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Uterus at a Price: Disability Insurance and Hysterectomy Elliott Fan Hsienming Lien

Uterus at a Price: Disability Insurance and Hysterectomy Elliott Fan Hsienming Lien Ching -To Albert Ma October 2013 National Taiwan University, National ChengChi University, and Boston University. Motivations. Health insurance implies moral hazard, excessive treatment

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Uterus at a Price: Disability Insurance and Hysterectomy Elliott Fan Hsienming Lien

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  1. Uterus at a Price: Disability Insurance and Hysterectomy Elliott Fan HsienmingLien Ching-To Albert Ma October 2013 National Taiwan University, National ChengChi University, and Boston University

  2. Motivations • Health insurance implies moral hazard, excessive treatment • What about treatment that means removal of an organ? • Disability insurance in Taiwan---incentives for organ removal • Cash payment to women who lose the ability to conceive before age 45

  3. Disability insurance • Three social programs: • Government Employees Insurance, GEIworkers in public sector, school teachers • Labor Insurance, LIworkers in the private sector • Farmers’ Insurance, FIfarmers • Women under age 45, undergoing a hysterectomy (surgical removal of uterus，子宮切除術) or an oophorectomy (surgical removal of both ovaries ，卵巢切除術) • Disability benefit = 6 months of insured salary for GEI, 5.5 months for LI and FI

  4. Several facts • Each year about 25000 women have hysterectomy in Taiwan. • NHI records show that one out of five women have hysterectomy in her life in Taiwan. • Each year about 6000 labor enrollees have hysterectomy, with NT130-140k per case. In total, LI paid NT 1 billion for disability benefits each year. • There is no clear associations between the number of hysterectomy and the economic conditions

  5. 立委要求放寬勞保給付標準 (2013/11/20) • 立法院衛環委員會今天審查勞委會預算，立委尤美女提案指出，勞保失能給付標準中「生殖器遺存顯著障害」認定，女性切除子宮與卵巢「未滿45歲，原有生殖能力因傷病割除..... 致不能生育者」，但對男性生殖障害並無年齡限制，勞團多年前即認為性別歧視，且年過45歲仍生育者亦不少，建議勞委會刪除年齡規定，否則將刪勞保預算。 • 但立委江慧貞認為，實務上的確有不少勞工因為生活過不去，或者因為已經生了很多孩子，不打算再生，就將子宮切除領給付，因此年齡限制反而是保護女性，避免有人真的為了給付而切除子宮。但她也說，反而很多女性45歲以後仍生育，45歲的門檻應延後，但不能不訂界線。

  6. 子宮切除勞保給付 擬放寬(2013/11/20) • 勞保現行規定45歲以下切除子宮才能領失能給付，等於認定年過45歲就沒有生育需要，但醫師立委蘇清泉認為，婦女生育年齡普遍延後，且女性停經年齡約49歲以後，因此主張延後至50歲。勞委會統計，目前失能給付每5件失能給付就有1件是切除子宮；是否放寬規定降低門檻，勞委會表示「可評估」，將與醫療等專業單位研議，但不宜刪除年齡規定。

  7. 切除子宮 大都是醫生建議(2013/11/20) • 女性勞工為領失能給付切除子宮？勞保局表示，切除子宮案件的確佔失能給付1/5以上，比率不低，但是近年案件已逐年降低，而且大都是醫生建議，原因是醫生認為無論是子宮或卵巢肌瘤復發率很高，直接切除可以一勞永逸，「又可領給付」。 • 勞保局統計，自97年以來近五年失能件數約每年2.9-3.3萬件，其中「喪失生育能力」案件從97年7萬多件降到101年的6萬多件，件數逐年降低，但比率都約20%-22%，亦即約佔1/5 。 • 立委指證很多女性勞工為了領失能給付而切除子宮，勞保局總經理羅五湖表示，實務上因為切除子宮而領給付者，大都是醫生建議切除，不會因為想領給付而切除。但是他說，很多醫生會向勞工說，子宮或卵巢肌瘤容易復發，大都會建議直接切除，加上「又可領失能給付」，因此案件佔失能給付大宗。

