Koyin Chang

Background: Existing research highlights the necessity of tailoring cost-containment policies to specific treatments due to the varying benefits across different diseases. This study contributes additional insights by examining the impact of such policies on a non-acute condition—cataracts. Methods: Leveraging 16 years of national health insurance claim data, this research assesses the influence of three prevalent cost-containment payment schemes on healthcare service utilization. Outcome variables for analysis include the decision to adopt intraocular lens (IOL) insertion, outpatient visit volume, and healthcare expenditures. The robustness of the findings is enhanced through the use of statistical methods, such as logit, Poisson, negative binomial, and panel fixed-effect models. Results: Global budgeting reduces the likelihood of procedure adoption and negatively impacts the volume of outpatient consultation services. Cost sharing does not affect procedure adoption but significantly impacts outpatient service volume. The prospective payment scheme for cataract IOL treatment shows no long-term effects on service utilization, with treatment rates stabilizing after a few years of policy implementation. Despite reimbursement points remaining unchanged for over two decades, there is no evidence of the under-provision of treatment. Conclusions: This study underscores the significant responsiveness of both patients and providers to policy reforms in the non-acute disease category. Manipulating payment schemes can lead to cost savings, particularly when treatment plans and procedures exhibit increased elasticity in their provision.

Objectives: Extant research on cost-sharing finds no impact on health care utilization when the amount is insubstantial. This research investigates the effects on nonacute outpatient services for schoolchildren with refractive errors in Taiwan and discusses the potential harm caused by cost sharing and relevant cost containment policies. Methods: Longitudinal claims data from the National Health Insurance database are employed. District demographic information is also used for aggregate-level analyses. Interventional modeling is conducted on pooled individual-level data with a Poisson model and negative binomial models. Generalized least square modeling is performed on aggregate district-level data to elucidate the impacts of cost sharing and the reimbursement rate with controls for patient and institutional characteristics, district socioeconomic factors, and competitiveness among institutions. Results: The findings of this study show that cost sharing does not significantly affect children’s utilization of outpatient services in the patient-level analyses. However, it significantly decreases the service volume based on the results of district aggregate analyses. There are potentially marginal patients in society, and they are more likely to be girls in poorer families, whose chances of seeking medical care significantly decrease when cost sharing increases. Conclusions: The gap in health inequity can be widened when stringent cost-containment policies are implemented. The offset effect caused by delayed care may also result in higher health care expenditures later. Cost sharing for children should be separately and prudently designed to better protect them from deprivations caused by changes in health policies.

Importance: Due to the evolving variants of coronavirus disease 2019 (COVID-19), it is important to understand the relationship between the disease condition and socioeconomic, demographic, and health indicators across regions. Background: Studies examining the relationships between infectious disease and socioeconomic variables are not yet well established. Design: A total of 3042 counties in the United States are included as the observation unit in the study. Two outcome variables employed in the study are the control of disease spread and infection prevalence rates in each county. Method: Data are submitted to quantile regression, hierarchical regression, and random forest analyses to understand the extent to which health outcomes are affected by demographics, socioeconomics, and health indicators. Results: Counties with better control of the disease spread tend to have lower infection rates, and vice versa. When measuring different outcome variables, the common risk factors for COVID-19 with a 5% level of statistical significance include employment ratio, female labor ratio, young population ratio, and residents’ average health risk factors, while protective factors include land size, housing value, travel time to work, female population ratio, and ratio of residents who identify themselves as mixed race. Conclusions: The implications of the findings are that the ability to maintain social distancing and personal hygiene habits are crucial in deterring disease transmission and lowering incidence rates, especially in the early stage of disease formation. Relevant authorities should identify preventive factors and take early actions to fight infectious diseases in the future.

