Health Insurance and Subjective Well-being: Evidence from Integrating Medical Insurance across urban and rural areas in China.

Health insurance coverage and the risk protection it provides may improve enrollees' subjective well-being (SWB), as demonstrated for example by Oregon Medicaid's randomized expansion significantly improving enrollees' mental health and happiness. Yet little evidence from low- and middle-incomen countries documents the link between insurance coverage and SWB. We analyze individual-level data on a large natural experiment in China: the integration of the rural and urban resident health insurance programs. This reform, expanded nationally since 2016, is recognized as a vital step toward attaining the goal of providing affordable and equitable basic healthcare in China, because integration raises the level of healthcare coverage for rural residents to that enjoyed by their urban counterparts. This study is the first to investigate the impact of urban-rural health insurance integration on the SWB of the Chinese population. Analyzing 2011-2018 data from the China Health and Retirement Longitudinal Study in a difference-in-difference (DID) framework with variation in the treatment timing, we find that the integration policy significantly improved the life satisfaction of rural residents, especially among low-income and elderly individuals. The positive impact of the integration on SWB appears to stem from the improvement of rural residents' mental health (decrease in depressive symptoms) and associated increases in some health behaviors, as well as a mild increase in outpatient care utilization and financial risk protection. There was no discernible impact of the integration on SWB among urban residents, suggesting that the reform reduced inequality in healthcare access and health outcomes for poorer rural residents without negative spillovers on their urban counterparts.

Potential health and economic impact associated with achieving risk factor control in Chinese adults with diabetes: a microsimulation modelling study.

Background: The prevalence of diabetes has risen sharply in China. Improving modifiable risk factors such as glycaemia and blood pressure could substantially reduce disease burden and treatment costs to achieve a healthier China by 2030. Methods: We used a nationally representative population-based survey of adults with diabetes in 31 provinces in mainland China to assess the prevalence of risk factor control. We adopted a microsimulation approach to estimate the impact of improved control of blood pressure and glycaemia on mortality, quality-adjusted life-years (QALYs), and healthcare cost. We applied the validated CHIME diabetes outcomes model over a 10-year time horizon. Baseline scenario of status quo was evaluated against alternative strategies based on World Health Organization and Chinese Diabetes Society guidelines. Findings: Among 24,319 survey participants with diabetes (age 30-70), 69.1% (95% CI: 67.7-70.5) achieved optimal diabetes control (HbA1c <7% [53 mmol/mol]), 27.7% [26.1-29.3] achieved blood pressure control (<130/80 mmHg) and 20.1% (18.6-21.6) achieved both targets. Achieving 70% control rate for people with diabetes could reduce deaths before age 70 by 7.1% (5.7-8.7), reduce medical costs by 14.9% (12.3-18.0), and gain 50.4 QALYs (44.8-56.0) per 1000 people over 10 years compared to the baseline status quo. The largest health gains were for strategies including strict blood pressure control of 130/80 mmHg, particularly in rural areas. Interpretation: Based on a nationally representative survey, few adults with diabetes in China achieved optimal control of glycaemia and blood pressure. Substantial health gains and economic savings are potentially achievable with better risk factor control especially in rural settings. Funding: Chinese Central Government, Research Grants Council of the Hong Kong Special Administrative Region, China [27112518].

Family physician services and blood pressure control in China: A population-based retrospective cohort study.

