evidence that the effect of winnings vary by whether individuals have private health insurance. We also find weak evidence that large winners are more likely to take up private medical insurance. Large winners are also more likely to drop private insurance coverage between approximately 9 and 10 months earlier than smaller winners, possibly after their winnings have been exhausted. Our estimates for the lottery income elasticities for public health care (relative to no care) are very small and are not statistically distinguishable from zero; those of private health care range from 0 - 0.26 for most of the health services considered, and 0.82 for cervical smear.

What factors affect physicians' labour supply: Comparing structural discrete choice and reduced-form approaches.

Little is known about the response of physicians to changes in compensation: Do increases in compensation increase or decrease labour supply? In this paper, we estimate wage elasticities for physicians. We apply both a structural discrete choice approach and a reduced-form approach to examine how these different approaches affect wage elasticities at the intensive margin. Using uniquely rich data collected from a large sample of general practitioners (GPs) and specialists in Australia, we estimate 3 alternative utility specifications (quadratic, translog, and box-cox utility functions) in the structural approach, as well as a reduced-form specification, separately for men and women. Australian data is particularly suited for this analysis due to a lack of regulation of physicians' fees leading to variation in earnings. All models predict small negative wage elasticities for male and female GPs and specialists passing several sensitivity checks. For this high-income and long-working-hours population, the translog and box-cox utility functions outperform the quadratic utility function. Simulating the effects of 5% and 10% wage increases at the intensive margin slightly reduces the full-time equivalent supply of male GPs, and to a lesser extent of male specialists and female GPs.

Estimating the Reference Incremental Cost-Effectiveness Ratio for the Australian Health System.

BACKGROUND: Spending on new healthcare technologies increases net population health when the benefits of a new technology are greater than their opportunity costs-the benefits of the best alternative use of the additional resources required to fund a new technology. OBJECTIVE: The objective of this study was to estimate the expected incremental cost per quality-adjusted life-year (QALY) gained of increased government health expenditure as an empirical estimate of the average opportunity costs of decisions to fund new health technologies. The estimated incremental cost-effectiveness ratio (ICER) is proposed as a reference ICER to inform value-based decision making in Australia. METHODS: Empirical top-down approaches were used to estimate the QALY effects of government health expenditure with respect to reduced mortality and morbidity. Instrumental variable two-stage least-squares regression was used to estimate the elasticity of mortality-related QALY losses to a marginal change in government health expenditure. Regression analysis of longitudinal survey data representative of the general population was used to isolate the effects of increased government health expenditure on morbidity-related, QALY gains. Clinical judgement informed the duration of health-related quality-of-life improvement from the annual increase in government health expenditure. RESULTS: The base-case reference ICER was estimated at AUD28,033 per QALY gained. Parametric uncertainty associated with the estimation of mortality- and morbidity-related QALYs generated a 95% confidence interval AUD20,758-37,667. CONCLUSION: Recent public summary documents suggest new technologies with ICERs above AUD40,000 per QALY gained are recommended for public funding. The empirical reference ICER reported in this article suggests more QALYs could be gained if resources were allocated to other forms of health spending.

LONGITUDINAL EVIDENCE FOR A MIDLIFE NADIR IN HUMAN WELL-BEING: RESULTS FROM FOUR DATA SETS.

There is a large amount of cross-sectional evidence for a midlife low in the life cycle of human happiness and well-being (a 'U shape'). Yet no genuinely longitudinal inquiry has uncovered evidence for a U-shaped pattern. Thus, some researchers believe the U is a statistical artefact. We re-examine this fundamental cross-disciplinary question. We suggest a new test. Drawing on four data sets, and only within-person changes in well-being, we document powerful support for a U shape in longitudinal data (without the need for formal regression equations). The article's methodological contribution is to use the first-derivative properties of a well-being equation.

Changes in Doctors' Working Hours: A Longitudinal Analysis.

The study examined changes in doctors' working hours and satisfaction with working hours over five time points and explored the influence of personal characteristics on these outcomes. Latent growth curve modeling was applied to Medicine in Australia: Balancing Employment and Life data, collected from 2008 to 2012. Findings showed that working hours significantly declined over time, with a greater decrease among males, older doctors, and doctors with fewer children. Satisfaction increased faster over time among specialists, doctors with poorer health, those whose partners did not work full-time, and those with older children. The more hours the doctors worked initially, the lower satisfaction reported, and the greater the increase in satisfaction. Findings are consistent with a culture change in the medical profession, whereby long working hours are no longer seen as synonymous with professionalism. This is important to take into account in projecting future workforce supply.

Attrition Bias in Panel Data: A Sheep in Wolf's Clothing? A Case Study Based on the Mabel Survey.

