Effects of nurse visit copayment on primary care use: Do low-income households pay the price?

Nurses are increasingly providing primary care, yet the literature on cost-sharing has paid little attention to nurse visits. We employ a staggered difference-in-differences design to examine the effects of adopting a 10-euro copayment for nurse visits on the use of public primary care among Finnish adults. We find that the copayment reduced nurse visits by 9%-10% during a one-year follow-up. There is heterogeneity by income in absolute terms, but not in relative terms. The spillover effects on general practitioner (GP) use are negative but small, with varying statistical significance. We also analyze the subsequent nationwide abolition of the copayment. However, we refrain from drawing causal conclusions from this due to the lack of credibility in the parallel trends assumption. Overall, our analysis suggests that moderate copayments can create a greater barrier to access for low-income individuals. We also provide an example of using a pre-analysis plan for retrospective observational data.

Association of copayments with healthcare utilization and expenditures among Medicaid enrollees with a substance use disorder

BACKGROUND

The purpose of this study was to examine the association between copayments and healthcare utilization and expenditures among Medicaid enrollees with substance use disorders.

METHODS

This study used claims data (2020-2021) from a private insurer participating in Arkansas's Medicaid expansion. We compared service utilization and expenditures for enrollees in different Medicaid program structures with varying copayments. Enrollees with incomes above 100 % FPL (N = 10,240) had copayments for substance use treatment services while enrollees below 100 % FPL (N = 2478) did not. Demographic, diagnostic, utilization, and cost information came from claims and enrollment information. The study identified substance use and clinical comorbidities using claims from July through December 2020 and evaluated utilization and costs in 2021. Generalized linear models (GLM) estimated outcomes using single equation and two-part modeling. A gamma distribution and log link were used to model expenditures, and negative binomial models were used to model utilization. A falsification test comparing behavioral health telemedicine utilization, which had no cost sharing in either group, assessed whether differences in the groups may be responsible for observed findings.

RESULTS

Substance use enrollees with copayments were less likely to have a substance use or behavioral health outpatient (-0.04 PP adjusted; p = 0.001) or inpatient visit (-0.04 PP; p = 0.001) relative to their counterparts without copayments, equal to a 17 % reduction in substance use or behavioral health outpatient services and a nearly 50 % reduction in inpatient visits. The reduced utilization among enrollees with a copayment was associated with a significant reduction in total expenses ($954; p = 0.001) and expenses related to substance use or behavioral health services ($532; p = 0.001). For enrollees with at least one behavioral health visit, there were no differences in outpatient or inpatient utilization or expenditures between enrollees with and without copayments. Copayments had no association with non-behavioral health or telemedicine services where neither group had cost sharing.

CONCLUSION

Copayments serve as an initial barrier to substance use treatment, but are not associated with the amount of healthcare utilization conditional on using services. Policy makers and insurers should consider the role of copayments for treatment services among enrollees with substance use disorders in Medicaid programs.

Policy implications of heterogeneous demand reactions to changes in cost-sharing: Patient-level evidence from Austria

Cost-sharing is a prominent tool in many healthcare systems, both for raising revenue and steering patient behaviour. Although the effect of cost-sharing on demand for healthcare services has been heavily studied in the literature, researchers often apply a macro-perspective to these issues, opening the door for policy makers to the fallacy of assuming uniform demand reactions across a spectrum of different forms of treatments and diagnostic procedures. We use a simple classification system to categorize 11 such healthcare services along the dimensions of urgency and price to estimate patients' (anticipatory) demand reactions to a reduction in the co-insurance rate by a sickness fund in the Austrian social health insurance system. We use a two-stage study design combining matching and two-way fixed effects difference-in-differences estimation. Our results highlight how an overall joint estimate of an average increase in healthcare service utilization (0.8%) across all healthcare services can be driven by healthcare services that are deferrable (+1%), comparatively costly (+1.4%) or both (+1.6%) and for which patients also postponed their consumption until after the cost-sharing reduction. In contrast, we do not find a clear demand reaction for inexpensive or urgent services. The detailed analysis of the demand reaction for each individual healthcare service further illustrates their heterogeneity. We show that even comparatively minor changes to the costs borne by patients may already evoke tangible (anticipatory) demand reactions. Our findings help policy makers better understand the implications of heterogeneous demand reactions across healthcare services for using cost-sharing as a policy tool.

Medicaid policy data for evaluating eligibility and programmatic changes

OBJECTIVES

Medicaid and the Children's Health Insurance Program (CHIP) provide health insurance coverage to more than 90 million Americans as of early 2023. There is substantial variation in eligibility criteria, application procedures, premiums, and other programmatic characteristics across states and over time. Analyzing changes in Medicaid policies is important for state and federal agencies and other stakeholders, but such analysis requires data on historical programmatic characteristics that are often not available in a form ready for quantitative analysis. Our objective is to fill this gap by synthesizing existing qualitative policy data to create a new data resource that facilitates Medicaid policy research.

DATA DESCRIPTION

Our source data were the 50-state surveys of Medicaid and CHIP eligibility, enrollment, and cost-sharing policies, and budgets conducted near annually by KFF since 2000, which we coded through 2020. These reports are a rich source of point-in-time information but not operationalized for quantitative analysis. Through a review of the measures captured in the KFF surveys, we developed five Medicaid policy domains with 122 measures in total, each coded by state-quarter-1) eligibility (28 measures), 2) enrollment and renewal processes (39 measures), 3) premiums (16 measures), 4) cost-sharing (26 measures), and 5) managed care (13 measures).

