Copayment Rate Research Articles

Manufacturer encroachment and extended warranty provision

This study focused on the interactions between manufacturer encroachment and extended warranty (EW) provision by examining the manufacturer's optimal encroachment decision with or without the extended warranty and the optimal EW provision decision under encroachment or no encroachment. Based on the combination of the two strategies, this study discussed four different models in which the manufacturer and retailer act as the Stackelberg leader and follower, respectively. It was shown that the manufacturer always finds it optimal to offer EW without encroachment. However, under encroachment, the manufacturer's motivation to offer EW weakens. Furthermore, when EW is not offered, the manufacturer can benefit from encroachment if the selling cost of the product is not sufficiently high. When the selling cost of EW is low, the manufacturer's motivation for encroachment strengthens. As the selling cost becomes moderate to high, offering EW weakens the manufacturer's motivation for encroachment. Our analysis reveals that for different values of the co-payment rate and the manufacturer's selling costs of products and EW, encroachment and EW provision may reinforce or impair each other. Therefore, manufacturer has to pay attention to the influence of one decison on another decision.

Does income matter for the policy effect of public long-term care insurance on informal care use in China? A quasi-experimental study.

Since 2016, the Chinese government has been piloting a public long-term care insurance (LTCI) scheme. This study examined whether the LTCI scheme reduced the use of informal care and how this has varied across income groups. We used data from the 2011, 2014, and 2018 waves of Chinese Longitudinal Healthy Longevity Survey, focusing on community-dwelling older adults aged 65 years and older. We used staggered difference-in-differences analyses with propensity score matching to examine the effects of the policy. The LTCI scheme reduced the probability and intensity of informal care use by 5.7% (p < .05) and 17.4% (p < .05), respectively. The policy impact was limited to older people in the middle-income group, reducing the probability and intensity of informal care use by 15.6% (p < .001) and 43.1% (p < .05), respectively. We did not find a statistically significant policy effect for older adults with high or low incomes. The LTCI scheme had different effects on reducing the informal care burden for family caregivers by income level. We suggest that the scheme should entitle people with low incomes to a preferential co-payment rate, thereby enhancing their access to formal care.

Evaluating the effects of the 2017 National Health Insurance coverage expansion on amenable mortality and its disparities between areas in South Korea using Bayesian structural time-series models

To improve the low coverage rate of the National Health Insurance (NHI), South Korea implemented the NHI coverage expansion plan in 2017 to cover medically essential non-covered services and reduce copayment rates. This study aimed to estimate the effects of the 2017 NHI coverage expansion on amenable mortality and its disparities between areas in South Korea under a controlled interrupted time-series design using Bayesian structural time-series models. Age-standardized amenable mortality rates and rate differences (RDs) and rate ratios (RRs) between areas for amenable mortality were calculated monthly between July 2012 and December 2021 and used as the response series. The non-equivalent control series were monthly non-avoidable mortality rates and their regional disparities. After the coverage expansion, amenable mortality rates decreased for both males (−8.8%, 95% credible interval [CrI] −13.4% to −3.9%) and females (−8.3%, 95% CrI −13.4% to −2.4%), with the largest decline in the non-Seoul-Capital metropolitan area (−11.6%, 95% CrI −16.5% to −6.3%) rather than the Seoul Capital Area (−7.5%, 95% CrI −11.9% to −2.5%) and a non-significant reduction in the non-Seoul-Capital non-metropolitan area in females. RDs and RRs between areas for amenable mortality decreased non-significantly (−16.2%, 95% CrI −31.3% to 2.6% for RD and −1.2%, 95% CrI −3.7% to 1.5% for RR), except for a significant decrease in RD in males (−21.8%, 95% CrI −38.0% to −1.5%), and decreased less in females than in males. The coverage expansion was generally effective in reducing amenable mortality rates by area, but had limited effects in closing amenable mortality disparities between areas, favoring males and the non-Seoul-Capital metropolitan area. These results implied that additional measures are necessary to improve access to quality health care for females and underserved areas to enhance the effectiveness of the coverage expansion.