OBJECTIVE: Given the importance of continuous family physician (FP) care in the management of hypertension, we explored the effects of such care among hypertensive patients in China, a country where such care is generally underutilized. We examined the longitudinal association between the use and continuity of FP services and health outcomes including blood pressure (BP) control rate, systolic blood pressure (SBP), and diastolic blood pressure (DBP). METHODS: We conducted a population-based cohort study using data from the retrospective regional electronic health record database in Xiamen City, China. The study considered 18,119 hypertensive patients aged over 18 years who had at least two visits to a health center in the preceding 12 months. The generalized estimating equation model was adopted to estimate the longitudinal association between FP service utilization and health outcomes. RESULTS: Hypertensive patients treated by their own FPs had a higher BP control rate (OR = 1.14, 95% CI: 1.02-1.28) and lower DBP (-0.36 mmHg, 95% CI: -0.52 to -0.20) than those without a FP or those with a FP but treated by a general community physician (GCP). Compared with hypertensive patients treated exclusively by GCPs, patients treated continuously and exclusively by a FP were 45% more likely to have their BP under control (OR = 1.45, 95% CI: 1.32-1.60), and their SBP and DBP were lower by 0.6 mmHg (95% CI: -0.78 to -0.39) and 0.6 mmHg (95% CI: -0.79 to -0.47), respectively. CONCLUSIONS: Hypertensive patients continuously treated by their own FPs performed better in terms of BP control rate, SBP and DBP values. In addition, the number and continuity of FP visits were associated with better BP control.

Assessing Taiwan's pay-for-performance program for diabetes care: a cost-benefit net value approach.

Pay-for-Performance (P4P) to better manage chronic conditions has yielded mixed results. A better understanding of the cost and benefit of P4P is needed to improve program assessment. To this end, we assessed the effect of a P4P program using a quasi-experimental intervention and control design. Two different intervention groups were used, one consisting of newly enrolled P4P patients, and another using P4P patients who have been enrolled since the beginning of the study. Patient-level data on clinical indicators, utilization and expenditures, linked with national death registry, were collected for diabetic patients at a large regional hospital in Taiwan between 2007 and 2013. Net value, defined as the value of life years gained minus the cost of care, is calculated and compared for the intervention group of P4P patients with propensity score-matched non-P4P samples. We found that Taiwan's implementation of the P4P program for diabetic care yielded positive net values, ranging from $40,084 USD to $348,717 USD, with higher net values in the continuous enrollment model. Our results suggest that the health benefits from P4P enrollment may require a sufficient time frame to manifest, so a net value approach incorporating future predicted mortality risks may be especially important for studying chronic disease management. Future research on the mechanisms by which the Taiwan P4P program helped improve outcomes could help translate our findings to other clinical contexts.

Association between the quality of primary care, insurance coverage, and diabetes-related health outcomes in a cohort of older adults in China: results from the China Health and Retirement Longitudinal Study.

OBJECTIVE: This study aims to identify the association between diabetes diagnosis, health outcomes, insurance scheme, and the quality of county-level primary care in a cohort of older Chinese adults. DESIGN AND SETTING: Data from the China Health and Retirement Longitudinal Study, a nationally-representative panel survey of people aged 45 and over in China. PARTICIPANTS: Among participants with valid diabetes-related and hypertension-related medical history and biomarkers (n=8207), participants with diabetes (n=1318) were identified using biomarkers and self-reported medical history. Individual models were run using complete case analysis. RESULTS: Among 1318 individuals with diabetes in 2011, 59.8% were unaware of their disease status. Diagnosis rates were significantly higher among participants with more generous public health insurance coverage (OR 3.58; 95% CI 2.15 to 5.98) and among those with other comorbidities such as dyslipidemia (OR 2.88; 95% CI 2.03 to 4.09). After adjusting for demographics, individuals with more generous public health insurance coverage did not have better glucose control at 4 years follow-up (OR 0.55; 95% CI 0.26 to 1.18) or fewer inpatient hospital admissions at 4 years (OR 1.29; 95% CI 0.72 to 2.33) and 7 years follow-up (OR 1.12; 95% CI 0.62 to 2.05). Individuals living in counties with better county-level primary care did not have better glucose control at 4 years follow-up (OR 0.69; 95% CI 0.01 to 33.36), although they did have fewer inpatient hospital admissions at 4 years follow-up (OR 0.03; 95% CI 0.00 to 0.95). Diabetes diagnosis was a significant independent predictor of both better glucose control at 4 years follow-up (OR 13.33; 95% CI 8.56 to 20.77) and increased inpatient hospital stays at 4 years (OR 1.72; 95% CI 1.20 to 2.47) and 7 years (OR 1.82; 95% CI 1.28 to 2.58) follow-up. CONCLUSIONS: These findings suggest that participants with diabetes are often diagnosed concurrently with other comorbid disease conditions or after diabetes-related complications have already developed, thus leading to worse health outcomes in subsequent years despite improvements in health associated with better primary care. These findings suggest the importance of strengthening primary care and insurance coverage among older adults to focus on diagnosing and treating diabetes early, in order to prevent avoidable health complications and promote healthy aging.

