Inequality in outpatient resource utilization among older adults during the 2007-2008 financial crisis: findings from Taiwan.

BACKGROUND: Equity in medical resource utilization is a crucial concern in countries with national health insurance systems. From the perspective of an active aging framework, public health insurance is one of the pillars of economic security, as suggested by the World Bank, to achieve the goal of social security for older adults. This study thus sought to quantify income-related inequality in national health insurance systems, especially during the global economic crisis of 2007-2008. METHODS: By employing the Taiwan National Health Interview Surveys (2005 and 2009) datasets, we analyzed the socioeconomic inequality of outpatient service utilization for older Taiwanese adults during the financial crisis of 2007-2008. We used corrected concentration indices (CCIs) to examine inequalities over time. Furthermore, we decomposed socioeconomic inequalities to reveal the contributions of determinant factors. The dependent variables related to whether participants had used outpatient services in the previous month, and the independent factors included individual's needs, enabling, predisposing, and environmental factors proposed by Andersen model. RESULTS: The sample consisted of 2415 observations in 2005 and 2554 observations in 2009. The income-related health care inequality was minor from pro-rich to pro-poor across the study duration, although the difference was insignificant (women: from a concentration index [CI] of 0.0256 in 2005 to a CI of - 0.0098 in 2009; men: from a CI of 0.0379 in 2005 to a CI of 0.0310 in 2009). We used a probit model to analyze the effect of explanatory factors on outpatient resource utilization by men and women. After other factors were controlled for, we found that that the income variable had a positive and significant effect on outpatient service utilization in 2009 and the absolute contribution of income to inequality notably increased from 0.0480 in 2005 to 0.3247 in 2009 for older women. CONCLUSIONS: In conclusion, Taiwan's National Health Insurance system guarantees the accessibility of health care services to older adults, but slight income-related inequality was maintained in the outpatient resource utilization of women during the 2007-2008 financial crisis. Close attention should be paid to the vulnerability of women during times of economic insecurity.

National health insurance expenditure for adult beneficiaries in Taiwan in their last year of life.

BACKGROUND AND PURPOSE: The cost of health care in the last year of life is a major issue of health services research. The purposes of this study were to examine health care use and expenditure under National Health Insurance (NHI) by Taiwanese adults in the last year of life, and to compare their results with those of randomly selected survivors. METHODS: A total of 9,369 adult decedent NHI beneficiaries were selected from NHI enrollee files and the Death Certificate data file for 1999. To compare expenses with those of patients without fatal illness, 10,000 randomly sampled adult beneficiaries of NHI who were alive on December 31, 1999, were selected as a survival group. NHI reimbursement and utilization information for these decedents and survivors were obtained by linking these samples to NHI claims files. RESULTS: The total NHI expenditure in the last year of life for the 9,369 decedents was US$71.6 million. About 54.5% of all medical expenses in the last year of life were incurred in the last 3 months of life. Nephritis and cancer were the most expensive causes of death, with per capita expenses of US$15,220 and US$10,828, respectively. The average expenses for survivors increased with age, while that for decedents increased with age from the 20- to 44-year age group to the 45- to 64-year age group, then decreased for decedents aged 65 and over. The age-dependent pattern of decreasing expenses with increasing age was found in cancer deaths for all age groups and in elderly decedent groups for most causes of death. CONCLUSIONS: This study demonstrated the relatively large amount of health care resources used by Taiwanese NHI participants in their last year of life and suggests the importance of greater awareness of the implications of allocation of medical care resources for terminally ill patients by policymakers and health care providers.