Out-of-Pocket Payments and Subjective Unmet Need of Healthcare

Comparison of the out-of-pocket costs of Medicare-funded telepsychiatry and face-to-face consultations: A descriptive study

OBJECTIVE

Telepsychiatry items in the Australian Medicare Benefits Schedule (MBS) were expanded following the COVID-19 pandemic. However, their out-of-pocket costs have not been examined. We describe and compare patient out-of-pocket payments for face-to-face and telepsychiatry (videoconferencing and telephone) MBS items for outpatient psychiatric services to understand the differential out-of-pocket cost burden for patients across these modalities.

METHODS

out-of-pocket cost information was obtained from the Medical Costs Finder website, which extracted data from Services Australia's Medicare claims data in 2021-2022. Cost information for corresponding face-to-face, video, and telephone MBS items for outpatient psychiatric services was compared, including (1) Median specialist fees; (2) Median out-of-pocket payments; (3) Medicare reimbursement amounts; and (4) Proportions of patients subject to out-of-pocket fees.

RESULTS

Medicare reimbursements are identical for all comparable face-to-face and telepsychiatry items. Specialist fees for comparable items varied across face-to-face to telehealth options, with resulting differences in out-of-pocket costs. For video items, higher proportions of patients were not bulk-billed, with greater out-of-pocket costs than face-to-face items. However, the opposite was true for telephone items compared with face-to-face items.

CONCLUSIONS

Initial cost analyses of MBS telepsychiatry items indicate that telephone consultations incur the lowest out-of-pocket costs, followed by face-to-face and video consultations.

Financial burden of medicines in five Northern European countries: A decommodification perspective

Affordable access to healthcare including medicines is a key social policy goal in Europe. However, it has rarely been addressed in comparative social policy research. Although the concept of decommodification has already been used in the context of healthcare and sickness benefits, we argue that the scope of such studies should be expanded to medicines to understand how welfare states protect their citizens from market forces in case of illness. We examine and compare the relationship between income, other characteristics, and subjective financial burden of medicines (FBM) across five countries with universal health systems pursuing egalitarian aims (Denmark, Finland, the Netherlands, Norway and Sweden). Analyses using 2017 EU-SILC microdata and linear probability models showed large differences in the level of FBM across countries, with the highest income quintile in Finland reporting FBM more frequently than the lowest income quintile in Denmark. Finland differed from the rest by increasing probability of FBM with age. In other countries, middle-aged adults tended to be the most affected, and older adults were well-protected. The association between income and FBM was strongest in the Netherlands; however, the higher probability of FBM was skewed towards the lower quintiles in all countries. FBM and financial burden of medical care were strongly associated although FBM tended to be more common. Unmet needs for medical examination were rare and lacked sensitivity in capturing manifestations of market risk. Decommodification literature has focused healthcare services as proxy of access; nevertheless, our study shows that further functions, and broader outcomes should be examined to capture market risk. Our evidence further highlights that important differences can be found even in countries with relatively similar health policy aims. The cost of medicines should be considered in comparative studies of health and welfare states.

The role of insurance policies in the drug pricing landscape

INTRODUCTION

This overview paper aims at summarizing and analyzing the available literature on healthcare system organization and pricing policies of 11 European countries, comparing them to the Bulgarian pharmaceutical system. The countries were selected based on the reference basket for the pricing of pharmaceuticals in Bulgaria - Belgium, Greece, Spain, Italy, Latvia, Lithuania, Romania, Slovakia, Slovenia, and France.

AREAS COVERED

In the first part, we explore the health system models in the above-mentioned countries. In the second part we explore the pricing and reimbursement policies, and in the third part we analyze healthcare and pharmaceutical economic indicators, as well as life expectancy. The major focus of the review is the outpatient care.

EXPERT OPINION

In this work, we attempted to outline differences and similarities between the countries of interest. Despite the differences in their healthcare system organization, health and pharmaceutical expenditures constantly increased during the observed 2 decades. This increase in expenditures, however, has not had a significant impact on life-expectancy. Minor increases were observed - from 2 to 4 years total. No country had an expectancy above 85 years of age. It might be said that other factors are influencing the life expectancy to a greater extent.

