OOP Payments Research Articles

Healthcare performance for patients with heart failure in Iran: addressing the tip of the iceberg.

Chronic diseases, such as heart failure with reduced ejection fraction (HFrEF), remain significant factors in the healthcare burden in Iran. Healthcare systems must have comprehensive data on the current usage, costs, and quality of care to tackle these challenges and formulate strategic plans effectively. The study included 209 patients with a mean age of 58 years (SD = 16.5) who met the inclusion criteria of having an ejection fraction of less than 40% and a confirmed diagnosis of HFrEF. This study used nationally representative data to assess the healthcare usage, costs, and quality of HFrEF management in Iran. The most used services were medication dispensing (76%) and outpatient visits (53%), while rehabilitation (3%) and homecare (2%) were used less frequently. The annual per-patient direct medical cost was $1,464, with $308 (21%) paid out-of-pocket (OOP). Hospitalization accounted for most of the total cost (68%), and pharmacy expenses comprised the largest portion of OOP payments (46%). Echocardiography was performed for 91.1% of patients upon admission. Only 71.6% of patients had arrangements for a cardiology visit within seven days following hospital discharge. Additionally, only 67.5% of patients received prescriptions for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and 85% were prescribed beta-blockers. Patients with heart failure in Iran face challenges in accessing adequate cardiac care, including a lack of care continuity and advanced cardiac services. The study provided an essential benchmark for future healthcare reform.

Why “free maternal healthcare” is not entirely free in Ghana: a qualitative exploration of the role of street-level bureaucratic power

BackgroundGhana introduced a free maternal healthcare policy within its National Health Insurance Scheme (NHIS) in 2008 to remove financial barriers to accessing maternal health services. Despite this policy, evidence suggests that women incur substantial out-of-pocket (OOP) payments for maternal health care. This study explores the underlying reasons for these persistent out-of-pocket payments within the context of Ghana’s free maternal healthcare policy.MethodsCross-sectional qualitative data were collected through interviews with a purposive sample of 14 mothers and 8 healthcare providers/administrators in two regions of Ghana between May and September 2022. All interviews were audio-recorded, transcribed and imported into the NVivo 14.0 software for analysis. An iteratively developed codebook guided the coding process. Our thematic data analysis followed the Attride-Sterling framework for network analysis, identifying basic, organising themes and global themes.ResultsWe found that health systems and demand-side factors are responsible for the persistence of OOP payments despite the existence of the free maternal healthcare policy in Ghana. Reasons for these payments arose from health systems factors, particularly, NHIS structural issues – delayed and insufficient reimbursements, inadequate NHIS benefit coverage, stockouts and supply chain challenges and demand-side factors – mothers’ lack of education about the NHIS benefit package, and passing of cost onto patients. Due to structural and system level challenges, healthcare providers, exercising their street-level bureaucratic power, have partly repackaged the policy, enabling the persistence of out-of-pocket payments for maternal healthcare.ConclusionsUrgent measures are required to address the structural and administrative issues confronting Ghana’s free maternal health policy; otherwise, Ghana may not achieve the sustainable development goals targets on maternal and child health.

Disparities in healthcare-seeking behaviors and associated costs between Venezuelan migrants and Colombians residing in Colombia

