Financial Burden Of Care Research Articles

Effects of Medicare Eligibility at Age 65 Among Individuals With and Without Functional Disability.

Medicare coverage at age 65 improves access to and use of care and alleviates financial hardship for the general population. However, less is known whether the effects differ between individuals without and with functional disability. To examine the effects of Medicare eligibility at age 65 on health insurance coverage, financial burden of care, and access to care among individuals without and with functional disability. We used a regression discontinuity design, which exploits the discontinuity in eligibility for Medicare at age 65 and compares individuals just before and after age 65. Our analysis included 19,876 individuals (aged 59-71) without functional disability and 8376 individuals with functional disability from the 2014-2021 Medical Expenditure Panel Survey. We assessed health insurance coverage, financial burden of care, and access to care. Medicare eligibility led to increases in any and Medicare coverage for both groups, but those with functional disability had a decrease in Medicaid coverage by - 2.6 percentage points. Medicare eligibility resulted in lower financial burden of care for both groups, but the effects were greater among those with functional disability (- $578 vs. - $344 for out-of-pocket spending, - 3.7 vs. - 4.9 percentage points for cost-sharing, and - 2.5 vs. - 0.8 percentage points for paying medical bills over time). Although Medicare eligibility led to a decrease in delayed medical care among those without functional disability (- 2.1 percentage points), no change was observed among those with functional disability. Notably, access to care remained limited among those with functional disability after obtaining Medicare eligibility (8.6% and 3.9% for being unable to get medical care and experiencing delay in getting medical care). Medicare coverage can reduce financial hardship, especially for individuals with functional disability. However, there is a need to develop policies that ensure equitable access to care for those with functional disability.

Patient-Provider Communication and Access, Use, and Financial Burden of Care

IntroductionEffective patient-provider communication is a critical component of optimal patient care, but its potential impact on the delivery of health care services remains unclear. This study examines the association of patient-provider communication with access to care, health care utilization, and financial burden of care. MethodsUsing the 2013-2021 Medical Expenditure Panel Survey longitudinal data, the level of patient-provider communication was measured across four domains (attentive listening, clear explanation, respectfulness, and time allocation) as a primary independent variable, categorized into low, moderate, and high. A lagged dependent model was employed to examine the associations of patient-provider communication at baseline with subsequent access to care, health care utilization, and financial burden of care, controlling for baseline sample characteristics and outcomes measured at the baseline. Analysis was conducted in February 2024. ResultsAmong 28,955 analytic samples (representing 709,547,678 US adults), 5.3%, 50.2%, and 44.3% reported low, moderate, and high levels of patient-provider communication. Marginalized populations, including racial/ethnic minorities, those with low education and income, and those lacking insurance, were more likely to report low patient-provider communication. Compared with adults with high patient-provider communication, those with low patient-provider communication were more likely to encounter difficulties in accessing medical care (2.6 percentage points; 95% CI: 1.2-3.9), experience delays in obtaining necessary medical care (2.8 percentage points; 1.3-4.4), have emergency room visits (4.2 percentage points; 1.9-6.4), and face difficulties paying medical bills (4.0 percentage points; 2.2-5.8) in the subsequent year. ConclusionsEncouraging effective patient-provider communication is essential for advancing patient-centered care and mitigating health inequities.

Informed Consent as a Means of Acknowledging and Avoiding Financial Toxicity as Iatrogenic Harm.

Negative health consequences stemming from the financial burden of care on patients and their loved ones are documented as financial toxicity in the literature, and these consequences should be included in informed consent discussions during patient-clinician interactions. However, codes of medical ethics have yet to require obtaining consent to financial costs, even as the No Surprises Act, effective on January 1, 2022, requires some clinicians to facilitate informed financial consent prior to an out-of-network elective service as a means of avoiding arbitration. This article discusses how this requirement can be more broadly applied to informed consent for any intervention.

