Copayments For Visits Research Articles

Health, Access to Care, and Financial Barriers to Care Among People Incarcerated in US Prisons

Decades-old data indicate that people imprisoned in the US have poor access to health care despite their constitutional right to care. Most prisons impose co-payments for at least some medical visits. No recent national studies have assessed access to care or whether co-pays are associated with worse access. To determine the proportion of people who are incarcerated with health problems or pregnancy who used health services, changes in the prevalence of those conditions since 2004, and the association between their state's standard prison co-payment and care receipt in 2016. This cross-sectional analysis was conducted in October 2023 and used data from the Bureau of Justice Statistics' 2016 Survey of Prison Inmates, a nationally representative sample of adults in state or federal prisons, with some comparisons to the 2004 version of that survey. The state's standard, per-visit co-payment amount in 2016 compared with weekly earnings at the prison's minimum wage. Self-reported prevalence of 13 chronic physical conditions, 6 mental health conditions, and current severe psychological distress assessed using the Kessler Psychological Distress Scale; proportion of respondents with such problems who did not receive any clinician visit or treatment; and adjusted odds ratios (aORs) comparing the likelihood of no clinician visit according to co-payment level. Of 1 421 700 (unweighted: n = 24 848; mean [SD] age, 35.3 [0.3] years; 93.2% male individuals) prison residents in 2016, 61.7% (up from 55.9% in 2004) reported 1 or more chronic physical conditions; among them, 13.8% had received no medical visit since incarceration. A total of 40.1% of respondents reported ever having a mental health condition (up from 24.5% in 2004), of whom 33.0% had received no mental health treatment. A total of 13.3% of respondents met criteria for severe psychological distress, of whom 41.7% had not received mental health treatment in prison. Of state prison residents, 90.4% were in facilities requiring co-payments, including 63.3% in facilities with co-payments exceeding 1 week's prison wage. Co-payments, particularly when high, were associated with not receiving a needed health care visit (co-pay ≤1 week's wage: aOR, 1.43; 95% CI, 1.10-1.86; co-pay >1 week's wage: aOR, 2.17; 95% CI, 1.61-2.93). This cross-sectional study found that many people who are incarcerated with health problems received no care, particularly in facilities charging co-payments for medical visits.

Does Abolishing a Copayment Increase Doctor Visits? A Comparative Case Study

Abstract Insurance coverage increases health care consumption, but less is known whether moderate copayments affect adults’ primary care utilization in a system characterized by gatekeeping. We analyze whether abolishing a 14-euro copayment for visits to general practitioners (GP) in Helsinki, the capital of Finland, increased the number of GP visits among adults and especially among low-income individuals. Using a difference-in-differences (DD) design and combining several administrative registers from 2011 to 2014, we find that the abolition is associated with only a small increase in GP visits (+0.04 visits annually, or +4.4 %, for all adults). The increase is driven by low-income adults (+0.06 visits, or +4.5 %, at the bottom 40 %). Although the point estimates are rather robustly positive, the conclusions regarding the statistical significance are sensitive to how we account for clustering in a setting characterized by only one treated cluster and a finite number of comparison clusters.

Evaluation of patient perspective of point of care testing and medication: Dispensing by community pharmacists for Streptococcus pyogenes and influenza

BackgroundRecent state-level legislation allows pharmacies to implement protocols for the testing and treatment of influenza and group A streptococcal pharyngitis infections, which may improve access. ObjectivesThis study evaluated patient perspectives on testing and treatment of influenza or streptococcal pharyngitis infections in the pharmacy and evaluated patient acceptance, willingness to seek testing, and willingness to pay. MethodsThis study used a cross-sectional paper survey administered at the community pharmacy after receiving a coronavirus disease 2019 vaccine. The survey consisted of multiple choice and rank order. Surveys were anonymous and returned after completion before leaving the pharmacy. Survey data were entered into an Excel database for analysis. ResultsThere were a total of 152 respondents. Most of them were older than the age of 50 years and female. Most (89%) have a primary care provider (PCP) and their preferred location for testing was their PCP or a walk-in, quick care setting. More than half of the respondents stated that they would use the pharmacy as a source for testing and treatment for streptococcal pharyngitis infections and influenza. Half of the respondents pay an office copay visit of less than $15 and 29% pay $25-$50 per visit. The majority of respondents (62%) were willing to pay $25 or more out of pocket for testing. ConclusionAlthough the pharmacy was not the preferred site for testing, more than half of the respondents stated that they would use the pharmacy for testing and treatment. Most respondents’ willingness to pay was more than their copayments for office visits, suggesting some may value the convenience of testing and treatment at the pharmacy.