Projecting prevalence of frailty and dementia and the economic cost of care in Japan from 2016 to 2043: a microsimulation modelling study.

BACKGROUND: Dementia and frailty often accompany one another in older age, requiring complex care and resources. Available projections provide little information on their joint impact on future health-care need from different segments of society and the associated costs. Using a newly developed microsimulation model, we forecast this situation in Japan as its population ages and decreases in size. METHODS: In this microsimulation modelling study, we built a model that simulates an individual's status transition across 11 chronic diseases (including diabetes, coronary heart disease, and stroke) as well as depression, functional status, and self-reported health, by age, sex, and educational strata (less than high school, high school, and college and higher), on the basis of nationally representative health surveys and existing cohort studies. Using the simulation results, we projected the prevalence of dementia and frailty, life expectancy with these conditions, and the economic cost for formal and informal care over the period 2016-43 in the population of Japan aged 60 years and older. FINDINGS: Between 2016 and 2043, life expectancy at age 65 years will increase from 23·7 years to 24·9 years in women and from 18·7 years to 19·9 years in men. Years spent with dementia will decrease from 4·7 to 3·9 years in women and 2·2 to 1·4 years in men. By contrast, years spent with frailty will increase from 3·7 to 4·0 years for women and 1·9 to 2·1 for men, and across all educational groups. By 2043, approximately 29% of women aged 75 years and older with a less than high school education are estimated to have both dementia and frailty, and so will require complex care. The expected need for health care and formal long-term care is anticipated to reach costs of US$125 billion for dementia and $97 billion for frailty per annum in 2043 for the country. INTERPRETATION: Japan's Government and policy makers should consider the potential social challenges in caring for a sizable population of older people with frailty and dementia, and a widening disparity in the burden of those conditions by sex and by educational status. The future burden of dementia and frailty should be countered not only by curative and preventive technology innovation, but also by social policies to mitigate the health gap. FUNDING: Japan Society for the Promotion of Science, Hitachi - the University of Tokyo Laboratory for a sustainable society, and the National Institute of Ageing.

The Association between Health Workforce and Health Outcomes: A Cross-Country Econometric Study.

This study investigates the strength and significance of the associations of health workforce with multiple health outcomes and COVID-19 excess deaths across countries, using the latest WHO dataset. Multiple log-linear regression analyses, counterfactual scenarios analyses, and Pearson correlation analyses were performed. The average density of health workforce and the average levels of health outcomes were strongly associated with country income level. A higher density of the health workforce, especially the aggregate density of skilled health workers and density of nursing and midwifery personnel, was significantly associated with better levels of several health outcomes, including maternal mortality ratio, under-five mortality rate, infant mortality rate, and neonatal mortality rate, and was significantly correlated with a lower level of COVID-19 excess deaths per 100 K people, though not robust to weighting by population. The low density of the health workforce, especially in relatively low-income countries, can be a major barrier to improving these health outcomes and achieving health-related SDGs; however, improving the density of the health workforce alone is far from enough to achieve these goals. Our study suggests that investment in health workforce should be an integral part of strategies to achieve health-related SDGs, and achieving non-health SDGs related to poverty alleviation and expansion of female education are complementary to achieving both sets of goals, especially for those low- and middle-income countries. In light of the strains on the health workforce during the current COVID-19 pandemic, more attention should be paid to health workforce to strengthen health system resilience and long-term improvement in health outcomes. Supplementary Information: The online version contains supplementary material available at 10.1007/s11205-022-02910-z.