BackgroundColombia, which hosts over 3 million of the Venezuelan diaspora, is lauded for its progressive approach to social integration, including providing migrants access to its universal health coverage system. However, barriers to healthcare persist for both migrant and host populations, with poorly understood disparities in healthcare-seeking behaviors and associated costs. This is the first study to link healthcare-seeking behaviors with costs for Venezuelan migrants in Colombia, encompassing costs of missing work or usual activities due to healthcare events.MethodsWe use self-reported survey data from Venezuelan migrants and Colombians living in Colombia (September-November 2020) to compare healthcare-seeking behaviors and cost variables by nationality using two-sampled t-tests or Chi-square tests (X2). The International Classification of Diseases was used to compare reported household illnesses for both populations. Average health service direct costs were estimated using the Colombian Government’s Suficiencia database and self-reported out-of-pocket (OOP) payments for laboratory and pharmacy services. Indirect costs were calculated by multiplying self-reported days of missed work or usual activities with estimated income levels, derived by matching characteristics using the Gran Enquesta Integrada de Hogares database. We calculate economic burdens for both populations, combining self-reported healthcare-seeking behaviors and estimated healthcare service unit costs across six healthcare-seeking behavior categories.ResultsDespite similar disease profiles, Venezuelan migrants are 21.3% more likely to forego formal care than Colombians, with 746.3% more Venezuelans reporting lack of health insurance as their primary reason. Venezuelan women and uninsured report the greatest difficulties in accessing health services, with accessing medications becoming more difficult for Venezuelan women during the COVID-19 pandemic. Colombians cost the health system more per treated illness event (US$40) than Venezuelans (US$26) in our sample, over a thirty-day period. Venezuelans incur higher costs for emergency department visits (123.5% more) and laboratory/ pharmacy OOP payments (24.7% more).ConclusionsWhile Colombians and Venezuelans share similar disease burdens, significant differences exist in access, cost, and health-seeking behaviors. Increasing Venezuelan health insurance enrollment and tackling accessibility barriers are crucial for ensuring healthcare equity and effectively integrating the migrant population. Findings suggest that improving migrant access to primary healthcare would produce savings in Colombian healthcare expenditures.

Impact of patient’s financial burden of COVID-19 treatment on antiviral prescription rates and clinical and economic outcomes

ABSTRACT Background In Japan, medical expenses for COVID-19 treatment transitioned from full public funding support to out-of-pocket (OOP) payment by patients plus partial public support in October 2023, and public support fully ended in March 2024. This study evaluated the clinical and economic impacts of initiating OOP payments. Research design and methods To assess the impact on prescription rates, we compared the prescription rates of antivirals from the 4-month pre- to post-OOP payment initiation period using a claims database. Subsequently, a budget impact model assessed the impacts of a hypothetical decline in the prescription rates on COVID-19-related hospitalizations, deaths, and direct medical costs for antiviral prescription and hospitalization. Results The antiviral prescription rate per 100 patients decreased from 17.5 for the pre-OOP payment initiation period to 11.5 for the post-OOP payment initiation period, that is, a change of − 34.3%. With prescription rate decreases of 40%, 60%, and 80%, the hospitalizations would increase annually by 22,533 (3.3%), 33800 (5.0%), and 45,066 (6.6%), respectively. The total costs would increase by JPY9.5 billion (USD67.3 million; 0.7%), JPY14.3 billion (USD100.9 million; 1.0%), and JPY19.0 billion (USD134.5 million; 1.3%), respectively. Conclusions Higher OOP payment decreased the antiviral prescription rate, potentially leading to clinical and economic loss.

Financial burden within first year of diagnosis for privately-insured patients with early-onset breast or colorectal cancer.

9 Background: Rising incidence of early-onset (E-O) cancers has been observed globally. E-O breast cancer (BC) are patients (pts) diagnosed ages 18 to 44 and E-O colorectal cancer (CRC) are aged 18 to 49. Because many E-O cancers are among pts who do not meet screening eligibility criteria by age, they are often diagnosed at advanced stage, which is also more expensive to treat. Younger pts may also have lower incomes and fewer assets, increasing risk of financial burden for pts with E-O cancers. We estimated the financial burden for pts and private payors for E-O BC and CRC, compared to non-elderly pts with BC and CRC diagnosed between the age of 45 to 64 and 50 to 64 (older-onset), respectively. Methods: We applied a claims-based algorithm to identify pts with incident BC and CRC diagnosed between 2014 and 2021 from MarketScan Commercial Claims and Encounters Data and required 12-month continuous enrollment before and after the index diagnosis for completeness of claims. Financial burden was quantified as total and out-of-pocket (OOP) payments, calculated as the sum of deductibles, copayments, and coinsurance. We used generalized linear models and quantile regressions to compare differences in mean and median costs, respectively, between pts with E-O vs. older onset cancer, adjusting for comorbidity, region, insurance plan type, sex (for CRC) and year. Results: Study cohort included 58,419 pts with BC and 11,251 pts with CRC. The proportion of E-O increased from 15% in 2014 to 17% in 2022 (Ptrend<0.01) in BC and from 23% to 30% (Ptrend<0.01) in CRC. Higher percentage of E-O pts were enrolled in high-deductible plans (BC: 25% v22%; CRC: 24% vs. 21%) and received systemic therapy (BC: 61% v 49%; CRC: 57% vs. 43%). Higher percent of surgery (93% v 89%) was observed in E-O BC and radiation (21% v 16%) in E-O CRC. Pts with E-O BC and CRC had significantly higher adjusted mean and median total and OOP payments (Table). Conclusions: E-O BC and CRC result in substantial costs to payors and moderately higher OOP payments. OOP maximums in private insurance may offer some financial protection for pts. E-O Older onset Difference 95% CIBC: BC: Mean total pay $182,770 $128,640 $54,130 $50445, $57817 Median total pay 143,351 93,317 50,034 47691, 52377 Mean OOP 6,014 5,063 951 817, 1085 Median OOP 5,142 4,258 884 791, 978 CRC: Mean total pay $153,446 $123,449 $29,998 $24244, $35752 Median total pay 119,747 89,340 30,406 25216, 35597 Mean OOP 5,429 4,791 638 428, 848 Median OOP 4,452 4,015 437 266, 607