A mathematical programming based decision support system for waste to resource market trading

In a linear economy, consumers typically dispose end-of-life products which are eventually incinerated or landfilled. Digital platforms could unlock rich waste reutilization opportunities and economic benefits by connecting the waste producers with potential waste buyers in online marketplaces. While previous studies mostly focus on input-output matching, this study proposes a decision support system that can be incorporated to an online marketplace to optimize the waste trading based on economic considerations. Moreover, the decision support system could facilitate higher level decisions such as capacity planning and incentive design. Based on a case study on Singapore’s organic waste streams, the waste trading platform presents economic benefits for agents that sell their waste. Additionally, enforcing waste reutilization targets would require relevant policy support in terms of incentives or levies, where the levies can be implemented as co-payment rate for the agents. For instance, results showed that when the food waste reutilization target is set as 6 t/d, increasing the co-payment rate from 0 to 20% allows the waste trading network to be self-sustaining without external funding. Finally, sensitivity analyses show that collecting more waste records in the database helps in optimizing the investment decisions, preferably when the number of records exceeds 64.

Willingness to pay for colorectal cancer screening: A systematic review

Colorectal cancer (CRC) screening is crucial to reduce the global economic burden related to CRC. The purpose of this study is to examine studies on assessing willingness to Pay (WTP) for CRC screening and to investigate any potential variables influencing WTP. A systematic review was conducted through databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. The study included 10 English-language studies that evaluated WTP for CRC screening. The study assessed how much participants were willing to pay for the assumed test cost by calculating the proportion of their WTP value. All values were converted to 2023 USD using a consumer price indices calculator and US Treasury converter. This study showed that the WTP value for CRC screening varied from USD 11.07 to USD 658.65. The co-payment rate ranged from 0.15 to 83.73. The factors influencing WTP value includes sociodemographic factors and the screening test attributes. Our study revealed the variative relationship between sociodemographic parameters and test features in influencing individuals’ decisions about CRC screenings. Understanding the importance of both demographic factors and test attributes is crucial for future research to develop targeted strategies for improving CRC screening uptake. Additionally, insights into WTP value aid in shaping public policies for CRC screening programs.

Association of individual-socioeconomic variation in quality-of-primary care with area-level service organisation: A multilevel analysis using linked data.

Ensuring equitable access to primary care (PC) contributes to reducing differences in health related to people's socioeconomic circumstances. However, there is limited data on system-level factors associated with equitable access to high-quality PC. We examine whether individual-level socioeconomic variation in general practitioner (GP) quality-of-care varies by area-level organisation ofPC services. Baseline data (2006-2009) from the Sax Institute's 45 and Up Study, involving 267,153 adults in New South Wales, Australia, were linked to Medicare Benefits Schedule claims and death data (to December 2012).Small area-level measures of PC service organisation were GPs per capita, bulk-billing (i.e., no copayment) rates, out-of-pocket costs (OPCs), rates of after-hours and chronic disease care planning/coordination services. Using multilevel logistic regression with cross-level interaction terms we quantified the relationship between area-level PC service characteristics and individual-level socioeconomic variation in need-adjusted quality-of-care (continuity-of-care, long-consultations, and care planning), separately by remoteness. In major cities, more bulk-billing and chronic disease services and fewer OPCs within areas were associated with an increased odds of continuity-of-care-more so among people of high- than low education (e.g., bulk-billing interaction with university vs. no school certificate 1.006 [1.000, 1.011]). While more bulk-billing, after-hours services and fewer OPCs were associated with long consultations and care planning across all education levels, in regional locations alone, more after-hours services were associated with larger increases in the odds of long consultations among people with low- than high education (0.970 [0.951, 0.989]). Area GP availability was not associated with outcomes. In major cities, PC initiatives at the local level, such as bulk-billing and after-hours access, were not associated with a relative benefit for low- compared withhigh-education individuals. In regional locations, policies supporting after-hours access may improve access to long consultations, more so for people with low- compared with high-education.