Impact of the COVID-19 Pandemic on Chronic Disease Care in India, China, Hong Kong, Korea, and Vietnam.

This study aims to provide evidence on how the COVID-19 pandemic has impacted chronic disease care in diverse settings across Asia. Cross-sectional surveys were conducted to assess the health, social, and economic consequences of the pandemic in India, China, Hong Kong, Korea, and Vietnam using standardized questionnaires. Overall, 5672 participants with chronic conditions were recruited from five countries. The mean age of the participants ranged from 55.9 to 69.3 years. A worsened economic status during the COVID-19 pandemic was reported by 19% to 59% of the study participants. Increased difficulty in accessing care was reported by 8% to 24% of participants, except Vietnam: 1.6%. The worsening of diabetes symptoms was reported by 5.6% to 14.6% of participants, except Vietnam: 3%. In multivariable regression analyses, increasing age, female participants, and worsened economic status were suggestive of increased difficulty in access to care, but these associations mostly did not reach statistical significance. In India and China, rural residence, worsened economic status and self-reported hypertension were statistically significantly associated with increased difficulty in access to care or worsening of diabetes symptoms. These findings suggest that the pandemic disproportionately affected marginalized and rural populations in Asia, negatively affecting population health beyond those directly suffering from COVID-19.

The Effects of Chronic Disease Management in Primary Health Care: Evidence from Rural China.

Health systems globally face increasing morbidity and mortality from chronic diseases, yet many - especially in low- and middle-income countries - lack strong chronic disease management in primary health care (PHC). We provide evidence on China's efforts to promote PHC management using unique five-year panel data in a rural county, including health care utilization from medical claims and health outcomes from biomarkers. Utilizing plausibly exogenous variation in management intensity generated by administrative and geographic boundaries, we compare hypertension/diabetes patients in villages within two kilometers distance but managed by different townships. Results show that, compared to patients in townships with median management intensity, patients in high-intensity townships have 4.8% more PHC visits, 5.2% fewer specialist visits, 11.7% lower likelihood of having an inpatient admission, and 3.6% lower medical spending. They also tend to have better medication adherence and better control of blood pressure. The resource savings from avoided inpatient admissions substantially outweigh the costs of the program.

The Impact of Catastrophic Medical Insurance in China: A five-year patient-level panel study.

Background: In an effort to provide greater financial protection from the risk of large medical expenditures, China has gradually added catastrophic medical insurance (CMI) to the various basic insurance schemes. Tongxiang, a rural county in Zhejiang province, China, has had CMI since 2000 for their employee insurance scheme, and since 2014 for their resident insurance scheme. Methods: Compiling and analysing patient-level panel data over five years, we use a difference-in-difference approach to study the effect of the 2014 introduction of CMI for resident insurance beneficiaries in Tongxiang. In our study design, resident insurance beneficiaries are the treatment group, while employee insurance beneficiaries are the control group. Findings: We find that availability of CMI significantly increases medical expenditures among resident insurance beneficiaries, including for both inpatient and outpatient spending. Despite the greater financial protection, out-of-pocket expenditures increased, in part because patients accessed treatment more often at higher-level hospitals. Interpretation: Better financial coverage for catastrophic medical expenditures led to greater access and expenditures, not only for inpatient admissions-the category that most often leads to catastrophic expenditures-but for outpatient visits as well. These patterns of expenditure change with CMI may reflect both enhanced access to a patient's preferred site of care as well as the influence of incentives encouraging more care under fee-for-service payment. Funding: Stanford University's Freeman Spogli Institute for International Studies' Policy Implementation Lab and a Shorenstein Asia Pacific Research Center faculty research award provided funding for this project. Chinese translation of the abstract (Appendix 1).