Challenges of Health Care Delivery at a Municipal Health Facility under Ghana’s National Health Insurance Scheme

Introduction: Empirical evidence on challenges to health care delivery at district/municipal level under the National Health Insurance Scheme (NHIS) in Ghana is limited. This study determined challenges to optimal health care delivery at a municipal hospital underGhana’s NHIS.Method: A cross-sectional study was undertaken between January-March 2010 at the Winneba Municipal Hospital (WHM) in Ghana to review out-patients (OPD) records from 2005- 2008. A structured questionnaire was used to collect data from 345 outpatients(170 insured and 175 uninsured), and from their folders. Eleven key informants from the WMH were interviewed.Results: The NHIS was introduced at the WMH in 2006, resulting in an increased OPD attendance of 77.3% in 2007. Insured clients visited the OPD many times and at shorter intervals than uninsured clients. Disease patterns at the OPD were however similarbefore and after the introduction of NHIS at the Hospital. Key health providers at the WMH admitted to increasing OPD numbers and prolonged client waiting times. Over 40% of insured clients spent three hours or more to receive OPD services. Financial support fromthe Government to the WMH has reduced since the introduction of NHIS. In 2008, over 70% of total hospital revenue was from the NHIS; delays in payment by District/Municipal Mutual Health Insurance Schemes (DMHIS) significantly strained hospital financesand provision of drugs and supplies.Conclusions: Increased OPD numbers, prolonged client waiting times, consumer moral hazard, limited Government financial support and delayed NHIS funds were critical challenges at the WMH. Innovative measures to limit moral hazard (i.e. reward mechanismsfor non-frequent visits, and introduction of copayments for multiple visits) are recommended. Means to improve the skills of hospital staff dealing with NHIS and staff of the DMHIS are policies worth pursuing.

Co-payment policies and breast and cervical cancer screening in Medicaid.

This study investigated the relationship between state Medicaid co-payment policies and cancer screening for Medicaid-enrolled women. Cross-sectional analysis of administrative claims and enrollment data. Our data included Medicaid Analytic eXtract (MAX) outpatient claims files across 43 states in 2003, 2008, and 2010, the years for which both MAX data and state cost-sharing data were available. Data on enrollee demographics and screening services from enrollment and claims files were merged with state-year data on co-payment policies and county-level controls from the Area Health Resources File. Participants were nonelderly, nondisabled, nonpregnant women in the recommended age range for each screening service (50-64 years for mammograms; 21-64 years for Pap tests) enrolled in fee-for-service Medicaid. The main independent variable is whether an enrollee faced cost sharing for preventive services. We examined 3 categories of cost sharing: co-payments for all visits, including for preventive services; co-payments for outpatient visits but waived for preventive services; and no co-payments. The main outcome measure was receipt of mammogram or Pap test within a 12-month period. Medicaid enrollees with co-payments for preventive services were less likely to receive both screening mammograms and Pap tests than enrollees in states not requiring cost sharing for preventive services. Co-payments for preventive services discourage breast and cervical cancer screening among Medicaid enrollees. The effect is larger for breast cancer screening, which is costlier and requires an additional visit. Considering this evidence, cost sharing for preventive services may lead to adverse health consequences and greater long-term costs.

Financial distress among breast cancer survivors.

Aims:there has been an increasing awareness of the potential for oncology care to result in long-term financial burdens and financial toxicity. Patients who report cancer-related financial problems or high costs are more likely to forgo or delay prescription medications and medical care.Materials and Methods:we examined financial distress using data from a survey of 164 breast cancer survivors who had completed primary therapy for the disease.Key Findings:among respondents, 8.6% (13 of 151) reported that “being less able to provide for the financial needs of their family” was as a severe problem; 14.4% (22 of 153) reported “difficulty in meeting medical expenses” was a severe problem; and 8.4% (13 of 154) reported that “no money for cost of or co-payment for medical visits” was a severe problem. About 8.4% (13 of 154) of the respondents reported that “no money for cost of or co-payment for medicine” was a severe problem. In logistic regression analysis, younger age and lower household income were significant predictors of financial distress. In multiple linear regression analysis, younger age and lower household income were significant predictors of financial distress.Significance:financial toxicity remains a major issue in breast cancer care. Efforts are needed to ensure patients experiencing high levels of financial toxicity are able to access recommended care. In addition, patients should talk with their providers about the costs of oncology care and about opportunities to reduce costs while maintaining high quality of care.