Impact of lower co-payments on risk-reducing salpingo-oophorectomy and BRCA testing in Japan

BackgroundIn April 2020, insurance coverage for risk-reducing salpingo-oophorectomy (RRSO) for breast cancer patients with hereditary breast and ovarian cancer (HBOC) syndrome and BRCA testing were started in Japan. We investigated the impact of insurance coverage on the number of RRSO and BRCA tests performed.MethodsThe subjects were 370 breast cancer patients and 23 of their relatives who received genetic counseling at our institution between April 2014 and December 2021. Finally, 349 patients and 15 relatives were analyzed. We retrospectively compared the number of BRCA tests, RRSO, insurance status, and co-payment of medical expenses before and after insurance coverage based on medical records.ResultsIn the 6-year pre-coverage period, 226 patients (mean: 37/year) received genetic counseling and 106 (17/year) received BRCA testing. In the 21-month post-coverage period, 161 patients (92/year) received genetic counseling and 127 (72/year) received BRCA testing. The rate of testing/counseling significantly increased in the post-coverage period (46.9% vs. 78.8%; p < .001). The number of patients who were diagnosed with HBOC were 24 (4/year) and 18 (10/year) and RRSO was performed for 7 (1/year) and 11 (6/year) patients in the pre- and post-coverage periods, respectively. The rate of RRSO/HBOC was significantly increased in the post-coverage period (29.1% vs. 61.1%; p = 0.039). RRSO patients' co-payment rates decreased from 64% to 25% pre- and post-coverage.ConclusionsOur findings suggest that decreased co-payments were the primary reason for these increases. Insurance coverage is an important factor when promoting preventive medical services such as RRSO.

Co-Payments and Inequality in Gingival Bleeding and Dental Visits

Japan's universal health insurance covers a wide range of dental treatments, and the co-payment rates differ by age. We investigated whether the inequality in gingival bleeding and dental visits was smaller amongst those with lower co-payment rates. This cross-sectional study used data from the 2019 Japan Gerontological Evaluation Study. The participants were functionally independent adults aged 65 years or older. The dependent variables were current gingival bleeding as a symptom of periodontal diseases and dental nonattendance for treatment in the past year. The independent variables were ridit scores of equivalent income and educational status. For covariates, we used age, sex, and the number of remaining teeth. To evaluate the inequalities, we used the slope index of inequality (SII) and the relative index of inequality (RII). We also conducted stratified analyses by co-payment rates (30%, 20%, and 10%) to clarify the difference in inequalities by co-payment rate. A total of 15,389 participants were included in the analysis; their mean age was 71.8 (SD=4.1) and 51.8% were women. There were significant absolute and relative inequalities in gingival bleeding and dental visits by equivalent income and education. With regards to educational status, inequalities were lower with a decrease in the co-payment rate. In particular, relative inequality by education in gingival bleeding was the largest amongst the 30% co-payment group (RII, 1.918; 95% confidence interval [CI], 1.386 to 2.656). For gingival bleeding, the absolute and relative inequality by equivalent income were not significant amongst the 10% co-payment group (SII, -0.003; 95% CI, -0.003 to 0.028; RII, 1.006; 95% CI=0.676 to 1.498). A low co-payment rate was associated with smaller inequalities in gingival bleeding and dental visits by equivalent income and educational status.

The effects of dental visits on the occurrence of acute hospitalization for systemic diseases among patients aged 75 years or older: A propensity score-matched study