Importance: Because of the high prevalence of myopia in Taiwan, understanding the risk factors for its development and progression is important to public health. Background: This study investigated the risk factors for myopia and their influence on the progression of myopia in schoolchildren in Taiwan. Design: Patients’ clinical records were obtained retrospectively from ophthalmologists. Questionnaires were given to collect demographic information, family background, hours spent on daily activities, myopia progression, and treatment methods. Participants: From a regional medical hospital in northern Taiwan, 522 schoolchildren with myopia participated in the study. Written informed consent was obtained from participants of legal age or the parents or legal guardians of younger children. Methods: Multivariable regression analyses were performed. Myopia measured in cycloplegic spherical equivalent (SE) was analysed, controlling for patients’ family and demographic information as well as their daily activity behaviours. Main Outcome Results: Children with high myopic parents were more myopic. Earlier onset age of myopia was associated with a higher level of myopia and greater annual myopic progression. Children reporting longer time usage of electronic devices had greater progression of myopia. Boys tended to be more myopic than girls. Lower levels of myopia were associated with more outdoor activities, and better vision care knowledge in children and parents. Conclusions and Relevance: In addition to genetics, education and environment can influence the development of myopia. Health policies for schoolchildren should promote protective activities and vision care knowledge at a young age, to protect the eyesight of schoolchildren.

Importance: Because of the high prevalence of myopia in Taiwan, understanding the risk factors for its development and progression is important to public health. Background: This study investigated the risk factors for myopia and their influence on the progression of myopia in schoolchildren in Taiwan. Design: Patients’ clinical records were obtained retrospectively from ophthalmologists. Questionnaires were given to collect demographic information, family background, hours spent on daily activities, myopia progression, and treatment methods. Participants: A total of 522 schoolchildren with myopia from a regional medical hospital in northern Taiwan participated the study. Written informed consent was obtained from the participants of legal age or the parents or legal guardians. Methods: Multivariable regression analyses were performed. Myopia measured in dioptres was analysed, controlling for patients’ family and demographic information as well as their daily behaviours. Main Outcome Results: Children with high myopic parents were more myopic. Earlier onset age of myopia was associated with a higher level of myopia and greater annual myopic progression. Children reporting more near work activities had higher levels of myopia and greater progression of myopia. Lower levels of myopia were associated with more exercise, longer periods of sleep, and better vision care knowledge in children and parents. Intake of food supplements had no effect on myopia. Conclusions and Relevance: In addition to genetics, education, environment, and near work activity can influence the development of myopia. Health policies for schoolchildren should promote protective activities and vision care knowledge in order to protect the eyesight of schoolchildren.

Taiwan’s National Health Insurance (NHI) program was implemented in 1995. The provision of publicly financed insurance has been hypothesized to 'crowd-out' private healthcare expenditure. However, the nature of the third party payment structure of insurance can cause national health expenditure to increase at a faster rate than before. Increased access to health care increases people's standards for what illnesses merit medical intervention; this increase then leads to further increases in demand for healthcare. As a result, it is hard to predict the extent to which private healthcare consumption is actually crowded out, without careful analysis. It is therefore of interest to investigate the relationship between private and public health expenditure, controlling for economic factors. Panel vector autoregression (VAR) and generalized method of moment (GMM) models are used to look at the dynamic interactions between public and private healthcare expenditure, controlling for district-specific fixed effects as well as year-specific effects. Panel unit root tests and panel cointegration are also examined in line with the general procedures for panel studies. Health expenditures in Taiwan's 23 districts from 1983 to 2016 serve as our unit of analysis; this span of years includes the implementation of single-payer National Health Insurance in Taiwan. Our empirical results reveal that (i) national health insurance spending crowded out private health spending, suggesting that an alleviation of individuals’ financial burden took place; and (ii) individuals’ out-of-pocket spending on healthcare had a positive impact on public expenditure pre-NHI, and in poor districts, a positive impact post-NHI as well. These results have two implications: (i) poor districts were under-served in terms of healthcare; (ii) wealthy districts experienced a shift in financial burden from providers to patients, perhaps fueled by supplier-induced demand in response to the stringent NHI-reimbursement scheme.

