Effect Of Cost-sharing Research Articles

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

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

Why higher copayments for opioids did not reduce use among Medicare beneficiaries.

To examine whether higher cost-sharing deterred prescription opioid use. Medicare Part D claims from 2007 to 2016 for a 20% random sample of Medicare enrollees. We obtain estimates of the effect of cost-sharing on prescription opioid use using ordinary least squares and instrumental variables methods. In both, we exploit the variation (change) in cost-sharing within plans over time for a sample of beneficiaries who remain in the same plan. Focusing on changes in cost-sharing within a plan for a constant sample of beneficiaries mitigates potential bias from plan selection and using a constant set of weights derived from use in year (t) eliminates changes in the cost-sharing indexes due to (endogenous) consumer choice in year (t+1). Part D plans adopted benefit changes designed to reduce opioid use, including moving opioids to higher cost-sharing tiers. Increasing plan copayments for hydrocodone or oxycodone was associated with reductions in plan-paid claims and offsetting increases in cash claims. Widespread availability of low-cost generics combined with the anti-clawback provision in Part D mediated the effect of higher cost sharing to curb opioid use. As plans moved generic opioids to higher cost-sharing tiers, beneficiaries simply paid cash prices and aggregate use remained largely unchanged. The anti-clawback provision in Part D, intended to protect beneficiaries from price gouging, limited plans' ability to constrain opioid use through typical demand-side measures such as increased cost-sharing.

Effects of Cost Sharing on Ophthalmic Care Utilization in the Affordable Care Act Marketplace

ABSTRACT Purpose To determine the distribution and quantity of ophthalmic care consumed on Affordable Care Act (ACA) plans, the demographics of the population utilizing these services, and the relationship between ACA insurance coverage plan tier, cost sharing, and total cost of ophthalmic care consumed. Methods This cross-sectional study analyzed ACA individual and small group market claims data from the Wakely Affordable Care Act (WACA) 2018 dataset, which contains detailed claims, enrollment, and premium data from Edge Servers for 3.9 million individual and small group market lives. We identified all enrollees with ophthalmology-specific billing, procedure, and national drug codes. We then analyzed the claims by plan type and calculated the total cost and out-of-pocket (OOP) cost. Results Among 3.9 million enrollees in the WACA 2018 dataset, 538,169 (13.7%) had claims related to ophthalmology procedures, medications, and/or diagnoses. A total of $203 million was generated in ophthalmology-related claims, with $54 million in general services, $42 million in medications, $20 million in diagnostics and imaging, and $86 million in procedures. Average annual OOP costs were $116 per member, or 30.9% of the total cost, and were lowest for members with platinum plans (16% OOP) and income-driven cost sharing reduction (ICSR) subsidies (17% OOP). Despite stable ocular disease distribution across plan types, beneficiaries with silver ICSR subsidies consumed more total care than any other plan, higher than platinum plan enrollees and almost 1.5× the cost of bronze plan enrollees. Conclusions Ophthalmic care for enrollees on ACA plans generated substantial costs in 2018. Plans with higher OOP cost sharing may result in lower utilization of ophthalmic care.

Do Financial Incentives Affect Utilization for Chronically Ill Medicare Beneficiaries?

The objective of this study was to examine the price sensitivity for provider visits among Medicare Advantage beneficiaries. We used Medicare Advantage encounter data from 2014 to 2017 accessed as part of an evaluation for the Center for Medicare & Medicaid Innovation. We analyzed the effect of cost-sharing on the utilization of 2 outcome categories: number of visits (specialist and primary care) and the probability of any visit (specialist and primary care). Our main independent variable was the size of the copayment for the visit, which we regressed on the outcomes with several beneficiary-level and plan-level control variables. We included beneficiaries with at least 1 of 4 specific chronic conditions and matched comparison beneficiaries. We did not require beneficiaries to be continuously enrolled from 2014 to 2017, but we required a full year of data for each year they were observed. This resulted in 371,140 beneficiary-year observations. Copay reductions were associated with increases in utilization, although the changes were small, with elasticities <-0.2. We also found evidence of substitution effects between primary care provider (PCP) and specialist visits, particularly cardiology and endocrinology. When PCP copays declined, visits to these specialists also declined. We find that individuals with chronic conditions respond to changes in copays, although these responses are small. Reductions in PCP copays lead to reduced use of some specialists, suggesting that lowering PCP copays could be an effective way to reduce the use of specialist care, a desirable outcome if specialists are overused.

