Melbourne Institute of Applied Economic and Social Research - Research Publications

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Age penalties and take-up of private health insurance

Zhang, Y ; Kettlewell, N (Melbourne Institute, 2021-12-01)

Penalty mandates are used in many countries to encourage people to purchase health insurance. But are they effective? We use a large administrative dataset for a 10% random sample of all Australian tax-filers to study how people respond to a step-wise age-based mandate, and whether this has changed over time. The mandate creates discontinuities in the incentive to insure by age, which we exploit to estimate causal effects. People who do not insure before the penalty dates face higher premiums in the future, which should encourage them to bring forward purchases. We find that people respond as expected to the initial age-penalty, but not to subsequent penalties. The 2% premium loading results in a 1-4% increase in take-up, with effects increasing after an annual government letter campaign that reminds people approaching the penalty deadline about the policy. We discuss the impact of the mandate on the overall efficiency of the market, and implications of potential reforms.
Temporal trends and variation in out-of-pocket expenditures and patient cost sharing: evidence from a Chinese national survey 2011-2015

Qin, VM ; Zhang, Y ; Chia, KS ; McPake, B ; Zhao, Y ; Hulse, ESG ; Legido-Quigley, H ; Lee, JT (BioMed Central, 2021-06-19)

OBJECTIVES: This study aims to examine: (1) temporal trends in the percentage of cost-sharing and amount of out-of-pocket expenditure (OOPE) from 2011 to 2015; (2) factors associated with cost-sharing and OOPE; and (3) the relationships between province-level economic development and cost-sharing and OOPE in China. SETTING: A total of 10,316 adults aged ≥45 years from China followed-up from 2011 to 2015 were included in the analysis. We measured two main outcome variables: (1) patient cost sharing, measured by the percentage of OOPE as total healthcare expenditure, and (2) absolute amount of OOPE. RESULTS: Based on self-reported data, we did not find substantial differences in the percentage of cost sharing, but a significant increase in the absolute amount of OOPE among the middle-aged and older Chinese between 2011 and 2015. The percentage of cost-sharing was considerably higher for outpatient than inpatient care, and the majority paid more than 80% of the total cost for prescription drugs. Provinces with higher GDP per capita tend to have lower cost-sharing and a higher OOPE than their counterparts, but the relationship for OOPE became insignificant after adjusting for individual factors. CONCLUSION: Reducing out-of-pocket expenditure and patient cost sharing is required to improve financial protection from illness, especially for those with those with chronic conditions and reside in less developed regions in China. Ongoing monitoring of financial protection using data from various sources is warranted.
Association between telehealth use and general practitioner characteristics during COVID-19: findings from a nationally representative survey of Australian doctors

Scott, A ; Bai, T ; Zhang, Y (BMJ PUBLISHING GROUP, 2021)

OBJECTIVE: To investigate factors associated with the use of telehealth by general practitioners (GPs) during COVID-19. DESIGN: A nationally representative longitudinal survey study of Australian doctors analysed using regression analysis. SETTING: General practice in Australia during the COVID-19 pandemic. PARTICIPANTS: 448 GPs who completed both the 11th wave (2018-2019) of the Medicine in Australia: Balancing Employment and Life (MABEL) Survey and the MABEL COVID-19 Special Online Survey (May 2020). OUTCOME MEASURES: Proportion of all consultations delivered via telephone (audio) or video (audiovisual); proportion of telehealth consultations delivered via video. RESULTS: 46.1% of GP services were provided using telehealth in early May 2020, with 6.4% of all telehealth consultations delivered via video. Higher proportions of telehealth consultations were observed in GPs in larger practices compared with solo GPs: between +0.21 (95% CI +0.07 to +0.35) and +0.28 (95% CI +0.13 to +0.44). Greater proportions of telehealth consultations were delivered through video for GPs with appropriate infrastructure and for GPs with more complex patients: +0.10 (95% CI +0.04 to +0.16) and +0.04 (95% CI +0.00 to +0.08), respectively. Lower proportions of telehealth consultations were delivered via video for GPs over 55 years old compared with GPs under 35 years old: between -0.08 (95% CI -0.02 to -0.15) and -0.15 (95% CI -0.07 to -0.22), and for GPs in postcodes with a higher proportion of patients over 65 years old: -0.005 (95% CI -0.001 to -0.008) for each percentage point increase in the population over 65 years old. CONCLUSIONS: GP characteristics are strongly associated with patterns of telehealth use in clinical work. Infrastructure support and relative pricing of different consultation modes may be useful policy instruments to encourage GPs to deliver care by the most appropriate method.
Association Between Preoperative Benzodiazepine Use and Postoperative Opioid Use and Health Care Costs