Practical psychiatry: On therapeutic equipoise - Principles of a balanced approach to psychiatric treatments

OBJECTIVE

There are many burgeoning treatments, and a large range of therapeutic options for 21st century psychiatry. This paper briefly comments upon considerations for balancing treatment to suit the patient, their illness, and their milieu.

CONCLUSIONS

Therapeutic equipoise, for psychiatric care, is an aspiration rather than a position easily achieved. In day-to-day clinical practice, there will be unexpected demands and barriers that cannot always be accommodated or surmounted. Psychiatrists can work collaboratively with patients, carers, and colleagues in conceptualising and care-planning to avoid extremes of therapeutic hubris and despair, and to adapt evidence-based care more effectively so that it is suited to the patient and their circumstances.

Characteristics of employment history and self-perceived barriers to healthcare access

BACKGROUND

Research suggests that people in disadvantaged social positions are more likely to perceive barriers to accessing healthcare, especially to specialists and preventive services. In this study, we analyze if adversity during past employment histories (e.g. spells of unemployment) is linked to subsequent subjectively perceived barriers in healthcare access. Further, we investigate if the associations vary according to national healthcare access and quality indicators.

METHODS

We use data from the Survey of Health, Ageing and Retirement in Europe with a study sample of 31 616 men and women aged 52-80 from 25 countries. Data include retrospective information on employment histories allowing us to derive characteristics of past careers, including the number of unemployment periods, main occupational position and pension contributions. Barriers to healthcare access are measured by self-perceived forgone care due to costs and unavailability of services. We apply multilevel Poisson regression for binary outcomes and test for cross-level interactions between career characteristics and national healthcare system characteristics.

RESULTS

Career characteristics are linked to later self-perceived healthcare access barriers, consistently in the case of cost barriers and less consistently for unavailability of services. Associations are similar for men and women, and persist after controlling for current income, wealth and subjective health. We find no cross-level interactions between career characteristics and country-level healthcare access and quality indicators.

CONCLUSION

Self-perceived barriers to healthcare access are linked to people's past working lives. More in-depth investigation is needed to identify the reasons for the lingering effects of characteristics of employment history on reduced healthcare access.

Financial Risk Protection and Unmet Healthcare Need in Russia

BACKGROUND

Achieving universal health coverage (UHC) includes financial risk protection. To date, catastrophic healthcare expenditure (CHE), the impoverishing effect of out-of-pocket (OOP) healthcare payments, and unmet healthcare need are the most widely used indicators for assessing the financial risk protection of a healthcare system. This study aimed to estimate the Russian healthcare system's financial risk protection by focusing on CHE, OOP and unmet healthcare need.

METHODS

The study used eight waves of the Russia Longitudinal Monitoring Survey (RLMS) (2010-2017) to analyze the financial risk protection of the Russian healthcare system. Commonly used indicators - CHE, both incidence and intensity, the impoverishing effect of CHE and unmet need -were used.

RESULTS

We found low incidence and intensity of CHE in the Russian Federation. Our results are robust to various definitions of CHE (eg, as a share of total household expenditure or total household income). Furthermore, the impoverishing effect of OOP healthcare payments remains limited, despite the most recent economic slowdown (2014- 2016). This could be explained by a noticeable reduction in CHE during the crisis years, as postponing healthcare was adopted as a coping mechanism, particularly among households heavily affected by the crisis.

CONCLUSION

As stressed by the UHC framework, our findings suggest that CHE only partly captures inefficiencies and inequities in coverage, because one tenth of households forwent medical care for medicines and certain services. As spending on medicines and dental care are the main drivers of CHE, policy interventions should focus on extending coverage for pharmaceutical and dental care and target financial barriers to seeking care, particularly for the poor and vulnerable.

Unmet health care needs among pregnant women during COVID-19 pandemic and its determinants in Kurdistan province, Iran: A cross-sectional study

Background and Aims

The aim of this study was to assess unmet needs for health care and its determinants during COVID-19 pandemic among pregnant women in Iran.

