Diffusion of new medication across different income groups under a universal health insurance program: an example involving newly enlisted nonsteroidal anti-inflammatory drugs for elderly osteoarthritis patients.

OBJECTIVES: The aim of this research was to determine whether socioeconomic status, as measured by income level, impacts on the diffusion to patients of newly reimbursed nonsteroidal anti-inflammatory drugs (NSAIDs) under the National Health Insurance program in Taiwan. METHODS: We used income tax records to identify the income levels of 324 male and 551 female randomly sampled osteoarthritis patients aged over 60 years in 2000. The study period was 2 years (t (1) = April 2001-March 2002 and t (2) = April 2002-March 2003). Generalized estimating equation models were used to analyze the impact of income level on being prescribed one of the newly reimbursed NSAIDs. RESULTS: The impact of income level on being treated with the new drug was positive and significant for females (OR = 2.11, p < 0.01) but not for males. The interaction term between income groups and the time trend was insignificant. Other factors associated with being treated with the new drug include age, habit of health-care utilization, and residential characteristics. CONCLUSIONS: Diffusion of new drugs still depends on income level despite the presence of a universal national health insurance system in Taiwan.

Disparities in appendicitis rupture rate among mentally ill patients.

BACKGROUND: Many studies have been carried out that focus on mental patients' access to care for their mental illness, but very few pay attention on these same patients' access to care for their physical diseases. Acute appendicitis is a common surgical emergency. Our population-based study was to test for any possible association between mental illness and perforated appendicitis. We hypothesized that there are significant disparities in access to timely surgical care between appendicitis patients with and without mental illness, and more specifically, between patients with schizophrenia and those with another major mental illness. METHODS: Using the National Health Insurance (NHI) hospital-discharge data, we compared the likelihood of perforated appendix among 97,589 adults aged 15 and over who were hospitalized for acute appendicitis in Taiwan between the years 1997 to 2001. Among all the patients admitted for appendicitis, the outcome measure was the odds of appendiceal rupture vs. appendicitis that did not result in a ruptured appendix. RESULTS: After adjusting for age, gender, ethnicity, socioeconomic status (SES) and hospital characteristics, the presence of schizophrenia was associated with a 2.83 times higher risk of having a ruptured appendix (odds ratio [OR], 2.83; 95% confidence interval [CI], 2.20-3.64). However, the presence of affective psychoses (OR, 1.15; 95% CI: 0.77-1.73) or other mental disorders (OR, 1.58; 95% CI: 0.89-2.81) was not a significant predictor for a ruptured appendix. CONCLUSION: These findings suggest that given the fact that the NHI program reduces financial barriers to care for mentally ill patients, they are still at a disadvantage for obtaining timely treatment for their physical diseases. Of patients with a major mental illness, schizophrenic patients may be the most vulnerable ones for obtaining timely surgical care.

Screening for cervical cancer among female physicians and their relatives in Taiwan: a population-based comparative study.

BACKGROUND: This study compares the practice of having the recommended Pap smear test every 3 years among female physicians, female relatives of physicians, and general women of similar socio-economic background. METHODS: This population-based cohort study followed a total of 5,815,781 Taiwanese women from January 2001 to December 2003, who were 30 years of age or older in 2001. Of the total study population, 1950 were physicians and 27,441 were female relatives of physicians. Multiple logistical regression models were used. RESULTS: After adjusting for age, ethnic status, physical disability status, and place of residence, of those women whose monthly insurable income was greater than $NT 40,000, female physicians (OR 0.54, 95% CI: 0.50-060) were the least likely to have undergone at least one Pap smear test during the three-year study period. The physicians' relatives (OR 0.90, 95% CI: 0.87-0.92) were also significantly less likely to take routine Pap smear tests compared to general women with equivalent socio-economic background. CONCLUSIONS: The female physician is a major player in disease prevention with advanced knowledge of the benefits associated with the Pap smear test, but may not adhere any better to the recommendations than the general population.

The distribution of net benefits under the National Health Insurance programme in Taiwan.

The redistributive effects of a social insurance programme are determined by how the programme is paid for-who pays and how much do they pay?-and how the benefits are distributed. As a result, the redistributive effects of a social health insurance programme should be evaluated on the basis of its net benefit-the difference between benefits and payment. Among the rich body of empirical analysis on equity in health care financing, however, most studies have relied on partial analysis, assessing equity by source of financing while ignoring the benefit side, or looking at equity in benefits but ignoring the funding side. Either approach risks misleading findings. In this study, therefore, the primary objective was to assess the distribution of net benefits across income groups under Taiwan's National Health Insurance (NHI) programme. This study observed a nationally representative sample of 74 012 NHI enrolees from 1996 to 2000. The unique NHI databases in Taiwan provide comprehensive enrolment and utilization information, and allowed linkage to each enrolee's income tax files. In addition to crude estimates, two-part models and ordinary least-square models were used to adjust inpatient and outpatient benefits for health care needs (age, sex, major disease status and physical disability). After adjusting for health care needs, the distribution of net benefits showed an apparent pro-poor pattern, with the lowest income group receiving the highest net benefits (NT$3353) and the top income group receiving the lowest net benefits (-NT$3072) in 1996. Although a clear pro-poor pattern was observed among those enrolees who paid wage-based premiums, this vertically equitable pattern was less evident among the enrolees who paid fixed premiums. Overall, a trend of increasing net benefits was observed in all income groups between 1996 and 2000, and all the NHI enrolees can be considered better off over time. In addition to contributing to the limited literature on equity in net benefits, the study provides an important policy reference to developing countries with large underground economies and relatively small populations of regular wage-earners as it indicates that using fixed premiums as a major financing scheme may pose a serious equity concern and policy challenge.