An optimisation model for incentivising the development of marginal oil and gas fields amidst increasingly complex ownership patterns: UKCS case study

Many recent discoveries in the UKCS have been economically marginal and comparatively small such that they are unable to be developed on a standalone basis. Nevertheless, there is a proliferation of production facilities and transport infrastructure that can, on accepting a tariff, process hydrocarbons from these smaller-sized oil and gas fields, thereby contributing to the UK Government's strategy of maximising economic recovery (MER). However, the empirical dimensions of cost-sharing arrangements between a field owner (host field or hub) and tie-in (satellite) fields are not well examined in the literature although they influence long-term economics in matured oil provinces. In this paper, we develop a mixed integer programming optimisation model to analyse how these third-party access to infrastructure issues impact MER in the UKCS. A first-best situation with only one regional operator is empirically compared with the actual situation of multiple ownership. We then assess the impact of different infrastructure unbundling provisions via pipeline tariff choices and their interaction with the fiscal regime on the net present value (NPV) and other project metrics such as timings of hub and field shutdowns. We find that differences in field ownership, tariff choice and changes to the fiscal regime impact the overall NPV of field developments. Our results also show that having a progressive fiscal regime in a mature basin such as the UKCS is important to support continued operations under low oil prices while increasing the government's take at high prices. The cost-sharing effect shows that imposing strict cost-sharing rules does not change overall project valuations, even in a low oil price scenario. An additional contribution to the extant literature is that tariff determination could be based on cost-sharing rules that enjoin each field tieback to a hub to pay a split tariff, comprised of a fixed cost of service (access charge) and variable (marginal) costs. • Presents MIP model for analysing economic dependencies of infrastructure assets. • Ownership style, choice of tariffs, and fiscal regime impact overall field value. • Reducing marginal tax rates improves profitability, reflecting neutrality and progressivity. • Tariffs are decisive as to whether satellite or user fields are developed. • Tariff determination to maximise MER should be based on two-part cost-sharing.

The Effects of Cost-Sharing On Healthcare Services Provision in Public Hospitals in Kenya: A Case Study of Kangundo District, Eastern Kenya

Purpose: The focus of this study was to determine the effects of cost-sharing on healthcare services provided in public hospitals in Kenya by examining a case study of Kangundo District Hospital in the Eastern Provision of Kenya&#x0D; Design/ Methodology/Approach: The study was conducted out in Kangundo District, Eastern Kenya which covers an area of 178.2 km. A survey research design was used to collect data and was supplemented by field research (qualitative approach). 150 household heads were sampled to generate quantitative data while 10 health care providers from Kangundo District Hospital were interviewed as key informants. A standardized questionnaire was used to interview household heads in the three research sites. Multi-stage cluster sampling was used to select household heads while non-probability (purposive) sampling was used in the selection of the three locations and three sub-locations, respectively.&#x0D; Findings: The study established that the introduction of cost-sharing has not led to diverting demand of health care from public to private health care providers in Kangundo District, though patients still utilized private health care facilities in the district.&#x0D; Contribution to policy and practice: There is a need for Situational analysis on Health Insurance programs as a supplement to cost-sharing in health care in order to strengthen the quality of policy decision making regarding access and equity in health care.&#x0D; Originality/Value: This study is the first to empirically establish the Effects Of Cost-Sharing On Healthcare Services Provision In Public Hospitals In Kenya

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

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

Cost-Sharing Effects on Hospital Service Utilization Among Older People in Fukuoka Prefecture, Japan