Methods

This cross-sectional study was performed among pregnant women in Kurdistan province in 2020 with a sample size of 800 people who were selected by multistage sampling method. Data were collected using a structured questionnaire that was completed through interviews. Also, multiple logistic regression was used to determine the relationship between independent variables and outcome variable. Statistical tests were performed using Stata software package.

Results

The highest unmet needs for health care were related to dental services with 66%, rehabilitation services with 58.6%, and psychological services with 43.2% and the lowest were related to hospital services with 12%, midwifery services with 15.6%, and physician visit services with 39.1%. The most important reasons for unmet needs for health care were fear of getting COVID-19 and the cost of the services. The variables of age group and spouse education for physician visit services; age group for midwifery services; age group, education and employment status for dental services; age group, supplementary insurance and economic status for rehabilitation services; and age group and economic status for psychological services were significantly associated with unmet needs for health care (p < 0.05).

Conclusion

A significant percentage of health care needs of pregnant women was unmet, for which the fear of getting COVID-19 and financial barriers were the main reasons.

Healthcare Utilization Under a Comprehensive Public Welfare Program: Evidence From Japan

The public assistance system in Japan provides detailed and comprehensive livelihood support for low-income families with various needs. As one example, and the beneficiaries of the public welfare program in Japan can receive the same medical treatments as those insured of the universal public health insurance without any financial burdens. This system has greatly contributed to maintaining and improving the health of public assistance beneficiaries but may cause excessive healthcare utilization: moral hazard. This study uses a large sample taken from two nationally representative claim data for public assistance and public health insurance patients to estimate the magnitude of moral hazard effect in basic outpatient utilization. The results of the fixed-effect regression analysis utilizing the concept of pseudo panel data analysis and those of propensity score matching show that the average treatment effect of public assistance assignment on healthcare utilization is significantly positive. Specifically, public assistance assignment increases monthly healthcare expenditure by 17.5 to 22.9 percent and the monthly number of doctor visits by 23.1 to 27.8 percent, respectively. In addition, the average treatment effects on the treated are also significantly positive, suggesting that monthly healthcare expenditure significantly decreases by 22.7 to 25.0 percent and the number of visits by 27.6 to 29.7 percent, respectively, when imposing a copayment on public assistance beneficiaries. However, the estimated price elasticity based on these results is very small, approximately −0.02, indicating that the level of copayment rate has little effect on the intensive margin of outpatient healthcare utilization.

Unmet dental care need in West of Iran: determinants and inequality

Purpose

The purpose of this study was to assess the self-perceived need, seeking and use of dental care and its main determinants in Kurdistan province, Iran.

Design/methodology/approach

A total of 1,056 adults in Kurdistan province were included in this cross-sectional study. Multistage sampling approach was used to select the samples. Data on sociodemographic characteristics, economic status, self-perceived need, seeking and use of dental care were collected using a self-administrated questionnaire. Multivariate logistic regression model was used to assess factors affecting the use of dental care. In addition, socioeconomic inequality relating to dental care needs and use of dental care were examined using concentration curve and concentration index.

Findings

In this study, unmet dental care need was 62.7%. There was a perceived need for dental care among 13.7% (n = 145) of the participants in the past month, with only 39.3% (n = 57) seeking the care. The most important reasons for unmet dental care need were “Could not afford the cost” and “Insurance did not cover the costs.” Multivariate logistic regression showed that supplementary insurance status and household economic status were identified as main determinants affecting dental care-seeking behavior. The result of concentration index revealed that seeking dental care was more concentrated among the rich, whereas the perceived dental care need is more prevalent among the poor.

Originality/value

This study demonstrated that the prevalence of unmet dental care needs is high in the study setting. Also, financial barrier was identified as the main determinant of unmet dental care needs.

Assessing unmet health-care needs of the elderly in west of Iran: A case study

Purpose

The purpose of this study is to investigate the status of perceived need, seeking behavior and utilization of health services in the elderly population of Sanandaj (west of Iran).

Design/methodology/approach

This is a cross-sectional study conducted on 800 elderly people in Sanandaj. Subjects were selected using multistage sampling and data were collected using self-report questionnaires. A multivariate logistic model with odds ratios (ORs) was used to determine the relationship of independent variables with seeking perceived need. Also, the concentration index was used to measure the inequality in using health services.

