The Reality of Cost Sharing in Japan.

Financial pressure on younger generation is mounting in Japan, a super-ageing society with staggering economy. The revision on the co-insurance rate for 70-74 with "Standard" category was implemented to mitigate such pressure, seeking better balance across generations in sharing the burden of healthcare cost. It raised the rate from 10% to 20% over the period of five years from 2014 to 2018. This report examined how it changed the share of cost sharing (cost sharing as percentage to total healthcare expenditure), among the 70-74 with "Standard" category in Citizens Health Insurance programme in 44 prefectures. It specifically focused on change in the population's actual share of cost sharing (ASCS) that better reflect the genuine amount of payment actually made by the patients themselves. The average ASCS increased from 7.28% (2013) to 10.78% (2019), resulting wider gap from the statutory planned share of cost sharing (i.e., the statutory co-insurance rate of 10% in 2013, and 20% in 2019). Also found was increased variance among prefectural ASCS, which may suggest a possibility of un-designed effect by the revision, of encouraging a move towards ability and willingness to pay. In terms of cost containment effect, Japan needs to consider various non-conventional options, including review of the current use of healthcare resources. First and foremost, however, the true state of cost sharing should be recognized in terms of ASCS and shared more widely as a reality. Such effort is essential in discussion of how to keep embracing the country's life line, UHC.

Inequality and Mother's Age as Determinants of Breastfeeding Continuation in Bangladesh.

The World Health Organization recommends continuing breastfeeding up to 2 years of age or beyond for sound growth and development of children. In Bangladesh, continuation rates for breastfeeding have recently decreased and effective measures are required to counter this downward trend. Although recent years have seen economic development and reductions in poverty, Bangladesh still has the highest rate of child marriage worldwide. Thus, we aimed to clarify the factors influencing breastfeeding continuation, especially from the perspective of inequality and mother's age in Bangladesh, using data from the Bangladesh Demographic and Health Survey 2011. Event history analyses were performed during a 24-month follow-up period on 7,041 mothers with duration of breastfeeding as the outcome variable, with wealth index (an indicator for inequality) and mother's age used as the main explanatory variables. The results showed that poorer mothers were on the whole more likely to continue breastfeeding through 24 months after childbirth, and younger mothers were less likely to continue breastfeeding particularly past the first year. However, both younger and older mothers continued breastfeeding to the same extent within the first year after childbirth. Mother's age had time-varying effects on breastfeeding continuation, meaning that the effects on breastfeeding continuation were affected by the child's age. These findings imply that policymakers should be aware that efforts to reduce child marriage may increase the rate of breastfeeding continuation beyond the first year after childbirth. In contrast, efforts at poverty alleviation, aimed at preventing child marriage, may decrease the rate irrespective of the child's age.

[Challenges in Healthcare Economics of Today's Cancer Treatment].

Healthcare economics concerns with the way in which to distribute and allocate scarce resources that result in maximized outcome. When the expenditure on cancer medicine was examined using the macro data open to the public, it was found to have increased in parallel with the National Medical Care Expenditure. More specifically, the growth rates of the two showed a similar trend in the five years from 2011 to 2015. However, when looked more closely by excluding the patient share and separating the care settings, the result was different. The expenditure in outpatient care displayed a significant increase, implying the influence of chemotherapy shifting to take place more in the outpatient setting. Current discussion on introducing the concept of cost effectiveness into the fee schedule scheme should be based on multidimensional consideration.

Cost-effectiveness analysis of cochlear dose reduction by proton beam therapy for medulloblastoma in childhood.

BACKGROUND: The aim of this study is to evaluate the cost-effectiveness of proton beam therapy with cochlear dose reduction compared with conventional X-ray radiotherapy for medulloblastoma in childhood. METHODS: We developed a Markov model to describe health states of 6-year-old children with medulloblastoma after treatment with proton or X-ray radiotherapy. The risks of hearing loss were calculated on cochlear dose for each treatment. Three types of health-related quality of life (HRQOL) of EQ-5D, HUI3 and SF-6D were used for estimation of quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) for proton beam therapy compared with X-ray radiotherapy was calculated for each HRQOL. Sensitivity analyses were performed to model uncertainty in these parameters. RESULTS: The ICER for EQ-5D, HUI3 and SF-6D were $21 716/QALY, $11 773/QALY, and $20 150/QALY, respectively. One-way sensitivity analyses found that the results were sensitive to discount rate, the risk of hearing loss after proton therapy, and costs of proton irradiation. Cost-effectiveness acceptability curve analysis revealed a 99% probability of proton therapy being cost effective at a societal willingness-to-pay value. CONCLUSIONS: Proton beam therapy with cochlear dose reduction improves health outcomes at a cost that is within the acceptable cost-effectiveness range from the payer's standpoint.

Effectiveness of health sector reforms in reducing disparities in utilization of skilled birth attendants in Tanzania.