Cost-sharing and horizontal compensation scheme of regional sulfur dioxide treatment: Evidence from China

Establishing a reasonable cost-sharing and compensation mechanism for air pollution control is a prerequisite for realizing inter-regional cooperative treatment. Taking inter-provincial sulfur dioxide (SO2) emissions in China from 2005 to 2019 as the research object, this paper proposes a data-driven approach to establish a cost-sharing index system of regional SO2 treatment in four dimensions and construct a cost-sharing and compensation scheme using the entropy-TOPSIS method. The results revealed that there are significant spatial and temporal differences in the treatment cost of SO2 emission, and the total SO2 treatment costs at the national level increased first and then decreased during the study period, meanwhile, the regional SO2 treatment costs are much higher in the less economically developed regions such as the central and western regions than in economically developed eastern coastal regions. The design of the cost-sharing and compensation mechanism of SO2 treatment should consider the regional differences in abatement capacity, abatement potential, abatement responsibility, and development demands. The economically developed regions should share higher treatment costs according to their historical cumulative abatement responsibilities, and provide economic compensation and technical support to the less economically developed regions. Specifically, the marginal abatement cost in the more economically developed eastern region is much higher than that in the less economically developed central and western areas due to their large abatement responsibility and strong reduction capacity but insufficient abatement potential, so the eastern regions can transfer part of their abatement responsibility to the central and western regions using economic compensation. Reasonable cost sharing and horizontal compensation can help promote regional cooperation and synergistic management in air pollution abatement. Finally, corresponding policy recommendations are given to provide a decision basis for cross-regional cooperation in air pollution control.

Minimum generosity levels in a competitive health insurance market

An important condition for optimal health insurance is that the level of health care coverage is inversely related to the elasticity of demand. We show that this condition is not satisfied for voluntary deductibles in the Netherlands, which are optional deductibles on top of the mandatory deductible introduced by the Dutch government. We find that low-risk types, that mainly choose voluntary deductibles, have a lower elasticity of demand than high-risk types. Moreover, we show that voluntary deductibles introduce equity problems as it results in non-trivial cross subsidies from high-risk to low-risk types. Capping the level of voluntary deductibles (imposing minimum generosity) is likely to be welfare enhancing in the Netherlands.

The impact of cost-sharing on prescription drug demand: evidence from a double-difference regression kink design

Pharmaceuticals represent the third-largest expenditure item in health care spending in the OECD countries, and cost growth is around 5% per year in many OECD countries. One possible way to contain the rise in pharmaceutical spending is the use of cost-sharing schemes that makes insured individuals directly bear parts of the cost of a drug. This study estimates the price sensitivity of demand for prescription drugs using data on all prescription drug purchases from a random sample of 400,000 Swedes followed from 2010 to 2013. We use a regression kink design (RKD) by exploiting the kinked Swedish cost-sharing scheme to assess the price elasticity. Further, since the cost-sharing scheme has changed over time, we also use a double-difference RKD to account for potential confounding nonlinearities around the kink. Our results indicate that the standard RKD results are biased and exaggerate the price sensitivity. Our preferred double-difference RKD specifications show no or minor price sensitivity (95% CI price elasticity from - 0.12 to 0.02). The results are similar in several sub-group analyses across age groups, sexes, and income quartiles.

The effects of patient cost-sharing on health expenditure and health among older people: Heterogeneity across income groups

Despite rapidly rising health expenditure associated with population aging, empirical evidence on the effects of cost-sharing on older people is still limited. This study estimated the effects of cost-sharing on the utilization of healthcare and health among older people, the most intensive users of healthcare. We employed a regression discontinuity design by exploiting a drastic reduction in the coinsurance rate from 30 to 10% at age 70 in Japan. We used large administrative claims data as well as income information at the individual level provided by a municipality. Using the claims data with 1,420,252 person-month observations for health expenditure, we found that reduced cost-sharing modestly increased outpatient expenditure, with an implied price elasticity of  - 0.07. When examining the effects of reduced cost-sharing by income, we found that the price elasticities for outpatient expenditure were almost zero,  - 0.08, and  - 0.11 for lower-, middle-, and higher-income individuals, respectively, suggesting that lower-income individuals do not have more elastic demand for outpatient care compared with other income groups. Using large-scale mail survey data with 3404 observations for self-reported health, we found that the cost-sharing reduction significantly improved self-reported health only among lower-income individuals, but drawing clear conclusions about health outcomes is difficult because of a lack of strong graphical evidence to support health improvement. Our results suggest that varying cost-sharing by income for older people (i.e., smaller cost-sharing for lower-income individuals and larger cost-sharing for higher-income individuals) may reduce health expenditure without compromising health.

Exploring variation of coverage and access to dental care for adults in 11 European countries: a vignette approach

BACKGROUND

Oral health, coupled with rising awareness on the impact that limited dental care coverage has on oral health and general health and well-being, has received increased attention over the past few years. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach.

METHODS

We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists.

RESULTS

Completed vignettes were received from 11 countries: Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different physical barriers to accessing dental care. The limited availability of contracted dentists (especially in rural areas) and the unequal distribution and lack of specialised dentists are major access barriers to public dental care.