Rishel, CA ; Zhang, Y ; Sun, EC (JAMA Network, 2020-10-27)

Importance The association between preoperative benzodiazepine use and long-term postoperative outcomes is not well understood. Objective To characterize the association between preoperative benzodiazepine use and postoperative opioid use and health care costs. Design, Setting, and Participants In this cohort study, retrospective analysis of private health insurance claims data on 946 561 opioid-naive patients (no opioid prescriptions filled in the year before surgery) throughout the US was conducted. Patients underwent 1 of 11 common surgical procedures between January 1, 2004, and December 31, 2016; data analysis was performed January 9, 2020. Exposures Benzodiazepine use, defined as long term (≥10 prescriptions filled or ≥120 days supplied in the year before surgery) or intermittent (any use not meeting the criteria for long term). Main Outcomes and Measures The primary outcome was opioid use 91 to 365 days after surgery. Secondary outcomes included opioid use 0 to 90 days after surgery and health care costs 0 to 30 days after surgery. Results In this sample of 946 561 patients, the mean age was 59.8 years (range, 18-89 years); 615 065 were women (65.0%). Of these, 23 484 patients (2.5%) met the criteria for long-term preoperative benzodiazepine use and 47 669 patients (5.0%) met the criteria for intermittent use. After adjusting for confounders, long-term (odds ratio [OR], 1.59; 95% CI, 1.54-1.65; P < .001) and intermittent (OR, 1.47; 95% CI, 1.44-1.51; P < .001) benzodiazepine use were associated with an increased probability of any opioid use during postoperative days 91 to 365. For patients who used opioids in postoperative days 91 to 365, long-term benzodiazepine use was associated with a 44% increase in opioid dose (additional 0.6 mean daily morphine milligram equivalents [MMEs]; 95% CI, 0.3-0.8 MMEs; P < .001), although intermittent benzodiazepine use was not significantly different (0.0 average daily MMEs; 95% CI, −0.2 to 0.2 MMEs; P = .65). Preoperative benzodiazepine use was also associated with increased opioid use in postoperative days 0 to 90 for both long-term (32% increase, additional 1.9 average daily MMEs; 95% CI, 1.6-2.1 MMEs; P < .001) and intermittent (9% increase, additional 0.5 average daily MMEs; 95% CI, 0.4-0.6 MMEs; P < .001) users. Intermittent benzodiazepine use was associated with an increase in 30-day health care costs ($1155; 95% CI, $938-$1372; P < .001), while no significant difference was observed for long-term benzodiazepine use. Conclusions and Relevance The findings of this study suggest that, among opioid-naive patients, preoperative benzodiazepine use may be associated with an increased risk of developing long-term opioid use and increased opioid dosages postoperatively, and also may be associated with increased health care costs.
Who is avoiding necessary health care during the COVID-19 pandemic?

Zhang, Y ; Liu, J ; Scott, A (Melbourne Institute of Applied Economic and Social Research, 2020-06-01)

Australians experiencing high levels of financial stress and mental distress are not seeking needed health care. This study looks into what policies could help encourage greater use of necessary health care to improve wellbeing and avoid more expensive care later on.
Using health care during the pandemic: should I stay or should I go?

Zhang, Y ; Liu, J ; Scott, A (Melbourne Institute of Applied Economic and Social Research, 2020-09-01)

The COVID-19 pandemic has caused significant financial and mental distress for many Australians, which according to results from Taking the Pulse of the Nation in early June, has caused some to avoid visiting a health care professional when needed. As the pandemic continues, are people still delaying seeing a doctor or has their been a resurgence in visits after people delayed their care earlier in the year? In this Research Insight, Professor Yuting Zhang, Dr. Judith Liu, and Professor Anthony Scott examine Australians' use of health care and telehealth, focusing on what changes have occured since early June. To understand how COVID-19 has impacted decision-making around seeing a health care professional, data from Taking the Pulse of the Nation have been used to see who has avoided seeing a doctor, who has sought health care, and who has used telehealth.
Who is ditching private health insurance during the pandemic?