Improving maternal health is a Millennium Development Goal adopted at the 2000 Millennium Summit of the United Nations. As part of the improving maternal health in Tanzania, it has been recommended that skilled birth attendants be present at all births to help reduce the high maternal mortality ratio. However, utilization of these attendants varies across socio-economic groups. The government of Tanzania has repeatedly attempted to carry out health sector reforms (HSRs) to alleviate disparities in health service utilization. In particular, around 1999, HSRs were incorporated into two approaches, including Decentralization by Devolution and Sector Wide Approach. This study aims to clarify the unresolved questions with little published evidence on the effect of HSRs on reducing disparities in utilization of skilled birth attendants across socio-economic groups over time. We used four cross-sectional datasets from the Tanzania Demographic and Health Survey: 1992, 1996, 1999, and 2004/05. Subjects included 14,752 women of reproductive age (15-49 years) and data on the most recent birth in the 5 years before each survey. Logistic regression analysis was performed with the dependent variable of whether respondents utilized skilled birth attendants or not, and with the main independent variables of time and socio-economic group. Results showed that the disparity in utilization of skilled birth attendants was significantly decreased from 1999 to 2004/05. These findings suggest that the two strategies, Decentralization by Devolution and Sector Wide Approach, in the process of HSRs are effective in reducing the disparities in utilization of skilled birth attendants among socio-economic groups.

The impact of Gonoshasthaya Kendra's Micro Health Insurance plan on antenatal care among poor women in rural Bangladesh.

Low utilization of antenatal care (ANC) by pregnant women, particularly in rural areas, is an obstacle to ensuring safe motherhood in Bangladesh. Currently, Micro Health Insurance (MHI) is being considered in many developing countries as a potential method for assuring greater access to health care, especially for the poor. So far, there is only limited evidence evaluating MHI schemes. This study assesses the impact of MHI administered by Gonoshasthaya Kendra (GK) on ANC utilization by poor women in rural Bangladesh. We conducted a questionnaire survey and collected 321 valid responses from women enrolled in GK's MHI scheme and 271 from women not enrolled in any health insurance plan. We used a two-part model in which dependent variables were whether or not women utilized ANC and the number of times ANC was used. The model consisted of logistic regression analysis and ordinary least squares regression analysis. The main independent variables were dummies for socioeconomic classes according to GK, each of which represented the premiums and co-payments charged by class. The results showed that destitute, ultra-poor, and poor women enrolled in MHI used ANC significantly more than women not enrolled in health insurance. Women enrolled in MHI, except for those who were destitute or ultra-poor, utilized ANC significantly more times than women not enrolled in health insurance. We assume that GK's sliding premium and co-payment scales are key to ANC utilization by women. Expanding the MHI scheme may enhance ANC utilization among poor women in rural Bangladesh.

Evaluation of the introduction of a diagnosis procedure combination system for patient outcome and hospitalisation charges for patients with hip fracture or lung cancer in Japan.

OBJECTIVES: To evaluate the effects of introducing the Diagnosis Procedure Combination (DPC) system on outcomes, length of stay (LOS) and hospitalisation charges for patients with hip fractures or lung cancer. Patient outcome was evaluated by inpatient mortality, condition at discharge, and readmission within 42 days after discharge. METHODS: DPC data were collected from 92 Japanese Red Cross Medical Centres and community hospitals between April 2005 and December 2008. Pre- and post-DPC outcomes were compared by multivariate regression with difference-in-difference analysis. RESULTS: For hip fractures, the percentage of patients in worse condition at discharge was 150% higher when DPC was used [odds ratio (OR)=2.556, P<0.001]. For lung cancer, the percentage of patients in worse condition at discharge was about 30% lower when DPC was used (OR=0.697, P=0.001). The number of lung cancer diagnosis groups that did not require a long LOS increased. Inpatient mortality and readmission rates and hospitalisation charges did not change for either diagnosis, though the average LOS decreased. CONCLUSIONS: Under the DPC system in Japan, some patients would be discharged 'quicker' and 'sicker', but other patients' outcome at discharge improved. Although LOS decreased, hospitalisation charges did not decrease, and the readmission rate did not increase.

[Economical effect of vaccine].

In Japan, some vaccines are provided partially or only at citizens' own expense, while France and Germany publicly cover immunization on the basis of findings in economical effect on VPD (vaccine preventable disease). Such study recently conducted in Japan by the government was reported. According to cost comparative analysis, pneumococcal conjugate vaccine (PCV) for both children and adults, mumps, and varicella were found to have certain economical effect, while cervical cancer, hepatitis B, and Hib virus were not. Cost effectiveness analysis found PCV for adults, pertussis, mumps, and cervical cancer to have favorable effect, while not for Hib and PCV for children. These results offer some perspective, but cautious interpretation may be necessary since premises differ among analyses.

Pharmacoeconomic analysis of consolidation therapy with pemetrexed after first-line chemotherapy for non-small cell lung cancer.

