Health Care Financing Research Articles

How much can we learn from each other? Polish and Hungarian good practices in financing ophthalmology care as a proposal for implementation in Ukraine.

The article aims to compare payment schemes for cataract, glaucoma, vitrectomy, cornea transplantations, DME, and AMD across Hungary, Poland, and Ukraine, and to identify implementable practices in Ukraine within the context of ongoing healthcare reforms. Researchers used mixed-method research-with legal documents and data analysis on utilisation of ophthalmology services between 2010 and 2019 and in-depth semi structured interviews with fifteen health experts from Hungary, Poland, and Ukraine. Interviewees, five from each country, were representatives from healthcare providers and payers with at least 10 years' experience in ophthalmology care and knowledge about financing schemes in each country of residence. We identified significant differences in healthcare delivery and financing of ophthalmology services between Hungary and Poland, despite both countries rely on Diagnosis-Related Group (DRG) based systems for hospital care. Good practices for financing specific eye treatments like cataract, glaucoma, age-related macular degeneration (AMD), diabetic macular edema (DME), cornea transplantations, and vitrectomy are identified. The financing scheme, including financial products and incentives, can influence the volume of treatments. Access to ophthalmic care is a key concern, with differences in treatment schemes between Hungary (ambulatory care) and Poland (hospital care), leading to higher costs and the need for centralization of complex procedures like cornea transplantations. The article highlights the importance of incentivizing quality improvements and removing financial barriers in Poland, while Hungary should focus on continuous monitoring of treatment methods and flexibility in reimbursement. For Ukraine, the research findings are significant due to ongoing healthcare reform, and the country seeks optimal practices while considering the experiences of other countries.

The level of medical care accessibility in Russia: Regional differentiation

The need to consider economic risks and respond to demographic challenges pushes the issues of creating and maintaining the quality of regions’ human potential, as well as saving population health to the research agenda. The aim of the study is to investigate the resourcing of regional health care systems in Russia in order to determine the level of medical care accessibility. Methodologically, the paper relies on the concepts of systems and regional economics, labour economics. The study applies time series and comparative analyses, as well as index, score-rating methods, composite coefficients calculation. The data is the socioeconomic and health care statistics by federal districts for 2005–2022 taken from the Federal State Statistics Service of the Russian Federation. The paper finds that regions differ in terms of the level of the medical care accessibility. Reportedly, the Ural Federal District ranked high for the efficiency of regional health care systems in 2021, which, according to the analysis, is due to the developed systems of preventive and emergency care. Conversely, the Siberian and Far Eastern Federal Districts were at the bottom of the ranking because of the deficit of physicians in emergency departments and scarce health care financing. The findings may underlie the development of measures on the improvement of health care resourcing, management, and efficiency both at national and regional levels.

Transforming Lives Through Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (ABPMJAY): A Review

Background: The Pradhan Mantri Jan Arogya Yojana (PMJAY) program was created in line with the global goal of Universal Health Coverage (UHC), and aims to ensure everyone has access to quality healthcare services without suffering financial difficulties. In India, over 60% of healthcare spending is still borne by households, and a significant portion of the population lacks any form of health protection coverage. Discussion: The High-Level Expert Group (HLEG) recommended a shift from supply-side healthcare financing to demand-side financing, leading to the introduction of government-sponsored health insurance schemes. To achieve Universal Health Coverage (UHC), the Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched following the recommendations of the National Health Policy 2017. The PMJAY program is the world's largest publicly sponsored social health insurance program, delivering comprehensive healthcare services covering primary, secondary, and tertiary care levels. The scheme covers approximately 12 crore households, including more than 50 crore beneficiaries, offering healthcare coverage of up to Rs. 5 lakh per family annually. PMJAY operates nationwide in India, covering all states and union territories except for a few.. Conclusion: To move forward, PMJAY can play a transformative role in the healthcare landscape, integrate with primary healthcare, contribute to economic development, and expand its scope to include more healthcare services.

A Mixed-Method Study of the Utilization and Determinants of Private Health Insurance Schemes in the Residents of Rural Communities in Central India: A Study Protocol.