BackgroundAlthough several studies examined the association between oral status and the risk of systemic diseases, few have examined whether dental visits affect the occurrence of acute hospitalization due to systemic diseases. This study examined the effects of dental visits on preventing the occurrence of acute hospitalization due to systemic diseases in adults aged ≥ 75 years, in order to optimize the healthcare system for older adults. MethodsThis propensity-score-matched retrospective cohort study was conducted using medical insurance claims data from Hokkaido, Japan. We analyzed 432,292 adult outpatients aged ≥ 75 years between September 2016 and February 2017 (baseline period). The exposure variable was visits to the dental office during the baseline period. The primary outcome variable was the occurrence of acute hospitalization due to pneumonia, urinary tract infections, cerebrovascular diseases, or coronary heart diseases between March 2017 and March 2019. ResultsAmong the 432,292 patients before propensity score matching, 149,639 (34.6%) had visited the dental office. One-to-one propensity score matching produced 149,289 matched pairs adjusted for the differences in all covariables (age, sex, copayment rate, annual health checkup, chronic diseases, and residential area). In these matched pairs, the risk ratio of the occurrence of acute hospitalization due to pneumonia, urinary tract infections, and cerebrovascular diseases was lower among patients who had visited dental office than among those who did not. ConclusionsDental visits appeared to be effective in preventing acute hospitalization due to systemic diseases, thus, dental care services would be an important component of healthcare for older adults.

Co-payment and adolescents' use of psychologist treatment: Spill over effects on mental health care and on suicide attempts.

The literature around co-payment shows evidence of increasing consumption following reduced co-payment. We apply difference-in-difference methods to assess the effect of abolishing the co-payment on psychologist treatment of anxiety and depression in 18 to 21-year olds. We apply nationwide individual level data with individuals close to this age interval as control group. The population amounts to approximately 1.2 million individuals and a total of 51 million patient months of observations. We show that after removing co-payment, the use of psychologist treatment almost doubles. We find that this increase involves moderately positive spill over effects on outpatient psychiatric care and on prescriptions of antidepressants. In the heterogeneity analysis we find evidence of higher effects on adolescents from families with lower income, indicating that reduced co-payments may increase equality in access. We also see that effects are higher for individuals listed with general practitioners (GPs) with a reluctant referral style; indicating that these GPs' behavior is affected by patient co-payment rates. Interestingly, we find evidence of significant reductions in suicide attempts - primarily among high-income women and low-income men. This indicates that better access to mental health care for adolescents may have a positive impact on their mental health and well-being.

Healthcare Utilization Under a Comprehensive Public Welfare Program: Evidence From Japan.

The public assistance system in Japan provides detailed and comprehensive livelihood support for low-income families with various needs. As one example, and the beneficiaries of the public welfare program in Japan can receive the same medical treatments as those insured of the universal public health insurance without any financial burdens. This system has greatly contributed to maintaining and improving the health of public assistance beneficiaries but may cause excessive healthcare utilization: moral hazard. This study uses a large sample taken from two nationally representative claim data for public assistance and public health insurance patients to estimate the magnitude of moral hazard effect in basic outpatient utilization. The results of the fixed-effect regression analysis utilizing the concept of pseudo panel data analysis and those of propensity score matching show that the average treatment effect of public assistance assignment on healthcare utilization is significantly positive. Specifically, public assistance assignment increases monthly healthcare expenditure by 17.5 to 22.9 percent and the monthly number of doctor visits by 23.1 to 27.8 percent, respectively. In addition, the average treatment effects on the treated are also significantly positive, suggesting that monthly healthcare expenditure significantly decreases by 22.7 to 25.0 percent and the number of visits by 27.6 to 29.7 percent, respectively, when imposing a copayment on public assistance beneficiaries. However, the estimated price elasticity based on these results is very small, approximately −0.02, indicating that the level of copayment rate has little effect on the intensive margin of outpatient healthcare utilization.

Difference of income inequalities of denture use by co-payment rates: A JAGES cross-sectional study.

