Care Payment Research Articles

Fragmentation of payment systems: an in-depth qualitative study of stakeholders’ experiences with the neonatal intensive care payment system in Iran

BackgroundIran’s fee-for-service (FFS) payment model in neonatal intensive care units (NICUs) is contentious due to the involvement of multiple stakeholders with differing interests, leading to increased costs, fragmentation, and reduced quality of care. This study explores the experiences and challenges of stakeholders with the NICU payment system and considers alternative payment methods.MethodA qualitative research approach was used, involving key informant interviews with stakeholders at various levels of the health system. Data were collected between March 2022 to September 2023 using a purposive sampling method with a snowball strategy. The transcribed data were analyzed using an inductive thematic approach in MAXQDA, with themes and sub-themes emerged and assessed by two independent coders. Four trustworthiness criteria were applied to ensure the quality of the results.ResultsThe study involved 23 participants with diverse NICU payment backgrounds, identifying issues related to service accessibility, rising costs, neonatologists’ income, and service quality. Stakeholders held differing views on the best payment model: health insurance executives favored a prospective payment method, faculty members favored supported modified FFS or per diem, and neonatal specialists expressed concerns about low tariffs and delayed payments.ConclusionIran’s NICU payment system is unsatisfactory and requires urgent reform. Although stakeholders disagree on the best approach, reforms must be evidence-based and collaborative, addressing structural and cultural issues within the health system. The identification of an optimal payment system is essential for supporting neonatal care, benefiting newborns, families, society, and the broader health system.

Why “free maternal healthcare” is not entirely free in Ghana: a qualitative exploration of the role of street-level bureaucratic power

BackgroundGhana introduced a free maternal healthcare policy within its National Health Insurance Scheme (NHIS) in 2008 to remove financial barriers to accessing maternal health services. Despite this policy, evidence suggests that women incur substantial out-of-pocket (OOP) payments for maternal health care. This study explores the underlying reasons for these persistent out-of-pocket payments within the context of Ghana’s free maternal healthcare policy.MethodsCross-sectional qualitative data were collected through interviews with a purposive sample of 14 mothers and 8 healthcare providers/administrators in two regions of Ghana between May and September 2022. All interviews were audio-recorded, transcribed and imported into the NVivo 14.0 software for analysis. An iteratively developed codebook guided the coding process. Our thematic data analysis followed the Attride-Sterling framework for network analysis, identifying basic, organising themes and global themes.ResultsWe found that health systems and demand-side factors are responsible for the persistence of OOP payments despite the existence of the free maternal healthcare policy in Ghana. Reasons for these payments arose from health systems factors, particularly, NHIS structural issues – delayed and insufficient reimbursements, inadequate NHIS benefit coverage, stockouts and supply chain challenges and demand-side factors – mothers’ lack of education about the NHIS benefit package, and passing of cost onto patients. Due to structural and system level challenges, healthcare providers, exercising their street-level bureaucratic power, have partly repackaged the policy, enabling the persistence of out-of-pocket payments for maternal healthcare.ConclusionsUrgent measures are required to address the structural and administrative issues confronting Ghana’s free maternal health policy; otherwise, Ghana may not achieve the sustainable development goals targets on maternal and child health.

Comparing Deprivation vs Vulnerability Index Performance Using Medicare Beneficiary Surgical Outcomes