Racial and ethnic differences in cost-of-care conversations among older adults

ABSTRACT Background The rapidly growing racially diverse ageing population in the United States presents unique challenges for the country’s social, economic, and healthcare systems. Rising health care costs, increased patient cost-sharing, and limited financial resources make this generation of older Americans susceptible to large medical bills or debt, which disproportionally impacts older adults who are from racial/ethnic minority communities. Cost of care (CoC) conversations between patients and healthcare providers is one recommended approach for containing healthcare costs and alleviating patients’ financial burden of care. Method The current study used focus group methods to qualitatively explore the contextual factors that influence CoC conversations in a diverse sample of older adults (N = 27). Three focus groups were held with non-Hispanic White (n = 10), Black/African American (n = 9), and Hispanic (n = 8) participants. Thematic analysis yielded four broad themes. Results The results suggest that CoC conversations do not occur with physicians. The facilitators of CoC conversations included positive provider affect, rapport/relationship building, and communication. Barriers included lack of physician training, wait time, lack of focus on the patient, language, provider preferences, fear of physicians, and religion. There were significant differences in the facilitators and barriers across racial/ethnic groups. Conclusions It is critical for physicians to have the tools and training to successfully discuss CoC with older patients. Cultural competency training and provider awareness of patient preferences and expectations may be important when it comes to enhancing rapport and increase the likelihood of these important conversations within racial/ethnic minority communities.

Patient Experience in Clinical Trials: Quality of Life, Financial Burden, and Perception of Care in Patients With Multiple Myeloma or Lymphoma Enrolled on Clinical Trials Compared With Standard Care.

Patients' concerns regarding clinical trial (CT) participation include apprehension about side effects, quality of life (QoL), financial burden, and quality of care. We prospectively evaluated the experience of patients with multiple myeloma or lymphoma who were treated on CTs (CT group, n = 35) versus patients treated with standard approaches (non-CT group, n = 88) focusing on QoL, financial burden of care, and patients' perception of quality of care over a 1-year period. There were no significant differences in any of the patient-reported outcomes in CT versus non-CT groups. We observed an initial decline in overall QoL in the first 3 months across both groups, driven primarily by physical and functional well-being. QoL gradually improved and was above baseline by month 12. Patients reported highest improvement in the functional well-being subdomain. Patients in both groups reported high satisfaction with the quality of care received, and there were no differences in overall satisfaction, communication with team, or access to care. At baseline, 16%-19% of patients reported financial burden, which increased to a peak of 33% in the CT group and to 49% in the non-CT group over the course of 1 year. There was no significant difference in financial burden in the two groups overall. Most of the patients reported getting all the care that was deemed medically necessary in both groups. However, a significant proportion of patients reported having to make other kinds of financial sacrifices because of their cancer (CT group: 33% of patients at baseline and 21%-40% over 1 year; non-CT group: 19% at baseline and 25%-36% over 1 year). Patients treated on CTs reported comparable QoL and quality of care with the non-CT group. A high proportion of patients reported financial burden over time in both groups. Our findings can serve as a guide to educate patients regarding CT participation and highlight the need to address the significant financial burden experienced by patients with cancer.

Factors associated with long intensive care unit (ICU) admission among inpatients with and without diabetes in South Western Sydney public hospitals using the New South Wales admission patient data collection (2014\u20132017)

BackgroundLong stay in intensive care unit (ICU) is associated with poor outcomes, particularly in people with diabetes. It increases the financial burden of care and this is a challenge to the South Western Sydney region, which is already a hotspot for diabetes in Australia. This study compared ICU admission characteristics of people with and without diabetes and the factors associated with long ICU stay among patients admitted to public hospitals in this metropolitan health district from 2014 to 2017.MethodsCross-sectional datasets on 187,660, including all ICU admissions in the New South Wales Admitted Patient Data Collection (APDC) from June 2014 – July 2017 in public hospital were extracted. Data on demographic and health insurance status, primary admission diagnosis using ICD-10, comorbidities including death among hospital inpatients aged ≥18 years residing in SWS were analysed. The ICU length of stay was the outcome variable and were classified into short stay (≤48 h) and long stay (> 48 h), and were examined against potential confounding factors using bivariate and multiple logistic regression analyses.ResultsOur results showed higher ICU admissions in patients with diabetes than in those without diabetes (5% vs. 3.3%, P < 0.001) over three years. The median and interquartile range (IQR) of length of the ICU stay were similar in both groups [diabetes: 40 h, IQR = 16–88 h vs. non-diabetes: 43 h, IQR = 19–79 h]. The prevalence of long ICU stays among people with and without diabetes were 44.9% [95% CI 42.1, 47.7%] and 43.6% [95% CI 42.2, 44.9%], respectively. For both groups, increased odds of long ICU stay were associated with death and circulatory system disease admissions, while musculoskeletal disease admissions were associated with lower risk of long ICU stay. In the non-diabetes group, male sex, nervous system disease admissions and living in peri-urban areas were associated with higher odds of long ICU stay.ConclusionsThe rate of ICU admissions among inpatients remain higher in people with diabetes. One in every two admissions to ICU had a long stay. Additional care for those admitted with circulatory system diseases are needed to reduce long ICU stay related deaths in SWS.

