Association of daily copayments with use of hospital care among medicare advantage enrollees

Economic Evidence on Cost Sharing and Alternative Insurance Designs to Address Moral and Behavioral Hazards in High-Income Health Care Systems: A Systematic Review

In health insurance, "moral hazard" describes the concept that coverage without an out-of-pocket cost to consumers could result in health care utilization beyond economically efficient levels. In response, payers in the United States (US) have designed pharmaceutical benefit plans with significant cost exposure (e.g., co-pays, co-insurance, or deductibles). While substantial evidence links patient cost exposure to reduced drug spending, it remains unclear to what degree this translates into greater efficiency or an indiscriminate drop in overall consumption also reducing needed utilization. We conducted a systematic literature review to understand whether commonly implemented utilization management (UM) strategies and insurance designs with a behavioral or value-based (BID/VBID) component have been explored as tools to mitigate moral hazard and to assess how cost-sharing policies and innovative insurance designs impact consumer spending. Eligible studies compared conventional cost-exposure policies to BID/VBID, including tiered cost-sharing and other UM strategies. We found that broad implementation of patient cost exposure is not well supported by empirical evidence assessing efficiency-defined as the use of clinically appropriate services with value at or above the marginal cost of health care utilization in the contemporary US setting. As a result, payers and policy makers alike ought to explore insurance alternatives that more closely align health care consumption incentives to value of care.

Is there an association between out-of-pocket hospital costs, quality and care outcomes? A systematic review of contemporary evidence

BACKGROUND

Out of pocket (OOP) costs vary substantially by health condition, procedure, provider, and service location. Evidence of whether this variation is associated with indicators of healthcare quality and/or health outcomes is lacking.

METHODS

The current review aimed to explore whether higher OOP costs translate into better healthcare quality and outcomes for patients in inpatient settings. The review also aimed to identify the population and contextual-level determinants of inpatient out-of-pocket costs. A systematic electronic search of five databases: Scopus, Medline, Psych Info, CINAHL and Embase was conducted between January 2000 to October 2022. Study procedures and reporting complied with PRISMA guidelines. The protocol is available at PROSPERO (CRD42022320763).

FINDINGS

A total of nine studies were included in the final review. A variety of quality and health outcomes were examined in the included studies across a range of patient groups and specialities. The scant evidence available and substantial heterogeneity created challenges in establishing the nature of association between OOP costs and healthcare quality and outcomes. Nonetheless, the most consistent finding was no significant association between OOP cost and inpatient quality of care and outcomes.

INTERPRETATION

The review findings overall suggest no beneficial effect of higher OOP costs on inpatient quality of care and health outcomes. Further work is needed to elucidate the determinants of OOP hospital costs.

FUNDING

This study was funded by Medibank Better Health Foundation.

Association of Disability Compensation With Mortality and Hospitalizations Among Vietnam-Era Veterans With Diabetes

IMPORTANCE

It remains poorly understood whether income assistance for adults with low income and disability improves health outcomes.

OBJECTIVE

To examine the association between eligibility for disability compensation and mortality and hospitalizations among Vietnam-era veterans with diabetes.

DESIGN, SETTING, AND PARTICIPANTS

Quasiexperimental cohort study of a July 1, 2001, policy that expanded eligibility for disability compensation to veterans with "boots on the ground" (BOG) during the Vietnam era on the basis of a diagnosis of diabetes; veterans who were "not on ground" (NOG) remained ineligible. Participants were Vietnam-era veterans with diabetes in the Veterans Affairs Healthcare System. Difference-in-differences were estimated during early (July 1, 2001-December 31, 2007), middle (January 1, 2008-December 31, 2012), and later (January 1, 2013-December 31, 2018) postpolicy periods. Data analysis was performed from October 1, 2020, to December 1, 2021.

EXPOSURES

Interaction between having served with BOG (as recorded in Vietnam-era deployment records) and postpolicy period.

MAIN OUTCOMES AND MEASURES

Primary outcomes were all-cause mortality and hospitalizations.

RESULTS

The study population included 14 247 BOG veterans (mean [SD] age at baseline, 51.2 [3.8] years; 25.7% were Black; 3.3% were Hispanic; 63.6% were White; and 6.9% were of other race) and 56 224 NOG veterans (mean [SD] age, 54.2 [6.3] years; 21.7% were Black; 2.1% were Hispanic; 67.1% were White; and 8.2% were of other race). Compared with NOG veterans, BOG veterans received $8025, $14412, and $17 162 more in annual disability compensation during the early, middle, and later postpolicy periods, respectively. Annual mortality rates were unchanged (prepolicy mortality rates: 3.04% for BOG and 3.56% for NOG veterans), with adjusted difference-in-differences of 0.24 percentage points (95% CI, -0.08 to 0.52), -0.08% (95% CI, -0.40 to 0.24), and -0.08% (95% CI, -0.48 to 0.36), during the early, middle, and later postpolicy periods. Among 3623 BOG veterans and 19 174 NOG veterans with Medicare coverage in 1999, a population whose utilization could be completely observed in our data, BOG veterans experienced reductions of -7.52 hospitalizations per 100 person-years (95% CI, -13.12 to -1.92) during the early, -10.12 (95% CI, -17.28 to -3.00) in the middle, and -15.88 (95% CI, -24.00 to -7.76) in the later periods. These estimates represent relative declines of 10%, 13%, and 21%. Falsification tests of BOG and NOG veterans who were already receiving maximal disability compensation prior to the policy yielded null findings.

CONCLUSIONS AND RELEVANCE

In this cohort study, disability compensation among Vietnam-era veterans with diabetes was not associated with lower mortality but was associated with substantial declines in acute hospitalizations. Veterans' disability compensation payments may have important health benefits.

Age Structural Transitions and Copayment Policy Effectiveness: Evidence from Taiwan's National Health Insurance System

Background: Population ageing is a worldwide phenomenon that could influence health policy effectiveness. This research explores the impact of age structural transitions on copayment policy responses under Taiwan’s National Health Insurance (NHI) system. Methods: The time-varying parameter vector autoregressive model was applied to create two measures of the copayment policy effectiveness, and multiple linear regression models were used to verify the nonlinear effect of age structural transitions on copayment policy responses. Results: Our results show that copayment policy effectiveness (in terms of the negative response of medical center outpatient visits to upward adjustments in copayment) is positively correlated with the proportions of the population in two older age groups (aged 55–64 and ≥ 65) and children (age < 15), but negatively correlated with the proportion of the population that makes up most of the workforce (aged 15‒54). These tendencies of age distribution, which influence the responses of medical center outpatient visits to copayment policy changes, predict that copayment policy may have a greater influence on medical center outpatient utilization in an ageing society. Conclusions: Policymakers should be concerned about the adverse effects of copayment adjustments on the elderly, such as an increasing financial burden and the effect of pricing some elderly patients out of Taiwan’s NHI system.