CONCLUSIONS

According to the results, statutory coverage of dental care varies across European countries, while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries, leading to high out-of-pocket spending. Socioeconomic status is thus a main determinant for access to dental care, but other factors such as geography, age and comorbidities can also inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care.

A systematic umbrella review of the association of prescription drug insurance and cost-sharing with drug use, health services use, and health

BACKGROUND

Increasing spending and use of prescription drugs pose an important challenge to governments that seek to expand health insurance coverage to improve population health while controlling public expenditures. Patient cost-sharing such as deductibles and coinsurance is widely used with aim to control healthcare expenditures without adversely affecting health.

METHODS

We conducted a systematic umbrella review with a quality assessment of included studies to examine the association of prescription drug insurance and cost-sharing with drug use, health services use, and health. We searched five electronic bibliographic databases, hand-searched eight specialty journals and two working paper repositories, and examined references of relevant reviews. At least two reviewers independently screened the articles, extracted the characteristics, methods, and main results, and assessed the quality of each included study.

RESULTS

We identified 38 reviews. We found consistent evidence that having drug insurance and lower cost-sharing among the insured were associated with increased drug use while the lack or loss of drug insurance and higher drug cost-sharing were associated with decreased drug use. We also found consistent evidence that the poor, the chronically ill, seniors and children were similarly responsive to changes in insurance and cost-sharing. We found that drug insurance and lower drug cost-sharing were associated with lower healthcare services utilization including emergency room visits, hospitalizations, and outpatient visits. We did not find consistent evidence of an association between drug insurance or cost-sharing and health. Lastly, we did not find any evidence that the association between drug insurance or cost-sharing and drug use, health services use or health differed by socioeconomic status, health status, age or sex.

CONCLUSIONS

Given that the poor or near-poor often report substantially lower drug insurance coverage, universal pharmacare would likely increase drug use among lower-income populations relative to higher-income populations. On net, it is probable that health services use could decrease with universal pharmacare among those who gain drug insurance. Such cross-price effects of extending drug coverage should be included in costing simulations.

How important is income in explaining individuals having forgone healthcare due to cost-sharing payments? Results from a mixed methods sequential explanatory study

Background

Patients having forgone healthcare because of the costs involved has become more prevalent in recent years. Certain patient characteristics, such as income, are known to be associated with a stronger demand-response to cost-sharing. In this study, we first assess the relative importance of patient characteristics with regard to having forgone healthcare due to cost-sharing payments, and then employ qualitative methods in order to understand these findings better.

Methods

Survey data was collected from a Dutch panel of regular users of healthcare. Logistic regression models and dominance analyses were performed to assess the relative importance of patient characteristics, i.e., personal characteristics, health, educational level, sense of mastery and financial situation. Semi-structured interviews (n = 5) were conducted with those who had forgone healthcare. The verbatim transcribed interviews were thematically analyzed.

Results

Of the 7,339 respondents who completed the questionnaire, 1,048 respondents (14.3%) had forgone healthcare because of the deductible requirement. The regression model indicated that having a higher income reduced the odds of having forgone recommended healthcare due to the deductible (odds ratios of higher income categories relative to the lowest income category (reference): 0.29–0.49). However, dominance analyses revealed that financial leeway was more important than income: financial leeway contributed the most (34.8%) to the model’s overall McFadden’s pseudo-R2 (i.e., 0.123), followed by income (25.6%). Similar results were observed in stratified models and in population weighted models. Qualitative analyses distinguished four main themes that affected the patient’s decision whether to use healthcare: financial barriers, structural barriers related to the complex design of cost-sharing programs, individual considerations of the patient, and the perceived lack of control regarding treatment choices within a given treatment trajectory. Furthermore, “having forgone healthcare” seemed to have a negative connotation.

Conclusion

Our findings show that financial leeway is more important than income with respect to having forgone recommended healthcare due to cost-sharing payments, and that other factors such as the perceived necessity of healthcare also matter. Our findings imply that solely adapting cost-sharing programs to income levels will only get one so far. Our study underlines the need for a broader perspective in the design of cost-sharing programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07527-z.

Copayment policy reforms and effective care utilization by patients with persistent asthma in Taiwan

OBJECTIVES

Reforms to the Taiwan National Health Insurance copayment scheme in 2005 imposed a notable increase in the cost of outpatient visits. This provided an ideal situation to determine whether such reforms lead to a reduction in the utilization of effective care by patients with persistent asthma.

METHODS

This study applied the pretest-posttest non-randomized control group design in our analysis of nationwide claims data (2002 to 2010). Based on propensity score matching, the patients were divided into two groups, subject and not subject to copayment reform. Medication Management for People with Asthma measure was used to identify patients with persistent asthma and instances of effective care.

RESULTS

Matching yielded a final panel of 7,890 individuals with persistent asthma (3,945 individuals in each cohort) eligible for the study. GEE analysis revealed that policy reforms had significant effects over the short-term (OR = 0.745, p < 0.05), medium-term (OR = 0.752, p < 0.01), and long-term (OR = 0.721, p < 0.01).

CONCLUSIONS

Reforms to copayment policy were significantly correlated with a reduction in the utilization of effective care by patients with persistent asthma over the short-, medium- and long-term. Government should develop implementation strategies aimed at protecting the economically disadvantaged patients.