Young Adult Preventive Healthcare: Changes in Receipt of Care Pre- to Post-Affordable Care Act

PurposeYoung adults have unique health and health care needs. Although morbidity and mortality stem largely from preventable factors, they lack a structured set of preventive care guidelines. The Affordable Care Act (ACA), enacted in 2010, increased young adult insurance coverage, prohibited copayments for preventive visits among privately insured and for many preventive services. The objectives were to evaluate pre- to post-ACA changes in young adults' past-year well visits and, among those using a past-year health care visit, the receipt of preventive services. MethodsWe used pooled Medical Expenditure Panel Survey data, comparing pre-ACA (2007–2009, N = 10,294) to post-ACA (2014–2016, N = 10,567) young adults aged 18–25 years. Bivariable and multivariable stratified logistic regression, adjusting for sociodemographic covariates, were conducted to determine differences in well visits and in preventive services among past-year health care utilizers: blood pressure and cholesterol checks, influenza immunization, and all three received. ResultsPast-year well visits increased from pre-ACA (28%) to post-ACA (32%), p < .001. Increases were noted for most demographic subgroups with greatest increases among males, Asian, and highest income subgroups. Larger pre- to post-ACA increases were found for most of the preventive services, p < .05, including the receipt of all three services (7% vs. 16%), p < .001, among past-year health care utilizers. ConclusionFollowing ACA implementation, young adults experienced modest increases in well visit rates and larger increases in most preventive services received. Overall rates of both remain low. Building on these improvements requires concerted efforts that account for young adults' unique combination of health care issues and challenges in navigating an adult health care system.

Påvirker egenandeler ungdoms legebesøk?

Do co-payments for adolescents affect the number of visits to the physician? To determine the advantages and disadvantages of co-payment for visits to physicians, it is important to quantify the effect of co-payments on the number of consultations. The article uses a change in the co-payment system from 2010, when adolescents between 12 and 15 no longer had to pay a co-payment, in order to estimate the effect of co-payment for this age group. Using a difference-in-difference model and comparing against changes in other age groups, the elimination of co-payments is estimated to have increased GP visits by 13 and 18 percent for males and females respectively. Placebo tests show that the results are robust.

Potential impact of co-payment at point of care to influence emergency department utilization.

Background. Many proponents for healthcare reform suggest increased cost-sharing by patients as a method to reduce overall expenditures. Prior studies on the effects of co-payments for ED visits have generally not been directed toward understanding patient attitudes/behavior at point of care.Objectives. We conducted a survey at point of care to test our hypothesis that a significant number of patients with urgent chief complaints might have avoided the ED if asked to provide a co-payment.Methods. Cross-sectional study design. Stable, oriented, consenting patients at an inner-city, academic ED were consecutively enrolled at hours in which trained research associates were available to assist with data collection. Enrolled patients completed a written survey providing demographic/chief complaint information, and then were asked whether 13 interval amounts of co-payment ranging from 0 to >500 would have impacted their decision to visit the ED. Categorical data are presented as frequency of occurrence and analyzed by chi-square; continuous data presented as means ± standard deviation, analyzed by t-tests. ORs and 95% confidence intervals provided. Primary outcome parameter was the % of patients who would have avoided the ED if asked to pay any co-payment for several urgent chief complaints: chest pain, SOB, and abdominal pain.Results. A total of 581 patients were enrolled; 63.1% female, mean age 42.4 ± 15.1 years, 65% Hispanic, 71.2% income less than 20,000, 28.6% less than high school graduate, 81.3% had primary care physician, 57.6% had 2 or more ED visits/past year. Overall, 30.2% of patients chose 0 as the maximum they would have been willing to pay if it was required to be seen in the ED. 16/58 (28%; 95% CI [18–40%]) of chest pain patients, 9/43 (20.9%; 95% CI [11–35%]) of SOB patients, and 24/127 (26.8%; 95% CI [13–27%]) of abdominal pain patients would have been unwilling to pay a co-pay. Patients with income >20,000 were more willing to pay a co-payment (OR = 2.55; 95% CI [1.59–4.10]). No significant relationship was identified between willingness to pay for: gender, race, education, established primary care provider, and frequency of ED visits.Conclusion. Overall, 30.2% of our patients would not have accepted a co-pay in order to be seen, including more than 20% of the patients with chest pain, shortness of breath, and abdominal pain respectively.