Background Private health insurance plays a critical role in healthcare financing, yet its utilization and determinants in rural settings still need to be studied, particularly in Central India. This study aims to address this gap by investigating the utilization and determinants of private health insurance schemes among residents of rural communities in Central India. Materials and methods A convergent parallel mixed-method study design, consisting of quantitative and qualitative approaches, will be employed. Quantitative data will be collected through structured questionnaires administered to residents aged 18 and above within the field practice area of a tertiary medical college hospital. Qualitative data will be gathered through in-depth interviews with key stakeholders. Statistical analysis will include descriptive and inferential statistics, while thematic analysis will be employed for qualitative data (CTRI Number CTRI/2024/06/069155). Conclusion The findings of this study will provide valuable insights into the utilization and determinants of private health insurance schemes in rural communities of Central India. By identifying barriers and facilitators to insurance uptake, policymakers and healthcare providers can develop targeted interventions to improve healthcare access and affordability in rural areas. In addition, the study will contribute to the existing literature on private health insurance utilization in India, informing future research endeavors and policy initiatives.

Infant and child mortality in Afghanistan: A scoping review.

Since 1990, global child and infant mortality rates have typically stabilized or decreased due to improved healthcare, vaccination rollouts, and international funding. However, Afghanistan continues to face the highest child and infant mortality rates globally, with 43 deaths per 1000 live births. This study aims to examine the factors contributing to this high mortality rate and propose interventions to address the issue. A comprehensive literature search was conducted using databases such as Google Scholar and PubMed, focusing on articles published in English within the last 10 years (2013-2023). The search terms included "Child mortality," "Infant mortality," "SIDS," "COVID-19," and "Afghanistan." Original studies, systematic reviews, case studies, and reports meeting the inclusion criteria were selected for analysis. Additional sources from organizations such as UNICEF, the World Bank Group, WHO, and EMRO were also reviewed. The study findings reveal significant challenges contributing to Afghanistan's high infant and child mortality rates. These challenges include birth defects, preterm birth, malnutrition, sudden infant death syndrome (SIDS), traumatic injuries, fatal infections, infanticide, and abuse. The ongoing conflict, insecurity, and humanitarian crises further exacerbate the situation, leading to increased child casualties. Despite efforts by international agencies like UNICEF to provide vaccines and maternal education, the infant mortality rate remains high. In conclusion, Afghanistan's child and infant mortality rates are of significant concern, and it is imperative that action be taken to reduce the incidence of child and infant mortality rates.

Healthcare Through the Lens of Music

In this episode of SoundPractice, host Mike Sacopulos interviews Stephen Klasko and Ken Terry about the future of healthcare. They talk about their book, Feelin’ Alright: How the Message in Music Can Make Healthcare Healthier, which explores the power of music to bring people together and send messages about healthcare. They discuss the negative effects of the current healthcare system, including fragmentation and inequity, and propose solutions such as moving healthcare to outpatient sites and using technology such as large language models and wearables to improve patient care. They also discuss the importance of addressing social determinants of health and reducing healthcare inequalities. Klasko and Terry offer a novel proposal for reforming healthcare financing and delivery without adopting Medicare for all, and they emphasize the importance of doctors having a stake in the healthcare system and address the mistrust that currently exists.

Development of a Prioritization Framework to Aid Healthcare Funding Decision Making in Health Technology Assessment in Australia: Application of Multicriteria Decision Analysis

ObjectivesThis study develops a prioritization framework to aid healthcare funding decision making in health technology assessment (HTA) in Australia using a multiple criteria decision analysis (MCDA) approach. MethodsMCDA frameworks for HTAs were reviewed through literature survey to identify the initial criteria and levels within each criterion. Key stakeholders and experts were consulted to confirm these criteria and levels. A conjoint analysis using 1000Minds was undertaken with policy makers from the Department of Health to establish ranking criteria and weighting scores. Monte Carlo simulations were used to examine the sensitivity of findings to factors affecting the ranking and weighting scores. The MCDA was then applied to 6 examples of chronic care models or technologies projects to demonstrate the performance of this approach. ResultsFive criteria (clinical efficacy/effectiveness, safety and tolerability, severity of the condition, quality/uncertainty, and direct impact on healthcare costs) were consistently ranked highest by healthcare decision makers. Among the criteria, patient-level health outcomes were considered the most important, followed by social and ethical values. The analyses were robust to inform the uncertainty in the parameter. ConclusionsThis study has developed an MCDA tool that effectively integrates key priorities for HTA reviews, reflecting the values and preferences of healthcare stakeholders in Australia. Although this tool aims to align the assessment process more closely with health benefits, it also highlights the importance of considering other criteria.