  8. Disability insurance • Three social programs: • Government Employees Insurance, GEIworkers in public sector, school teachers • Labor Insurance, LIworkers in the private sector • Farmers’ Insurance, FIfarmers • Women under age 45, undergoing a hysterectomy (surgical removal of uterus，子宮切除術) or an oophorectomy (surgical removal of both ovaries ，卵巢切除術) • Disability benefit = 6 months of insured salary for GEI, 5.5 months for LI and FI

  9. Uninsured group (control) • Women not covered by the above three social programs • Mostly unemployed women

  10. Hazard by quarterTotal and partial hysterectomies

  11. Hazard by quarterTotal and partial hysterectomies

  12. Summary • Treatment groups: occurrences and hazard of hysterectomy increase as 45th birthday approaches, then sharp drop • Control group: no such pattern • For partial oophorectomy or myomectomy (surgical removal of uterine myomas) (both ineligible), no such pattern

  13. Hazard by quarterPartial oophorectomies

  14. Hazard by quarterMyomectomies

  15. Research questions • How many “induced” hysterectomies due to disability insurances? • Any health impact?

  16. Institutional background • Taiwan social insurance programs • Disability benefits • Surgeries

  17. Taiwan social insurance programs • Mandatory major social insurance programs, through employment • Comprehensive benefits • GEI: disability, life insurance, dependents' funeral allowance, pension, parental leave • LI: all GEI benefits, plus unemployment benefit • FI: less generous than GEI, no pension or parental leave

  18. 育嬰留職停薪 眷屬喪葬 公教保險 給付項目 養老給付 殘廢給付 死亡給付 勞工保險 給付項目

  19. Government employee insurance • Eligibility • Public workers • Teachers (private and public schools) • Number of enrollees: about 600,000 • Premium • Insured salary, about 60-70% of full wage, but capped at NTD52,000 • premium rate: 8.25% of insured salary • contribution: 35% (employees) 65% (employers) • employee premium: 8.25%*35%*insured salary

  20. Labor insurance (I) • Eligibility • Employees in private sector or private schools (15--65 years old and in firms with more than 5 employees) • Employees in small companies or self employed---through trade unions • Number of enrollees: about 8,000,000 • Premium • Insured salary based on full wage, but capped at NTD42,000 • premium rate: 9% (1% for unemployment insurance) • contribution: 20% (employees), 70% (employers), 10% (government) • employee premium: 9%*20%*insured salary

  21. Labor Insurance (II) • Labor Law: firms with 5 or more employees to purchase LI for workers; workers in small businesses may be uninsured • Trade unions allow these left-out workers (e.g. taxi drivers, lawyers, fishermen) to participate in LI • Lax requirements for joining labor insurance through trade unions

  22. Farmer insurance • Eligibility • Farmers (members of farmer’s associations) • Number of enrollees • about 1,500,000 • Premium • The insured salary is fixed at NTD10,200 • premium rate: 6.8% (1% for unemployed insurance) • contribution: 30% (employees), 70% (government) • employee premium: 6.8%*30%*insured salary

  23. 25 Disability benefits (I) • Eligibility of reproduction impairment • Women younger than 45 years old • Sterility due to (1) total or partial removal of uterus; (2) removal of both ovaries; or (3) radiation therapy • Accordingly, women who have one of the following surgeries before age 45 are eligible: (1) Hysterectomy (partial or total removal of uterus) (2) Total oophorectomy (surgical removal of both ovaries)

  24. Disability benefits (II) • Disability benefit of reproduction impairment • GEI: 6 months of insured salary • FI and LI: 5.5 months of insured salary. • GEI and LI more generous than FI • FI’s insured salary at NT10,200; benefit fixed at NT51,000 • High-income LI enrollees have less benefits than GEI enrollees; LI insured salary capped at NT42,000.