The Organization of Diagnosis, Care and Funding for Specific Learning and Developmental Disorders (SLDD): A French Regional Experimental Protocol.

Introduction: Access in France to early diagnosis and care for the most severe, but infrequent, Neurodevelopmental Disorders (NDD), autism spectrum disorder and global developmental delay, in children aged 0–7 was improved through measures implemented in 2019. However, there are no such measures for specific learning disorders (SLD), attention, motricity and language disorders (SLDD), despite their annual incidence of between 5 and 8%.Method: We describe the design of a new type of organization and financing of care for SLDD including evaluation procedure, as well as other factors, mainly at the prevention level that will contribute to local and national policy for this frequent health problem. This in response to a national call for projects, commonly called Article 51, targeted innovation in healthcare delivery and funding in the context of medium-term national reform. This provides project stakeholders with the opportunity to set up and implement “bottom-up” projects, mainly using local professionals. A joint initiative by the regional Health Authorities of the Occitanie region, the French Social Security system and a non-profit Association (Occitadys) proposed an experimental new structure of NDD care and funding.Discussion: We here discuss the design of this experiment that aims, over two to three years, to alleviate families' financial burden of care and establish a regional three-tier care system with respect to evaluation, re-education and rehabilitation care. Our approach may benefit SLDD health-care planning, and addresses the questions of prevention, early detection and care-design for families, taking local and socioeconomic disparities into account.

ACCESS TO WORK LEAVE AND IN VITRO FERTILIZATION (IVF) OUTCOMES

BackgroundAssisted Reproductive Technology (ART) including IVF is the most expensive method of infertility treatment, at a median cost of $19,000/cycle (1). It is also the most time intensive, resulting in an average of 8.74 days taken off work per cycle (2). In 2009, only an estimated 24% of ART need was being met in the U.S. ART is responsible for 1.5% of total live births in the U.S., compared to 3% in Europe despite no difference in incidence (1). The financial burden of care has been researched extensively, and state mandated insurance coverage improves access and outcomes associated with IVF. States with mandated coverage have fewer embryos transferred and fewer multiple births per cycle (3). There is less research examining the amount of time off work that is required during treatment. Existing literature suggests that increased time off from work is associated with increased stress and early termination of care (4,5). However, to our knowledge, there is no research examining access to employment leave during IVF and how this influences outcomes.ObjectiveTo examine the current state of access to employment leave during IVF cycles, evaluate the relationship between access to employment leave during IVF treatment and IVF outcomes as measured by number of embryos transferred, live birth rate, and multiple pregnancy rate in an academic infertility clinic located in a state with no insurance mandate.Materials and MethodsWomen who underwent IVF with a fresh embryo transfer from 2016-2018 were asked to complete an email survey with questions about their access to work leave, type of work leave, ease of requesting leave, and impact of taking leave on their work. IVF outcomes were collected from the clinic’s SART data set and demographics were collected from both the SART data and clinic records.ResultsOf the 409 cycles identified during the study period, 335 had email addresses and were contacted. 69 responses were received (20.5% response rate). 46 patients reported having access to leave during IVF, 17 patients reported not having access, and 6 patients did not require leave (unemployed or self-employed). Patients without leave transferred 1.4 embryos per cycle, had a live birth rate of 52.9%, and 17.6% of cycles resulted in multiple pregnancies. In patients with leave, 1.6 embryos were transferred per cycle, the live birth rate was 50%, and the rate of multiple pregnancies was 13%. There are no statistically significant differences between the groups for any of the outcomes. There is a significant difference (0.0342) in the percentage of patients that believe time off for IVF affected their work, 65% of patients in the group without access to leave felt time off affected their work compared to 35% of the group with leave.ConclusionsThe present study found no difference in IVF outcomes based on patient access to work leave during treatment, however it suggests that limited access to leave could be a barrier, preventing people from receiving appropriate fertility treatment. Research investigating the barriers that limit access to care serves as an important tool to help address the socioeconomic discrepancies that exist with infertility treatment.

