The Walter H. Shorenstein Asia-Pacific Research Center (APARC) is pleased to invite applications for four types of fellowship in contemporary Asia studies for the 2022-23 academic year.

The Center offers postdoctoral fellowships that promote multidisciplinary research on contemporary Japan, contemporary Asia broadly defined, health or healthcare policy in the Asia-Pacific region, and a fellowship for experts on Southeast Asia. Learn more about each fellowship and its eligibility and specific application requirements:

Postdoctoral Fellowship on Contemporary Japan

Hosted by the Japan Program at APARC, the fellowship supports research on contemporary Japan in a broad range of disciplines including political science, economics, sociology, law, policy studies, and international relations. Appointments are for one year beginning in fall quarter 2022. The application deadline is January 3, 2022.
 

In this relatively well-insured population, annual health care utilization significantly increases primarily because of more intensive use of outpatient care at retirement. This increase in outpatient care stems from a decline in the patient cost-sharing rate, the reduced time constraints upon retirement, and the interaction of these factors with supply-side incentives such as prescribing antibiotics. There is no evidence of change in inpatient care at retirement.

The economics of medical expenditure growth and its interaction with population aging is of considerable policy importance for countries in all income groups. “Our findings may provide useful evidence as one consideration for policymakers in other cities in China and elsewhere looking to increase insurance benefits and control medical spending for burgeoning elderly populations.

Shorenstein APARC is pleased to share that Radhika Jain, our 2019-22 Asia Health Policy Postdoctoral Fellow, is the recipient of the inaugural Adam Wagstaff Award for Outstanding Research on the Economics of Healthcare Financing and Delivery in Low- and middle-Income Countries. Hosted by the International Health Economics Association (iHEA), the award recognizes Jain’s excellent paper, "Private Hospital Behavior Under Government Health Insurance in India." She received the award on July 13 at a special session of the iHEA 2021 Congress.

Jain is a health economist working on public health policy in India. Her research focuses on the role of the private sector in the country’s health system, frictions in health care markets, socioeconomic and gender inequality, and health policy design. Her award-winning paper provides the first large-scale evidence on the behavior of private hospitals within public health insurance programs in India. In a major policy shift away from direct public provision of health care, the Indian government has been expanding health insurance programs that contract private hospitals for service delivery and pay them at fixed rates for services. Until now, however, there has been little empirical evidence on the behavior of private hospitals within these programs. 

Earlier this year, Jain presented the results of her study as part of the Asia Health Policy Program’s 2020-21 colloquium series, "Health, Medicine, and Longevity: Exploring Public and Private Roles.” Watch the conversation here:

For her research, Jain used over 1.6 million insurance claims, 20,000 patient surveys, and a policy-induced natural experiment that changed hospital reimbursement rates. Her study reveals that private hospitals in India engage in coding manipulation to increase revenues at government expense and charge patients out-of-pocket for care against program rules. As a result, almost half of all patients pay for care that should be free, and these payments constitute a 35% markup over the price the government pays. The charges decrease if reimbursement rates increase, but hospitals capture approximately half the increased reimbursements.

Jain's findings indicate that hospitals exploit market frictions and poor program enforcement to capture a substantial share of the public subsidy as profit. “In contexts of weak oversight,” she writes, “profit-motivated private agents systematically flout program rules to increase their revenues at considerable expense to the government and patients.”

She also finds, however, that hospital non-compliance partially compensates for prices set too low to meet the participation constraints of agents. Reimbursement rates, says Jain, are a significant policy lever that drives agent behavior, and simply increasing monitoring without appropriate price-setting may increase compliance but decrease service provision.

Jain’s research shows that market structure — a factor rarely taken into account in social policy design in lower-income contexts — can affect the extent to which public subsidies benefit citizens. Her findings provide broader insights into contracting the private sector for delivering health and other social services in settings with limited institutional capacity for monitoring and optimal price-setting.

On our podcast, Jain discusses her efforts to develop measures that improve how health systems serve vulnerable populations and her collaborative research with Stanford development economist Pascaline Dupas on how India's COVID-19 lockdown affected access to non-COVID-related health care and outcomes. Listen here:

The Adam Wagstaff Award honors the legacy of the late Adam Wagstaff, who was a research manager in the Development Research Group of the World Bank and former president of iHEA, and celebrates his lifelong commitment to improving healthcare financing and delivery and promoting equity in low- and middle-income countries. The award also contributes to iHEA’s efforts to promote excellence in health economics globally and advance internationalization through greater inclusion of low- and middle-income country researchers.

