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On February 26, 2009, the Asia Health Policy Program and the Stanford Center on Longevity co-sponsored a conference entitled Aging Asia: Economic and Social Implications of Rapid Demographic Change in China, Japan, and Korea. Held at the Bechtel Conference Center at Stanford University, the conference brought together scholars from China, Japan, Korea, Singapore, and the US with expertise in demography, economics, biology, political science, medicine, health services research, social policy, and psychology.

Topics of discussion included how demography shapes individual, social and economic transitions in China, Japan and Korea; intergenerational transfers and the impact of population aging on economic growth; the challenges to financing health care, long term care, and pensions in China, Japan and Korea; the chronic disease burden and comparative international experience with chronic disease management; and perspectives from Singapore on public policy for aging populations. 

A book gathering together the policy-relevant insights of the conference presenters will be forthcoming in 2010, edited by Asia Health Policy Program Director Karen Egglestonand Professor of Biology Shripad Tuljapurkar.

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This article uses incomplete contract theory to study the allocation of control rights in public-private partnerships (PPPs) between pharmaceutical enterprises and nonprofit organizations; it also investigates how this allocation influences cooperation efficiency. We first develop a mathematic model for the allocation of control rights and its influence on cooperation efficiency, and then derive some basic hypotheses from the model. The results of an empirical test show that the allocation of control rights influences how enterprises invest in PPPs. A proper allocation provides incentives for firms to make fewer self-interested and more public-interested investments. Such an allocation also improves the cooperation efficiency of PPPs.

Published: Zhang, Zhe, Ming Jia, and Difang Wan. "Allocation of control rights and cooperation efficiency in public-private partnerships: theory and evidence from the Chinese pharmaceutical industry." International journal of health care finance and economics 9.2 (2009): 169-182.

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Asia Health Policy Program working paper #6
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Hospitals in Thailand operate in a multiple insurance payment environment. This paper examines 1) access to medicines and other medical technologies, 2) treatment outcomes, and 3) efficiency in resource use, among beneficiaries of the three government health insurance schemes in Thailand. Using 2003-2005 inpatient data for patients with three tracer diseases from three government hospitals, we find that utilization of more expensive items differs between patients whose insurers pay on a closed- or open-ended basis. Where new vs. conventional drugs are both available, patients whose insurer pays on a fee-for-service basis tend to have greater access to new drugs, compared to patients whose insurer pays on a capitated or case basis. Similar patterns were found where there are options between originator vs. generic drugs, drugs in different dosage forms, and more vs. less advanced diagnostic technologies. Effects of insurance payment are more pronounced where price gaps among the medical technologies are significant. Efficiency results are mixed, depending on nature of the disease conditions and type of resources required for treatment.

Published: Hirunrassamee, Sanita, and Sauwakon Ratanawijitrasin. "Does your health care depend on how your insurer pays providers? Variation in utilization and outcomes in Thailand." International journal of health care finance and economics 9.2 (2009): 153-168.

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Asia Health Policy Program working paper #4
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This seminar will feature two presentations: an attempt to evaluate the impact of health policy under a decade of progressive governments in Korea; and an investigation into the health and economic well-being of the elderly in Korea. The presenters will be Dr. Byongho Tchoe, a 2008-09 visiting scholar at Stanford University, and Dr. Young Kyung Do, the inaugural postdoctoral fellow in the Asia Health Policy Program at Stanford.

Korea achieved universal health care coverage in 1989 only twelve years after the introduction of social health insurance under an authoritarian government. In 1992 a civil government won the presidential election. Consistent with a conservative ideology oriented toward market principles and globalization, that government emphasized competitive principles in health care policy. However, at the end of 1997 in the face of economic crisis, the progressive party won the Korean presidential election; their health emphasized strengthening equity, redistribution, and regulation of providers’ rent seeking behavior. Under successive progressive governments from 1998 to 2007, ambitious health policy reforms integrated insurers, separated prescribing from dispensing, reformed provider payment, expanded benefits coverage, increased medical-aid enrollees, and increased the role of government providers in the health care market. But in the election of 2007, they were defeated by a conservative party, which insists that competition among insurers and providers will enhance efficiency and quality in health care, and stresses consumer choice and responsibility.