Household financial burden associated with out-of-pocket payments for healthcare in Iran: insights from a cross-sectional survey

BackgroundOne of the key functions and ultimate goals of health systems is to provide financial protection for individuals when using health services. This study sought to evaluate the level of financial protection and its inequality among individuals covered by the Social Security Organization (SSO) health insurance between September and December 2023 in Iran.MethodsWe collected data on 1691 households in five provinces using multistage sampling to examine the prevalence of catastrophic healthcare expenditure (CHE) at four different thresholds (10%, 20%, 30%, and 40%) of the household’s capacity to pay (CTP). Additionally, we explored the prevalence of impoverishment due to health costs and assessed socioeconomic-related inequality in OOP payments for healthcare using the concentration index and concentration curve. To measure equity in out-of-pocket (OOP) payments for healthcare, we utilized the Kakwani progressivity index (KPI). Furthermore, we employed multiple logistic regression to identify the main factors contributing to households experiencing CHE.Findings: The study revealed that households in our sample allocated approximately 11% of their budgets to healthcare services. The prevalence of CHE at the thresholds of 10%, 20%, 30%, and 40% was found to be 47.1%, 30.1%, 20.1%, and 15.7%, respectively. Additionally, we observed that about 7.9% of the households experienced impoverishment due to health costs. Multiple logistic regression analysis indicated that the age of the head of the household, place of residence, socioeconomic status, utilization of dental services, utilization of medicine, and province of residence were the main factors influencing CHE. Furthermore, the study demonstrated that while wealthy households spend more money on healthcare, poorer households spend a larger proportion of their total income to healthcare costs. The KPI showed that households with lower total expenditures had higher OOP payments relative to their CTP.ConclusionThe study findings underscore the need for targeted interventions to improve financial protection in healthcare and mitigate inequalities among individuals covered by SSO. It is recommended that these interventions prioritize the expansion of coverage for dental services and medication expenses, particularly for lower socioeconomic status household.

Analyzing HPV Vaccination Service Preferences among Female University Students in China: A Discrete Choice Experiment.

Despite being primary beneficiaries of human papillomavirus (HPV) vaccines, female university students in China exhibit low vaccination rates. This study aimed to assess their preferences for HPV vaccination services and evaluate the relative importance of various factors to inform vaccination strategy development. Through a literature review and expert consultations, we identified five key attributes for study: effectiveness, protection duration, waiting time, distance, and out-of-pocket (OOP) payment. A D-efficient design was used to create a discrete choice experiment (DCE) questionnaire. We collected data via face-to-face interviews and online surveys from female students across seven universities in China, employing mixed logit and latent class logit models to analyze the data. The predicted uptake and compensating variation (CV) were used to compare different vaccination service scenarios. From 1178 valid questionnaires, with an effective response rate of 92.9%, we found that effectiveness was the most significant factor influencing vaccination preference, followed by protection duration, OOP payment and waiting time, with less concern for distance. The preferred services included a 90% effective vaccine, lifetime protection, a waiting time of less than three months, a travel time of more than 60 min, and low OOP payment. Significant variability in preferences across different vaccination service scenarios was observed, affecting potential market shares. The CV analysis showed female students were willing to spend approximately CNY 5612.79 to include a hypothetical 'Service 5' (a vaccine with higher valency than the nine-valent HPV vaccine) in their prevention options. The findings underscore the need for personalized, need-based HPV vaccination services that cater specifically to the preferences of female university students to increase vaccination uptake and protect their health.