Health care researchers, professionals, payers, and policymakers are increasingly relying on publicly available composite indices of area-level socioeconomic deprivation to address health equity. Implications of index selection, however, are not well understood. To compare the performance of 2 frequently used deprivation indices using policy-relevant outcomes among Medicare beneficiaries undergoing 3 common surgical procedures. This cross-sectional study examined outcomes among Medicare beneficiaries (65 to 99 years old) undergoing 1 of 3 common surgical procedures (hip replacement, knee replacement, or coronary artery bypass grafting) between 2016 and 2019. Index discriminative performance was compared for beneficiaries residing in tracts with high- and low-deprivation levels (deciles) according to each index. Analyses were conducted between December 2022 and August 2023. Tract-level deprivation was operationalized using 2020 releases of the area deprivation index (ADI) and the social vulnerability index (SVI). Binary outcomes were unplanned surgery, 30-day readmissions, and 30-day mortality. Multivariable logistic regression models, stratified by each index, accounted for beneficiary and hospital characteristics. A total of 2 433 603 Medicare beneficiaries (mean [SD] age, 73.8 [6.1] years; 1 412 968 female beneficiaries [58.1%]; 24 165 Asian [1.0%], 158 582 Black [6.5%], and 2 182 052 White [89.7%]) were included in analyses. According to both indices, beneficiaries residing in high-deprivation tracts had significantly greater adjusted odds of all outcomes for all procedures when compared with beneficiaries living in low-deprivation tracts. However, compared to ADI, SVI resulted in higher adjusted odds ratios (adjusted odds ratios, 1.17-1.31 for SVI vs 1.09-1.23 for ADI), significantly larger outcome rate differences (outcome rate difference, 0.07%-5.17% for SVI vs outcome rate difference, 0.05%-2.44% for ADI; 95% CIs excluded 0), and greater effect sizes (Cohen d, 0.076-0.546 for SVI vs 0.044-0.304 for ADI) for beneficiaries residing in high- vs low-deprivation tracts. In this cross-sectional study of Medicare beneficiaries, SVI had significantly better discriminative performance-stratifying surgical outcomes over a wider range-than ADI for identifying and distinguishing between high- and low-deprivation tracts, as indexed by outcomes for common surgical procedures. Index selection requires careful consideration of index differences, index performance, and contextual factors surrounding use, especially when informing resource allocation and health care payment adjustment models to address health equity.

Baseline characteristics of parents enrolled in ACCL20N1CD: Financial distress during treatment for pediatric acute lymphoblastic leukemia (ALL) in the US.

220 Background: Personal costs of childhood cancer can contribute to disparities in health outcomes. The purpose of ACCL20N1CD is to examine trajectories of parental costs and the associated financial distress, cost coping behaviors, and household material hardships (HMH) during treatment for pediatric ALL. Objective is to report baseline characteristics of the parents and their households. Methods: The study used a prospective cohort design with repeated measures. Setting was Children’s Oncology Group (COG) practices at National Cancer Institute Community Oncology Research Program (NCORP) institutions. Parents who use English or Spanish, and have children newly diagnosed with ALL treated at COG NCORP practices were eligible. Parents were asked to complete surveys at 3 time points, including baseline (T1; during induction and <7 days after planned induction remission evaluation). Surveys included items about (a) parent socio‐economic status, financial distress measured by 8-item Personal Wellness Scale (PFWS), and cost coping behaviors, and (b) HMH. Factors related to high PFWS scores were evaluated by logistic regression. Results: Of 104 evaluable parents, most were female (83.7%), white (65.4%), non-Hispanic (48.1%), partnered (79.8%), > high school diploma (93.3%), used English (84.6%), worked full (48.1%) or part (5.8%) time, and paid for their child’s care with public insurance (57.7%). Median household income=$50,000 (Inter-Quartile Range/IQR 20,000-100,000) for 4 (IQR 4-5) people. Not including wages lost due to caregiving, out of pocket payments for medical care + other ALL-related costs in the prior month >15% of monthly income for 51.9% of households, which is considered financially catastrophic. 24.0% of households lacked food stability; 21% had housing insecurity. Conclusions: At baseline, sizeable proportions of parents exhibit high out of pocket costs, high financial distress level, and multiple cost coping behaviors with implications for future health and individual and household quality of life.

Unlocking success: Full year quality and utilization metrics of payer-provider OMH partnership.