Congratulations, Dr. Jain, on this well-deserved honor!

Modeling Health Outcomes Among East Asian Populations

The chronic progression to diabetes-related complications is apt for computer simulation modeling due to the long-term nature of health outcomes and the time lag for interventions to impact patient outcomes. It is problematic, however, to estimate the impacts of health interventions on East Asian populations with diabetes using existing models, which were developed and validated in European and North American populations with different epidemiology and outcomes.

To fill in this gap, Eggleston and her colleagues set out to develop and validate an outcomes model for the progression of diabetes and related complications in Chinese populations. They compared this new model, called the Chinese Hong Kong Integrated Modeling and Evaluation (CHIME), to two widely used existing models developed and validated in the United Kingdom (known as the United Kingdom Prospective Diabetes Study Outcomes Model 2, or UKPDS-OM2) and in the United States/Canada (called Risk Equations for Complications of type 2 Diabetes, or RECODe). Despite the continuum of risk across the spectrum of risk factor values, these two existing models ignore the progression from prediabetes to diabetes.

The CHIME integrates prediabetes and diabetes into a comprehensive model comprising 13 outcomes. These include mortality, micro- and macrovascular complications, and the development of diabetes. The researchers developed the CHIME simulation model using data from a population-based cohort of 97,628 participants in Hong Kong with type 2 diabetes (43.5%) or prediabetes (56.5%) from 2006 to 2017. Known as the Hong Kong Clinical Management System (CMS), this cohort makes one of the largest Chinese electronic health informatics systems with detailed clinical records. 

The next step was to externally validate the CHIME model against individual-level data from the China Health and Retirement Longitudinal Study (CHARLS) cohort (2011-2018), a nationally representative longitudinal cohort of middle-aged and elderly Chinese residents age 45 and older. The researchers validated the CHIME model against six outcomes measures recorded in the CHARLS data and an additional 80 endpoints from nine published trials of diabetes patients using simulated cohorts of 100,000 individuals.

Towards Reducing the Disease Burden of Diabetes

The researchers found that the CHIME model outperformed the widely used UKPDS-OM2 and RECODe models on the data used, meaning that the validation of the CHIME model was more accurate for trials with mainly Asian participants than trials with mostly non-Asian participants. The results indicate that the CHIME model is a validated tool for predicting the progression of diabetes and its outcomes, particularly among Chinese and East Asian populations, for which the existing models have been unsuitable.

With the new model, clinicians and health economists can evaluate population health status for prediabetes and diabetes using routinely recorded data and therapies related to the long-term management of diabetes. In particular, the CHIME outcomes model enables them to assess patients' quality of life and measure cost per quality-adjusted life-years over the long-time horizon of chronic disease conditions. The new model thus supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes, address micro- and macrovascular complications associated with these conditions, and improve life expectancy.

Does the new wave of digital technologies portend a future in which robots and automation increasingly replace workers and destroy livelihoods? In one of the first studies of service sector robots, APARC experts find evidence to offset dystopian predictions of robot job replacement.

The researchers — Asia Health Policy Program Director Karen Eggleston, SK Center Fellow Yong Suk Lee, and University of Tokyo health economist Toshiaki Iizuka, our former visiting scholar — set out to examine how robots affect labor, productivity, and quality of care in Japan’s nursing homes. Their findings indicate that robot adoption may not be detrimental to labor and may help address the challenges of rapidly aging societies.

Eggleston recently joined the Future Health podcast, an initiative of the New South Wales Ministry of Health, to discuss the study and its implications. The program is available both as a video and audio podcast. Watch and listen below:

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Published by the National Bureau of Economic Research, the study suggests that robot adoption has increased employment opportunities for non-regular care workers, helped mitigate the turnover problem that plagues nursing homes, and provided greater flexibility for workers. It is also published in AHPP's working paper series and is part of a broader research project by Eggleston, Lee, and Iizuka, that explores the impact of robots on nursing home care in Japan and the implications of robotic technologies adoption in aging societies.

The study has attracted media attention. The Financial Times Magazine, in a feature story and podcast, called it “groundbreaking in several ways but perhaps most clearly for setting its sights not on manufacturing but on the services sector, where robots are only just beginning to make their mark.” The Freakonomics Radio podcast also hosted Eggleston and Lee for a conversation about their research as part of an episode on collaborative robots and the future of work.