The Impact of Eliminating Out-of-Pocket Payments on Asthma Medication Use.

High costs of controller therapies may be a barrier to guideline-recommended asthma treatment. We determined whether eliminating out-of-pocket (OOP) payments among low-income patients with asthma impacted controller medication use. We applied a controlled interrupted time series design to administrative claims data in British Columbia, Canada from 2017-2020. Cases were individuals with an annual household income <$13,750 in whom copays were eliminated on January 2019; there was no change in public coverage for the control group with annual income >$45,000. We evaluated trends in asthma medication costs, use, the ratio of inhaled corticosteroid (ICS)-containing medications to all asthma medications, excessive use of short-acting β-agonists (SABA) (>1 canister/month), and the proportion of days (PDC) covered by controller therapies. There were 12,940 cases (62% female, mean age 30.3 years, SD 14.9), and 71,331 controls (55% female, mean age of 31.3 years, SD 16.3). Removal of OOP payments increased monthly mean medication costs by $3.32 (95% CI $0.08 - $6.56, 2020 Canadian dollars), days supply of controller medications by 1.50 days (95% CI 0.61 - 2.40), and the ratio of ICS-containing medications to total medications by 4.20% (95% CI 0.73% - 7.66%) compared to the control group. The policy had no effect on PDC by controller therapies (0.01, 95% CI -0.01 - 0.04), but non-significantly decreased the percentage of patients with excessive SABA use (-6.37%; 95% CI -12.90% - 0.16%). Removal of OOP payments increased the dispensation of controller therapies, suggesting cost-related non-adherence could impair optimal asthma management.

Association of State Insulin Out-of-Pocket Caps With Insulin Cost-Sharing and Use Among Commercially Insured Patients With Diabetes : A Pre-Post Study With a Control Group.

Twenty-five states have implemented insulin out-of-pocket (OOP) cost caps, but their effectiveness is uncertain. To examine the effect of state insulin OOP caps on insulin use and OOP costs among commercially insured persons with diabetes. Pre-post study with control group. Eight states implementing insulin OOP caps of $25 to $30, $50, or $100 in January 2021, and 17 control states. Commercially insured persons with diabetes and insulin users younger than 65 years. Subgroups of particular interest included members from states with insulin OOP caps of $25 to $30, enrollees with health savings accounts (HSAs) that require high insulin OOP payments, and lower-income members. Mean monthly 30-day insulin fills and OOP costs. State insulin caps were not associated with changes in insulin use in the overall population (relative change in fills per month, 1.8% [95% CI, -3.2% to 6.9%]). Insulin users in intervention states saw a 17.4% (CI, -23.9% to -10.9%) relative reduction in insulin OOP costs, largely driven by reductions among HSA enrollees; there was no difference in OOP costs among nonaccount plan members. More generous ($25 to $30) state insulin OOP caps were associated with insulin OOP cost reductions of 40.0% (CI, -62.5% to -17.6%), again primarily driven by a larger reduction in the subgroup with HSA plans. Single national insurer; 9-month follow-up. Insulin OOP caps were associated with reduced insulin OOP costs but no overall increases in insulin use. A proposed national insulin cap of $35 for commercially insured persons might lead to meaningful insulin OOP savings but have a limited effect on insulin use. Centers for Disease Control and Prevention and National Institute of Diabetes and Digestive and Kidney Diseases.

An assessment of primary health care costs and resource requirements in Kaduna and Kano, Nigeria.

