Journal of Preventive Medicine and Public Health

Original Articles

Increase in Potential Low-value Magnetic Resonance Imaging Utilization Due to Out-of-pocket Payment Reduction Across Income Groups in Korea: An Experimental Vignette Study: Yukyung Shin, Ji-su Lee, Young Kyung Do; J Prev Med Public Health. 2022;55(4):389-397. Published online July 11, 2022; DOI: https://doi.org/10.3961/jpmph.22.208

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Objectives
This study examined the effect of out-of-pocket (OOP) payment reduction on the potential utilization of low-value magnetic resonance imaging (MRI) across income groups.
Methods
We conducted an experimental vignette survey using a proportional quota-based sample of individuals in Korea (n=1229). In two hypothetical vignettes, participants were asked whether they would be willing to use MRI if they had uncomplicated headache and non-specific low back pain, each before and after OOP payment reduction. To account for the possible role of physician inducement, half of the participants were initially presented with vignettes that included a physician recommendation for low-value care. The predicted probability, slope index of inequality (SII), and relative index of inequality (RII) were calculated using logistic regression.
Results
Before OOP payment reduction, the lowest income quintile was least likely to use low-value MRI regardless of physician inducement (36.7-49.6% for low back pain; 30.5-39.3% for headache). After OOP payment reduction, almost all individuals in each income quintile were willing to use low-value MRI (89.8-98.0% for low back pain; 78.1-90.3% for headache). Absolute and relative inequalities concerning potential low-value MRI utilization decreased after OOP payments were reduced, even without physician inducement (SII: from 8.15 to 5.37%, RII: from 1.20 to 1.06 for low back pain; SII: from 6.99 to 0.83%, RII: from 1.20 to 1.01 for headache).
Conclusions
OOP payment reduction for MRI has the potential to increase low-value care utilization among all income groups while decreasing inequality in low-value care utilization.

Summary

Korean summary
실험적 비네트 디자인을 활용하여 환자 본인부담금 감소가 잠재적 저가치 MRI 이용에 미치는 영향을 소득 수준별로 분석한 연구이다. 본인부담금 감소로 인해 잠재적 저가치 MRI 이용은 모든 소득 수준에서 증가하고 잠재적 저가치 MRI 이용의 소득 수준에 따른 차이는 감소하는 결과를 보였다.

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Socioeconomic inequality in organized and opportunistic screening for colorectal cancer: results from the Korean National Cancer Screening Survey, 2009-2021
Xuan Quy Luu, Kyeongmin Lee, Jae Kwan Jun, Mina Suh, Kui Son Choi
Epidemiology and Health.2023; 45: e2023086. CrossRef

Inequality in Private Health Care Expenditures: A 36-Year Trend Study of Iranian Households: Ehsan Aghapour, Mehdi Basakha, Seyed Hossein Mohaqeqi Kamal, Abolghasem Pourreza; J Prev Med Public Health. 2022;55(4):379-388. Published online June 27, 2022; DOI: https://doi.org/10.3961/jpmph.22.123

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Abstract PDF

Objectives
Throughout history, societies have been impacted by inequality. Many studies have been conducted on the topic more broadly, but only a few have investigated inequalities in out-of-pocket health payments (OHP). This study measures OHP inequality trends among the Iranian households.
Methods
This study used data from the Iranian Statistics Center on Iranian household income and expenditures. The analysis included a total of 995 300 households during the 36 years from 1984 to 2019. The Gini coefficient, Atkinson index, and Theil index were calculated for Iranian OHP.
Results
Average Iranian household OHP increased from 33 US dollar (USD) in 1984 to 47 USD in 2019. During this 36-year span, the average±standard deviation Gini coefficient for OHP was 0.73±0.04, and the Atkinson and Theil indexes were 0.68±0.05 and 1.14±0.29, respectively. The Gini coefficients for the subcategories of OHP of outpatient diagnostic services, medical assistant accessories, hospital inpatient services, and addiction cessation were 0.70, 0.61, 0.84, and 0.64, respectively.
Conclusions
In this study, we scrutinized trends of inequality in the OHP of Iranian households. Inequality in OHP decreased slightly over the past four decades. An analysis of trends among different subgroups revealed that affluent households, such as households with insurance coverage and households in higher income deciles, experienced higher inequality. Therefore, lower inequality in health care expenditures may be related to restricted access to health care services in Iran.