Healthcare utilization at retirement in China.

Previous studies, mostly analyzing data from high-income economies, present mixed evidence on the relationship between retirement and healthcare utilization. This study leverages administrative data for over 80,000 urban Chinese workers to explore the effect of retirement on outpatient and inpatient care utilization using a fuzzy regression discontinuity design. The analyses of medical claims from a large city in China complement and extend the current literature by providing evidence of potential mechanisms underlying increased short-run utilization. In this relatively well-insured population, annual total healthcare expenditures significantly increase primarily because of more intensive use of outpatient care at retirement, especially at the right tail of the distribution of outpatient visits. This increase in outpatient care appears to stem from a decline in the patient cost-sharing rate and the reduced opportunity cost of time upon retirement, interacting with supplier-induced demand, not from any sudden impact on health. We do not find evidence of change in inpatient care at retirement. The results hold for both females and males, and are robust to a number of sensitivity analyses.

Patient experiences and perceptions of chronic disease care during the COVID-19 pandemic in India: a qualitative study.

OBJECTIVE: People with chronic conditions are known to be vulnerable to the COVID-19 pandemic. This study aims to describe patients' lived experiences, challenges faced by people with chronic conditions, their coping strategies, and the social and economic impacts of the COVID-19 pandemic. DESIGN, SETTING AND PARTICIPANTS: We conducted a qualitative study using a syndemic framework to understand the patients' experiences of chronic disease care, challenges faced during the lockdown, their coping strategies and mitigators during the COVID-19 pandemic in the context of socioecological and biological factors. A diverse sample of 41 participants with chronic conditions (hypertension, diabetes, stroke and cardiovascular diseases) from four sites (Delhi, Haryana, Vizag and Chennai) in India participated in semistructured interviews. All interviews were audio recorded, transcribed, translated, anonymised and coded using MAXQDA software. We used the framework method to qualitatively analyse the COVID-19 pandemic impacts on health, social and economic well-being. RESULTS: Participant experiences during the COVID-19 pandemic were categorised into four themes: challenges faced during the lockdown, experiences of the participants diagnosed with COVID-19, preventive measures taken and lessons learnt during the COVID-19 pandemic. A subgroup of participants faced difficulties in accessing healthcare while a few reported using teleconsultations. Most participants reported adverse economic impact of the pandemic which led to higher reporting of anxiety and stress. Participants who tested COVID-19 positive reported experiencing discrimination and stigma from neighbours. All participants reported taking essential preventive measures. CONCLUSION: People with chronic conditions experienced a confluence (reciprocal effect) of COVID-19 pandemic and chronic diseases in the context of difficulty in accessing healthcare, sedentary lifestyle and increased stress and anxiety. Patients' lived experiences during the pandemic provide important insights to inform effective transition to a mixed realm of online consultations and 'distanced' physical clinic visits.

Development and validation of the CHIME simulation model to assess lifetime health outcomes of prediabetes and type 2 diabetes in Chinese populations: A modeling study.