Background: The cost-sharing impact on hospital service utilization of different services is a critical issue that has not been well addressed worldwide. This study aimed to investigate the cost-sharing effects based on income status on hospital service utilization of different services among elderly people in Japan and provide a comprehensive examination and discussion for the reasonability of a cost-sharing system. Methods: The data were extracted from the Latter-Stage Elderly Healthcare Insurance database in the fiscal year 2016. A total of 610 182 insured people aged ≥75 years old, with 155 773 hospitalization patients, were identified. Hospitalization rate, length of stay (LOS), and total hospitalization cost were used to test the statistical significance among patients categorized by income levels. Generalized linear models for total hospitalization cost were constructed based on bed types to further assess different hospital service utilization. Results: For medical chronic care and psychiatric beds, which both required long-term care treatment, much higher hospitalization rates were observed in the patients with low- and middle-income levels than patients with high-income level. The LOS and total hospitalization cost of the patients with low- and middle-income levels were significantly higher than the patients with high-income level treated in medical chronic care and psychiatric beds. For psychiatric beds, the total hospitalization cost for patients with low-income level was significantly higher than that for patients with highincome level.Conclusion: The cost-sharing policy in Japan, especially the cap for out-of-pocket needs further determination. The importance of community-based care services needs to be emphasized, and the collaboration between hospitals and community-based care facilities should be enhanced.

The effect of out-of-pocket costs on initiation of disease-modifying therapies among medicare beneficiaries with multiple sclerosis

BackgroundMedicare beneficiaries with multiple sclerosis (MS) often face high out-of-pocket (OOP) costs for disease-modifying therapies (DMTs). It is unclear how cost-sharing affects therapy initiation. ObjectivesTo estimate the effects of patient cost-sharing on initiation of a DMT among Medicare beneficiaries with a new diagnosis code for MS. MethodsUsing Medicare claims data from 2010 to 2014, we identified a cohort of individuals with at least one inpatient or two outpatient diagnostic claims for MS. We restricted this group to beneficiaries with continuous Part A, B, and D coverage in the year before and after their initial diagnosis. To estimate the effect of cost-sharing on time to self-administered DMT initiation, we compared beneficiaries with a Low-Income Subsidy (LIS), who are shielded from cost-sharing, to those without LIS using multivariate Cox Proportional Hazards models adjusting for potential demographic and health-related confounders. ResultsThere were 39,661 Medicare beneficiaries who met inclusion criteria; 3827 had full LIS benefits throughout the study period. Beneficiaries were predominately White (36,447, 91.9%) and female (29,406, 74.1%). LIS recipients were generally younger (55 vs 67 years, p<0.001) and more likely to be enrolled through disability eligibility (79% vs 36%, p<0.001). In the year after their index diagnosis, 434 LIS recipients initiated DMT versus 1682 non-LIS (11% vs 5%; p<0.001). Among those who started a DMT, the average time to initiation was 115 days in those with LIS and 137 days for non-LIS (p<0.001). After adjustment for covariates, individuals with LIS benefits were significantly more likely to initiate a DMT in the year following their diagnosis (adjusted hazard ratio 1.4, 95% CI 1.25 to 1.57). The effect of OOP costs on initiation did not differ by demographic subgroups. ConclusionsMedicare beneficiaries with MS who are shielded from traditional cost-sharing are more likely to initiate a DMT in the year following receipt of their first diagnosis code. Future work should examine the effect of cost-related treatment delays on relapse rates and disability progression.

Cost-sharing strategy for carbon emission reduction and sales effort: A nash game with government subsidy

We investigate the cost-sharing strategies of a retailer and a manufacturer in a Nash game considering government subsidy, consumers' green preference and retailer's sales effort. We provide a function to describe the demand for green products considering the effect of green preference of consumers and the sales effort of the retailer. Next, we construct profit functions of the manufacturer and the retailer considering government subsidy for four scenarios: no sharing of cost (NSC), sharing of carbon emission reduction cost (SCERC), sharing of sales effort cost (SSEC), and sharing both carbon emission reduction cost and sales effort cost (SBC). Furthermore, we determine the optimal policies of price, sales effort level, wholesale price and carbon emission reduction effort level for the four scenarios by maximizing the profits of the manufacturer and the retailer in the Nash game. We find that the sales effort cost-sharing ratio and the carbon emission reduction cost-sharing ratio can affect the optimal policies of the manufacturer and the retailer, and the trends and extent of effects may be different. Our results show that it is advantageous for the manufacturer and the retailer to consider the cost-sharing effects of sales effort and carbon emission reduction effort, and the optimal policies of the retailer and the manufacturer are different for different scenarios.