Studies suggest that wearing dentures to restore missing teeth can have a positive impact on health status. However, income inequalities in denture wearing exist. The aim of this study was to investigate how differing co-payment rates under the current Japanese Universal Health Insurance Coverage System affect income inequalities in denture non-use among older adults with severe tooth loss. This cross-sectional study used data from the 2019 Japan Gerontological Evaluation Study (JAGES). Self-administered questionnaires were mailed to 345 356 independent people who did not receive long-term care insurance benefits and were aged ≥65 years. The dependent variable was denture non-use, and the independent variable was the equivalent annual household income. The Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were used with regression-based approaches to determine both absolute and relative inequalities in denture non-use by co-payment rates. The covariates were sex, age, years of education, number of teeth and comorbidities. Of the 240 889 responses received (response rate =69.9%), we analysed 21 594 participants who fulfilled the inclusion criteria. The mean age was 72.8 years (standard deviation =4.1), and 57.6% were men. For 30 per cent, 20 per cent and 10 per cent co-payment rates, the percentages of people who did not use dentures and had severe tooth loss (≤9 teeth) were 18.3%, 13.3%, and 8.5%, respectively. All analyses confirmed significant inequalities in denture non-use. The lower the co-payment rate, the smaller the inequalities. SIIs for each co-payment rate were as follows: 30 per cent =13.35% (95% confidence interval [CI]=9.61-17.09); 20 per cent =7.85% (95% CI=4.88-10.81); and 10 per cent =4.85% (95% CI=2.55-7.16). Inclusion of interaction term between income and co-payment rate significantly lowered the inequalities by co-payment rate in logistic regression analysis and SII. For RII, although the interaction was not statistically significant, a similar trend was observed. Income inequalities in denture use existed among older adults with severe tooth loss in Japan, and the inequalities appeared to be greater when the co-payment rate was higher.

Pediatric Medication Noninitiation in Spain.

To estimate medication noninitiation prevalence in the pediatric population and identify the explanatory factors underlying this behavior. Observational study of patients (<18 years old) receiving at least 1 new prescription (28 pharmaceutical subgroups; July 2017 to June 2018) in Catalonia, Spain. A prescription was considered new when there was no prescription for the same pharmaceutical subgroup in the previous 6 months. Noninitiation occurred when a prescription was not filled within 1 month or 6 months (sensitivity analysis). Prevalence was estimated as the proportion of total prescriptions not initiated. To identify explanatory factors, a multivariable multilevel logistic regression model was used, and adjusted odds ratios were reported. Overall, 1 539 003 new prescriptions were issued to 715 895 children. The overall prevalence of 1-month noninitiation was 9.0% (ranging from 2.6% [oral antibiotics] to 21.5% [proton pump inhibitors]), and the prevalence of 6-month noninitiation was 8.5%. Noninitiation was higher in the youngest and oldest population groups, in children from families with a 0% copayment rate (vulnerable populations) and those with conditions from external causes. Out-of-pocket costs of drugs increased the odds of noninitiation. The odds of noninitiation were lower when the prescription was issued by a pediatrician (compared with a primary or secondary care clinician). The prevalence of noninitiation of medical treatments in pediatrics is high and varies according to patients' ages and medical groups. Results suggest that there are inequities in access to pharmacologic treatments in this population that must be taken into account by health care planners and providers.

Current status of specific pediatric chronic diseases in Japan: National measures, disease types, treatment availability, copayment assistance, and research.

In Japan, specific pediatric chronic diseases include 788 diseases in 16 groups of diseases, 278 categories, and 845 subcategories as of November 1, 2021. The national specific pediatric chronic diseases measures - also called the Medical Aid Program for Chronic Pediatric Diseases of Specified Categories (MAPChD) - was established in Japan in 1974 and enshrined in law in 2005. Patients with specific pediatric chronic diseases can receive government support and welfare in several ways: i) MAPChD requires diagnosis and medical treatment at designated hospitals and by designated physicians so that patients receive optimal treatment; ii) the copayment rate for medical expenses is reduced to 20% and a maximum is set depending on household income; and iii) the analysis of specific pediatric chronic diseases from different perspectives is continuously being promoted. In addition to these three aspects, various measures are being implemented to provide ongoing support for patients with specific pediatric chronic diseases as they grow up.

Health Care Insurance and Moral Hazard

In this article, we discuss how moral hazard affects health care insurance, the social benefit and the harmfulness of moral hazard in health care insurance. We also discuss the relationship between copayment rate and decease risks and indicate that it is necessary to reduce copayment ratio for serious decease in social health care insurance in order to generate social gain. Finally, we carry out sensitivity analysis to illustrate the effect of the change of important parameters on optimal copayment rate.