The Ariadne's thread in co-payment, primary health care usage and financial crisis: findings from Cyprus public health care sector

ObjectivesCyprus entered a prolonged financial recession in 2011 and by early 2013 it applied for an international bail-out agreement. This presupposed massive reforms in public governance. Health sector was considerably reformed and one of the measures was the introduction of co-payment for outpatient visits to public health care sector. The scope of this study is to assess the impact of financial crisis and co-payment to public outpatient visits in Nicosia urban and greater Nicosia region. Study designAn Interrupted time-series analysis. MethodsAll outpatient visits to public health care family doctor/general practitioners in Nicosia urban and greater Nicosia region from January 2011 until May of 2014 were registered and analysed. ResultsFinancial crisis did not alter outpatient visits. Introduction of co-payment led to a statistically significant decrease from the second month after its introduction (p = 0.048) (R2 = 0.329, Q = 23.75, p = 0.137). This decrease was consistent until the end of the observational period and it did not level off. ConclusionsFinancial crisis did not affect outpatient visits while co-payment can be considered as a potent cost containment measure during financial recession, by normalising utilisation of healthcare resources.

La atención primaria en Francia

The poor planning of health care professionals in Spain has led to an exodus of doctors leaving the country. France is one of the chosen countries for Spanish doctors to develop their professional career.The French health care system belongs to the Bismarck model. In this model, health care system is financed jointly by workers and employers through payroll deduction. The right to health care is linked to the job, and provision of services is done by sickness-funds controlled by the Government. Primary care in France is quite different from Spanish primary care. General practitioners are independent workers who have the right to set up a practice anywhere in France. This lack of regulation has generated a great problem of “medical desertification” with problems of health care access and inequalities in health. French doctors do not want to work in rural areas or outside cities because “they are not value for money”.Medical salary is linked to professional activity. The role of doctors is to give punctual care. Team work team does not exist, and coordination between primary and secondary care is lacking. Access to diagnostic tests, hospitals and specialists is unlimited. Duplicity of services, adverse events and inefficiencies are the norm. Patients can freely choose their doctor, and they have a co-payment for visits and hospital care settings.Two years training is required to become a general practitioner. After that, continuing medical education is compulsory, but it is not regulated.Although the French medical Health System was named by the WHO in 2000 as the best health care system in the world, is it not that good. While primary care in Spain has room for improvement, there is a long way for France to be like Spain.

Effects of changes in copayment for obstetric emergency room visits on the utilization of obstetric emergency rooms

In view of the growing proportion of “non-urgent” admissions to obstetric emergency rooms (OERs) and recent changes in copayment policies for OER visits in Israel, we assessed factors contributing to OER overcrowding. The changes investigated were (a) exemption from copayment for women with birth contractions, (b) allowing phone referrals to the OER and (c) exemption from copayment during primary care clinic closing hours.We analyzed data of a large tertiary hospital with 37 deliveries per day. Counts of women discharged to home from the OER were an indicator of “non-urgent” visits.The annual number of non-urgent visits increased at a higher rate (3.4%) than the natural increase in deliveries (2.1%). Exemption from copayment for visits during non-working hours of primary care clinics was associated with increases in OER admissions (IRR=1.22) and in non-urgent OER visits (IRR=1.54). Younger and first-time mothers with medically unjustified complaints were more likely to be discharged to home.We showed that the changes in the policy for OER copayment meant to attract new clients to the HMO had an independent impact on OER utilization, and hence, added to the workload of medical personnel. The change in HMO policy regulating OER availability requires rigorous assessment of possible health system implications.

Capsule Commentary on Duru et al., Adherence to Metformin, Statins, and ACE/ARBs Within the Diabetes Health Plan (DHP).

The employer-level “intent-to-treat” cohort study by Duru et al. evaluated the impact of an employer-initiated disease management program, the Diabetes Health Plan (DHP), on adherence to diabetes-related medications.1 Using a quasi-experimental design, the investigators estimated employer-level adherence post-initiation of DHP for three medications covered by the DHP (metformin, statins, ACE/ARBs) and two medications not covered by the DHP (thyroxine, montelukast). The DHP provided enrolled participants discounted copayments for medications and provider visits, and access to online or telephone wellness coaching. There was a modest improvement in adherence to the three DHP-covered medications after 1 year.

Cost sharing as a tool to drive higher-value care.

Cost sharing as a tool to drive higher-value care.

