Academic journal article Bulletin of the World Health Organization

Health Benefits of Reduced Patient Cost Sharing in Japan/Avantages Sanitaires De la Reduction Du Partage Des Couts Au Japon/Beneficios Sanitarios De la Participacion Reducida En Los Gastos En Japon

Academic journal article Bulletin of the World Health Organization

Health Benefits of Reduced Patient Cost Sharing in Japan/Avantages Sanitaires De la Reduction Du Partage Des Couts Au Japon/Beneficios Sanitarios De la Participacion Reducida En Los Gastos En Japon

Article excerpt

Abstracts in [TEXTO IRREPRODUCIBLE EN ASCII] Francais, Pyccknn and Espanol at the end of each article.

Introduction

Asking patients to share the cost of health care is a measure frequently used to reduce demand and control the health-care budget. (1-5) Moreover, patient cost sharing can also help finance universal health-care systems by raising additional revenue. (6) However, there is still some debate about the level of cost sharing that is best able to control costs while ensuring access to health care, preventing impoverishment from out-of-pocket spending and avoiding adverse health effects. (7,8) Several studies have quantified the effects of health insurance coverage and cost sharing on the use of important health services, but few have investigated their influence on health outcomes. (9-14) Most studies were conducted in the United States of America, where universal insurance coverage has not been achieved. (9,11,12,15-20) The extent to which health outcomes are influenced by cost sharing under national health insurance programmes in other countries is Unclear. In this study, we assessed how health outcomes in elderly adults were affected by a change in cost sharing under the universal national health insurance programme in Japan.

Japanese national health insurance provides universal coverage for inpatient, outpatient, dental and pharmaceutical services. There is a fixed cost-sharing rate that varies with age and a general upper limit on monthly out-of-pocket spending for all age groups. (21) In 2007, the proportion of Japan's total national health expenditure that was publicly financed through a tax transfer and social health insurance programme was 81.9%, which ranks among the highest rates for countries in the Organisation for Economic Co-operation and Development's Asia-Pacific region. (22,23) The remainder is private spending by households, which comprises out-of-pocket medical spending for services that may or may not be covered (e.g. non-prescribed over-the-counter medications) by the universal programme. (22)

Although the exact proportion of patient cost sharing under the public insurance scheme is fixed across services, the level varies by age and income. In particular, in 2001 the Japanese government introduced a system of two different cost-sharing rates: 30% for adults aged less than 70 years and 10% for those aged 70 years or older who had a relatively low income. The rate remained 30% for older individuals with a sufficiently high income. (24) We took advantage of this natural experiment to investigate the effect of the change in patient cost sharing at the age of 70 years on physical and mental health.

Methods

Study population

We obtained data from the 2007 Comprehensive Survey of People's Living Conditions--a nationally-representative, cross-sectional survey administered by the Japanese Ministry of Health, Labour and Welfare. (25) In total, 2000 sampling units were randomly selected from all 47 prefectures in Japan. All individuals and households in each unit were asked to complete a self-administered questionnaire in July 2007. We restricted our study population to 10 906 individuals aged between 64 and 75 years (i.e. 70 [+ or -] 6 years). We excluded individuals who were hospitalized or institutionalized (n = 408) and those who were eligible for free health care (n = 205). For the remaining 10 293, we performed multiple imputation to address potential bias due to missing data (e.g. data on general health status were missing for 13.3%).

Since 2001, the cost-sharing rate is normally reduced from 30% to 10% in the first month after people turn 70 years of age, provided their annual taxable income is below 12 000 United States dollars (US$), which was equivalent to 1.45 million Japanese yen in July 2007. (24) Overall, 83.3% of the study population was eligible for the reduction in 2007.

Study variables

We analysed three dependent variables: out-of-pocket medical spending, physical health and mental health. …

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