Financial protection in health among the middle-aged and elderly: Evidence from the Greek economic recession

Since the late 2000s, the Greek economy has entered a long period of recession, with reforms and retrenchment in health care being among the main public policy priorities. This study investigates the extent to which financial protection in health has changed among older households during the Greek crisis. We focus on the middle-aged and elderly, the heavy users of health services, who have faced a substantial health and financial burden during the crisis. Our analysis shows that the headcount and overshoot of catastrophic health expenditure (CHE) substantially increased from 2007 to 2015, suggesting that financial protection has eroded to a great extent. Prior to the crisis, CHE was mainly due to inpatient care, followed by outpatient care and medicines. However, the contribution of spending for outpatient medicines to CHE substantially increased during the study period. The headcount of CHE rose across all socioeconomic groups we examined, with low-income households and households with chronic patients being disproportionately affected. In 2007, we do not report signs of socioeconomic inequalities in the risk of CHE. On the contrary, our results show that households of low socioeconomic status are more likely to incur CHE in 2015, revealing substantial inequalities in the risk of CHE. This finding raises significant distributional and equity concerns. Strengthening financial protection among older households is an imperative challenge for the Greek health system, and several policy responses need to be adopted towards this direction.

Experiences of health care costs among people with employer-sponsored insurance and bipolar disorder

BACKGROUND

Cost-sharing disproportionately affects people with chronic illnesses needing more care. Our qualitative study examined lived experiences navigating insurance benefits and treatment for bipolar disorder, which requires ongoing access to behavioral specialists and psychotropic medications.

METHODS

Forty semi-structured telephone interviews with individuals with bipolar disorder and employer-sponsored health insurance, or their family caregivers, explored health care needs, coverage details, out-of-pocket (OOP) costs, and perspectives on value. An iterative analytic approach identified salient themes.

RESULTS

Most individuals in our sample faced an annual insurance deductible, from $350-$10,000. OOP costs for specialist visits ranged from $0-$450 and for monthly psychotropic medications from $0-$1650. Acute episodes and care for comorbidities, including medication side effects, added to cost burdens. Medication nonadherence due to OOP costs was rare; respondents frequently pointed to the necessity of medications: "whatever it takes to get those"; "it's a life or death situation." Respondents also prioritized visits to psychiatrist prescribers, though visits were maximally spaced because of cost. Psychotherapy was often deemed unaffordable and forgone, despite perceived need. Interviewees cited limited networks and high out-of-network costs as barriers to specialists. Cost-sharing sometimes led to debt, skimping on nonbehavioral care or other necessities, exacerbated or prolonged mood symptoms, and stress at home.

LIMITATIONS

Volunteer respondents may not fully represent the target population.

CONCLUSIONS

Many people with bipolar disorder in US employer-sponsored plans experience undertreatment, hardship, and adverse health consequences due to high cost-sharing. More nuanced insurance benefit designs should accommodate the needs of individuals with complex conditions.

Gaps in coverage and access in the European Union

This study identifies gaps in universal health coverage in the European Union, using a questionnaire sent to the Health Systems and Policy Monitor network of the European Observatory on Health Systems and Policies. The questionnaire was based on a conceptual framework with four access dimensions: population coverage, service coverage, cost coverage, and service access. With respect to population coverage, groups often excluded from statutory coverage include asylum seekers and irregular residents. Some countries exclude certain social-professional groups (e.g. civil servants) from statutory coverage but cover these groups under alternative schemes. In terms of service coverage, excluded or restricted services include optical treatments, dental care, physiotherapy, reproductive health services, and psychotherapy. Early access to new and expensive pharmaceuticals is a concern, especially for rare diseases and cancers. As to cost coverage, some countries introduced protective measures for vulnerable patients in the form of exemptions or ceilings from user chargers, especially for deprived groups or patients with accumulation of out-of-pocket spending. For service access, common issues are low perceived quality and long waiting times, which are exacerbated for rural residents who also face barriers from physical distance. Some groups may lack physical or mental ability to properly formulate their request for care. Currently, available indicators fail to capture the underlying causes of gaps in coverage and access.

Out-of-pocket spending for oral contraceptives among women with private insurance coverage after the Affordable Care Act

Objectives

We aimed to identify which types and brands of oral contraceptive pills have the largest shares of oral contraceptive users in large employer plans with out-of-pocket spending and which oral contraceptives have the highest average annual out-of-pocket costs.

Study design

We analyzed a sample of medical claims obtained from the 2003-2018 IBM MarketScan Commercial Claims and Encounters Database (MarketScan), which is a database with claims information provided by large employer plans. We only included claims for women between the ages of 15 and 44 years who were enrolled in a plan for more than half a year as covered workers or dependents. To calculate out-of-pocket spending, we summed copayments, coinsurance and deductibles for the oral contraceptive prescriptions.

Results

We found that 10% of oral contraceptive users in large employer plans still had out-of-pocket costs in 2018. Oral contraceptives with the largest share of users with annual out-of-pocket spending are brand-name contraceptives with generic alternatives. The three contraceptives with the highest average annual out-of-pocket spending were brand-name contraceptives without generic alternatives. Three of the 10 contraceptives with the largest shares of users who have annual out-of-pocket spending and 3 of the 10 contraceptives with the highest average annual out-of-pocket spending contain iron.

Conclusions

Women with health insurance are still paying out of pocket for oral contraception, and future research should investigate which health plans have fewer fully covered contraceptives and effective modes of educating providers and patients about how to maximize the no-cost coverage benefit that has been extended to women.