Nanotechnology and osteoarthritis; part 1: Clinical landscape and opportunities for advanced diagnostics.

Osteoarthritis (OA) is a disease of the entire joint, often triggered by cartilage injury, mediated by a cascade of inflammatory pathways involving a complex interplay among metabolic, genetic, and enzymatic factors that alter the biochemical composition, microstructure, and biomechanical performance. Clinically, OA is characterized by degradation of the articular cartilage, thickening of the subchondral bone, inflammation of the synovium, and degeneration of ligaments that in aggregate reduce joint function and diminish quality of life. OA is the most prevalent joint disease, affecting 140 million people worldwide; these numbers are only expected to increase, concomitant with societal and financial burden of care. We present a two-part review encompassing the applications of nanotechnology to the diagnosis and treatment of OA. Herein, part 1 focuses on OA treatment options and advancements in nanotechnology for the diagnosis of OA and imaging of articular cartilage, while part 2 (10.1002/jor.24842) summarizes recent advances in drug delivery, tissue scaffolds, and gene therapy for the treatment of OA. Specifically, part 1 begins with a concise review of the clinical landscape of OA, along with current diagnosis and treatments. We next review nanoparticle contrast agents for minimally invasive detection, diagnosis, and monitoring of OA via magnetic resonace imaging, computed tomography, and photoacoustic imaging techniques as well as for probes for cell tracking. We conclude by identifying opportunities for nanomedicine advances, and future prospects for imaging and diagnostics.

Making the Case: Clinical Assessment of Financial Toxicity.

Clinical nurse assessment determines clinical status, status changes, and trends that affect the patient's plan of care. With the financial burden of care being a prominent source of patient stress, financial toxicity is a vital component of clinical nurse assessment. For selected clinical nurse roles, this article provides a foundation for clinical financial toxicity assessment, which is initiated during the patient's treatment and continues into survivorship. With a focus on financial toxicity affecting patients with cancer, this article is an overview of financial toxicity as a part of clinical assessment. It includes an explanation of clinical nurse roles and definitions, assessment as a clinical nurse standard of care, assessment frameworks and components, how clinicians can approach assessment with patients and family members, and implications for clinical practice. Based on a clinical assessment of financial toxicity risk and status, a clinical nurse who is educated about patient healthcare financial issues can start or continue conversations about financial toxicity, provide and mobilize resources to help address financial burden, and/or refer patients and family members to expert guidance from designated healthcare financial experts when they are available in the healthcare system.

Improving Hypertension Outcome Measurement in Low- and Middle-Income Countries

High blood pressure is the leading modifiable risk factor for mortality, accounting for nearly 1 in 5 deaths worldwide and 1 in 11 in low-income countries. Hypertension control remains a challenge, especially in low-resource settings. One approach to improvement is the prioritization of patient-centered care. However, consensus on the outcomes that matter most to patients is lacking. We aimed to define a standard set of patient-centered outcomes for evaluating hypertension management in low- and middle-income countries. The International Consortium for Health Outcomes Measurement convened a Working Group of 18 experts and patients representing 15 countries. We used a modified Delphi process to reach consensus on a set of outcomes, case-mix variables, and a timeline to guide data collection. Literature reviews, patient interviews, a patient validation survey, and an open review by hypertension experts informed the set. The set contains 18 clinical and patient-reported outcomes that reflect patient priorities and evidence-based hypertension management and case-mix variables to allow comparisons between providers. The domains included are hypertension control, cardiovascular complications, health-related quality of life, financial burden of care, medication burden, satisfaction with care, health literacy, and health behaviors. We present a core list of outcomes for evaluating hypertension care. They account for the unique challenges healthcare providers and patients face in low- and middle-income countries, yet are relevant to all settings. We believe that it is a vital step toward international benchmarking in hypertension care and, ultimately, value-based hypertension management.