This paper investigates the nature and consequences of sample attrition in a unique longitudinal survey of medical doctors. We describe the patterns of non-response and examine if attrition affects the econometric analysis of medical labour market outcomes using the estimation of physician earnings equations as a case study. We compare the econometric gestimates obtained from a number of different modelling strategies, which are as follows: balanced versus unbalanced samples; an attrition model for panel data based on the classic sample selection model; and a recently developed copula-based selection model. Descriptive evidence shows that doctors who work longer hours, have lower years of experience, are overseas trained and have changed their work location are more likely to drop out. Our analysis suggests that the impact of attrition on inference about the earnings of general practitioners is small. For specialists, there appears to be some evidence for an economically significant bias. Finally, we discuss how the top-up samples in the Medicine in Australia: Balancing Employment and Life survey can be used to address the problem of panel attrition.

Cream skimming and hospital transfers in a mixed public-private system.

The increasing prominence of the private sector in health care provision has generated considerable interest in understanding its implications on quality and cost. This paper investigates the phenomenon of cream skimming in a mixed public-private hospital setting using the novel approach of analysing hospital transfers. We analyse hospital administrative data of patients with ischemic heart disease from the state of Victoria, Australia. The data set contains approximately 1.77 million admission episodes in 309 hospitals, of which 132 are public hospitals, and 177 private hospitals. We ask if patients transferred between public and private hospitals differ systematically in the severity and complexity of their medical conditions; and if so, whether utilisation also differs. We find that patients with higher disease severity are more likely to be transferred from private to public hospitals whereas the opposite is true for patients transferred to private hospitals. We also find that patients transferred from private to public hospitals stayed longer and cost more than private-to-private transfer patients, after controlling for patients' observed health conditions and personal characteristics. Overall, the evidence is suggestive of the presence of cream skimming in the Victorian hospital system, although we cannot conclusively rule out other mechanisms that might influence hospital transfers.

Propagation of human corneal endothelial cells: a novel dual media approach.

Corneal endothelium-associated corneal blindness is the most common indication for corneal transplantation. Restorative corneal transplant surgery is the only option to reverse the blindness, but a global shortage of donor material remains an issue. There are immense clinical interests in the development of alternative treatment strategies to alleviate current reliance on donor materials. For such endeavors, ex vivo propagation of human corneal endothelial cells (hCECs) is required, but current methodology lacks consistency, with expanded hCECs losing cellular morphology to a mesenchymal-like transformation. In this study, we describe a novel dual media culture approach for the in vitro expansion of primary hCECs. Initial characterization included analysis of growth dynamics of hCECs grown in either proliferative (M4) or maintenance (M5) medium. Subsequent comparisons were performed on isolated hCECs cultured in M4 alone against cells expanded using the dual media approach. Further characterizations were performed using immunocytochemistry, quantitative real-time PCR, and gene expression microarray. At the third passage, results showed that hCECs propagated using the dual media approach were homogeneous in appearance, retained their unique polygonal cellular morphology, and expressed higher levels of corneal endothelium-associated markers in comparison to hCECs cultured in M4 alone, which were heterogeneous and fibroblastic in appearance. Finally, for hCECs cultured using the dual media approach, global gene expression and pathway analysis between confluent hCECs before and after 7-day exposure to M5 exhibited differential gene expression associated predominately with cell proliferation and wound healing. These findings showed that the propagation of primary hCECs using the novel dual media approach presented in this study is a consistent method to obtain bona fide hCECs. This, in turn, will elicit greater confidence in facilitating downstream development of alternative corneal endothelium replacement using tissue-engineered graft materials or cell injection therapy.

Measuring the effects of reducing subsidies for private insurance on public expenditure for health care.

This paper investigates the effects of reducing subsidies for private health insurance on public sector expenditure for hospital care. An econometric framework using simultaneous equation models is developed to analyse the interrelated decisions on the intensity and type of health care use and private insurance. The framework is applied to the context of the mixed public-private system in Australia. The simulation projections show that reducing premium subsidies is expected to generate net cost savings. This arises because the cost savings achieved from reducing subsidies are larger than the potential increase in public expenditure on hospital care.

High throughput gene expression analysis identifies reliable expression markers of human corneal endothelial cells.

Considerable interest has been generated for the development of suitable corneal endothelial graft alternatives through cell-tissue engineering, which can potentially alleviate the shortage of corneal transplant material. The advent of less invasive suture-less key-hole surgery options such as Descemet's Stripping Endothelial Keratoplasty (DSEK) and Descemet's Membrane Endothelial Keratoplasty (DMEK), which involve transplantation of solely the endothelial layer instead of full thickness cornea, provide further impetus for the development of alternative endothelial grafts for clinical applications. A major challenge for this endeavor is the lack of specific markers for this cell type. To identify genes that reliably mark corneal endothelial cells (CECs) in vivo and in vitro, we performed RNA-sequencing on freshly isolated human CECs (from both young and old donors), CEC cultures, and corneal stroma. Gene expression of these corneal cell types was also compared to that of other human tissue types. Based on high throughput comparative gene expression analysis, we identified a panel of markers that are: i) highly expressed in CECs from both young donors and old donors; ii) expressed in CECs in vivo and in vitro; and iii) not expressed in corneal stroma keratocytes and the activated corneal stroma fibroblasts. These were SLC4A11, COL8A2 and CYYR1. The use of this panel of genes in combination reliably ascertains the identity of the CEC cell type.