Implications

The Affordable Care Act eliminated out-of-pockets costs for contraception for most insured women. However, some women still pay out of pocket for certain oral contraceptive brands and types that may have covered alternatives. Providers and patients could benefit from more education on how to maximize the no-cost coverage benefit extended to women.

Use of cervical cancer preventive services among US women aged 21-29: an assessment of the 2010 Affordable Care Act rollout through 2018

PURPOSE

The 2010 Affordable Care Act (ACA) provided millions of people with health insurance coverage and facilitated routine cancer screening by requiring insurers to cover preventive services without cost-sharing. Despite greater access to affordable cancer screening, Pap testing has declined over time. The aim of this study is to assess participation in Pap test and HPV vaccination, and adherence to guidelines as outlined by the American Cancer Society (ACS) from the 2010 ACA provision eliminating cost-sharing for preventive services.

METHODS

Using multi-year responses from the Behavioral Risk Factor Surveillance System, we examined the association between the ACA and participation in and adherence to Pap testing and HPV vaccination behaviors as set by the ACS. The sample included women aged 21-29 who completed the survey between 2008 and 2018 (every other year) and who live in 24 US States (N = 37,893).

RESULTS

Results showed significant decreases in Pap testing rates but increases in the uptake of the HPV vaccine series for all age groups and across all demographics. Post-ACA year significantly predicted increases in HPV + Pap co-testing participation and adherence. Women with health insurance coverage were more likely to engage in both behaviors.

CONCLUSION

Findings raise concerns around declines in the proportion of women receiving and adhering to Pap testing guidelines. A need exists for research to examine the role of increases in HPV vaccination uptake on decreases in Pap testing. Moreover, effective strategies should target increases in cervical cancer screening uptake among women vaccinated against HPV.

Incentives to use primary care and their impact on healthcare utilization: Evidence using a public health insurance dataset in China

Large hospitals in China are overcrowded, while primary care tends to be underutilized, resulting in inefficient allocation of resources. This paper examines the impacts of a policy change in a mandatory public employee health insurance program in China designed to encourage the utilization of primary care by reducing patient cost-sharing. We use a unique administrative insurance claim dataset from the Urban Employee Basic Medical Insurance (UEBMI) scheme between 2013 and 2015. The sample includes 40,024 individuals. We conduct an event-study analysis controlling for individual fixed effects and find that the change in cost-sharing increased primary care utilization, decreased non-primary care utilization, and increased total outpatient utilization without impacting total spending. In addition, the policy change did not affect the likelihood of having avoidable inpatient admissions. Further, patients with hypertension or diabetes increased their primary care utilization even when using additional coverage for patients with chronic diseases, the cost-sharing rates for which did not change during the period of our study, rather than their standard UEBMI benefits. This study provides evidence that changes in cost-sharing can affect healthcare utilization, suggesting that supply-side incentives can play an important role in building a primary care-based integrated healthcare delivery system in China.

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

BACKGROUND

While the traditional Medicare program imposes a deductible for hospital admissions, many Medicare Advantage plans have instituted per-diem copayments for hospital care. Little evidence exists about the effects of changes in cost-sharing for hospital care among the elderly. Changing inpatient benefits from a deductible to a per diem may benefit enrollees with shorter lengths of stay, but adversely affect the out-of-pocket burden for hospitalized enrollees with longer lengths of stay.

METHODS

We used a quasi-experimental difference-in-differences study to compare longitudinal changes in proportion hospitalized, inpatient admissions and days per 100 enrollees, and hospital length of stay between enrollees in MA plans that changed inpatient benefit from deductible at admission to per diem, intervention plans, and enrollees in matched control plans - similar plans that maintained inpatient deductibles. The study population included 423,634 unique beneficiaries enrolled in 23 intervention plans and 36 matched control plans in the 2007-2010 period.

RESULTS

The imposition of per-diem copayments were associated with adjusted declines of 1.3 admissions/100 enrollees (95% CI - 1.8 to - 0.9), 6.9 inpatient days/100 enrollees (95% CI - 10.1 to - 3.8) and 0.7 percentage points in the probability of hospital admission (95% CI - 1.0 to - 0.4), with no significant change in adjusted length of stay in intervention plans relative to control plans. For persons with 2 or more hospitalizations in the year prior to the cost-sharing change, adjusted declines were 3.5 admissions/100 (95% CI - 8.4 to 1.4), 31.1 days/100 (95% CI - 75.2 to 13.0) and 2.2 percentage points in the probability of hospitalization (95% CI - 3.8 to - 0.6) in intervention plans relative to control plans.

CONCLUSIONS

Instituting per-diem copayments was associated with reductions in number of admissions and hospital stays, but not length of stay once admitted. Effects of inpatient cost-sharing changes were magnified for persons with greater baseline use of hospital care.

Impact of removing cost sharing under the affordable care act (ACA) on mammography and pap test use

BACKGROUND

The Affordable Care Act (ACA) required private insurers and Medicare to cover recommended preventive services without any cost sharing to improve utilization of these services. This study is an attempt to identify the impact of removing cost sharing on mammography and pap test utilization rates.

METHODS

Counterfactual analysis was used to predict what would have been the screening rates in post-ACA if ACA was not there. This was done by estimating a model that examines determinants of dependent variable for the pre-ACA year (pre-ACA year is 2009). The estimated model was then used to predict the dependent variable for the post-ACA year using individual characteristics and other relevant variables unlikely to be affected by ACA (post-ACA year is 2016). Effect of ACA is defined as the difference between the values of dependent variables in post-ACA and the predicted values of dependent variables in the post-ACA year using counterfactual.