BACKGROUND: Existing predictive outcomes models for type 2 diabetes developed and validated in historical European populations may not be applicable for East Asian populations due to differences in the epidemiology and complications. Despite the continuum of risk across the spectrum of risk factor values, existing models are typically limited to diabetes alone and ignore the progression from prediabetes to diabetes. The objective of this study is to develop and externally validate a patient-level simulation model for prediabetes and type 2 diabetes in the East Asian population for predicting lifetime health outcomes. METHODS AND FINDINGS: We developed a health outcomes model from a population-based cohort of individuals with prediabetes or type 2 diabetes: Hong Kong Clinical Management System (CMS, 97,628 participants) from 2006 to 2017. The Chinese Hong Kong Integrated Modeling and Evaluation (CHIME) simulation model comprises of 13 risk equations to predict mortality, micro- and macrovascular complications, and development of diabetes. Risk equations were derived using parametric proportional hazard models. External validation of the CHIME model was assessed in the China Health and Retirement Longitudinal Study (CHARLS, 4,567 participants) from 2011 to 2018 for mortality, ischemic heart disease, cerebrovascular disease, renal failure, cataract, and development of diabetes; and against 80 observed endpoints from 9 published trials using 100,000 simulated individuals per trial. The CHIME model was compared to United Kingdom Prospective Diabetes Study Outcomes Model 2 (UKPDS-OM2) and Risk Equations for Complications Of type 2 Diabetes (RECODe) by assessing model discrimination (C-statistics), calibration slope/intercept, root mean square percentage error (RMSPE), and R2. CHIME risk equations had C-statistics for discrimination from 0.636 to 0.813 internally and 0.702 to 0.770 externally for diabetes participants. Calibration slopes between deciles of expected and observed risk in CMS ranged from 0.680 to 1.333 for mortality, myocardial infarction, ischemic heart disease, retinopathy, neuropathy, ulcer of the skin, cataract, renal failure, and heart failure; 0.591 for peripheral vascular disease; 1.599 for cerebrovascular disease; and 2.247 for amputation; and in CHARLS outcomes from 0.709 to 1.035. CHIME had better discrimination and calibration than UKPDS-OM2 in CMS (C-statistics 0.548 to 0.772, slopes 0.130 to 3.846) and CHARLS (C-statistics 0.514 to 0.750, slopes -0.589 to 11.411); and small improvements in discrimination and better calibration than RECODe in CMS (C-statistics 0.615 to 0.793, slopes 0.138 to 1.514). Predictive error was smaller for CHIME in CMS (RSMPE 3.53% versus 10.82% for UKPDS-OM2 and 11.16% for RECODe) and CHARLS (RSMPE 4.49% versus 14.80% for UKPDS-OM2). Calibration performance of CHIME was generally better for trials with Asian participants (RMSPE 0.48% to 3.66%) than for non-Asian trials (RMPSE 0.81% to 8.50%). Main limitations include the limited number of outcomes recorded in the CHARLS cohort, and the generalizability of simulated cohorts derived from trial participants. CONCLUSIONS: Our study shows that the CHIME model is a new validated tool for predicting progression of diabetes and its outcomes, particularly among Chinese and East Asian populations that has been lacking thus far. The CHIME model can be used by health service planners and policy makers to develop population-level strategies, for example, setting HbA1c and lipid targets, to optimize health outcomes.

Health, psychosocial, and economic impacts of the COVID-19 pandemic on people with chronic conditions in India: a mixed methods study.

BACKGROUND: People with chronic conditions are disproportionately prone to be affected by the COVID-19 pandemic but there are limited data documenting this. We aimed to assess the health, psychosocial and economic impacts of the COVID-19 pandemic on people with chronic conditions in India. METHODS: Between July 29, to September 12, 2020, we telephonically surveyed adults (n = 2335) with chronic conditions across four sites in India. Data on participants' demographic, socio-economic status, comorbidities, access to health care, treatment satisfaction, self-care behaviors, employment, and income were collected using pre-tested questionnaires. We performed multivariable logistic regression analysis to examine the factors associated with difficulty in accessing medicines and worsening of diabetes or hypertension symptoms. Further, a diverse sample of 40 participants completed qualitative interviews that focused on eliciting patient's experiences during the COVID-19 lockdowns and data analyzed using thematic analysis. RESULTS: One thousand seven hundred thirty-four individuals completed the survey (response rate = 74%). The mean (SD) age of respondents was 57.8 years (11.3) and 50% were men. During the COVID-19 lockdowns in India, 83% of participants reported difficulty in accessing healthcare, 17% faced difficulties in accessing medicines, 59% reported loss of income, 38% lost jobs, and 28% reduced fruit and vegetable consumption. In the final-adjusted regression model, rural residence (OR, 95%CI: 4.01,2.90-5.53), having diabetes (2.42, 1.81-3.25) and hypertension (1.70,1.27-2.27), and loss of income (2.30,1.62-3.26) were significantly associated with difficulty in accessing medicines. Further, difficulties in accessing medicines (3.67,2.52-5.35), and job loss (1.90,1.25-2.89) were associated with worsening of diabetes or hypertension symptoms. Qualitative data suggest most participants experienced psychosocial distress due to loss of job or income and had difficulties in accessing in-patient services. CONCLUSION: People with chronic conditions, particularly among poor, rural, and marginalized populations, have experienced difficulties in accessing healthcare and been severely affected both socially and financially by the COVID-19 pandemic.