A Comparison of Healthcare Funding Systems between Low- /Medium-Income and High-Income Countries: Equity, Equality, and Fairness in the Rationing of Healthcare Resources

A Comparison of Healthcare Funding Systems between Low- /Medium-Income and High-Income Countries: Equity, Equality, and Fairness in the Rationing of Healthcare Resources

Funding Health Care for People Experiencing Homelessness: An Examination of Federally Qualified Health Centers' Funding Streams and Homeless Patients Served (2014-2019).

It is estimated that three million people annually experience homelessness, with about a third of the homeless population being served by Federally Qualified Health Centers (FQHCs). Thus, FQHCs, dependent on government funding for financial viability, are vital to the infrastructure addressing the complex issues facing people experiencing homelessness. This study examines the relationship between various government funding streams and the number of homeless patients served by FQHCs. Data for this study come from three publicly available databases: the Uniform Data System (UDS), the IRS Core files, and the Area Resource File. Fixed-effects models employed examine changes across six years from 2014 to 2019. The results suggest that, on average, an additional homeless patient served increases the expenses of FQHCs more than other patients and that federal funding, specifically Health Care for the Homeless (HCH) funding, is a vital revenue source for FQHCs. We found that the number of homeless patients served is negatively associated with contemporaneous state and local funding but positively associated with substance use and anxiety disorders. Our findings have important implications for the effective management of FQHCs in the long term and for broader public policy supporting these vital elements of the social safety net.

Внешние факторы, определяющие изменения в системе подготовки специалистов медицинской службы Вооруженных Сил Российской Федерации.

External factors determining changes in the system of training specialists of the medical service of the Armed Forces of the Russian Federation are characterized by changes in the regulatory and legal system of the state, political decisions and directions, economic factors such as financing of healthcare and defense, social factors such as changes in society, including demographic, lifestyle, public health and technological factors such as the use of modern technologies and innovations in the system of training specialists of the medical service of the Armed Forces of the Russian Federation. The purpose of the study is to identify external factors that affect the system of additional professional education of the medical service of the Armed Forces of the Russian Federation and to make recommendations on reducing the negative impact of these factors. Materials and methods. To analyze the external environment, we used the STEP-analysis method, which determines the factors affecting the system of additional professional education of the medical service of the Armed Forces of the Russian Federation (social – S, technological – T, economic – E and political – P). Results. The following tables present the results of the STEP analysis, the influence of factors on the state of the DPO system is distributed, the significance of each factor is calculated, and key factors affecting the training of specialists of the medical service of the Armed Forces of the Russian Federation are identified. Conclusions. The conducted STEP analysis allowed us to identify external factors that have a significant impact on the system of additional professional education of the medical service of the Armed Forces of the Russian Federation. Recommendations are given to reduce the negative impact of these factors on the DPO system in accordance with the detected trends.

Амбулаторнодополняющие технологии в условиях формирования «Новой модели медицинской организации, оказывающей первичную медико-санитарную помощь».

Purpose: propose new terminology “outpatient complementary technologies” in the provision of primary health care and justify their use. Materials and methods. Guidance documents, reports, open literary sources, orders, directives of the Russian Ministry of Health were analyzed. Results. The primary link of domestic health care is currently becoming more and more actively developed. The reason for this is the implementation of the tasks of national projects in order to achieve their most important key indicators. The successful implementation of lean manufacturing technologies into the practice of medical organizations providing primary health care within the framework of the “New Model of a Medical Organization Providing Primary Health Care” has shown its effectiveness. Undoubtedly, all this is facilitated by the significant economic growth of our country, accompanied by an annual increase in healthcare funding. In primary care medical organizations, special attention is paid to the organization and quality of preventive measures, as well as the successful conduct of dispensary work. This direction contains such factors as the formation of a healthy lifestyle, assessment of the existing risks of diseases, the presence of which requires timely treatment and observation. The ongoing therapeutic and preventive measures are, of course, aimed at increasing the life expectancy of the population of our country. The modernization of primary healthcare, which began in 2020, is one of the priorities for healthcare development in the coming years. This allows us to improve the accessibility of medical care and smoothly move to a completely new level of quality of medical care, achieving the maximum level of patient satisfaction. Conclusion. The modern development of healthcare in the Russian Federation lies in the most intensive use of all modern, latest medical technologies, in particular, in the provision of primary health care. As part of its development, significant changes are taking place in professional terminology. A thorough study of the possibility of introducing and widespread use of modern, cutting-edge medical technologies in medical organizations providing primary health care allowed us to propose a new, not previously encountered, concept of “outpatient complementary technologies” and justify its existence. A definition of the new terminology with the prerequisites for its emergence is given and prospects for further development are proposed. As part of the project “New model of a medical organization providing primary health care,” the introduction of the use of the concept of “outpatient complementary technologies” is aimed at improving the efficiency of activities and improving the system for organizing the provision of primary health care.