Findings

The perceived need for outpatient (during the last 30 days) and inpatient health-care services (during the past 12 months) was 69.7% and 29.7%, respectively. Among them, the unmet need for outpatient and inpatient health-care services was 46.6% and 17%, respectively. Having health insurance (adjusted OR 12.08; 95% confidence interval [CI] 1.04–140.11), middle economic status (adjusted OR 5.18; 95% CI 1.30–20.51) and being in an age group of 65–70 years (adjusted OR 7.60; CI 1.42–40.61) increased the chance of seeking inpatient care. Also, being in an age group of 60–65 years (adjusted OR 0.41; 95% CI 0.18–0.95) reduced the chance of seeking outpatient care. There was also a pro-rich inequality in using outpatient health services.

Originality/value

The elderly population suffers from unmet health-care needs, especially in outpatient services. The most important reason for not seeking outpatient and inpatient services was financial barriers and self-medication, respectively. So, designing targeted policies and interventions to address barriers in the conversion of need to demand in the elderly population is essential.

Socioeconomic determinants of unmet need for outpatient healthcare services in Iran: a national cross-sectional study

BACKGROUND

Unmet need is a critical indicator of access to healthcare services. Despite concrete evidence about unmet need in Iran's health system, no recent evidence of this negative outcome is available. This study aimed to measure the subjective unmet need (SUN), the factors associated with it and various reasons behind it in Iran.

METHODS

We used the data of 13,005 respondents over the age of 15 from the Iranian Utilization of Healthcare Services Survey in 2016. SUN was defined as citizens whose needs were not sought through formal healthcare services, while they did not show a history of self-medication. The reasons for SUN were categorized into availability, accessibility, responsibility and acceptability of the health system. The multivariable logistic regression was used to determine significant predictors of SUN and associated major reasons.

RESULTS

About 17% of the respondents (N = 2217) had unmet need for outpatient services. Nearly 40% of the respondents chose only accessibility, 4% selected only availability, 78% chose only responsibility, and 13% selected only acceptability as the main reasons for their unmet need. Higher outpatient needs was the only factor that significantly increased SUN, responsibility-related SUN and acceptability-related SUN. Low education was associated with higher SUN and responsibility-related SUN, while it could also reduce acceptability-related SUN. While SUN and responsibility-related SUN were prevalent among lower economic quintiles, having a complementary insurance was associated with decreased SUN and responsibility-related SUN. The people with basic insurance had lower chances to face with responsibility-related SUN, while employed individuals were at risk to experience SUN. Although the middle-aged group had higher odds to experience SUN, the responsibility-related SUN were prevalent among elderly, while higher age groups had significant chance to be exposed to acceptability-related SUN.

CONCLUSION

It seems that Iran is still suffering from unmet need for outpatient services, most of which emerges from its health system performance. The majority of the unmet health needs could be addressed through improving financial as well as organizational policies. Special attention is needed to address the unmet need among individuals with poor health status.

Incentivizing efficient utilization without reducing access: The case against cost-sharing in insurance

Cost-sharing is regarded as an important tool to reduce moral hazard in health insurance. Contrary to standard prediction, however, such requirements are found to decrease utilization both of efficient and of inefficient care. I employ a simple model that incorporates two possible explanations-consumer mistakes and limited access-to assess the welfare implications of different insurance designs. I find cost-sharing never to be an optimal solution as it produces two novel inefficiencies by limiting access. An alternative design, relying on bonuses, has no such side effects and achieves the same incentivization. I show how the optimal design can be deduced empirically and discuss possible impediments to its implementation.

Funding paediatric surgery procedures in sub-Saharan Africa

Background

In sub-Saharan Africa, there is a growing awareness of the burden of paediatric surgical diseases. This has highlighted the large discrepancy between the capacity to treat and the ability to afford treatment, and the effect of this problem on access to care. This review focuses on the sources and challenges of funding paediatric surgical procedures in sub-Saharan Africa.

Methods

We undertook a search for studies published between January 2007 and November 2016 that reported the specific funding of paediatric surgical procedures and were conducted in sub-Saharan Africa. Abstract screening, full-text review and data abstraction were completed and resulting data were analysed using Statistical Package for Social Sciences (SPSS) software.