41 Background: For more than a decade, CMS and commercial payers have sought to engage provider organizations in value-based cancer care payment models (VBPMs). Success of VBPMs requires payer/provider alignment on quality/utilization measures indicative of high-value care and the efficiency of data exchange between providers and payers. The following describes several key metrics from the first full year 2022 of the Tennessee Oncology (TO) and BlueCross BlueShield of Tennessee (BCBST) Oncology Medical Home (OMH) partnership. Methods: TO and BCBST implemented reporting methodologies for a combination of practice-reported quality and utilization measures and payer claims-based measures: Patient experience, Pathway adherence, Distress screening / interventions, Admissions/1000 patients, ED visits/1000 patients, Imaging utilization, and Observation stays. Bi-weekly meetings between practice and payer were necessary to review quality/utilization measure reporting, coordinate overall program administration, and monitor member attribution for care management and performance-based payments. Results: TO/BCBST co-developed a VBPM that included bi-directional reporting of practice-reported quality and utilization measures and payer claims-based measures. Technical challenges in data sharing and reporting occurred frequently and required regular troubleshooting. Questions regarding trends in observed data arose frequently for both TO and BCBST and required regular discussions between clinical/operational leaders of payer and practice (Table). Conclusions: These data suggest that payers and community oncology practices can co-develop value-based payment models that yield transparency in quality and utilization data reporting, and observed differences in performance and cost-efficiency among different practices in a market. Payers can gain increased transparency in quality and cost-efficiency of cancer care for their members. Practices can leverage care management payments and performance-based payments to support care delivery and quality/utilization data reporting improvements. Provider and payer capabilities to execute transparent QM/UM reporting is a major challenge in implementing OMH programs. 2022 OMH results. Measure % higher or lower than benchmarks Admissions /k -7.0 ED visit /k -8.4 Imaging utilization + 9.4 Observation stays -10.0 Patient experience NA Pathway adherence NA Distress screening / interventions NA Hospice reporting NA NA = not applicable, no benchmark data available/measured; /k = per 1000 patients; negative = lower than benchmarks; positive = higher than benchmarks.

Primary care payment models and avoidable hospitalizations in Ontario, Canada: A multivalued treatment effects analysis.

Improving access to primary care physicians' services may help reduce hospitalizations due to Ambulatory Care Sensitive Conditions (ACSCs). Ontario, Canada's most populous province, introduced blended payment models for primary care physicians in the early- to mid-2000s to increase access to primary care, preventive care, and better chronic disease management. We study the impact of payment models on avoidable hospitalizations due to two incentivized ACSCs (diabetes and congestive heart failure) and two non-incentivized ACSCs (angina and asthma). The data for our study came from health administrative data on practicing primary care physicians in Ontario between 2006 and 2015. We employ a two-stage estimation strategy on a balanced panel of 3710 primary care physicians (1158 blended-fee-for-service (FFS), 1388 blended-capitation models, and 1164 interprofessional team-based practices). First, we account for the differences in physician practices using a generalized propensity score based on a multinomial logit regression model, corresponding to three primary care payment models. Second, we use fractional regression models to estimate the average treatment effects on the treated outcome (i.e., avoidable hospitalizations). The capitation-based model sometimes increases avoidable hospitalizations due to angina (by 7 per 100,000 patients) and congestive heart failure (40 per 100,000) relative to the blended-FFS-based model. Switching capitation physicians into interprofessional teams mitigates this effect, reducing avoidable hospitalizations from congestive heart failure by 30 per 100,000 patients and suggesting better access to primary care and chronic disease management in team-based practices.

Организационно-финансовые аспекты выбора интраокулярных линз при хирургии катаракты в условиях ценностно-ориентированной системы здравоохранения.

Relevance. In modern conditions, value-based healthcare provides for the provision by medical organizations of medical care of appropriate quality with mandatory control of its cost. Treatment outcomes that are important to the patient become no less significant than clinical performance indicators and payment for medical services, regardless of the profile of medical care. The gradual change in paradigms of healthcare systems from a paternalistic to a person-centric model required changes in organizational, legislative and financial approaches when introducing health-saving healthcare technologies. Purpose of the study: analysis of the current organizational, legal, financial and clinical models of surgical treatment of patients with age-related cataracts, astigmatism and development of proposals for the implementation of the patient’s right to choose intraocular lenses, taking into account his modern expectations from the results of treatment. Materials and methods. Statistical and analytical methods were used (content analysis methods, expert assessment methods, analysis and synthesis methods). Results. An analysis of the legislation in organizing the provision and financing of medical care to the adult population in the field of ophthalmology is presented, and state guarantees for the use of medical products – types of intraocular lenses implanted into the human body for the surgical treatment of senile cataracts and astigmatism – are considered. Clinical models of the disease are systematized, taking into account the frequency and frequency of provision of medical services and the list of medical devices implanted into the human body, professional, medico-economic, medico-legal and reputational risks are described when exercising the patient’s right to choose intraocular lenses in the treatment of ophthalmological pathology. Proposals have been developed to change clinical recommendations, standards of medical care for senile cataracts and astigmatism, and improve payment for ophthalmological care. Conclusions. The transition to value-based healthcare requires the consolidation of the efforts of all structures of the healthcare industry to achieve the best results in the treatment of ophthalmic diseases and increase the clinical effectiveness associated with the choice of intraocular lenses in the surgical treatment of adults in the field of ophthalmology.