Whole genome sequencing as a ticket to cancer treatment in the Netherlands: Are inequalities in access to molecular diagnostics unfair?

Whole genome sequencing (WGS) of a tumour may sometimes reveal additional potential targets for medical treatment. Practice variation in the use of WGS is therefore a source of unequal access to targeted therapies and, as a consequence, of disparities in health outcomes. Moreover, this may even be more significant if patients seek access to WGS by paying a relatively limited amount of money out of pocket, and sometimes effectively buy themselves a ticket to (very) expensive publicly funded treatments. Should resulting unequal access to WGS be considered unfair? Drawing from current practice in the Dutch healthcare system, known as egalitarian, we argue that differences in employment of WGS between hospitals are the consequence of the fact that medical innovation and its subsequent uptake inevitably takes time. Consequently, temporal inequalities in access can be deemed acceptable, or at least tolerated, because and insofar as, ultimately, all patients benefit. However, we argue against allowing a practice of out-of-pocket payments for WGS in publicly funded healthcare systems, for four reasons: because allowing private spending favours patients with higher socio-economic status significantly more than practice variation between hospitals does, may lead to displacement of publicly funded health care, does not help to ultimately benefit all, and may undermine the solidaristic ethos essential for egalitarian healthcare systems.

Updating of Standard Performance Indicators of Polyclinics in the Context of Value-Based Healthcare

The key to providing high-quality and affordable health care to all citizens of the Russian Federation is to efficiently use the funds allocated within the state guarantee programs for free medical care. It is also one of the main tasks for optimizing the healthcare funding process. It is considered that medical organizations, especially those of primary care (i.e., providing outpatient services), must operate in an efficient way. This principle lays the foundation for value-based healthcare, which puts people first in the healthcare system. The list of performance indicators for medical organizations financed under the per capita funding standard by the number of attached persons was provided as a mandatory annex to the tariff agreement concluded in the Russian regions. The article discusses the relevance of laying down the criteria for evaluating the effectiveness of medical organizations in a regulatory document. The changes made by the Ministry of Health of the Russian Federation in the requirements for the structure and content of such documents are addressed. The adjustments to the list of indicators depicting the effectiveness of outpatient polyclinic care were assessed, and additional criteria were given.

Financing of Neurosurgical Care for Brain Tumors in Low- and Middle-Income Countries : A Scoping Review of Barriers and Strategies

Making neurosurgical care accessible to a larger portion of the population in low- and middle-income countries (LMICs) is integral due to the high mortality and morbidity associated with brain tumors. However, the high cost of care often makes it financially out of reach for many individuals. Therefore, this review aims to identify barriers to neurosurgical care of brain tumors in terms of financing in LMICs. Without restriction to language, a search of the literature was undertaken in a number of databases, including PubMed, Scopus, Google Scholar, and CINAHL, in order to find the most pertinent research involving financing of brain tumors in LMICs. The last day of the search was October 20, 2022. Following screening and data extraction, significant themes were found and categorized using thematic analysis. A total of 28 studies were analyzed in this review. The review highlighted some of the barriers to providing surgical care of brain tumors in LMICs. In the cited studies, surgical expenses (41%), neuroimaging costs (30%), and care-related expenses (33%) were the primary concerns. Addressing these challenges involves cross-border collaboration (23%), transparent financing systems (46%), awake craniotomy (15%), cost-effective/reusable intra-operative supplies (8%), and optimizing resources in healthcare systems (8%). This study explored barriers and challenges to financing neurosurgical care of brain tumors in LMICs. Government support and transparency in healthcare financing should be prioritized to ensure that all individuals have access to surgical care of brain tumors.

