Income Related Inequality of Health Care Access in Japan: A Retrospective Cohort Study

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Abstract

The purpose of this retrospective cohort study was to analyze the association between income level and health care access in Japan. Data from a total of 222,259 subjects (age range, 0–74 years) who submitted National Health Insurance claims in Chiba City from April 2012 to March 2014 and who declared income for the tax period from January 1 to December 31, 2012 were integrated and analyzed. The generalized estimating equation, in which household was defined as a cluster, was used to evaluate the association between equivalent income and utilization and duration of hospitalization and outpatient care services. A significant positive linear association was observed between income level and outpatient visit rates among all age groups of both sexes; however, a significantly higher rate and longer period of hospitalization, and longer outpatient care, were observed among certain lower income subgroups. To control for decreased income due to hospitalization, subjects hospitalized during the previous year were excluded, and the data was then reanalyzed. Significant inverse associations remained in the hospitalization rate among 40–59-year-old men and 60–69-year-old women, and in duration of hospitalization among 40–59 and 60–69-year-olds of both sexes and 70–74-year-old women. These results suggest that low-income individuals in Japan have poorer access to outpatient care and more serious health conditions than their higher income counterparts.

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Most cited references 21

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Akaike's information criterion in generalized estimating equations.

W. Pan (2001)

Correlated response data are common in biomedical studies. Regression analysis based on the generalized estimating equations (GEE) is an increasingly important method for such data. However, there seem to be few model-selection criteria available in GEE. The well-known Akaike Information Criterion (AIC) cannot be directly applied since AIC is based on maximum likelihood estimation while GEE is nonlikelihood based. We propose a modification to AIC, where the likelihood is replaced by the quasi-likelihood and a proper adjustment is made for the penalty term. Its performance is investigated through simulation studies. For illustration, the method is applied to a real data set.

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Inequalities in access to medical care by income in developed countries.

Eddy Van Doorslaer, Cristina Masseria, Xander Koolman (2006)

Most of the member countries of the Organization for Economic Cooperation and Development (OECD) aim to ensure equitable access to health care. This is often interpreted as requiring that care be available on the basis of need and not willingness or ability to pay. We sought to examine equity in physician utilization in 21 OECD countries for the year 2000. Using data from national surveys or from the European Community Household Panel, we extracted the number of visits to a general practitioner or medical specialist over the previous 12 months. Visits were standardized for need differences using age, sex and reported health levels as proxies. We measured inequity in doctor utilization by income using concentration indices of the need-standardized use. We found inequity in physician utilization favouring patients who are better off in about half of the OECD countries studied. The degree of pro-rich inequity in doctor use is highest in the United States and Mexico, followed by Finland, Portugal and Sweden. In most countries, we found no evidence of inequity in the distribution of general practitioner visits across income groups, and where it does occur, it often indicates a pro-poor distribution. However, in all countries for which data are available, after controlling for need differences, people with higher incomes are significantly more likely to see a specialist than people with lower incomes and, in most countries, also more frequently. Pro-rich inequity is especially large in Portugal, Finland and Ireland. Although in most OECD countries general practitioner care is distributed fairly equally and is often even pro-poor, the very pro-rich distribution of specialist care tends to make total doctor utilization somewhat pro-rich. This phenomenon appears to be universal, but it is reinforced when private insurance or private care options are offered.

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Health inequalities among British civil servants: the Whitehall II study.

S. Head, Charles I. White, M Marmot … (1991)

The Whitehall study of British civil servants begun in 1967, showed a steep inverse association between social class, as assessed by grade of employment, and mortality from a wide range of diseases. Between 1985 and 1988 we investigated the degree and causes of the social gradient in morbidity in a new cohort of 10,314 civil servants (6900 men, 3414 women) aged 35-55 (the Whitehall II study). Participants were asked to answer a self-administered questionnaire and attend a screening examination. In the 20 years separating the two studies there has been no diminution in social class difference in morbidity: we found an inverse association between employment grade and prevalence of angina, electrocardiogram evidence of ischaemia, and symptoms of chronic bronchitis. Self-perceived health status and symptoms were worse in subjects in lower status jobs. There were clear employment-grade differences in health-risk behaviours including smoking, diet, and exercise, in economic circumstances, in possible effects of early-life environment as reflected by height, in social circumstances at work (eg, monotonous work characterised by low control and low satisfaction), and in social supports. Healthy behaviours should be encouraged across the whole of society; more attention should be paid to the social environments, job design, and the consequences of income inequality.

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Author and article information

Contributors

Gianni Virgili: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 15 March 2016

Publication date Collection: 2016

Volume: 11

Issue: 3

Electronic Location Identifier: e0151690

Affiliations

[1 ]Chiba University Graduate School of Medicine, Department of Public Health, Chiba City, Chiba, Japan

[2 ]Chiba University Graduate School of Medicine, Department of Global Clinical Research, Chiba City, Chiba, Japan

[3 ]Chiba University Hospital, Clinical Research Center, Chiba City, Chiba, Japan

University of Florence, ITALY

Author notes

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: MF AH. Performed the experiments: MF. Analyzed the data: MF YS KN ST. Contributed reagents/materials/analysis tools: MF YS KN ST. Wrote the paper: MF AH YS KN ST. Obtained data: MF AH.

* E-mail: fujitam@ 123456chiba-u.jp

Article

Publisher ID: PONE-D-15-51499

DOI: 10.1371/journal.pone.0151690

PMC ID: 4792389

PubMed ID: 26978270

SO-VID: 2157a320-d281-474a-bb71-6f493603643c

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 25 November 2015

Date accepted : 2 March 2016

Page count

Figures: 8, Tables: 1, Pages: 19

Funding

This work was supported by a Japan Society for the Promotion of Science KAKENHI grant (URL: https://www.jsps.go.jp/j-grantsinaid/, Number:26460826, author:MF) and the Chiba Foundation for Health Promotion & Disease Prevention (URL: http://www.kenko-chiba.or.jp/, author: MF). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Data Availability Data were obtained from a third party (Chiba City Hall, National Health Insurance Division, Japan ( http://www.city.chiba.jp/)). The authors made a contract with Chiba City Hall prohibiting us for disclosing any data provided without written consent. To request the data, please contact Misuzu Fujita (Affiliation: Department of Public Health, Chiba University Graduate School of Medicine. Adress: 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan. E-mail: fujitam@ 123456chiba-u.jp ).

Income Related Inequality of Health Care Access in Japan: A Retrospective Cohort Study

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Abstract

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PLOS Global Public Health

Most cited references 21

Akaike's information criterion in generalized estimating equations.

Inequalities in access to medical care by income in developed countries.

Health inequalities among British civil servants: the Whitehall II study.

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