The availability of quality primary health care (PHC) services in Nigeria is limited. The PHC system faces significant challenges and the improvement and expansion of PHC services is constrained by low government spending on health, especially on PHC. Out-of-pocket (OOP) expenditures dominate health spending in Nigeria and the reliance on OOP payments leads to financial burdens on the poorest and most vulnerable populations. To address these challenges, the Nigerian government has implemented several legislative and policy reforms, including the National Health Insurance Authority (NHIA) Act enacted in 2022 to make health insurance mandatory for all Nigerian citizens and residents. Our study aimed to determine the costs of providing PHC services at public health facilities in Kaduna and Kano, Nigeria. We compared the actual PHC service delivery costs to the normative costs of delivering the Minimum Service Package (MSP) in the two states. We collected primary data from 50 health facilities (25 per state), including PHC facilities-health posts, health clinics, health centers-and general hospitals. Data on facility-level recurrent costs were collected retrospectively for 2019 to estimate economic costs from the provider's perspective. Statewide actual costs were estimated by extrapolating the PHC cost estimates at sampled health facilities, while normative costs were derived using standard treatment protocols (STPs) and the populations requiring PHC services in each state. We found that average actual PHC costs per capita at PHC facilities-where most PHC services should be provided according to government guidelines-ranged from US$ 18.9 to US$ 28 in Kaduna and US$ 15.9 to US$ 20.4 in Kano, depending on the estimation methods used. When also considering the costs of PHC services provided at general hospitals-where approximately a third of PHC services are delivered in both states-the actual per capita costs of PHC services ranged from US$ 20 to US$ 30.6 in Kaduna and US$ 17.8 to US$ 22 in Kano. All estimates of actual PHC costs per capita were markedly lower than the normative per capita costs of delivering quality PHC services to all those who need them, projected at US$ 44.9 in Kaduna and US$ 49.5 in Kano. Bridging this resource gap would require significant increases in expenditures on PHC in both states. These results can provide useful information for ongoing discussions on the implementation of the NHIA Act including the refinement of provider payment strategies to ensure that PHC providers are remunerated fairly and that they are incentivized to provide quality PHC services.

Estimating Out-of-Pocket Payments Among Iranian Women with Breast Cancer

Background: Breast cancer is the most common type of cancer among Iranian women with more than 10 000 cases per year. Objectives: This study aimed at determining out-of-pocket (OOP) payments among women with breast cancer at health care centers affiliated to Iran University of Medical Sciences. Methods: This descriptive cross-sectional and applied study was done among 336 women with breast cancer referring to hospitals affiliated to Iran University of Medical Sciences. The data on inpatient expenses were obtained from the cost bills and the outpatient was collected, using a researcher-made questionnaire. Finally, the data were analyzed, using SPSS V2 software. Results: The average monthly OOP payment for direct hospitalization costs in inpatient breast cancer patients was estimated 146 ± 47.98 dollars and the average OOP payment for direct costs of treatment in outpatients was 69 ± 102.99 dollars, and the average OOP payment for non-medical direct cost per month 34.88 ± 31.12 dollars. The results of this study showed the average OOP payment included drug costs with the rate of 37.99 ± 45.31 dollars imposed the highest medical direct costs. Among the non-medical direct costs of OOP payment for transportation, the average of 30.65 ± 103.23 dollars imposed the highest OOP payment on breast cancer patients. Conclusions: These findings show that individuals with breast cancer endure high OOP payments that could adversely affect their quality of life; hence, decision-makers should pay more attention to implementing proper policies.

Non-communicable Diseases in India: The Growing Public Health Challenge and the Role of Health Insurance

Objective: The purpose of this study is to investigate the connection between non-communicable diseases (NCDs) and out-of-pocket (OOP) medical expenses in India. Methods: The study utilized information from the National Sample Survey (NSS) conducted in 2018 to examine the prevalence of NCDs and their relationship with OOP health expenditures. Results: There is a significant association between NCDs and higher OOP health spending in India. For individuals with NCDs, the average health expense per hospitalization episode was INR 19,420, with 89.3% covered by OOP payments and only 10.7% supported by health insurance. Additionally, the prevalence of NCDs varied by state, with Uttar Pradesh, Maharashtra, Bihar, West Bengal, and Madhya Pradesh experiencing the highest burden of NCDs. Conclusions: The study underscores the urgent need for a comprehensive and multi-sectoral strategy to address the growing burden of NCDs in India. This strategy should encompass NCD prevention, early identification, and management. Policy initiatives should focus on reducing the financial strain of NCDs on Indian households, potentially through increased public health spending, enhanced insurance coverage, and specialized programs targeting NCD prevention and management.