NURS-05. CATALYZING AND INFORMING THE DEVELOPMENT OF MORE COMPREHENSIVE AND ACCESSIBLE PROGRAMS FOR CAREGIVERS OF YOUNG ADULT SURVIVORS OF CHILDHOOD BRAIN TUMORS

Abstract BACKGROUND The chronic and intensive care needs of young adult survivors of childhood brain tumors are most often addressed by their maternal caregivers with limited, specific psychosocial or other programs to reduce caregiving demands and enhance their family management. Using a social ecological perspective, the purpose of this study was to catalyze and inform the development of more comprehensive and accessible programs for caregivers of young adult survivors of childhood brain tumors. METHODS Semi-structured interviews were conducted with 21 maternal caregivers, 6 post baccalaureate students/professional coaches for a problem-solving intervention for maternal caregivers, and 16 neuro-oncology clinical experts using interview guides tailored to their roles and constructed based on the Consolidated Framework for Implementation Science. Qualitative. Interview data were analyzed using content analysis. RESULTS Barriers included: need for internet connected devices (microsystem level); lack of care matched to their identified needs (mesosystem); poor tracking of long-term survivors and lack of survivorship psychosocial services (macrosystem); and lack of supportive health care policies and funding mechanisms for individuals and organizations (exosystem). Facilitators included: web-based platform accessible to the individuals and population (microsystem); widespread acknowledgement regarding gaps in survivorship psychosocial care (mesosystem); partnerships with survivors of childhood brain tumors, caregivers, and organizations that treat them (macrosystem); and dissemination among childhood brain tumor treatment/survivorship programs, healthcare systems, and community organization and endorsement from them (exosystem). CONCLUSIONS Multilevel approaches that address barriers and facilitators for improving health equity for maternal caregivers of young adult survivors of childhood brain tumors incorporate the design and dissemination of accessible, web-based programs designed in partnership with survivors, caregivers, and organizations to build care matched to need, as well as organizational, political, and community advocacy.

Primary Health Care Financing Methods in Georgia: Challenges and Prospects

Primary Health Care Financing Methods in Georgia: Challenges and Prospects

Patient empowerment in public healthcare funding system reform: a power network perspective

ABSTRACT This paper examines a reform of the French healthcare system that aimed to empower patients and improve their access to care but led to various adverse consequences for patients. Specifically, already socio-economically disadvantaged groups of patients found their positions becoming even more precarious. Conceptually, we draw upon Emerson’s power dependence theory and find that, rather than empowering patients, the reform resulted in private health insurance providers emerging as critical actors and primary beneficiaries of power network changes. This healthcare system-level analysis highlights the need for patients to be the direct focus of healthcare system reform and the importance of considering their position within the power network for understanding reform outcomes. This attention to the power network adds to the extant theorisation on the effects of funding mechanism reform on the nature of patient empowerment and access to healthcare.

Application of Mobile Telephony to Improve Medication Adherence in Type 2 Diabetes Patients

Therapeutic failure, poor quality of life and high economic costs have been linked to poor adherence to medication in Type 2 diabetes (T2D) patients. This paper aims to assess patients’ glycemic control, knowledge of T2D and adherence to medications, and evaluate the impact of mobile telephone-based intervention on these indices. A one-year retrospective review of pharmacy refill records was followed by a 6-months’ randomized controlled intervention conducted among 121 T2D patients in a secondary health care facility in Nigeria. Participants were assigned to control (n = 60) and intervention (n = 61) groups. The intervention comprised twice-weekly short message service (SMS) follow-up messaging to the intervention group alongside usual healthcare services. Control group received no SMS. Primary (HbA1c) and secondary (knowledge and adherence) outcome indicators were measured and compared pre- and post-intervention. The same copy of questionnaire was administered at baseline and post-intervention to both groups. Chi-square test was used to examine association of variables while two-sample t-test was conducted to compare mean pre- and post- intervention scores in both groups at p<0.05. The study revealed that intervention significantly improved glycemic control (HbA1c reduction) (p = 0.01). For the control group, mean pre- and post- intervention knowledge scores were 2.798 and 3.118 respectively (t = 1.1368, p = 0.2705) while intervention group recorded 2.714 and 4.193 respectively (t = 5.6772, p<0.001) on a 5-point Likert scale. Pre- and post- intervention adherence scores for control group were 3.804 and 4.013 respectively, (t = 0.2343, p = 0.8182) while intervention group had 3.430 and 6.859 respectively (t = 6.3216, p>0.001) on the 8-point Morisky Medication Adherence Scale (MMAS-8). The study concluded that patients initially had poor glycemic control, fair knowledge of T2D and low adherence to medications. SMS intervention significantly improved all three indices. Policy reforms in healthcare financing is recommended for sustainable provision of mhealth follow-up in diabetes care.