Results

Thirty-five studies met our inclusion criteria and were reviewed. The countries that were predominantly emphasized in the publications reviewed were Nigeria, South Africa, Kenya, Ghana and Uganda. The paediatric surgical procedures involved general paediatric surgery/urology, cardiac surgery, neurosurgery, oncology, plastics, ophthalmology, orthopaedics and otorhinolaryngology. The mean cost of these procedures ranged from 60 to 21,140 United States Dollars (USD). The source of funding for these procedures was mostly out-of-pocket payments (OOPs) by the patient's family in 32 studies, (91.4%) and medical mission/non-governmental organizations (NGOs) in 21 (60%) studies. This pattern did not differ appreciably between the articles published in the initial and latter 5 years of the study period, although there was a trend towards a reduction in OOP funding. Improvements in healthcare funding by individual countries supported by international organizations and charities were the predominant suggested solutions to challenges in funding.

Conclusion

While considering the potential limitations created by diversity in study design, the reviewed publications indicate that funding for paediatric surgical procedures in sub-Saharan Africa is mostly by OOPs made by families of the patients. This may result in limited access to some procedures. Coordinated efforts, and collaboration between individual countries and international agencies, may help to reduce OOP funding and thus improve access to critical procedures.

[Access to healthcare in Portugal in the wake of the crisis. Not everything is money?]

Unmet healthcare needs have been used to assess access to healthcare. In scenarios of recession and financial constraints on public policies, it is important to identify which factors besides income can be used to mitigate barriers to access. This was the focus of our study on Portugal's case in the wake of the crisis. We used 17,698 observations from the 5th National Health Survey (2014). We analyzed self-reported unmet needs for medical appointments and treatments, dental healthcare, and prescribed medications. We used a bivariate selection model, considering the fact that unmet needs could only be observed in the subsample of individuals that felt the need for healthcare. The risk of unmet needs for healthcare decreased in individuals with higher income and schooling levels and in the elderly and men. Exclusive coverage by the National Health Service increased the risk of unmet dental healthcare needs. The absence of a circle of close friends to whom one can ask for help and lack of trust in others increased the likelihood of unmet healthcare needs. Better health decreased the risk of unmet needs. While income is an important predictor of unmet needs, we found the impact of other factors such as gender, age, and education. Participation in informal groups reduced the likelihood of unmet needs. Individuals with more healthcare needs end up suffering additional risk.

Financial Burden of Prescribed Medicines Included in Outpatient Benefits Package Schemes: Comparative Analysis of Co-Payments for Reimbursable Medicines in European Countries

OBJECTIVE

The study aimed to analyse the financial burden that co-payments for prescribed and reimbursed medicines pose on patients in European countries.

METHODS

Five medicines used in acute conditions (antibiotic, analgesic) and in chronic care (hypertension, asthma, diabetes) were selected. Co-payments (standard and five defined population groups, e.g. low-income people, patients with high consumption) were surveyed based on information retrieved from national price lists (September 2017) and co-payment regulation in nine countries (Albania, Austria, England, France, Germany, Greece, Hungary, Kyrgyzstan and Sweden). The financial burden of the selected medicines (originator and lowest-priced generic) was described as the percentage of patients' payments for 1 month's therapy or treatment of one episode in comparison to the national minimum monthly wage.

RESULTS

The study showed large variation in co-payments between the countries. Financial burden resulting from co-payments for reimbursed medicines tended to be higher in lower-income countries (Kyrgyzstan: 9% of minimum monthly wage for generic amlodipine; 2-4% for generic and originator salbutamol; Albania: approximately 3% for originator amoxicillin/clavulanic acid and metformin). Most studied countries applied reduction or exemption mechanisms (children were exempt in five countries, no or lower co-payments for low-income people in five countries, exemptions from co-payments upon reaching a threshold of expenses in six countries).

CONCLUSIONS

Co-payments for prescribed medicines can pose a substantial financial burden for outpatients, particularly in lower-income countries. The price of a medicine, availability of lower-priced medicines and the design of co-payments, including exemptions and reductions for specific groups, can considerably impact patients' expenses for medicines.