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Decomposition of Healthcare Utilization Inequality in Iran: The Prominent Role of Health Literacy and Neighborhood Characteristics
Neda Soleimanvandiazar, Seyed Hossein Mohaqeqi Kamal, Mehdi Basakha, Salah Eddin Karimi, Sina Ahmadi, Gholamreza Ghaedamini Harouni, Homeira Sajjadi, Ameneh Setareh Forouzan
INQUIRY: The Journal of Health Care Organization, Provision, and Financing.2024;[Epub] CrossRef

Has the Copayment Ceiling Improved Financial Protection in the Korean National Health Insurance System? Evidence From the 2009 Policy Change: Tae-Jin Lee, Chelim Cheong; J Prev Med Public Health. 2017;50(6):393-400. Published online November 9, 2017; DOI: https://doi.org/10.3961/jpmph.17.151

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Abstract PDF

Objectives
To relieve the financial burden faced by households, the Korean National Health Insurance (NHI) system introduced a “copayment ceiling,” which evolved into a differential ceiling in 2009, with the copayment ceiling depending on patients’ income. This study aimed to examine the effect of the differential copayment ceiling on financial protection and healthcare utilization, particularly focusing on whether its effects varied across different income groups.
Methods
This study obtained data from the Korea Health Panel. The number of households included in the analysis was 6555 in 2008, 5859 in 2009, 5539 in 2010, and 5372 in 2011. To assess the effects of the differential copayment ceiling on utilization, out-of-pocket (OOP) payments, and catastrophic payments, various random-effects models were applied. Utilization was measured as treatment days, while catastrophic payments were defined as OOP payments exceeding 10% of household income. Among the right-hand side variables were the interaction terms of the new policy with income levels, as well as a set of household characteristics.
Results
The differential copayment ceiling contributed to increased utilization regardless of income levels both in all patients and in cancer patients. However, the new policy did not seem to reduce significantly the incidence of catastrophic payments among cancer patients, and even increased the incidence among all patients.
Conclusions
The limited effect of the differential ceiling can be attributed to a high proportion of direct payments for services not covered by the NHI, as well as the relatively small number of households benefiting from the differential ceilings; these considerations warrant a better policy design.

Summary

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Distribution and Determinants of Out-of-pocket Healthcare Expenditures in Bangladesh: Rashidul Alam Mahumud, Abdur Razzaque Sarker, Marufa Sultana, Ziaul Islam, Jahangir Khan, Alec Morton; J Prev Med Public Health. 2017;50(2):91-99. Published online February 7, 2017; DOI: https://doi.org/10.3961/jpmph.16.089

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441 Download
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Abstract PDF

Objectives
As in many low-income and middle-income countries, out-of-pocket (OOP) payments by patients or their families are a key healthcare financing mechanism in Bangladesh that leads to economic burdens for households. The objective of this study was to identify whether and to what extent socioeconomic, demographic, and behavioral factors of the population had an impact on OOP expenditures in Bangladesh.
Methods
A total of 12 400 patients who had paid to receive any type of healthcare services within the previous 30 days were analyzed from the Bangladesh Household Income and Expenditure Survey data, 2010. We employed regression analysis for identify factors influencing OOP health expenditures using the ordinary least square method.
Results
The mean total OOP healthcare expenditures was US dollar (USD) 27.66; while, the cost of medicines (USD 16.98) was the highest cost driver (61% of total OOP healthcare expenditure). In addition, this study identified age, sex, marital status, place of residence, and family wealth as significant factors associated with higher OOP healthcare expenditures. In contrary, unemployment and not receiving financial social benefits were inversely associated with OOP expenditures.
Conclusions
The findings of this study can help decision-makers by clarifying the determinants of OOP, discussing the mechanisms driving these determinants, and there by underscoring the need to develop policy options for building stronger financial protection mechanisms. The government should consider devoting more resources to providing free or subsidized care. In parallel with government action, the development of other prudential and sustainable risk-pooling mechanisms may help attract enthusiastic subscribers to community-based health insurance schemes.

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