  25. Surgeries (covered by National Health Insurance) • Hysterectomy • Partial: surgical removal of uterus except cervix • Total: surgical removal of uterus and cervix • Both qualify for disability benefit • Oophorectomy • Removal of both ovaries • Qualify for disability benefit • Number of total oophorectomies small, as illustrated by the following graphs

  26. Occurrences by quarter (restricted sample)Total oophorectomies

  27. 29 Surgeries for comparison • Two reproductive-system related treatments that don’t qualify for disability benefits: (1) Myomectomy (surgical removal of one or more uterine myomas，切除子宮肌瘤手術) (2) Partial oophorectomy (surgical removal of only one ovary，部分切除卵巢手術)

  28. A simple (two-period) model • Let u be the utility of receiving treatment, assuming u~F(u) • Let p be the price for treatment. For simplicity, p is the same in two periods. • Now at the second period (t=2) • Obtain treatment if, last period straight forward decision • Value for period t=2 is

  29. Let be discount factor • In period 1 : let the draw f utility be u • If common receive treatment for payoff is • If not, then period 2 applies. In which case for payoff is • For at t=1, receive treatment if or

  30. Reservation period : Incidence rate :

  31. Now suppose that in period 1, then a bonus if treatment is received then : or This means a drop is the reservation utility at t=1

  32. Reservation period : Incidence rate : t=1 t=2 t=1 t=2

  33. Multiple periods reservation utility t

  34. reservation utility t Bonus B Without bonus

  35. Incidence of treatment Incidence of treatment t Bonus B Without bonus

  36. 38 Data • National Health Insurance (NHI): complete medical records of all Taiwanese from 1997 to 2011 (15 years) • Registry of beneficiaries (ID files): date of birth, gender, insurance type at the start of each year • Inpatient admissions (DD files): admission and discharge dates, diagnoses, expenses of each admission (copayment, drugs, bed, examinations (itemized), surgeries (itemized), etc.) • Physician and hospital identifiers for every surgery • Limited information about demographic characteristics

  37. 39 Sampling issues (I) Broad sample for this study: • Women aged between 40 and 49 in the sample period, covering 5 years before and after 45 • That is, women born between 1947 and 1970 • Enrolled in NHI every year during the sample period(very few not enrolled)

  38. 40 Sampling issues (I)

  39. 41 Sampling issues (II) Restricted sample for this study: • Furthermore, dropwomen who have ever changed social insurance programs between ages 40 and 49 • Eliminate selection bias between insurance programs • Restricted sample about 69% of broad sample • Results based on the restricted sample; results of broad sample in robustness checks

  40. 42 Broad vs restricted samples, four surgeries(by insurance type)

  41. 43 Broad vs restricted samples(by surgery)

  42. 44 Sampling issues (III) • Left , right censoring unimportant if unrelated to hysterectomy incidence • Each censoring type depends only on age, so censoring unlikely to be important • Main results based on the unbalanced sample • Balanced sample results in the robustness check

  43. Sample statistics • Show mainly the characteristics of surgery providers • Separate into two subsamples • Age 40-44 • Age 45-49

  44. 47 Difference-in-Difference • Estimate D-in-D model at the cohort level • Cohort defined by an individual’s birth year and birth quarter • In each estimation, treatment group (those women insured by a social program); control group (the uninsured) • Each woman has a clock zeroed at 45th birthday • Time variable q, standardized quarter, number of quarters to 45th birthday • q=-19,-18,…,-1,0,1,…,20

  45. 48 D-in-D model • The specification is • :the ratio of women who underwent hysterectomy in quarter q to those who had no such prior experience • : dummy indicating standardized quarter q • : treatment dummy • X: hospital types, inpatient costs, and birth-quarter cohort fixed effects

  46. 49 Preliminary examinations • Omitted quarter is q= -20 • : Mean difference in hysterectomy hazard between quarter q and the omitted quarter • : Captures extra difference between the same two quarters given the mean difference between control and treatment groups • If disability insurance does not alter the hysterectomy hazard, effect should be all zero • Robust errors, clustering by groups formed by (birth quarter cohort) x (insurance type) • Compare the results with and without controls

  47. 50 D-in-D results for hysterectomy(restricted sample)

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