The Relationship between Resilience and Care Burden among Parents of Students with Intellectual Disability in Golestan Province, Iran, in 2016

Introduction: Children with intellectual disabilities sometimes disrupt the mental health of the family and cause serious damages in their parents. Consideration of the mental health of parents of exceptional children is important due to the psychological, social, and financial burden of care and increased care burden on families of children with intellectual disabilities. Materials and Methods: This was a descriptive-correlation study. The subjects consisted of 200 parents of students in special schools of Golestan Province, Iran, in 2016. The participants were selected through multistage random sampling method. A demographic information questionnaire, the Conner-Davidson Resilience Scale (CD-RISC), and Elmstahl’s Caregiver Burden Scale were used to collect data. The collected data were analyzed using descriptive and inferential statistics in SPSS software at the significance level of P < 0.05. Results: In this study, the resilience and burden of care scores of parents of children with intellectual disabilities were 51.86 ± 17.27 and 56.89 ± 14.27, respectively. Simple linear regression test showed a significant relationship between resilience and burden of care [B = 0.32, Beta = 0.39, P < 0.01, %95 CI: -6 (-4.2 to -8.1)]; with 1 degree decrease in resilience, the burden of care score will increase 0.3 points. Conclusion: In this study, the burden of care was higher and resilience was lower than average and resilience of parents of students with intellectual disabilities could be increased with reduction in the amount of burden of care. Among the predictive variables, the effect of income on the burden of care was evident to a greater extent in parents of children with intellectual disabilities compared to other variables. This indicates that the burden of care can be reduced and resilience can be increased by raising income levels and economic well-being. Therefore, it is suggested that the necessary economic and counseling measures be taken to reduce the burden of care.

Community that pays together stays together: Sharing of resources for colorectal cancer screening and treatment of the underserved population.

561 Background: Bridging disparities to increase colorectal cancer (CRC) screening and treatment can be expensive and time consuming. This insurmountable cost often limits care; however, for every $1 spent on cancer screening $22.37 is saved on treatment costs and economic benefits. By finding cancer through free screening initiatives for the public, a new problem arises of how to fund further treatment. Methods: Project goals are to increase screening rates and knowledge about CRC and screening in our medically underserved region. The project provides screening at no cost, but these unfunded patients do not have coverage to treat their cancer diagnosis. By establishing partnerships with home health organizations, hospital CEOs, federally qualified health centers, locally elected officials, department of public health employees, and healthcare professionals our project has navigated patients through screening and treatment free of charge by encouraging community sharing of resources. Community relationships have been nurtured by utilizing quarterly program meetings, educational outreach for providers with CME credit, and cancer symposiums. This outreach provides an open forum to ask for feedback and coordinate care for the community with a primary focus on population healthcare management. Results: In addition to the many precancerous lesions removed, two cases were identified that needed further cancer treatment. The first patient did not qualify for county indigent clinic care. One private hospital waived the facility fees and we waived the surgeon fees, and the local cancer center agreed to cover adjuvant chemotherapy costs. Another patient was navigated to a local indigent care clinic, with CT scans paid by another nonprofit organization. This patient received surgery at no cost from the surgeon or hospital. These illustrations reflect community involvement in sharing cost for the uninsured. Conclusions: Utilizing cost and resource sharing through patient navigation can lessen the financial burden of caring for uninsured patients. By focusing on community relationships, our project is overcoming limitations to provide comprehensive care for patients.

Societal costs of home and hospital end-of-life care for palliative care patients in Ontario, Canada.

In Canada, health system restructuring has led to a greater focus on home-based palliative care as an alternative to institutionalised palliative care. However, little is known about the effect of this change on end-of-life care costs and the extent to which the financial burden of care has shifted from the acute care public sector to families. The purpose of this study was to assess the societal costs of end-of-life care associated with two places of death (hospital and home) using a prospective cohort design in a home-based palliative care programme. Societal cost includes all costs incurred during the course of palliative care irrespective of payer (e.g. health system, out-of-pocket, informal care-giving costs, etc.). Primary caregivers of terminal cancer patients were recruited from the Temmy Latner Centre for Palliative Care in Toronto, Canada. Demographic, service utilisation, care-giving time, health and functional status, and death data were collected by telephone interviews with primary caregivers over the course of patients' palliative trajectory. Logistic regression was conducted to model an individual's propensity for home death. Total societal costs of end-of-life care and component costs were compared between home and hospital death using propensity score stratification. Costs were presented in 2012 Canadian dollars ($1.00 CDN = $1.00 USD). The estimated total societal cost of end-of-life care was $34,197.73 per patient over the entire palliative trajectory (4 months on average). Results showed no significant difference (P > 0.05) in total societal costs between home and hospital death patients. Higher hospitalisation costs for hospital death patients were replaced by higher unpaid caregiver time and outpatient service costs for home death patients. Thus, from a societal cost perspective, alternative sites of death, while not associated with a significant change in total societal cost of end-of-life care, resulted in changes in the distribution of costs borne by different stakeholders.