Impact of a High-deductible Health Plan on Outpatient Visits and Associated Diagnostic Tests

By shifting a greater share of out-of-pocket medical costs to consumers, high-deductible health plans (HDHP) might discourage use of essential outpatient services. The objective of the study was to examine the impact of an HDHP on outpatient visits and associated laboratory and radiology tests. We used a pre-post with comparison group study design to examine the differential change in outpatient service utilization among 7953 adults who were switched from a traditional Health Maintenance Organization plan to an HDHP compared with 7953 adults remaining in traditional plans. HDHP members had full coverage of preventive laboratory tests and modest copayments for outpatient visits, similar to controls, but faced full cost sharing under the deductible for radiology tests and laboratory tests not classified as preventive. Compared with controls, the HDHP group experienced moderate relative decreases in overall office visits (incidence rate ratios = 0.91, or a 9% relative reduction; 95% confidence interval: 0.88, 0.94) and visits for higher-priority (0.91; 0.85, 0.97) and lower-priority (0.89; 0.81, 0.99) chronic conditions. There were no significant differences in changes in visit rates for acute higher-priority or lower-priority conditions (both 0.93; 0.86, 1.01) or preventive laboratory tests (0.97; 0.93, 1.02). HDHP members showed moderate relative reductions in the use of general laboratory tests (0.91; 0.86, 0.97) but not radiology tests (0.97; 0.91, 1.03). Chronic outpatient visits declined among HDHP members, although preventive laboratory tests and acute visits remained unchanged. HDHP patients with chronic illnesses who have more contact with the health care system might be more likely to reduce utilization because of increased exposure to costs associated with ambulatory visits.

THU0132 Prevalence and Predictive Value of Serum Autoantibodies in the General Population: Results of a Longitudinal Study on 2690 Subjects with a 13-Year Observation

BackgroundThe prevalence of serum autoantibodies in the general population is generally obtained from large datasets including blood donors or employees and are thus poorly representative. Similarly, it is challenging to...

Out of Pocket, Out of Sight? An Unmeasured Component of the Burden of Cancer

Out of Pocket, Out of Sight? An Unmeasured Component of the Burden of Cancer

HOW PRICE RESPONSIVE IS THE DEMAND FOR SPECIALTY CARE?

Outpatient visit co-payments have increased in recent years. We estimate the patient response to a price change for specialty care, based on a co-payment increase from $15 to $50 per visit for veterans with hypertension. A retrospective cohort of veterans required to pay co-payments was compared with veterans exempt from co-payments whose nonequivalence was reduced via propensity score matching. Specialty care expenditures in 2000-2003 were estimated via a two-part mixed model to account for the correlation of the use and level outcomes over time, and results from this correlated two-part model were compared with an uncorrelated two-part model and a correlated random intercept two-part mixed model. A $35 specialty visit co-payment increase had no impact on the likelihood of seeking specialty care but induced lower specialty expenditures over time among users who were required to pay co-payments. The log ratio of price responsiveness (semi-elasticity) for specialty care increased from -0.25 to -0.31 after the co-payment increase. Estimates were similar across the three models. A significant increase in specialty visit co-payments reduced specialty expenditures among patients obtaining medications at the Veterans Affairs medical centers. Longitudinal expenditure analysis may be improved using recent advances in two-part model methods.

When co‐payments for physician visits can affect supply as well as demand: findings from a natural experiment in Israel's national health insurance system

In 1998, Israel's national health insurance system introduced a modest co-payment for visits to specialist physicians. This study takes advantage of a natural experiment in which 15% of the population--the poor and disabled--was exempted from these co-payments. It used the micro-level panel data of three large health plans on the physician visits of 50,000 members per plan in 1997-2001. The data indicate that, following introduction of the co-payment, specialist visits increased among non-exempt members, relative to exempt members, of two health plans that together account for two-thirds of the population. This paper illustrates how, unlike the Health Insurance Experiment and other US studies of cost sharing, the structure of the co-payment in Israel may have inadvertently limited the incentive to decrease consumer demand and may have created an incentive for the health plans to increase visit rates, especially among the non-exempt members. Other countries that have implemented co-payment systems with exemptions may benefit from the Israeli experience in designing and evaluating their systems.

Copayments Did Not Reduce Medicaid Enrollees’ Nonemergency Use Of Emergency Departments

Eager to reduce unnecessary use of hospital emergency departments by Medicaid enrollees, states are increasingly implementing cost sharing for nonemergency visits. This paper uses monthly data from the 2001-2006 Medical Expenditure Panel Surveys (MEPS) to examine how changes in nine states' copayment policies influence enrollees' use of emergency departments. The results suggest that requiring copayments for nonemergency visits did not decrease emergency department use by Medicaid enrollees. Future research should examine more closely the effects at the state level and investigate whether these copayments affected the use of other services, such as hospitalizations or visits to physicians by Medicaid enrollees.