The rate of vaginal birth after cesarean section (VBAC) is extremely low in Taiwan probably due to the high perceived risk of trial of labor after a cesarean (TOLAC). To promote the benefits associated with vaginal birth, this study provides evidence to potentially assist relevant public authorities adopt appropriate guidelines or optimize health insurance reimbursement policies to achieve a higher VBAC rate. Employing the National Health Insurance (NHI) Claim Data, this study analyzes women’s adoptions of birth-giving methods for those who had previous cesarean section (CS) experiences. Empirical methods include logit, probit, and hierarchical regression models controlling women’s demographics, incentive indicators, as well as hospital and obstetrician characteristics. Taiwan continues to have a decreasing trend in VBAC rate even with an increase in NHI payment for vaginal birth delivery in 2005, which stimulated a surge in VBAC rate only temporarily. Factors that significantly influence women’s adoption of VBAC include institution-specific random effects, weekend admission, comorbidities during pregnancy, and income and fertility of women. Change in service payment from National Health Insurance (NHI) to healthcare providers constitutes an effective policy in directing clinical practices in the short term. Constant and systematic policy review should be undertaken to promote safe and beneficial medical practices. The results of the study suggest that women’s adoption of birth-giving method is dominated by non-medical considerations. Significant institution-specific effects imply that women might not be well-informed regarding their optimal birth-giving choice. Health education and training programs for hospital personnel should be kept up to date to better serve society.

Background: Babies are sometimes delivered by cesarean section (CS) to women eligible for trial of labor after a cesarean (TOLAC) due to a fear of complications during the delivery process. This view is especially widespread in Taiwan, as evidenced by the extremely low rate (Methods: A specially designed questionnaire was employed that incorporated the perceived risk of VBAC, institutional managerial attitude, and obstetricians’ personal characteristics. Face-to-face surveys were conducted with obstetricians from across Taiwan. Regression analysis was used as appropriate. Results: Among the 231 recruited obstetricians, 86.7% were willing to undertake VBAC, but only 71.4% had actually done so. Obstetricians with a more risk-tolerant personality were more likely to undertake VBAC. Institutional characteristics, such as the time it takes to transfer a woman from the delivery table to the operating table (table to table) and the general facilities of the hospital to handle delivery complications resulting from VBAC were also key determinants for attempting VBAC. Conclusion: In Taiwan, a country with a low birthrate, obstetricians need to be risk-tolerant to undertake VBAC. This phenomenon is probably due to underinvestment in facilities for vaginal delivery and thus a general perception that VBAC is risky. The study’s results will potentially help medical institutions to adopt appropriate guidelines and build incentive structures to achieve a higher VBAC rate.

With advancements in information technology, computerized physician order entry (CPOE) and electronic Medical Records (eMR), have become widely utilized in medical settings. The predominant mode of CPOE in Taiwan is free text entry (FTE). Dynamic structured data entry (DSDE) was introduced more recently, and has increasingly drawn attention from hospitals across Taiwan. This study assesses how DSDE compares to FTE for CPOE. A quasi-experimental study was employed to investigate the time-savings, productivity, and efficiency effects of DSDE in an outpatient setting in the gynecological department of a major hospital in Taiwan. Trained female actor patients were employed in trials of both entry methods. Data were submitted to Shapiro-Wilk and Shapiro-Francia tests to assess normality, and then to paired t-tests to assess differences between DSDE and FTE. Relative to FTE, the use of DSDE resulted in an average of 97% time saved and 55% more abundant and detailed content in medical records. In addition, for each clause entry in a medical record, the time saved is 133% for DSDE compared to FTE. The results suggest that DSDE is a much more efficient and productive entry method for clinicians in hospital outpatient settings. Upgrading eMR systems to the DSDE format would benefit both patients and clinicians.