Economic implications of end-of-life care in the ICU.

Advance care planning and palliative care interventions can improve the quality of end-of-life care by reducing unwanted high intensity care at the end of life. This may have important economic implications and may reduce the financial burden of patients' families. We review the literature to examine the impact advance care planning and palliative care has on ICU utilization, specifically ICU admissions and ICU length of stay (LOS), and to provide insight into ways to reduce costs and financial burden of care while simultaneously improving quality of care. We identified three studies assessing the impact of palliative care consultation on ICU admissions for patients with life-limiting illness; all three demonstrate reduced ICU admissions for patients receiving palliative care consultation. Among 16 studies evaluating ICU LOS as an outcome, five report no change and 11 report decrease in LOS for patients receiving advance care planning or palliative care. These studies are heterogeneous in design and target population; however, a trend toward reduced ICU utilization exists. Advance care planning and palliative care can reduce ICU utilization at the end of life. The degree to which reducing ICU utilization decreases emotional and financial burden of end-of-life care for patients and families is unknown.

There is a mismatch between the medicare benefit package and the preferences of patients with cancer and their caregivers.

To identify insured services that are most important to Medicare beneficiaries with cancer and their family caregivers when coverage is limited. A total of 440 participants (patients, n = 246; caregivers, n = 194) were enrolled onto the CHAT (Choosing Health Plans All Together) study from August 2010 to March 2013. The exercise elicited preferences about what benefits Medicare should cover for patients with cancer in their last 6 months of life. Facilitated sessions lasted 2.5 hours, included 8 to 10 participants, and focused on choices about Medicare health benefits within the context of a resource-constrained environment. Six of 15 benefit categories were selected by > 80% of participants: cancer care, prescription drugs, primary care, home care, palliative care, and nursing home coverage. Only 12% of participants chose the maximum level of cancer benefits, a level of care commonly financed in the Medicare program. Between 40% and 50% of participants chose benefits not currently covered by Medicare: unrestricted cash, concurrent palliative care, and home-based long-term care. Nearly one in five participants picked some level of each of these three benefit categories and allocated on average 30% of their resources toward them. The mismatch between covered benefits and participant preferences shows that addressing quality of life and the financial burden of care is a priority for a substantial subset of patients with cancer in the Medicare program. Patient and caregiver preferences can be elicited, and the choices they express could suggest potential for Medicare benefit package reform and flexibility.

Out‐of‐pocket health care expenditure burden for Medicare beneficiaries with cancer

There is increasing concern regarding the financial burden of care on cancer patients and their families. Medicare beneficiaries often have extensive comorbidities and limited financial resources, and may face substantial cost sharing even with supplemental coverage. In the current study, the authors examined out-of-pocket (OOP) spending and burden relative to income for Medicare beneficiaries with cancer. This retrospective, observational study pooled data for 1997 through 2007 from the Medicare Current Beneficiary Survey linked to Medicare claims. Medicare beneficiaries with newly diagnosed cancer were selected using claims-based diagnoses. Generalized linear models were used to estimate OOP spending. Logistic regression models identified factors associated with a high OOP burden, defined as spending > 20% of one's income during the cancer diagnosis and subsequent year. The cohort included 1868 beneficiaries with and 10,047 without cancer. Compared with the noncancer cohort, cancer patients were older, had more comorbidities, and were more likely to lack supplemental coverage. The mean OOP spending for cancer patients was $4727. Cancer patients faced an adjusted $976 (P < .01) incremental OOP spending. Greater than one-quarter (28%) of beneficiaries with cancer experienced a high OOP burden compared with 16% of beneficiaries without cancer (P < .001). Supplemental insurance and higher income were found to be protective against a high OOP burden, whereas assets, comorbidity, and receipt of cancer-directed radiation and antineoplastic therapy were associated with a higher OOP burden. Medicare beneficiaries with cancer face a higher OOP burden than their counterparts without cancer; some of the higher burden was explained by the higher comorbidity burden and lack of supplemental insurance noted among these patients. Financial pressures may discourage some elderly patients from pursuing treatment.