Maternal Exposure to Heavy Metals From Industrial Sources During Pregnancy and Childhood Cancer Risk in California.

The study investigated maternal exposure to heavy metals from industrial sources during pregnancy as potential risk factors for childhood cancer. Cases ages 0-19 were identified from California Cancer Registry. Controls (20:1 ratio) were randomly selected from California Birth Registry, frequency-matched by birth year (1998-2016). We estimated maternal exposure to lead, nickel, and cobalt in ambient air from the Toxics Release Inventory. We examined "ever/never" and "high/low" exposures categorized by median exposure. Models were adjusted for maternal age, race/ethnicity, method of payment for prenatal care, neighborhood socioeconomic status, and urban/rural residence. Among highly exposed persons, lead was associated with an increased teratoma risk (adjusted odds ratio [aOR]: 1.52; 95% confidence interval [CI]: 0.97, 2.37), whereas nickel was associated with an increased rhabdomyosarcoma risk (aOR: 1.45; 95% CI: 1.03, 2.04). Cobalt was associated with an increased glioma risk (aOR: 2.25; 95% CI: 1.39, 3.65) among ever-exposed persons. Inverse associations were found between Wilms tumor and nickel among the ever exposed and highly exposed (ever: aOR: 0.75; 95% CI: 0.59, 0.96; high: aOR: 0.64; 95% CI: 0.45, 0.93). Findings suggest that air pollution from heavy metals released by industrial sources may elevate childhood cancer risk.

Integrating Maternity Care Through Bundled Payments In The Netherlands: Early Results And Policy Lessons.

Bundled payments are increasingly used globally to move health care delivery in a value-based direction. However, evidence remains scant in key clinical areas. We evaluated bundled payments for maternity care in the Netherlands during the period 2016-18. We used a quasi-experimental difference-in-differences design to measure the association between the bundled payment model and changes in key clinical and economic outcomes. Bundled payments were associated with an increase in outpatient, midwife-led births and a reduction in in-hospital, obstetrician-led births, along with changes in the use of labor inductions and planned versus emergency cesarean deliveries. Total spending on maternity care decreased by US$328 (5percent) per pregnancy. No changes in maternal or neonatal health outcomes were observed. Several policy lessons emerged. First, bundled payments appeared to help affect providers' behavior in the maternity care setting. Second, bundled payments seemed to exert heterogeneous effects across participating maternity care networks, as the same financial incentive translated into different changes in clinical practices and outcomes. Third, alternative payment models should be designed with clear goals and definitions of success to guide evaluation and implementation.

Quality Measurement in Oncology: Time to Take the Next Step!

Oncology is a complex clinical specialty often requiring the close interaction of teams of different medical specialists for a successful outcome. The field is rapidly evolving scientifically, with successive discoveries of oncologic driver mutations soon followed by therapeutic agents able to interrupt the neoplastic process. Unfortunately, objective quality measurement demonstrates that many patients are not receiving optimal care, from diagnostic accuracy, therapeutic, or end-of-life perspectives. Quality measurement, reporting, and payment programs have the potential to focus attention on these care gaps and drive improvement. The federal government, as the largest single payer of health care services in the United States, has a compelling national interest to ensure that the medical care of Americans is at the highest level achievable. Accordingly, quality reporting and payment programs have been established in federal health care payment programs to drive improvements in care. This article reviews the science of quality measurement, documented gaps in oncology care, and ways to use new information technologies to decrease clinician burden associated with quality reporting. The article reviews how a measure is developed and incorporated into a Centers for Medicare & Medicaid Services (CMS) program. It also summarizes federal programs relevant to oncology care and the individual measures used in these programs. CMS looks forward to working jointly with the oncology community to drive continuous improvements in care.