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

BackgroundCost-sharing programs are often too complex to be easily understood by the average insured individual. Consequently, it is often difficult to determine the amount of expenses in advance. This may preclude well-informed decisions of insured individuals to adhere to medical treatment advised by the treating physician. Preliminary research has showed that the uncertainty in these cost-sharing payments are affected by four design characteristics, i.e. 1) type of payments (copayments, coinsurances or deductibles), 2) rate of payments, 3) annual caps on cost-sharing and 4) moment that these payments must be made (directly at point of care or billed afterwards by the insurer).MethodsAn online discrete choice experiment was used to assess the extent to which design characteristics of cost-sharing programs affect the decision of individuals to adhere to recommended care (prescribed medications, ordered diagnostic tests and referrals to medical specialist care). Analyses were performed using mixed multinomial logits.ResultsThe questionnaire was completed by 7921 members of a patient organization. Analyses showed that 1) cost-sharing programs that offer clear information in advance on actual expenses that are billed afterwards, stimulate adherence to care recommended by the treating physician; 2) the relative importance of the design characteristics differed between respondents who reported to have forgone health care due to cost-sharing and those who did not; 3) price-awareness among respondents was limited; 4) the utility derived from attributes and respondents’ characteristics were positively correlated; 5) an optimized cost-sharing program revealed an adherence of more than 72.9% among those who reported to have forgone health care.ConclusionsThe analyses revealed that less complex cost-sharing programs stimulate adherence to recommended care. If these programs are redesigned accordingly, individuals who had reported to have forgone a health service recommended by their treating physician due to cost-sharing, would be more likely to use this service. Such redesigned programs provide a policy option to reduce adverse health effects of cost-sharing in these groups. Considering the upcoming shift from volume-based to value-based health care provision, insights into the characteristics of a cost-sharing program that stimulates the use of recommended care may help to design value-based insurance plans.

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

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

Adherence to antiepileptic drugs among diverse older Americans on Part D Medicare.

Older minority groups are more likely to have poor AED adherence. We describe adherence to antiepileptic drugs (AEDs) among older Americans with epilepsy. In retrospective analyses of 2008-2010 Medicare claims for a 5% random sample of beneficiaries augmented by minority representation, epilepsy cases in 2009 were those with ≥1 claim with ICD-9345.x or ≥2 with 780.3x, and ≥1 AED. New-onset cases had no such claims or AEDs in the year before the 2009 index event. We calculated the Proportion of Days Covered (PDC) (days with ≥1 AED over total follow-up days) and used logistic regression to estimate associations of non-adherence (PDC <0.8) with minority group adjusting for covariates. Of 36,912 epilepsy cases (19.2% White, 62.5% African American (AA), 11.3% Hispanic, 5.0% Asian and 2% American Indian/Alaskan Native), 31.8% were non-adherent (range: 24.1% Whites to 34.3% AAs). Of 3706 new-onset cases, 37% were non-adherent (range: 28.7% Whites to 40.5% AAs). In adjusted analyses, associations with minority group were significant among prevalent cases, and for AA and Asians vs. Whites among new cases. Among other findings, beneficiaries from high-poverty ZIP codes were more likely to be non-adherent than their counterparts, and those in cost-sharing drug benefit phases were less likely to be non-adherent than those in deductible phases. About a third of older adults with epilepsy have poor AED adherence; minorities are more likely than Whites. Investigations of reasons for non-adherence, and interventions to promote adherence, are needed with particular attention to the effect of cost-sharing and poverty.

The Effect of Cost Sharing on an Employee Weight Loss Program: A Randomized Trial.

To test the effects of employer subsidies on employee enrollment, attendance, and weight loss in a nationally available weight management program. A randomized trial tested the impact of employer subsidy: 100%; 80%, 50%, and a hybrid 50% subsidy that could become a 100% subsidy by attaining attendance targets. NCT01756066. Twenty three thousand twenty-three employees of 2 US companies. The primary outcome was the percentage of employees who enrolled in the weight management program. We also tested whether the subsidies were associated with differential attendance and weight loss over 12 months, as might be predicted by the expectation that they attract employees with differing degrees of motivation. Analysis and Results: Enrollment differed significantly by subsidy level ( P < .0001). The 100% subsidy produced the highest enrollment (7.7%), significantly higher than each of the lower subsidies (vs 80% subsidy: 6.2%, P = .002; vs 50% subsidy: 3.9%, P < .0001; vs hybrid: 3.7%, P < .0001). Enrollment in the 80% subsidy group was significantly higher than both lower subsidy groups (vs 50% subsidy: 3.9%, P < .0001; vs hybrid: 3.7%, P < .0001). Among enrollees, there were no differences among the 4 groups in attendance or weight loss. This pragmatic trial, conducted in a real-world workplace setting, suggests that higher rates of employer subsidization help individuals to enroll in weight loss programs, without a decrement in program effectiveness. Future research could explore the cost-effectiveness of such subsidies or alternative designs.