The use of antimicrobial dressings for the management of diabetic foot ulcers: A survey of podiatrists in Aotearoa New Zealand.

Diabetic foot ulcers (DFUs) are commonly contaminated with pathogenic organisms and precede most diabetes-related amputations. Antimicrobial dressings are used in the treatment of DFUs; however, recent guidelines do not support their use. There are no data describing the experience of antimicrobial dressing use among podiatrists in Aotearoa New Zealand (AoNZ). This study aimed to (i) determine which antimicrobial dressings podiatrists in AoNZ use for the management of diabetic foot ulcers; and (ii) determine what factors influence AoNZ podiatrists' use of antimicrobial dressing when managing DFUs. An anonymous cross-sectional web-based survey was undertaken. Participants were AoNZ registered podiatrists who managed DFUs in their practice. The survey included questions relating to personal and professional demographic characteristics and DFU management and dressing practices. Descriptive statistics were computed to address the research aims. Responses from 43 AoNZ podiatrists were included. Participants reported both cadexomer iodine and silver dressings were the most common antimicrobial dressings used, with honey dressings being the least frequently used. The most influential factors in choosing antimicrobial dressings when managing DFUs were the presence of current infection, ulcer exudate and ability to prevent future infection. The least influential factors in choosing antimicrobial dressings when managing DFUs were patient preferences, cost of dressings and comfort of dressing/pain on removal. AoNZ podiatrists managing DFUs primarily use antimicrobial dressings containing cadexomer iodine or silver as active ingredients, while lower-cost options, such as honey and povidone iodine are less often used. Current recommendations highlight the lack of evidence to support positive outcomes from any particular antimicrobial dressing over another and advocate that exudate control, comfort and cost be prioritised in decision-making. As cost has been an increasing burden to our healthcare funding, clinicians and organisations may consider this before purchasing and stocking expensive dressings.

Administrative burden of establishing health care coverage for the uninsured and its impact on timely access to care.

11050 Background: Although safety net coverage programs like Medicaid exist to fund health care for low-income patients, the administrative burden of the lengthy application limits uptake by eligible individuals. Therefore, many patients do not attempt to enroll until they become ill, which is common among uninsured adults diagnosed with cancer. The literature reports worse cancer outcomes for those with Medicaid, but reasons for this are unclear. The delays in enrollment for patients with uncertain coverage at the time of diagnosis – those in limbo – are understudied and may explain some of this persisting disparity. We estimated the patient and health system burdens for those with uncertain coverage status at the time of cancer diagnosis at Parkland Health, the main provider of cancer treatment for the uninsured in Dallas, Texas. Methods: We assembled the electronic health record financial encounter data of patients with an incident cancer diagnosis in the Parkland tumor registry, diagnosed from 2010 – 2022. We defined patients as being “in limbo” if they had self-pay, pending, or missing insurance plans at the date of diagnosis. We also included patients whose coverage verification date occurred after diagnosis date, since coverage programs can apply retroactively for 90 days. We used plan verification dates to identify when limbo status resolved. We used coarsened exact matching to balance across age, race, Spanish-language preference, Charlson, and screenable cancer type, then multivariate regression to compare patients that were in limbo to those that had established coverage before cancer diagnosis. Results: We identified 17,468 adults newly diagnosed with cancer, 80% of whom were < age 65, 55% female, 73% Hispanic and/or Black, and 30% Spanish-language preferring. The most common cancer types were GI/colorectal (19%), breast (17%), and lung (9%); 23% were advanced stage at diagnosis and 13% died within 180 days of diagnosis. 52.1% were already enrolled in Medicaid/charity care, but one-third (35%) were in limbo at diagnosis, which lasted for a median 31 days (IQR 13 – 126). Over half (55%) of patients in limbo resolved to Medicaid or charity care. Patients who experienced limbo had a median of 596 financial account notes in the first year after diagnosis, 121 more than the comparison group (95% CI 86.7 - 156.1) and began treatment 10 days later (95% CI 7.7 - 12.7). They also had a median of 1 ED visit in the year after diagnosis, 0.2 more than patients never in limbo (95% CI 0.11 - 0.26). Conclusions: The administrative burden of enrolling into coverage programs for the uninsured may impose direct and indirect costs on patients and safety-net health systems and may contribute to worse cancer care outcomes. A more comprehensive accounting of the effects of administrative burdens might suggest ways to redesign coverage enrollment for the uninsured to improve care and reduce costs.