Methods for Estimating Costs for Stays at Inpatient Rehabilitation Facilities and Long-Term Care Hospitals

ObjectiveTo describe and compare 3 methods for estimating stay-level Medicare facility (Part A) costs using claims and cost report data for inpatient rehabilitation facilities (IRFs) and long-term care hospitals (LTCHs), the 2 hospital-based postacute care providers. DesignWe calculated stay-level facility costs using different methods. Method 1 used routine costs per day and ancillary cost-to-charge ratios. Method 2 used routine and ancillary cost-to-charge ratios (freestanding IRFs and LTCHs only). Method 3 used facility-specific operating cost-to-charge ratios from the Provider Specific File. For each method, we compared the costs with payments and charges at the claim and facility levels and examined facility margins. SettingData are from 1619 providers, including 266 freestanding IRFs, 909 IRF units, and 444 LTCHs. ParticipantsThe analyses included 239,284 claims from 2014, of which 86,118 claims were from freestanding IRFs, 92,799 claims were from IRF units, and 60,367 claims were from LTCHs. InterventionsNot applicable. Main Outcome MeasuresCosts and payments in 2014 United States Dollars. ResultsFor freestanding IRFs, the mean facility stay-level costs were calculated to be $13,610 (method 1), $13,575 (method 2), and $13,783 (method 3). For IRF units, the mean facility stay-level costs were $17,385 (method 1) and $19,093 (method 3). For LTCHs, the mean facility stay-level costs were $36,362 (method 1), $36,407 (method 2), and $37,056 (method 3). ConclusionsThe 3 methods resulted in small differences in facility mean stay-level costs. Using the facility-level cost-to-charge ratio (method 3) is the least resource-intensive method. Although more resource-intensive, using routine cost per day and ancillary cost-to-charge ratios (method 1) for cost calculations allows for differentiation in costs across patients based on differences in the mix of services used. As policymakers consider postacute care payment reforms, cost, rather than charge or payment data, needs to be calculated and the results of the methods compared.

Assessing the state of obesity care: Quality, access, guidelines, and standards.

An international panel of obesity medicine experts from multiple professional organizations examined patterns of obesity care and current obesity treatment guidelines to identify areas requiring updating in response to emerging science and clinical evidence. The panel focused on multiple medical health and societal issues influencing effective treatment of obesity and identified several unmet needs in the definition, assessment, and care of obesity. The panel was held in Leesburg, Virginia in September 2019. The panelists recommended addressing these unmet needs in obesity medicine through research, education, evaluation of delivery and payment of care, and updating clinical practice guidelines (CPG) to better reflect obesity's pathophysiological basis and heterogeneity, as well as the disease's health, sociocultural, and economic complications; effects on quality of life; need for standards for quantitative comparison of treatment benefits, risks, and costs; and the need to more effectively integrate obesity treatment guidelines into routine clinical practice and to facilitate more direct clinician participation to improve public understanding of obesity as a disease with a pathophysiological basis. The panel also recommended that professional organizations working to improve the care of people with obesity collaborate via a working group to develop an updated, patient-focused, comprehensive CPG establishing standards of care, addressing identified needs, and providing for routine, periodic review and updating. Unmet needs in the definition, assessment and treatment of obesity were identified and a blueprint to address these needs developed via a clinical practice guideline that can be utilized worldwide to respond to the increasing prevalence of obesity.

Who participates in value-based care models? Physician characteristics and implications for value-based care.

Value-based care (VBC) payment models are becoming increasingly prevalent as alternatives to the traditional fee-for-service paradigm. This research quantifies the relationship between physician characteristics and participation in VBC payment models using the Association of American Medical Colleges' 2022 National Sample Survey of Physicians. We specified logistic regressions using physician-level variables to assess associations with current and new participation in Accountable Care Organizations, Primary Care First model, capitation, and bundled payments. Our results indicate that most respondents engaged in at least 1 VBC. Participation varied based on several characteristics, and physician specialty was highly predictive of overall participation. Compared with primary care physicians (PCPs), hospital-based physicians (odds ratio [OR] = 0.6, P < .001), medical specialists (OR = 0.5, P < .001), psychiatrists (OR = 0.4, P < .001), and surgeons (OR = 0.5, P < .001) were less likely to participate in VBC models. Medical specialists and surgeons were less likely to participate in commercial capitation than PCPs, while medical specialists and obstetricians/gynecologists were more likely to participate in certain bundles than PCPs. We suggest several policies to close the cross-specialty participation gap by including specialists and appealing to providers and patients.