Ethnic disparities in out–of–pocket expense on medicines in Peru: Evidence from a nationwide survey

BackgroundDespite improvements in health insurance coverage, out-of-pocket (OOP) health spending remains a public health issue in Peru, and OOP payment has implications for disease treatment in ethnic minorities. We aimed to analyze the ethnic disparities in the OOP payment and estimate the gaps related to observable risk factors in the OOP payment on medicines by ethnic conditions during 2014–2016 in Peru. Study designcross-sectional study. MethodsWe conducted a secondary data analysis using the National Health User Satisfaction Survey. The outcome was the participants' OOP payment in self-reported medications. Ethnic minorities were considered participants who habitually spoke a language other than Spanish at home. Crude and adjusted linear regression models were performed, and the Oaxaca-Blinder decomposition method was used to assess the OPP payment differential by ethnic minority condition, explained by their individual and sociodemographic characteristics. ResultsWe analyzed 11,346 surveyed, the mean age was 40.78 years, and 57.67 % were women. There was lower OOP payment in medications among ethnic minorities in the adjusted analysis (Beta coefficient [β]: −0.11; 95 % confidence interval [95%CI]: −0.21 to −0.01; p = 0.043). In the Oaxaca-Blinder decomposition analysis, a gap of 0.19 USD in the OOP payment in medicines among ethnic minorities was found (p < 0.001), and the explained component by the variables measured in this research only represents 40.5 % of the gap (p = 0.001). ConclusionThere was less OOP expenditure on medicines in ethnic minorities. However, the measured variables explain only 40.5 % of these gaps. Therefore, we recommend future research that measures other variables that explain aspects of OOP spending on medicines not identified in this research. Likewise, our findings can be used to establish policies with an intercultural approach that adapt health documents to native languages or are disseminated by trained people from their communities.

Catastrophic Health Expenditure and Out-of-pocket Payments for Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Grafting (CABG)

Background: When households have high out-of-pocket (OOP) expenses, they are more likely to experience poverty and encounter catastrophic health expenditures (CHE). Heart disease is a significant cause of health decline and mortality. Objectives: This study aimed to provide essential knowledge about CHE and OOP for heart disease patients who underwent coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in Shiraz, Iran. Methods: This cross-sectional study with two prospective follow-ups was conducted in three heart surgery centers in Shiraz, Iran. The data were collected using the world health survey (WHS). Catastrophic health expenditures and OOP were asked from the most informed family member. Generalized estimating equation (GEE) modeling was employed to identify the main factors related to CHE and OOP. Binary distribution with logit link and gamma distribution with log link were used for CHE and OOP, respectively. The significance level was set at 0.05. Results: We found that OOP payment among patients who needed cardiovascular services in public-private partnership (PPP) hospitals was 76,953,100 Rials (R), equal to 2,506.78 $ (USD) (SD = 53,247,600 R/1,734.56 $) in the PCI group and 230,937,700 R equal to 7,522.89 $ (SD = 248,295,200 R/8,088.32 $) in the CABG group. This value in public hospitals was 15,083,800 R, equal to 491.36 $ (SD = 18,637,600 R/ 607.13 $) in the PCI group and 12,276,800 R, equal to 399.92 $ (SD = 11,131,900 R/ 362.63 $) in the CABG group. We also found that admission duration, age, type of hospital, and being currently a smoker were significant factors for OOP (P-value &lt; 0.05). During baseline assessment, we also found that the percentage of PCI patients that faced CHE was 95.56% and 47.92% in PPP and public hospitals, respectively. This value in CABG patients was 92.31% and 40.45%. Our study showed that the type of hospital and socioeconomic status were significant factors (P-value &lt; 0.05) that pushed a family facing CHE. Conclusions: The baseline CHE is very high in both PCI and CABG patients. Thus, the government should pay special attention to this issue. Further investigations are needed on factors affecting OOP and CHE.