Commentary: The Battle of Louisville: Money, Power, Politics, and Publicity at an Academic Medical Center

In 2009, the entire clinical faculty of the Department of Neurosurgery of the University of Louisville School of Medicine elected to become employees of a nearby community hospital. This took place in the context of the financial burden of caring for the indigent, declining reimbursement, clinical demands for neurosurgical coverage of a level 1 trauma center, rising salaries for neurosurgeons, and competitive pressure on hospitals. The author, who was dean of the school of medicine at the time, would not accept the abrupt withdrawal of these clinicians from the faculty practice plan, single-point contracting, and academic governance of clinical work assignments. Politicians, the press, and accreditation bodies quickly weighed in as the university, the school, and the public good were placed in jeopardy. The motivations for this event-the community hospital defending its market share and physician recruitment and retention pipeline, the dean defending principles of academic governance and the faculty practice plan-and the responses of the participants offer an instructive case study for academic medical management. The author concludes that one might view the protagonists of this episode not as defenders of principles but, rather, as pawns in a larger drama playing out related to a perfect storm of economic and social pressures in American medicine.

Getting in line: Coordinating responses for children affected by HIV and AIDS in sub-Saharan Africa

Only one in every eight households containing orphans and vulnerable children (OVC) in African countries received any support from an external source (UNICEF, 2008). This is a reflection of how governments, both rich and poor, have ignored obligations ratified in conventions to ensure the social protection of vulnerable children (United Nations, 1989). Consequently, a disproportionate proportion of the financial burden of care of vulnerable children is borne by affected families and communities. It is deplorable that vulnerable children are forced to rely on the charity of income poor relatives and community members (Wilkinson-Maposa et al., 2005; Foster, 2005b). This situation is likely to continue until governments adequately assume their responsibilities. In countries such as Botswana, governments have responded to the crisis of children and AIDS and consequently most households containing vulnerable children now receive external support (UNAIDS et al., 2006). The movement to establish national social protection schemes for vulnerable households is gaining momentum. If cash transfers become established nationally, they may alleviate suffering on a wide scale (JLICA, 2009). In that case, community groups and non-governmental organizations (NGOs) that are currently responsible for implementing responses to support children affected by HIV and AIDS will still be needed to administer psychosocial and other services that are complementary to those provided by these schemes. It is vital that governments develop a central role in coordinating civil society responses and ensure that resources for vulnerable children are used more effectively. But most African governments have limited capacity to coordinate responses and have only recently engaged in this area that involves a few well-resourced international organisations, many local NGOs and innumerable community initiatives. This article reviews the responses of different sectors responding to the impacts of HIV/AIDS on children, and discusses how these may be better funded, coordinated and monitored, utilizing the findings from a study of civil society OVC initiatives and evolving national responses (Foster, 2008).

Inpatient Hospital Service Utilization of the Uninsured in Nebraska: Policy Implications for Addressing Uncompensated Care

In order better to inform policymakers about financing uncompensated hospital care through appropriate allocation of resources among Nebraska communities, this study used seven years (1996-2002) of county-level data from multiple sources to examine the relationship between population economic factors and the hospital inpatient care use by uninsured patients. The generalized estimating equation (GEE) regression analysis showed that, at the county level, the population uninsurance rate and other economic factors (e.g., per capita income, the percentage of population receiving welfare) are statistically significant predictors of average hospital self-pay inpatient charge per resident. Residents in the three western regions of the state also incurred statistically higher per-resident hospital self-pay inpatient charges than did their counterparts in the three eastern regions. State policymakers in Nebraska can use our study results to allocate resources on the basis of community economic characteristics and geographic location, to help reduce the financial burden of caring for the uninsured to safety net hospitals. The study may have a wide application to other states examining the same policy issues. The model used in this study can be easily created for other states, as the required data are readily available.