Dr. Tchoe's talk will attempt to evaluate impact of health care policy under a decade of progressive governments in Korea. Although equity in both access to care and financial responsibility appear to be enhanced, there is controversy about whether the policies were cost-effective or improved health, and what will happen as the new government repeals regulations in the health care market. The return of economic crisis also brings renewed urgency to debates of economic and social policy.

Byongho Tchoe is a 2008-09 visiting scholar at Stanford University. After working at the Korea Development Institute from 1983 to 1995, he took up his current post with the Korea Institute for Health and Social Affairs. He has been influential in formulating health and social policy in Korea, having served as an advisor to the minister of health and social welfare and participated in many task forces and committees. In 2007, he was awarded a National Medal in honor of 30 years achievement related to Korea’s National Health Insurance. He has published many articles and books and served as president of the Korean Association of Health Economics and Policy and as vice president of the Korea Association of Social Security. He holds a master’s degree in public policy from Seoul National University and a Ph.D. in economics from the University of Georgia.

Young Kyung Do is the inaugural Postdoctoral Fellow in Asia Health Policy Program at the Walter H. Shorenstein Asia-Pacific Research Center. He completed his Ph.D. in health policy and administration at the University of North Carolina at Chapel Hill School of Public Health in August 2008. He has also earned M.D. and Master of Public Health degrees from Seoul National University (in 1997 and 2003, respectively). He earned board certification in preventive medicine from the Korean Medical Association in 2004. He received the First Prize Award in the Graduate Student Paper Competition in the Korea Labor and Income Panel Study Conference in 2007. He also is the recipient of the Harry T. Phillips Award for Outstanding Teaching by a Doctoral Student from the UNC Department of Health Policy and Administration in 2007. In May 2008, he was selected as a New Investigator in Global Health by the Global Health Council.

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Visiting Scholar, 2008-09
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Byongho Tchoe is a 2008-09 visiting scholar at Stanford University. He began his research career at the KDI (Korea Development Institute) which is a topnotch government think tank in Korea and served from 1983 to 1995. After earning his PhD in economics, he continued his research career at KIHASA (Korea Institute for Health and Social Affairs) from 1995 up to now. 

He has always been an influential resource in formulating health and social policy in Korea, and served as an advisor to the minister of health and social welfare in 2000. He participated as a member of many task forces and committees for health and social policy making. He was awarded a National Medal for contributing 30 years achievement of National Health Insurance in 2007. 

He was also active in academic society. He published many articles and books. He served as a president of Korean Association of Health Economics and Policy and a vice president of Korea Association of Social Security. He holds a master's degree in public policy from Seoul National University and a PhD in economics from the University of Georgia. 

Byong Ho Tchoe Visiting Scholar, 2008-09 Speaker Shorenstein APARC
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Postdoctoral Fellow in Asia Health Policy Program, 2008-09
Do.JPG MD, PhD

Young Kyung Do is the inaugural Postdoctoral Fellow in the Asia Health Policy Program at the Walter H. Shorenstein Asia-Pacific Research Center. He completed his Ph.D. in health policy and administration at the University of North Carolina at Chapel Hill School of Public Health in August 2008. He has also earned M.D. and Master of Public Health degrees from Seoul National University (in 1997 and 2003, respectively). He earned board certification in preventive medicine from the Korean Medical Association in 2004. His research interests include population aging and health care, comparative health policy, health and development, quality of care, program evaluation, and quantitative methods in health research.

He received the First Prize Award in the Graduate Student Paper Competition in the Korea Labor and Income Panel Study Conference in 2007. He also is the recipient of the Harry T. Phillips Award for Outstanding Teaching by a Doctoral Student from the UNC Department of Health Policy and Administration in 2007. In May 2008, he was selected as a New Investigator in Global Health by the Global Health Council.