Dementia Severity Is Associated With Early Potentially Avoidable Readmissions in an Acute Care Hospital

Understanding the association of dementia severity with early potentially avoidable readmissions (PAR) could encourage the identification of the target patients for the health care providers to provide transitional care (i.e. follow-up and coordination care) to prevent early readmissions. This study examined whether dementia severity before admission was associated with PAR within 90 days (90-day PAR). This retrospective cohort study was conducted using a Diagnosis Procedure Combination database linked with routinely collected dementia assessment data from a large acute general hospital in Tokyo, Japan. Patients aged 65 or older who were discharged to home or facilities (n=8,910; mean age: 79.8 years, standard deviation: 7.4 years) between July 2016 and September 2018. The dementia severity was classified as normal, slight, moderate, severe dementia based on the Dementia Assessment Sheet for Community-based Integrated Care System 21-items (DASC-21) from the patient or their family at admission. We conducted a multivariable logistic regression adjusted for covariates (sex, age, insurance copayment rate, diagnosis at admission, Charlson Comorbidity Index, unscheduled admission, ICU utilization, surgical treatment, length of hospital stay, discharge place) to examine the association of severity of dementia with 90-day PAR. Among the patients, 225 (2.5%) experienced 90-day PAR. The adjusted odds of 90-day PAR among patients with moderate dementia were 1.571 times (95% confidence interval [CI]: 1.102-2.240) and patients with severe dementia were 2.386 times (95% CI: 1.294-4.398) higher than the odds among patients without dementia. Patients with moderate and severe dementia before admission would be the target with high priority for providing transitional care.

Policies to Reduce Antibiotic Consumption: The Impact in the Basque Country.

In 2013, a change in copayment rate was introduced in the Basque Country (one year later than in the other regions in Spain), and improvements were made to drug packaging. In 2014, a National Program Against Bacterial Resistance (Spanish abbreviation: PRAN) was approved. The aim of this study is to analyze the impact of change to the copayment rate, the adjustment of drug packaging, and the approval of PRAN on the consumption of antibiotics. Raw monthly data on the consumption of antibiotics (costs, packages, and daily defined doses per thousand people (DID)) were collected from January 2009 to December 2018 in the Basque Country. Counterfactual and intervention analysis (Autoregressive integrated moving average (ARIMA) model) was performed for the total series, disaggregated by group of antibiotics (2019 WHO Access, Watch, and Reserve (AWaRe) Classification) and active substances with the highest cost per prescription (cefditoren and moxifloxacin), the lowest cost per prescription (doxycycline and cloxacillin), and the most prescribed active ingredients (amoxicillin, azithromycin, and levofloxacin). Introduction of copayment led to a ‘stockpiling effect’ one month before its implementation, equal to 8% in the three consumption series analyzed. Only the adjustment of drug packaging significantly reduced the number of packages dispensed (−12.19%). PRAN approval reduced consumption by 0.779 DID (−4.51%), representing a significant decrease for both ’access’ and ’watch’ group antibiotics. Despite the delay in implementing changes to copayment, there was a ‘stockpiling effect’. With the adjustment of packaging, fewer packs were prescribed but with a higher drug load and price. PRAN approval reduced both the consumption of ’access group antibiotics’ (first-line treatment) and ’watch group antibiotics’ (second-line treatment).