County Hospital Responses to Funding Reforms in Zhejiang, China: An Interrupted Time-Series Analysis

ABSTRACT This study aimed to assess the effects of a two-stage funding reform, involving DRGs-based (Diagnostic Related Groups) payments for inpatient care and capitation funding for outpatient care, respectively, on services volume and care expenditure of county hospitals in Zhejiang province, China. A quasi-experimental design was adopted, involving 6 hospitals from 2 counties in the intervention group and 12 hospitals from 5 counties in the control group. The DRGs-based payments for inpatient care and capitation funding for outpatient care were introduced in January 2018 and January 2019, respectively. Controlled interrupted time-series analyses were performed to determine the effects of the funding reforms using monthly data over the period from January 2017 to December 2019. The volume of inpatient care decreased after the introduction of the first-stage DRGs-based payments, which was accompanied by an increase in the volume of outpatient visits. The DRGs-based payments led to a reduction of on average 1390 Yuan total expenditure per episode of inpatient care and 1116 Yuan out-of-pocket (OOP) payment per episode of inpatient care. However, the average outpatient expenditure per visit increased. So did the corresponding OOP payment per outpatient visit. The introduction of the second-stage capitation funding for outpatient care reversed the increasing trend of outpatient care. The average expenditure and OOP payment per outpatient visit decreased. The funding reforms create a significant effect on service volumes and expenditures in county hospitals. A coordinated approach to both inpatient and outpatient funding mechanisms is needed to minimize cost-shifting between inpatient and outpatient care and to achieve the intended policy outcomes.

Catastrophic Out-of-Pocket Expenditure on Health: Evidence from the Regions in the Philippines

This study estimates Filipino’s catastrophic and impoverishing out-of-pocket (OOP) healthcare expenditures on a regional perspective to measure the effectiveness and progress of Philippines’ healthcare financing system in ensuring population protection from excessive and unequal healthcare costs. Observations are drawn from the most recent household-based survey in the Philippines, 2018 and 2021 Family Income and Expenditure Survey, and grouped by four major regions: National Capital Region, the rest of Luzon, Visayas, and Mindanao region. From 2018 to 2021, results showed that the distribution of catastrophic OOP healthcare expenditures decreases while depth of these payments increases across the four major regions. The highest incidences of these catastrophic payments were found in the rest of Luzon and Visayas regions, while the highest intensities were found in Mindanao region. Despite medicines and pharmaceuticals products dominance on OOP healthcare expenditures, payment on inpatient medical services drives the catastrophic expenditures of households. Aside, deepening poverty caused by healthcare payments were more evident in households residing in Mindanao regions, thus exposing this Filipino families to financial risk and poverty threats. Logistic regression analysis showed that aging households head, employment, and socio-economic status are significant and common factors affecting the likelihood of incurring excessive health expenditures across the regions. The risk of catastrophic and impoverishing effects of healthcare expenditures persists in the country. Low levels of catastrophic OOP healthcare expenditures may indicate that disadvantaged households focused on spending on basic necessities and struggle to afford healthcare due to high costs amid COVID 19, leading to foregone treatment. Thus, continuous implementation of fair and innovative ways of financing the healthcare system to reduce the financial burden of OOP payments on Filipino households is recommended.

Economic burden of non-communicable diseases on households in Nigeria: evidence from the Nigeria living standard survey 2018-19.

The importance of non-communicable diseases (NCDs) in Nigeria is reflected in their growing burden that is fast overtaking that of infectious diseases. As most NCD care is paid for through out-of-pocket (OOP) expenses, and NCDs tend to cause substantial income losses through chronic disabilities, the rising NCD-related health burden may also be economically detrimental. Given the lack of updated national-level evidence on the economic burden of NCDs in Nigeria, this study aims to produce new evidence on the extent of financial hardship experienced by households with NCDs in Nigeria due to OOP expenditure and productivity loss. This study analysed cross-sectional data from the most recent round (2018-19) of the Nigeria Living Standard Survey (NLSS). Household-level health and consumption data were used to estimate catastrophic health expenditure (CHE) and impoverishing effects due to OOP health spending, using a more equitable method recently developed by the World Health Organization European region in 2018. The productivity loss by individuals with NCDs was also estimated from income and work-time loss data, applying the input-based human capital approach. On average, a household with NCDs spent ₦ 122,313.60 or $ 398.52 per year on NCD care, representing 24% of household food expenditure. The study found that OOP on cancer treatment, mental problems, and renal diseases significantly contribute to the cost of NCD care. The OOP expenditure led to catastrophic and impoverishing outcomes for households. The estimations showed that about 30% of households with NCDs experienced CHE in 2018, using the WHO Europe method at the 40% threshold. The study also found that the cost of NCD medications was a significant driver of CHE among NCD-affected households. The results showed heterogeneity in CHE and impoverishment across states and geographical regions in Nigeria, with a higher concentration in rural and North East geopolitical locations. The study also found that 20% of NCD-affected households were impoverished or further impoverished by OOP payment, and another 10% were on the verge of impoverishment. The results showed a negligible rate of unmet needs among households with NCDs. The study highlights the significant effect of NCDs on Nigerian households and the need for effective policy interventions to address this challenge, particularly among the poor and vulnerable.