Prolongation of progression-free survival and overall survival have been reported with consolidation therapy after first-line chemotherapy in non-small cell lung cancer, but only a few pharmacoeconomic analyses have been performed. We performed a pharmacoeconomic analysis to assess the cost-effectiveness of consolidation therapy with pemetrexed compared with non-consolidation therapy. We developed a Markov model to evaluate the incremental cost-effectiveness ratio (ICER) of consolidation therapy with pemetrexed compared with non-consolidation therapy based on previous reports. We analyzed all histology groups together, and individually analyzed non-squamous cell carcinoma, in which pemetrexed has been shown to be more effective, and squamous cell carcinoma, in which pemetrexed has been shown to be less effective. We conducted a Monte-Carlo simulation to assess the uncertainty for our analysis model and the willingness to pay using thresholds. The ICER for consolidation therapy with pemetrexed was about US$ 109,024/life years gained (LYG) (JPY 12.5 million/LYG) and US$ 203,022/quality-adjusted life years (QALY) (JPY 23.3 million/QALY) for all histology. For non-squamous cell carcinoma, respective values were US$ 80,563/LYG (JPY 9.3 million/LYG) and US$ 150,115/QALY (JPY 17.3 million/QALY). Both % of probability at a threshold of JPY 5.0 million (US$ 43,478) for all histology and non-squamous cell carcinoma were less than 0.1%. This result indicates that it is difficult to use consolidation therapy as the standard of care in Japan while being covered by general medical insurance.

[Evaluation of utility index of quality of life (QOL) in prostate cancer patients: comparison of QOL utility index EuroQol-5D (EQ-5D) and visual analogue scale (VAS) with health-related QOL questionnaires SF-36 and EPIC].

PURPOSE: For the management of patients with localized prostate cancer, a number of therapeutic options are available. To compare the therapeutic modalities, it is important and necessary to evaluate economical aspects based on cost-effectiveness analysis. In addition, the survival time adjusted by quality of life (QOL), quality adjusted life year (QALY), is more reliable than the crude survival time. Thus, the usefulness of the commonly used QOL utility indexes, EuroQol-5D (EQ-5D) and visual analogue scale (VAS, 0-100 points), was investigated in prostate cancer patients. PATIENTS AND METHODS: A total of 81 patients with prostate cancer were included. The patients were asked to answer the four sets of questionnaires (EQ-5D, VAS, SF-36 and EPIC). The QOL utility indexes (EQ-5D and VAS) were evaluated in relation to the general and prostate cancer-specific QOL questionnaires (SF-36 and EPIC, respectively). RESULTS: The results of EQ-5D and VAS were significantly correlated to all domains of the general QOL questionnaire (SF-36). On the contrary, no remarkable relationship of EQ-5D and VAS was observed with any domain (urinary, bowel, sexual or hormonal) of the prostate cancer-specific QOL questionnaire (EPIC). There was significant and close correlation between the actual values of VAS and the estimates of VAS calculated from SF-36 data (R = 0.53, p < 0.0001). CONCLUSIONS: The QOL utility indexes (EQ-5D and VAS) are pertinent to evaluation of QOL utility index in prostate cancer patients and can be utilized for cost-utility analysis. It is suggested that the accumulated data of SF-36 could be used by conversion to QOL utility index.

New casemix classification as an alternative method for budget allocation in thai oral healthcare service: a pilot study.

This study aimed to develop a new casemix classification system as an alternative method for the budget allocation of oral healthcare service (OHCS). Initially, the International Statistical of Diseases and Related Health Problem, 10th revision, Thai Modification (ICD-10-TM) related to OHCS was used for developing the software "Grouper". This model was designed to allow the translation of dental procedures into eight-digit codes. Multiple regression analysis was used to analyze the relationship between the factors used for developing the model and the resource consumption. Furthermore, the coefficient of variance, reduction in variance, and relative weight (RW) were applied to test the validity. The results demonstrated that 1,624 OHCS classifications, according to the diagnoses and the procedures performed, showed high homogeneity within groups and heterogeneity between groups. Moreover, the RW of the OHCS could be used to predict and control the production costs. In conclusion, this new OHCS casemix classification has a potential use in a global decision making.

[Socio-economics on care for the elderly patients with hip fracture].

We conducted research on elderly patients with hip fracture. It started with investigating relationship between the length of stay (LOS) and walking ability as the chosen indicator for outcome. We then used extended LOS that included days at transferred hospitals, and also conducted cost performance analysis. Thirdly, procedure and schedule were compared among UK, US, and Japan. We found positive relationship between LOS and walking ability. LOS required to gain final walking ability was shorter when a single hospital completed procedure. Japan had more than 3 times longer LOS than the other two countries, due to more variety of procedure and longer interval between steps. New guideline on treatment process is awaited, and outcome-based measurement should be included in calculating reimbursement.