Smoking, life expectancy, and chronic disease in South Korea, Singapore, and the United States: A microsimulation model.

The substantial social and economic burden attributable to smoking is well-known, with heavy smokers at higher risk of chronic disease and premature mortality than light smokers and nonsmokers. In aging societies with high rates of male smoking such as in East Asia, smoking is a leading preventable risk factor for extending lives (including work-lives) and healthy aging. However, little is known about whether smoking interventions targeted at heavy smokers relative to light smokers lead to disproportionately larger improvements in life expectancy and prevalence of chronic diseases and how the effects vary across populations. Using a microsimulation model, we examined the health effects of smoking reduction by simulating an elimination of smoking among subgroups of smokers in South Korea, Singapore, and the United States. We found that life expectancy would increase by 0.2 to 1.5 years among light smokers and 2.5 to 3.7 years among heavy smokers. Whereas both interventions led to an increased life expectancy and decreased the prevalence of chronic diseases in all three countries, the life-extension benefits were greatest for those who would otherwise have been heavy smokers. Our findings illustrate how smoking interventions may have significant economic and social benefits, especially for life extension, that vary across countries.

Future projection of the health and functional status of older people in Japan: A multistate transition microsimulation model with repeated cross-sectional data.

Accurate future projections of population health are imperative to plan for the future healthcare needs of a rapidly aging population. Multistate-transition microsimulation models, such as the U.S. Future Elderly Model, address this need but require high-quality panel data for calibration. We develop an alternative method that relaxes this data requirement, using repeated cross-sectional representative surveys to estimate multistate-transition contingency tables applied to Japan's population. We calculate the birth cohort sex-specific prevalence of comorbidities using five waves of the governmental health surveys. Combining estimated comorbidity prevalence with death record information, we determine the transition probabilities of health statuses. We then construct a virtual Japanese population aged 60 and older as of 2013 and perform a microsimulation to project disease distributions to 2046. Our estimates replicate governmental projections of population pyramids and match the actual prevalence trends of comorbidities and the disease incidence rates reported in epidemiological studies in the past decade. Our future projections of cardiovascular diseases indicate lower prevalence than expected from static models, reflecting recent declining trends in disease incidence and fatality.

Are quality-adjusted medical prices declining for chronic disease? Evidence from diabetes care in four health systems.

Improvements in medical treatment have contributed to rising health spending. Yet there is relatively little evidence on whether the spending increase is "worth it" in the sense of producing better health outcomes of commensurate value-a critical question for understanding productivity in the health sector and, as that sector grows, for deriving an accurate quality-adjusted price index for an entire economy. We analyze individual-level panel data on medical spending and health outcomes for 123,548 patients with type 2 diabetes in four health systems: Japan, The Netherlands, Hong Kong and Taiwan. Using a "cost-of-living" method that measures value based on improved survival, we find a positive net value of diabetes care: the value of improved survival outweighs the added costs of care in each of the four health systems. This finding is robust to accounting for selective survival, end-of-life spending, and a range of values for a life-year or fraction of benefits attributable to medical care. Since the estimates do not include the value from improved quality of life, they are conservative. We, therefore, conclude that the increase in medical spending for management of diabetes is offset by an increase in quality.