The financial burden of out of pocket payments on medicines among households in Ethiopia: analysis of trends and contributing factors

BackgroundIn Ethiopia, out-of-pocket (OOP) payment is the key means of healthcare financing, and expenses on medicines are a crucial component of such payment. This study aims to investigate the financial implications of OOP payments on medicines for Ethiopian households.MethodsThe study involved a secondary data analysis of the national household consumption and expenditure surveys of 2010/11 and 2015/16. The "capacity-to-pay" method was used to calculate catastrophic OOP medicine expenditures. The extent of economic status related to catastrophic medicine payment inequity was calculated using concentration index estimation. The impoverishment consequences of OOP payment on medicine were estimated using poverty headcount and poverty gap analysis methods. Logistic regression models were used to identify the variables that predict catastrophic medicine payments.ResultsMedicines accounted for the majority of healthcare spending (> 65%) across the surveys. From 2010 to 2016, the total percentage of households facing catastrophic medicine payments decreased from 1% to 0.73%. However, the actual number of people expected to have experienced catastrophic medicine payments increased from 399,174 to 401,519 people. Payment for medicines pushed 11,132 households into poverty in 2015/16. The majority of disparities were explained by economic status, place of residence, and type of health services.ConclusionOOP payment on medicine accounted for the majority of total health expenses in Ethiopia. A high medicine OOP payment continued to push households into catastrophic payments and impoverishment. Household seeking inpatient care, those with lower economic status and urban residents were among the most affected. Hence, innovative approaches to improve the supply of medicines in public facilities especially those in urban settings and risk protection mechanisms for medicine expenditures particularly for inpatient care are recommended.

Cost of bladder cancer in Lebanon before and after the economic collapse: a probabilistic modeling study

Background and objectivesLebanon has one of the highest incidence rates of bladder cancer (BC) in the world. In 2019, Lebanon’s economy collapsed which majorly impacted healthcare costs and coverage. This study assesses the overall direct costs of urothelial BC in Lebanon, from the perspective of public and private third-party payers (TPP) and households, and evaluates the impact of the economic collapse on these costs.MethodsThis was a quantitative, incidence-based cost-of-illness study, conducted using a macro-costing approach. Costs of medical procedures were obtained from the records of various TPPs and the Ministry of Public Health. We modeled the clinical management processes for each stage of BC, and conducted probabilistic sensitivity analyses to estimate and compare the cost of each stage, pre-and post-collapse, and for each payer category.ResultsBefore the collapse, the total annual cost of BC in Lebanon was estimated at LBP 19,676,494,000 (USD 13,117,662). Post-collapse, the total annual cost of BC in Lebanon increased by 768% and was estimated at LBP 170,727,187,000 (USD 7,422,921). TPP payments increased by 61% whereas out-of-pocket (OOP) payments increased by 2,745% resulting in a decrease in TPP coverage to only 17% of total costs.ConclusionOur study shows that BC in Lebanon constitutes a significant economic burden costing 0.32% of total health expenditures. The economic collapse induced an increase of 768% in the total annual cost, and a catastrophic increase in OOP payments.

Does reducing out-of-pocket costs for children’s surgical care protect families from poverty in Somaliland? A cross-sectional, national, economic evaluation modelling study

ObjectivesAn estimated 1.7 billion children around the world do not have access to safe, affordable and timely surgical care, with the financing through out-of-pocket (OOP) expenses being one of the...