Unmet needs across Europe: Disclosing knowledge beyond the ordinary measure

Unmet healthcare needs (or foregone healthcare) is a widely used intermediate indicator to evaluate healthcare systems attainment since it relates to health outcomes, financial risk protection, improved efficiency and responsiveness to the individuals' legitimate expectations. This paper discusses the ordinary measure of this indicator used so far, prevalence of unmet needs in the whole population, based on the level of healthcare needs among the population. The prevalence of needs and the prevalence of unmet needs among those in need are key aspects that have not yet been fully explored when it comes to foregone healthcare. We break down the ordinary measure into prevalence of needs and prevalence of unmet needs among those in need based on data taken from the European Social Survey 2014. Afterwards, we analyse these different measures in a cross-country perspective. We also discuss the link between them and the implicit relative assessment of healthcare systems considering the whole population and the sub-group of the population aged 65 or more. Comparisons across countries show different attainment levels unveiling varying challenges across European countries, depending on the combination of levels of need and levels of unmet needs for those in need.

Evolution of catastrophic health expenditure in a high income country: incidence versus inequalities

BACKGROUND

Catastrophic health expenditure (CHE) is well established as an indicator of financial protection on which there is extensive literature. However, most works analyse mainly low to middle income countries and do not address the different distributional dimensions of CHE. We argue that, besides incidence, the latter are crucial to better grasp the scope and nature of financial protection problems. Our objectives are therefore to analyse the evolution of CHE in a high income country, considering both its incidence and distribution.

METHODS

Data are taken from the last three waves of the Portuguese Household Budget Survey conducted in 2005/2006, 2010/2011 and 2015/2016. To identify CHE, the approach adopted is capacity to pay/normative food spending, at the 40% threshold. To analyse distribution, concentration curves and indices (CI) are used and adjusted odds ratios are calculated.

RESULTS

The incidence of CHE was 2.57, 1.79 and 0.46%, in 2005, 2010 and 2015, respectively. CHE became highly concentrated among the poorest (the respective CI evolved from - 0.390 in 2005 to - 0.758 in 2015) and among families with elderly people (the absolute CI evolved from 0.520 in 2005 to 0.740 in 2015). Absolute CI in geographical context also increased over time (0.354 in 2015, 0.019 in 2005). Medicines represented by far the largest share of catastrophic payments, although, in this case concentration decreased (the median share of medicines diminished from 93 to 43% over the period analysed). Contrarily, the weight of expenses incurred with consultation fees has been growing (even for General Practitioners, despite the NHS coverage of primary care).

CONCLUSIONS

The incidence of CHE and inequality in its distribution might progress in the same direction or not, but most importantly policy makers should pay attention to the distributional dimensions of CHE as these might provide useful insight to target households at risk. Greater concentration of CHE can actually be regarded as an opportunity for policy making, because interventions to tackle CHE become more confined. Monitoring the distribution of payments across services can also contribute to early detection of emerging (and even, unexpected) drivers of catastrophic payments.

No unmet needs without needs! Assessing the role of social capital using data from European social survey 2014

This paper examines the determinants of unmet healthcare needs in Europe. Special emphasis is put on the impact of social capital. Data come from the European Social Survey, 2014. Our study includes 32,868 respondents in 20 countries. Because unmet needs are observed only in those individuals who are exposed to, and recognise, the need of medical care, sample selection can be an issue. To address it, we analyse the data using the bivariate sample selection model. When there is no need, there is no assessment of access to healthcare. Accordingly, in this situation, our model assumes that unmet need is unobserved. The magnitude and statistical significance of the error correlation support our modelling strategy. A high proportion (18.4%) of individuals in need in Europe reported unmet needs. Informal connections seem to mitigate barriers to access as well as trust in other people and institutions, particularly in health services. Financial strain still is a strong predictor of unmet needs. Other vulnerable groups include informal carers, minorities and individuals feeling discriminated. Unmet needs might also arise due to persistent needs of healthcare as it seems to be the case of individuals with lower health status and chronic conditions. A result that merits further research concerns the positive impact of civic engagement on unmet needs.