Zhang, Y ; Liu, J ; Scott, A (Melbourne Institute of Applied Economic and Social Research, 2020-11-01)

Following the recent increase in private health insurance (PHI) premiums in October, as well as people's growing financial and mental stresses due to the COVID-19 pandemic, many Australians may be wondering whether they should drop or downgrade their PHI. In this Research Insight, authors Professor Yuting Zhang, Dr Judith Liu, and Professor Anthony Scott examine how Australians have changed their PHI memberships during the pandemic. Using data from the Melbourne Institute's Taking the Pulse of the Nation survey, they look specifically at who has dropped, downgraded or upgraded their PHI since March 2020.
Risk Factors for Cardiovascular Events in Patients on Antidementia Medications.

He, M ; Stevenson, JM ; Zhang, Y ; Hernandez, I (SAGE Publications, 2020-01)

OBJECTIVE: To identify characteristics associated with an increased risk of cardiovascular events in patients diagnosed with Alzheimer disease (AD) and treated with antidementia medications. METHODS: Demographics, diagnoses, and medication usage of 30 433 Medicare patients were analyzed using 2006 to 2013 claims data and a combined model of screening, ranking and stepwise logistic regressions to evaluate factors associated with composite outcomes of 6 cardiovascular events. RESULTS: Incidence rate of at least 1 cardiovascular event was 25.1%. Fifty-five factors were identified from the 10 381 candidate variables by the combined model with a c-statistic of 67% and an accuracy of 75%. Factors associated with increased risk of cardiovascular events include history of heart rhythm disorders, alteration of consciousness (odds ratio [OR]: 1.25; 95% confidence interval [CI]: 1.14-1.36), and usage of β-blockers (OR: 1.19; 95% CI: 1.13-1.27). CONCLUSIONS: Clinicians should consider the increased risk of cardiovascular events in patients with AD with heart rhythm disorders and on β-blockers.
Preoperative opioid use and complications following total joint replacement: a protocol for a systematic review and meta-analysis.

Shadbolt, C ; Gould, D ; Camacho, X ; Knight, J ; Rele, S ; Thuraisingam, S ; Zhang, Y ; Dowsey, MM ; Choong, PF (BMJ Journals, 2020-06-16)

INTRODUCTION: Mounting evidence now indicates that preoperative opioid use is associated with an array of complications following total joint replacement (TJR). However, evidence of these risks remains fragmented. A comprehensive and well-integrated understanding of this body of evidence is necessary to appropriately inform treatment decisions, the allocation of limited healthcare resources, and the direction of future clinical research. The proposed systematic review and meta-analysis aims to identify and synthesise the available evidence of an association between opioid use prior to TJR and postoperative complications, categorised by complication type. METHODS AND ANALYSIS: We will search MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from inception to April 2020. Observational and experimental studies that compare preoperative opioid users who have undergone elective TJR to opioid naïve TJR patients will be included. The primary outcomes will be postoperative complications, which will be categorised as either mortality, morbidity, or joint-related complications. The secondary outcomes will be persistent postoperative opioid use, readmission, and length of stay. Individual study quality will be assessed using the relevant NIH-NHLBI study quality assessment tools. Findings will be reported in narrative and tabular form, and, where possible, odds ratios (dichotomous outcomes) or standardised mean differences (continuous outcomes) will be reported with 95% confidence intervals. Where appropriate, random effect meta-analyses will be conducted for each outcome, and heterogeneity will be quantified using the I2 statistic and Cochran's Q test. This study will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines. ETHICS AND DISSEMINATION: Ethics approval will not be required as no primary or private data are being collected. Findings will be disseminated through peer-reviewed publication and presentation at academic conferences. PROSPERO REGISTRATION NUMBER: CRD42020153047.