Potentially Inappropriate End of Life Care and Healthcare Costs in the Last 30 Days of Life in Regions Providing Integrated Palliative Care in the Netherlands: A Registration-based Study.

This study aimed to assess the effect of integrated palliative care (IPC) on potentially inappropriate end- of-life care and healthcare-costs in the last 30 days of life in the Netherlands. Nationwide health-insurance claims data were used to assess potentially inappropriate end-of-life care (≥2 emergency room visits; ≥2 hospital admissions; >14 days hospitalization; chemotherapy; ICU admission; hospital death) and healthcare-costs in all deceased adults in IPC regions pre- and post- implementation and in those receiving IPC compared to a 1:2 matched control group. In regions providing IPC deceased adults (n = 37,468) received significantly less potentially inappropriate end-of-life care post-implementation compared to pre-implementation (26.5% vs 27.9%; p < 0.05). Deceased adults who received IPC (n = 210) also received significantly less potentially inappropriate end-of-life care compared to a matched control group (14.8% vs 28.3%; p < 0.05). Mean hospital costs significantly decreased for deceased adults who received IPC (€2,817), while mean costs increased for general practitioner services (€311) and home care (€1,632). These results highlight the importance of implementation of integrated palliative care and suitable payment. Further research in a larger sample is needed. This study shows less potentially inappropriate end-of-life care and a shift in healthcare costs from hospital to general practitioner and home care with IPC.

The Road To Value Can't Be Paved With A Broken Medicare Physician Fee Schedule.

Value-based payment has been promoted for increasing quality, controlling spending, and improving patient and practitioner experience. Meanwhile, needed reforms to fee-for-service payment (the Medicare Physician Fee Schedule) have been ignored as policy makers seek to move payment toward alternatives, even though the fee schedule is an intrinsic part of Alternative Payment Models. In this article, we show how value-based payment and the fee schedule should be viewed as complementary, rather than as separate silos. We trace the origins of embedded flaws in the fee schedule that must be fixed if value-based payment is to succeed. These include payment distortions that directly compromise value by overpaying for certain procedures and imaging services while underpaying for services that add value for beneficiaries. We also show how the fee schedule can accommodate bundled payments and population-based payments that are central to Alternative Payment Models. We draw two conclusions. First, the Centers for Medicare and Medicaid Services should correct misvalued services and establish a hybrid payment for primary care that blends fee-for-service and population-based payment. Second, Congress should alter the thirty-five-year-old statutory basis for setting Medicare fees to allow CMS to explicitly consider policy priorities such as workforce shortages in refining fee levels.

Kidney Stone Care and Value-Based Payment Transformation: Design and Implementation of a Novel, Clinician-Led Bundled Payment Program.

Kidney Stone Care and Value-Based Payment Transformation: Design and Implementation of a Novel, Clinician-Led Bundled Payment Program.

Use Of High- And Low-Value Health Care Among US Adults, By Income, 2010-19.

Health care payment reforms in the US have aimed to encourage the use of high-value care while discouraging the use of low-value care. However, little is known about whether the use of high- and low-value care differs by income level. Using data from the 2010-19 Medical Expenditure Panel Survey, we examined the use of specified types of high- and low-value care by income level. We found that high-income adults were significantly more likely than low-income adults to use nearly all types of high-value care. Findings were consistent across age categories, although differences by income level in the use of high-value care were smaller among the elderly. Our analysis of differences in the use of low-value care had mixed results. Among nonelderly adults, significant differences between those with high and low incomes were found for five of nine low-value services, and among elderly adults, significant differences by income level were found for three of twelve low-value services. Understanding the mechanisms underlying these disparities is crucial to developing effective policies and interventions to ensure equitable access to high-value care and discourage low-value services for all patients, regardless of income.