RESULTS

The counterfactual analysis show that the utilization of mammogram and pap test did not improve following ACA.

CONCLUSION

Removal of cost-sharing under the ACA did not improve mammography or pap test rates. Therefore, financial barrier may not be an important factor in affecting utilization of the screening tests and policy makers should focus on other non-financial barriers in order to improve coverage of the tests.

The effect of cost-sharing design characteristics on use of health care recommended by the treating physician; a discrete choice experiment

BACKGROUND

Cost-sharing programs are often too complex to be easily understood by the average insured individual. Consequently, it is often difficult to determine the amount of expenses in advance. This may preclude well-informed decisions of insured individuals to adhere to medical treatment advised by the treating physician. Preliminary research has showed that the uncertainty in these cost-sharing payments are affected by four design characteristics, i.e. 1) type of payments (copayments, coinsurances or deductibles), 2) rate of payments, 3) annual caps on cost-sharing and 4) moment that these payments must be made (directly at point of care or billed afterwards by the insurer).

METHODS

An online discrete choice experiment was used to assess the extent to which design characteristics of cost-sharing programs affect the decision of individuals to adhere to recommended care (prescribed medications, ordered diagnostic tests and referrals to medical specialist care). Analyses were performed using mixed multinomial logits.

RESULTS

The questionnaire was completed by 7921 members of a patient organization. Analyses showed that 1) cost-sharing programs that offer clear information in advance on actual expenses that are billed afterwards, stimulate adherence to care recommended by the treating physician; 2) the relative importance of the design characteristics differed between respondents who reported to have forgone health care due to cost-sharing and those who did not; 3) price-awareness among respondents was limited; 4) the utility derived from attributes and respondents' characteristics were positively correlated; 5) an optimized cost-sharing program revealed an adherence of more than 72.9% among those who reported to have forgone health care.

CONCLUSIONS

The analyses revealed that less complex cost-sharing programs stimulate adherence to recommended care. If these programs are redesigned accordingly, individuals who had reported to have forgone a health service recommended by their treating physician due to cost-sharing, would be more likely to use this service. Such redesigned programs provide a policy option to reduce adverse health effects of cost-sharing in these groups. Considering the upcoming shift from volume-based to value-based health care provision, insights into the characteristics of a cost-sharing program that stimulates the use of recommended care may help to design value-based insurance plans.

Revisiting out-of-pocket requirements: trends in spending, financial access barriers, and policy in ten high-income countries

Background

Countries rely on out-of-pocket (OOP) spending to different degrees and employ varying techniques. The article examines trends in OOP spending in ten high-income countries since 2000, and analyzes their relationship to self-assessed barriers to accessing health care services. The countries are Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

Methods

Data from three sources are employed: OECD statistics, the Commonwealth Fund survey of individuals in each of ten countries, and country-specific documents on health care policies. Based on trends in OOP spending, we divide the ten countries into three groups and analyze both trends and access barriers accordingly. As part of this effort, we propose a conceptual model for understanding the key components of OOP spending.

Results

There is a great deal of variation in aggregate OOP spending per capita spending but there has been convergence over time, with the lowest-spending countries continuing to show growth and the highest spending countries showing stability. Both the level of aggregate OOP spending and changes in spending affect perceived access barriers, although there is not a perfect correspondence between the two.

Conclusions

There is a need for better understanding the root causes of OOP spending. This will require data collection that is broken down into OOP resulting from cost sharing and OOP resulting from direct payments (due to underinsurance and lacking benefits). Moreover, data should be disaggregated by consumer groups (e.g. income-level or health status). Only then can we better link the data to specific policies and suggest effective solutions to policy makers.

Patient cost-sharing, socioeconomic status, and children's health care utilization

This paper estimates the effect of cost-sharing on the demand for children's and adolescents' use of medical care. We use a large population-wide registry dataset including detailed information on contacts with the health care system as well as family income. Two different estimation strategies are used: regression discontinuity design exploiting age thresholds above which fees are charged, and difference-in-differences models exploiting policy changes. We also estimate combined regression discontinuity difference-in-differences models that take into account discontinuities around age thresholds caused by factors other than cost-sharing. We find that when care is free of charge, individuals increase their number of doctor visits by 5-10%. Effects are similar in middle childhood and adolescence, and are driven by those from low-income families. The differences across income groups cannot be explained by other factors that correlate with income, such as maternal education.

Tiered co-payments, pricing, and demand in reference price markets for pharmaceuticals

Health insurance companies curb price-insensitive behavior and the moral hazard of insureds by means of cost-sharing, such as tiered co-payments or reference pricing in drug markets. This paper evaluates the effect of price limits - below which drugs are exempt from co-payments - on prices and on demand. First, using a difference-in-differences estimation strategy, we find that the new policy decreases prices by 5 percent for generics and increases prices by 4 percent for brand-name drugs in the German reference price market. Second, estimating a nested-logit demand model, we show that consumers appreciate co-payment exempt drugs and calculate lower price elasticities for brand-name drugs than for generics. This explains the different price responses of brand-name and generic drugs and shows that price-related co-payment tiers are an effective tool to steer demand to low-priced drugs.

