Abstract
BackgroundPatients 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.MethodsSurvey 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.ResultsOf 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.ConclusionOur 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.
Highlights
Patients having forgone healthcare because of the costs involved has become more prevalent in recent years
Phase 1: Quantitative results Sample Of the 7,339 respondents included in the main analysis (Table 1), 1048 respondents (14.3%) had forgone recommended healthcare due to the deductible and differed from those who did not
The regression model indicated that having a higher income reduced the odds of having forgone recommended healthcare due to the deductible (ORs of higher income categories relative to the lowest income category: 0.29–0.49)
Summary
Patients having forgone healthcare because of the costs involved has become more prevalent in recent years. Smaller in relative growth rate, OOP spending has increased among countries with historically high levels (e.g., the United States (US) and Switzerland) [4] These trends have shifted a larger share of the costs to the insured individuals which forces them to devote an increasing portion of their annual income to these expenses [5, 6]. This shift should make those insured more aware of the costs involved which may, in turn, contribute to slowing down the rise of healthcare expenditures. The policy shift towards more OOP spending may cancel out any costs initially saved due to cost-sharing if those insured forgo relatively cheap health services such as outpatient physician visits, but require additional and more expensive health services such as a hospitalization in the long run
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