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Young Kyung Do Postdoctoral Fellow, 2008-09 Speaker Shorenstein APARC
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To analyze the impact of population aging on medical costs in South Korea, the authors use several approaches. Observation of the medical cost profile by age showed that, as the data was closer to the present, the medical costs for older people increased. The treatment quantity excluding price index was also increasing for older people. This implies that the medical resources that are allocated to older people are increasing, due to the increased resources applied to extend the expected life span that was enabled through higher income levels, rather than by aging itself.

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Asia Health Policy Program working paper #3
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Byongho Tchoe
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In late 2006, the Chinese government appointed a high-level inter-ministerial commission—composed of fourteen government agencies, co-chaired by the National Development and Reform Commission and the Ministry of Health—to develop a blueprint for China’s healthcare system. One party to that process, China’s Insurance Regulatory Commission (CIRC), has developed a program of cooperation with its U.S. counterpart, the National Association of Insurance Commissioners (NAIC). To provide input to policymaking, representatives of CIRC, NAIC, private insurers in China and the United States, as well as Chinese and American scholars of health insurance gathered in Yichang, Hubei, PRC, on 18-19 June 2007, for a joint seminar on the role of commercial health insurance in the Chinese and U.S. healthcare systems.

The first section of this field report provides a brief description of China’s health care reforms in the past decades. The second section highlights the progress and challenges to date in developing commercial health insurance in China, and the final section summarizes the recommendations that the NAIC Commissioners provided to CIRC in 2007 at this critical juncture in China’s health policy reforms.

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Field Note in Perspectives: China and the World
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Karen Eggleston
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Since the mid-1980s, health maintenance organizations (HMOs) have grown rapidly in the United States.  Despite initial successes in constraining health care costs, HMOs have come under increasing criticism due to their restrictive practices.  To remain viable, this would seem to suggest that HMOs have to change at least some of these behaviors.  However, there is little empirical evidence on how restrictive aspects of HMOs may be changing.  The present study investigates one mechanism for constraining costs that is often associated with HMOs – the role of the primary care physician as a gatekeeper (e.g., monitoring patients’ use of specialist physicians).  In particular, we estimate the effect of primary care physician involvement with HMOs on the percentage of their patients for whom these physicians serve as gatekeepers.  We examine these relationships over two time periods: 2000-2001 and 2004-2005.  Because physicians can choose whether and to what extent they will participate in HMOs, we employ instrumental variables (IV) estimation to correct for endogeneity of the HMO measure.  Although the single-equation estimates suggest that the role of HMOs in terms of requiring primary care physicians to serve as gatekeepers diminished modestly over time, the endogeneity-corrected estimates show no changes between the two time periods.  Thus, one major tool used by HMOs to constrain health care costs – the physician as gatekeeper – has not declined even in the era of managed care backlash.

Published: Fang, Hai, Hong Liu, and John A. Rizzo. "Has the use of physician gatekeepers declined among HMOs? Evidence from the United States." International journal of health care finance and economics 9.2 (2009): 183-195.

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Asia Health Policy Program working paper #2
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Embedded in traditional culture perpetuating family-centered elderly care, informal care is still viewed as a family or moral issue rather than a social and policy issue in South Korea. Using newly available microdata from the Korean Longitudinal Study of Aging, this study investigates the effect of informal caregiving on labor market outcomes in South Korea. By doing so, this study provides evidence to inform elderly long-term care policy in South Korea, and also fills a gap in the international literature by providing results from an Asian country. Empirical analyses address various methodological issues by investigating gender differences, by examining both extensive and intensive labor market adjustments with two definitions of labor force participation, by employing different functional forms of care intensity, and by accounting for the potential endogeneity of informal care as well as intergenerational co-residence. Robust findings suggest negative effects of informal caregiving on labor market outcomes among women, but not among men. Compared with otherwise similar non-caregivers, female intensive caregivers who provide at least more than 10 hours of care per week are at an increased risk of being out of the labor force by 15.2 percentage points. When examining the probability of employment in the formal sector only, the effect magnitude is smaller. Among employed women, more intensive caregivers receive lower hourly wages by 1.65K Korean Won than otherwise similar non-caregivers. Informal care is already an important economic issue in South Korea even though aging is still at an early stage.

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Asia Health Policy Program working paper #1
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Young Kyung Do
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