The Effects of Cost Sharing on Adherence to Medications Prescribed for Concurrent Use: Do Definitions Matter?

Accurate estimates of the effects of cost sharing on adherence to medications prescribed for use together, also called concurrent adherence, are important for researchers, payers, and policymakers who want to reduce barriers to adherence for chronic condition patients prescribed multiple medications concurrently. But measure definition consensus is lacking, and the effects of different definitions on estimates of cost-related nonadherence are unevaluated. To (a) compare estimates of cost-related nonadherence using different measure definitions and (b) provide guidance for analyses of the effects of cost sharing on concurrent adherence. This is a retrospective cohort study of Medicare Part D beneficiaries aged 65 years and older who used multiple oral antidiabetics concurrently in 2008 and 2009. We compared patients with standard coverage, which contains cost-sharing requirements in deductible (100%), initial (25%), and coverage gap (100%) phases, to patients with a low-income subsidy (LIS) and minimal cost-sharing requirements. Data source was the IMS Health Longitudinal Prescription Database. Patients with standard coverage were propensity matched to controls with LIS coverage. Propensity score was developed using logistic regression to model likelihood of Part D standard enrollment, controlling for sociodemographic and health status characteristics. For analysis, 3 definitions were used for unadjusted and adjusted estimates of adherence: (1) patients adherent to All medications; (2) patients adherent on Average; and (3) patients adherent to Any medication. Analyses were conducted using the full study sample and then repeated in analytic subgroups where patients used (a) 1 or more costly branded oral antidiabetics or (b) inexpensive generics only. We identified 12,771 propensity matched patients with Medicare Part D standard (N = 6,298) or LIS (N = 6,473) coverage who used oral antidiabetics in 2 or more of the same classes in 2008 and 2009. In this sample, estimates of the effects of cost sharing on concurrent adherence varied by measure definition, coverage type, and proportion of patients using more costly branded drugs. Adherence rates ranged from 37% (All: standard patients using 1+ branded) to 97% (Any: LIS using generics only). In adjusted estimates, standard patients using branded drugs had 0.63 (95% CI = 0.57-0.70) and 0.70 (95% CI = 0.63-0.77) times the odds of concurrent adherence using All and Average definitions, respectively. The Any subgroup was not significant (OR = 0.89, 95% CI = 0.87-1.17). Estimates also varied in the full-study sample (All: OR = 0.79, 95% CI = 0.74-0.85; Average: OR = 0.83, 95% CI = 0.77-0.89) and generics-only subgroup, although cost-sharing effects were smaller. The Any subgroup generated no significant estimates. Different concurrent adherence measure definitions lead to markedly different findings of the effects of cost sharing on concurrent adherence, with All and Average subgroups sensitive to these effects. However, when more study patients use inexpensive generics, estimates of these effects on adherence to branded medications with higher cost-sharing requirements may be diluted. When selecting a measure definition, researchers, payers, and policy analysts should consider the range of medication prices patients face, use a measure sensitive to the effects of cost sharing on adherence, and perform subgroup analyses for patients prescribed more medications for which they must pay more, since these patients are most vulnerable to cost-related nonadherence.

The effect of cost-sharing in private health insurance on the utilization of health care services between private insurance purchasers and non-purchasers: a study of the Korean health panel survey (2008-2012).