First-dollar cost-sharing for skilled nursing facility care in medicare advantage plans

BACKGROUND

The initial days of a Medicare-covered skilled nursing facility (SNF) stay may have no cost-sharing or daily copayments depending on beneficiaries' enrollment in traditional Medicare or Medicare Advantage. Some policymakers have advocated imposing first-dollar cost-sharing to reduce post-acute expenditures. We examined the relationship between first-dollar cost-sharing for a SNF stay and use of inpatient and SNF services.

METHODS

We identified seven Medicare Advantage plans that introduced daily SNF copayments of $25-$150 in 2009 or 2010. Copays began on the first day of a SNF admission. We matched these plans to seven matched control plans that did not introduce first-dollar cost-sharing. In a difference-in-differences analysis, we compared changes in SNF and inpatient utilization for the 172,958 members of intervention and control plans.

RESULTS

In intervention plans the mean annual number of SNF days per 100 continuously enrolled inpatients decreased from 768.3 to 750.6 days when cost-sharing changes took effect. Control plans experienced a concurrent increase: 721.7 to 808.1 SNF days per 100 inpatients (adjusted difference-in-differences: -87.0 days [95% CI (-112.1,-61.9)]). In intervention plans, we observed no significant changes in the probability of any SNF service use or the number of inpatient days per hospitalized member relative to concurrent trends among control plans.

CONCLUSIONS

Among several strategies Medicare Advantage plans can employ to moderate SNF use, first-dollar SNF cost-sharing may be one influential factor.

TRIAL REGISTRATION

Not applicable.

Association between copayment, medication adherence and outcomes in the management of patients with diabetes and heart failure

OBJECTIVE

To determine the association between copayment, medication adherence and outcomes in patients with Heart failure (HF) and Diabetes Mellitus (DM).

METHODS

PubMed, Scopus and Cochrane databases were searched using combinations of four sets of key words for: drug cost sharing; resource use, health and economic outcomes; medication adherence; and chronic disease.

RESULTS

Thirty eight studies were included in the review. Concerning the direct effect of copayment changes on outcomes, the scarcity and diversity of data, does not allow us to reach a clear conclusion, although there is some evidence indicating that higher copayments may result in poorer health and economic outcomes. Seven and one studies evaluating the relationship between copayment and medication adherence in DM and HF population, respectively, demonstrated an inverse statistically significant association. All studies (29) examining the relationship between medication adherence and outcomes, revealed that increased adherence is associated with health benefits in both DM and HF patients. Finally, the majority of studies in both populations, showed that medication adherence was related to lower resource utilization which in turn may lead to lower total healthcare cost.

CONCLUSION

The results of our systematic review imply that lower copayments may result in higher medication adherence, which in turn may lead to better health outcomes and lower total healthcare expenses. Future studies are recommended to reinforce these findings.

Impact of Copayment Changes on Children's Albuterol Inhaler Use and Costs after the Clean Air Act Chlorofluorocarbon Ban

OBJECTIVE

To examine changes in children's albuterol use and out-of-pocket (OOP) costs in response to increased copayments after the Food and Drug Administration banned inhalers with chlorofluorocarbon (CFC) propellants.

SETTING

Four health maintenance organizations (HMOs), two that increased copayments for albuterol inhalers that went from generic CFC-containing to branded CFC-free versions, and two that retained generic copayments for CFC-free inhalers (controls). We included children with asthma aged 4-17 years with commercial coverage from 2007 to 2010.

DESIGN

Interrupted time series with comparison series.

DATA

We obtained enrollee and plan characteristics from enrollment files, and utilization data from pharmacy and medical claims; OOP expenditures were extracted from pharmacy claims for two HMOs with cost data available.

FINDINGS

There were no significant differences in albuterol use between the group with increased cost-sharing and controls with respect to changes after the policy change. There was a postpolicy increase of $6.11 OOP per month per child using albuterol among those with increased cost-sharing versus $0.36 in controls; the difference between groups was significant (p < .01).

CONCLUSIONS

Increased copayments for brand-name CFC-free albuterol after the CFC ban did not lead to a decrease in children's albuterol use, but it led to a modest increase in OOP costs.

Patient cost-sharing for ambulatory neuropsychiatric services in Abu Dhabi, UAE

Background and objectives

Neuropsychiatric disorders are of high concern and burden of disease in the United Arab Emirates (UAE). The aim of this study is to describe patient cost-sharing patterns, insurance coverage of ambulatory neuropsychiatric disorders, and utilization of neuropsychiatric services in Abu Dhabi.

Methods

The study utilized the data published by Health Authority-Abu Dhabi (HAAD) and the American Center for Psychiatry and Neurology (ACPN) records in Abu Dhabi. The data were collected from the ACPN to describe patterns of insurance coverage and patient cost-sharing. The data included information on patient visits to the ACPN from January 1, 2010 till May 16, 2013. The data also included insurance coverage, total cost of treatment for each patient and the amount of coinsurances and deductibles paid by each patient. Additionally, the study utilized data published by HAAD on health services utilization, and health insurance plans in 2014. The percentage of total costs paid by patients and insurance were calculated by insurance groups and health service. Insurance plans with different patient cost-sharing arrangements for mental health treatment benefits were divided into three groups. ANOVA and MANOVA analyses were performed to test for differences among three categories of neuropsychiatric services (neurology, psychiatry and psychotherapy) in terms of the total costs and patient cost-sharing. The data were analysed using STATA version 12.