Burden of out-of-pocket payment for maternal healthcare and its catastrophic effects in the era of free maternal and child health policy in Ghana

BackgroundGhana introduced a free maternal healthcare policy within its national health insurance program in 2008. Despite this, there are reports of significant out-of-pocket (OOP) payments for maternal healthcare in Ghana. This study examines OOP payments for maternal healthcare services and their catastrophic effects, including the correlates of catastrophic OOP payments. MethodsCross-sectional quantitative data were collected from 414 mothers through health facility exit interviews in two regions of Ghana. Catastrophic OOP payments were computed by expressing total health expenditure as a percentage of household total expenditure and non-food expenditure at various thresholds (5 %, 10 %, 20 % and 25 %). The correlates of catastrophic OOP payments were assessed using logistic regression models. ResultsThe median OOP payments for maternal healthcare was GH₵866.5(US$109.3). The median non-medical OOP cost (GH₵479[US$ 59.9]) was higher than the median medical OOP cost (GH₵296.5[US$ 37.1]). The median OOP cost was higher for delivery (GH₵454[US$56.8]) compared to ANC (GH₵356.5[US$44.5]) and PNC (GH₵21.5[US$2.6]). Non-medical supplies comprise 58 % of the total OOP payments. About 73 % and 90 % of respondents spent more than 5 % of their annual household total and non-food expenditure on maternal healthcare, respectively. Rural areas and care at private facilities were significantly associated (AORs<1; p-values<0.05) with lower probabilities of incurring catastrophic OOP expenditure. Tertiary education was associated (AORs> 1; p-values<0.05) with a higher probability of incurring catastrophic OOP payments. ConclusionOOP payments for maternal care are still prevalent in Ghana. We call for a reform of Ghana’s free maternal healthcare policy to include non-medical supplies within its benefit package.

Household Health Care Payments Under Rate Setting, Spending Growth Target, and Single-Payer Policies

Households have high burden of health care payments. Alternative financing approaches could reduce this burden for some households. To estimate the distribution of household health care payments across income under health care reform policies. Cross-sectional study with microsimulation used nationally representative data of the US population in 2030. Civilian, noninstitutionalized population from the 2022 Current Population Survey linked to expenditures from the 2018 and 2019 Medical Expenditure Panel Survey and 2022 National Health Expenditure Accounts were included. Rate regulation of hospital, physician, and other health care professional payments equal to the all-payer mean in the status quo, spending growth target at 4% annual per capita growth, and single-payer health care financed through taxes. Household health care payments (out-of-pocket expenses, premiums, and taxes) as a share of compensation. The synthetic population contained 154 456 records representing 339.5 million individuals, with 51% female, 7% Asian, 14% Black, 18% Hispanic White, 56% non-Hispanic White, and 5% other races and ethnicities (American Indian or Alaskan Native only; Native Hawaiian or other Pacific Islander only; and 2 or more races). In the status quo, mean household health care payments as a share of compensation was 24% to 27% (standard error [SE], 0.2%-1.2%) across income groups (median [IQR] 22% [4%-52%] below 139% of the federal poverty level [FPL]; 21% [4%-34%] for households above 1000% FPL [11% of the population]). Under rate setting, mean (SE) payments by households above 1000% FPL increased to 29% (0.6%) (median [IQR], 22% [6%-35%]) and decreased to 23% to 25% for other income groups. Under the spending growth target, mean (SE) payments decreased from 23% to 26% (SE, 0.2%-1.2%) across income groups. Under the single-payer system, mean (SE) payments declined to 15% (0.7%) (median [IQR], 4% [0%-30%]) for those below 139% FPL and increased to 31% (0.6%) (median [IQR], 23% [3%-39%]) for those above 1000% FPL. Uninsurance fell from 9% to 6% under rate setting due to improved Medicaid access, and to zero under the single-payer system. Single-payer financing based on the current federal income tax schedule and a payroll tax could substantially increase progressivity of household payments by income. Rate setting led to slight increases in payments by higher-income households, who financed higher payment rates in Medicare and Medicaid. Spending growth targets reduced payments slightly for all households.

Emerging Value-Based Care Payment Mechanisms to Reduce Health Inequities: The Accountable Care Organization Realizing Equity, Access, and Community Health Model

Emerging Value-Based Care Payment Mechanisms to Reduce Health Inequities: The Accountable Care Organization Realizing Equity, Access, and Community Health Model