BackgroundPrivate health insurance in South Korea mainly functions as supplementary and complementary health insurance that compensates for insufficient coverage by National Health Insurance. However, full private coverage of public sector cost-sharing led to the problem of encouraging moral hazard–induced utilization, resulting in a policy change that occurred in October 2009. At that time, the Korean government introduced a minimum cost-sharing policy for indemnity health insurance. The purpose of this study was to analyze the effect of cost-sharing in private health insurance on health care utilization.MethodsWe analyzed data collected from the Korean Health Panel Survey from October 2008 to December 2011. We restricted the two groups to 803 purchasers with indemnity health insurance and 7023 non-purchasers who did not obtain any private health insurance. A difference-in-difference analysis was used to evaluate the effect of the 2009 policy.ResultsAfter the policy change, the utilization of outpatient visits by purchasers gradually decreased more than non-purchasers (0.015 in 2009 [p = 0.758], −0.117 in 2010 [p < 0.016], and −0.140 in 2011 [p = 0.004]). However, utilization of inpatient services was not statistically significant. Notably, the magnitude of the cost-sharing effect in indemnity health insurance was stronger for those receiving medical aid. Among this group, utilization of outpatient services (after the policy change in 2009) decreased more so than non-purchasers. Patients with three or more chronic diseases have not changed their health care utilization.ConclusionsOur results implied meaningful lessons for decision-makers and future health insurance policies in Korea and other countries in terms of cost-sharing in medical care. When policy makers intend to implement the cost-sharing, a different copayment scheme is needed according to the socioeconomic status or disease severity.

An Analysis of Moral Hazard and Effect of Cost Sharing in Korean Private Health Insurance Market

An Analysis of Moral Hazard and Effect of Cost Sharing in Korean Private Health Insurance Market

Effects of cost sharing on seeking outpatient care: a propensity‐matched study in Germany and Switzerland

Several studies have assessed the effect of cost sharing on health service utilization (HSU), mostly in the USA. Results are heterogeneous, showing different effects. Whereas previous studies compared insurants within one health care system but different modes of insurance, we aimed at comparing two different health care systems in Europe: Germany and Switzerland. Furthermore, we assessed the impact of cost sharing depending on socio-demographic factors as well as health status. Two representative samples of 5197 Swiss insurants with and 5197 German insurants without cost sharing were used to assess the independent association between cost sharing and the use of outpatient care. To minimize confounding, we performed cross-sectional analyses between propensity score matched Swiss and German insurants. We investigated subgroups according to health and socio-economic status to assess a potential social gradient in HSU. We found a significant association between health insurance scheme and the use of outpatient services. German insurants without cost sharing (visit rate: 4.8 per year) consulted a general practitioner or specialist more frequently than Swiss insurants with cost sharing (visit rate: 3.0 per year; P < 0.01). Subgroup analyses showed that vulnerable populations were differently affected by cost sharing. In the group of respondents with poor health and low socio-economic status, the cost-sharing effect was strongest. Cost-sharing models reduce HSU. The challenge is to create cost-sharing models which do not preclude vulnerable populations from seeking essential health care.

The Effects of Cost Sharing on Access to Care among Childless Adults

To analyze the impact of public health insurance expansions and the use of enrollee cost sharing on insurance status and receipt of clinically indicated preventive screenings and physician services. This study uses Behavioral Risk Factor Surveillance System (BRFSS) data from 1997 to 2007. This study uses multivariate difference-in-difference logistic regression modeling of pooled cross-sectional time series data. The effect of the expansions on insurance status and access to care is identified by cross-state variation in program implementation, as well as cross-state and within-state variation in program eligibility criteria over time. Childless adult expansions, regardless of cost-sharing levels, reduced uninsurance rates and decreased the likelihood that childless adults needed to see a physician but did not because of cost. Expansions with traditional public insurance cost-sharing requirements increased the use of preventive screenings, while expansions with increased cost-sharing requirements did not. Cost-sharing requirements did not have an impact on the ability to see a physician when needed, but they played an important role in the utilization of preventive services. Expanding public health insurance to low-income, childless adults presents a promising policy opportunity, but there are trade-offs between the efficiencies obtained through increased cost sharing and the potential inefficiencies due to the lower use of preventive services.

Cost-Sharing: A Blunt Instrument

Cost-sharing is a health care cost-containment technique in which health care services are partially paid for by patients out of pocket. Cost-sharing can reduce non-cost-effective care, but it can also undermine the financial protection and access values of health insurance. We review the empirical evidence published since the mid-1980s about cost-sharing's effect on utilization, expenditures, health, and adverse consequences, including how the effects vary by form of care, by health status, and by sociodemographic characteristics. Some cost-sharing, such as emergency department copayments, reduces utilization without any harmful effects, whereas other cost-sharing reduces valuable care such as maintenance drug use among the chronically ill. Cost-sharing should be used judiciously, with attention taken not to reduce highly cost-effective care.