The effects of raising the long‐term care insurance co‐payment rate on the utilization of long‐term care services

The effect of raising insurance co-payment rates on healthcare service utilization in Japan remains unclear. In this study, we utilized patient-level long-term care (LTC) insurance claims data to analyze these effects. Claims data were obtained on individuals certified as requiring LTC in City A and City B, Fukuoka Prefecture, Japan during August 2014-July 2016. Individuals whose LTC insurance co-payment rate increased from 10% to 20% in August 2015 were regarded as high-income individuals; individuals whose co-payment rate remained at 10% were regarded as non-high-income individuals. We examined the changes in LTC service utilization between high-income individuals and non-high-income individuals during the study period. Monthly LTC insurance charges were analyzed to evaluate service utilization. We created monthly panel data for the study participants, and quantified the differences in LTC service utilization before and after August 2015 between the high-income and non-high-income groups. Care needs levels and age were included as covariates in a fixed-effects model. The sample comprised 7711 individuals (1000 high-income individuals and 6711 non-high-income individuals) in City A and 647 individuals (84 high-income individuals and 563 non-high-income individuals) in City B. After adjusting for care needs levels and age, the co-payment rate increase was associated with reductions in monthly LTC insurance charges of $34.3 (P < 0.001) in City A and $91.0 (P = 0.022) in City B. The increase in co-payment rate for high-income individuals in August 2015 negatively affected their utilization of LTC services. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2020; ••: ••-••.

Can income-based co-payment rates improve disparity? The case of the choice between brand-name and generic drugs

BackgroundHigher income population tend to prefer brand-name to generic drugs, which may cause disparity in access to brand-name drugs among income groups. A potential policy that can resolve such disparity is imposing a greater co-payment rate on high-income enrollees. However, the effects of such policy are unknown. We examined how patients’ choice between brand-name and generic drugs are affected by the unique income-based co-payment rates in Japan; 10% for general enrollees and 30% for those with high income among the elderly aged 75 and over.MethodsWe drew on cross-sectional price variation among commonly prescribed 311 drugs using health insurance claims data from a large prefecture in Japan between October 2013 and September 2014 to identify between-income-group differences in responses to differentiated payments.ResultsRunning 311 multivariate logistic regression models controlling individual demographics, the median estimate indicated that high-income group was 3% (odds ratio = 0.97) less likely to choose a generic drug than the general-income group and the interquartile estimates ranged 0.92–1.02. The multivariate feasible generalized least squares model indicated high-income group’s higher likelihood to choose brand-name drugs than the general-income group without co-payment rate differentiation (p < 0.001). Such gap in the likelihood was attenuated by 0.4% (p = 0.027) with an US$1 increase in the difference in additional payment/month for brand-name drugs between income groups — no gap with US$10 additional payment/month. This attenuation was observed in drugs for chronic diseases only, not for acute diseases.ConclusionsIncome-based co-payment rates appeared to reduce disparity in access to brand-name drugs across income groups, in addition to reducing total medical expenditure among high-income group who shifted from brand-name drugs to generic ones due to larger drug price differences.

The impact of Medicare copayments for skilled nursing facilities on length of stay, outcomes, and costs.

ObjectiveTo investigate the impact of Medicare's skilled nursing facility (SNF) copayment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs.Data Sources and Study SettingRetrospective cohort study from 2012 to 2016 using Medicare claims and SNF assessment data, including SNF admissions for Medicare fee‐for‐service beneficiaries.Study DesignWe first estimate how changes in Medicare's SNF copayment on the 21st day of a patient's benefit period affect length of SNF stay. We then use benefit day on admission as an instrumental variable to estimate the impact of SNF length of stay related to the copayment policy on readmission and Medicare payment.Principal FindingsFrom 2012 to 2016, we examined 291 134 SNF admissions. Higher benefit day on SNF admission was strongly associated with shorter SNF stays. A 1‐day shorter SNF stay was associated with higher readmission rate within 30 days of hospital discharge (1.5 percentage points; 95% CI 1.4‐1.6, P < .001) and within 30 days of SNF discharge (0.9 percentage points; 95% CI 0.8‐1.0), lower total Medicare payment for the 90‐day episode after hospital discharge ($396; 95% CI 361‐431, P < .001), but $179 higher payment for the 90 days after SNF discharge (95% CI 149‐210, P < .001), offsetting the lower payment for the shorter index SNF stay.ConclusionsMedicare's SNF copayment policy is associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy has unintended and negative effects on patient outcomes.