Results

About 36 % of the total costs on ambulatory neuropsychiatric services was paid directly by patients; 1 % of total costs was covered by patients as co-insurances and deductibles, and 63 % of total costs was covered by insurance providers. The average cost per visit was about 485 AED ($132), including 304 AED ($83) paid by insurance and 181 AED ($49) paid by patient. About 44 % of total costs was related to psychiatry services, 28 % of total costs was related to neurology services, and 28 % of total costs was related to psychotherapy services. Using ANOVA analyses, statistical differences were found among three categories of neuropsychiatric services in terms of the total costs and patient cost-sharing. These findings provide hint on some degree of association between patient cost-sharing and neuropsychiatry services utilization.

Conclusions

The determination of parities in the coverage and finance between neuropsychiatric and physical health services will help policymakers make informed decisions on regulations of health insurance plans. Given the level of unmet need for neuropsychiatric services in Abu Dhabi, there is a need to fully include neuropsychiatric services in all basic and enhanced insurance plans. The study provided a description of patient cost-sharing and coverage of neuropsychiatric services in order for policymakers to recognize the disparities of the coverage and the degree of economic burden on households.

The incidence of high medical expenses by health status in seven developed countries

Health care policy seeks to ensure that citizens are protected from the financial risk associated with needing health care. Yet rising health care costs in many countries are leading to a greater reliance on out-of-pocket (OOP) measures. This paper uses 2010 household survey data from seven countries to measure and compare the burden OOP expenses place on individuals. It compares countries based on the extent to which citizens with health problems devote a large share of their income to OOP expenses. The paper finds that in all countries but France, and to a lesser extent Slovenia, citizens with health problems face considerably higher medical costs than do those without. As many as one-quarter of less healthy citizens in the US, Poland, Russia and Israel devote a large share of their income to OOP expenses. The paper also finds a strong cross-national correlation between the degree to which citizens face high OOP expenses, and the disparities in OOP expenses between those with and without health problems. The levels of high OOP spending uncovered, and their inequitable impact on those with health problems in the seven countries, underscore the potential for OOP measures to undermine core objectives of health care systems, including those of equitable financing, equal access, and improved health among the population.

Has recommended preventive service use increased after elimination of cost-sharing as part of the Affordable Care Act in the United States?

BACKGROUND

An early provision of the Affordable Care Act (ACA) eliminated cost-sharing for a range of recommended preventive services. This provision took effect in September 2010, but little is known about its effect on preventive service use.

METHODS

We evaluated changes in the use of recommended preventive services from 2009 (before the implementation of ACA cost-sharing provision) to 2011/2012 (after the implementation) in the Medical Expenditure Panel Survey, a nationally representative household interview survey in the US. Specifically, we examined: blood pressure check, cholesterol check, flu vaccination, and cervical, breast, and colorectal cancer screening, controlling for demographic characteristics and stratifying by insurance type.

RESULTS

There were 64,280 (21,310 before and 42,970 after the implementation of ACA cost-sharing provision) adults included in the analyses. Receipt of recent blood pressure check, cholesterol check and flu vaccination increased significantly from 2009 to 2011/2012, primarily in the privately insured population aged 18-64years, with adjusted prevalence ratios (95% confidence intervals) 1.03 (1.01-1.05) for blood pressure check, 1.13 (1.09-1.18) for cholesterol check and 1.04 (1.00-1.08) for flu vaccination (all p-values<0.05). However, few changes were observed for cancer screening. We observed little change in the uninsured population.

CONCLUSIONS

These early observations suggest positive benefits from the ACA policy of eliminating cost-sharing for some preventive services. Future research is warranted to monitor and evaluate longer term effects of the ACA on access to care and health outcomes.

Cross-national comparison of medical costs shared by payers and patients: a study of postmenopausal women with early-stage breast cancer based on assumption case scenarios and reimbursement fees

BACKGROUND

The objectives of this study were to estimate and cross-nationally compare the medical costs shared by payers and patients and the distributions of medical costs by cost category.

MATERIAL AND METHODS

We estimated the medical costs covered from definitive diagnosis to completion of treatments of early-stage breast cancer and follow-up, assuming almost identical medical care provided in Japan, the UK, and Germany. The analysis was performed from the payer's perspective. Medical costs were calculated by multiplying the unit costs by the number of units consumed, based on assumption case scenarios. The medical costs incurred by payers or patients were estimated according to the cost-sharing and the cost-bearing systems in each country.

RESULTS

The total medical costs in Japan were much lower than those in the UK and Germany, and these differences were mainly caused by the low costs of surgery and radiotherapy in Japan. For the base-case scenario, the co-payment in Japan (€ 3,486) was found to be 6.4-fold higher than that in Germany (€ 548). The payers in the European countries paid 2.9-fold more than those in Japan (€ ∼25,000 vs. € 8,627).

CONCLUSION

Our results will be useful for policy makers in considering how to share medical costs and how to allocate limited resources.

Do cost-sharing and entry deregulation curb pharmaceutical innovation?

This paper examines the role of both cost-sharing schemes in health insurance systems and the regulation of entry into the pharmaceutical sector for pharmaceutical R&D expenditure and drug prices. The analysis suggests that both an increase in the coinsurance rate and stricter price regulations adversely affect R&D spending in the pharmaceutical sector. In contrast, entry deregulation may lead to higher R&D spending of pharmaceutical companies. The relationship between R&D spending per firm and the number of firms may be hump-shaped. In this case, the number of rivals which maximizes R&D expenditure per firm is decreasing in the coinsurance rate and increasing in labor productivity.