OOP Spending Research Articles

Association between oral targeted cancer drug net health benefit, uptake, and spending.

Targeted cancer drugs (TCDs) have revolutionized oncology but vary in clinical benefit and patient out-of-pocket (OOP) costs. The American Society of Clinical Oncology (ASCO) Value Framework uses survival, toxicity, and symptom palliation data to quantify the net health benefit (NHB) of cancer drugs. We evaluated associations between NHB, uptake, and spending on oral TCDs. We conducted a retrospective cohort study of patients aged 18-64 years with an incident oral TCD pharmacy claim in 2012-2020 in a nationwide deidentified commercial claims dataset. TCDs were categorized as having high (>60), medium (40-60), and low (<40) NHB scores. We plotted the uptake of TCDs by NHB category and used standard descriptive statistics to evaluate patient OOP and total spending. Generalized linear models evaluated the relationship between spending and TCD NHB, adjusted for cancer indication. We included 8524 patients with incident claims for 8 oral TCDs with 9 first-line indications in advanced melanoma, breast, lung, and pancreatic cancer. Medium- and high-NHB TCDs accounted for most TCD prescriptions. Median OOP spending was $18.78 for the first 28-day TCD supply (interquartile range [IQR] = $0.00-$87.57); 45% of patients paid $0 OOP. Median total spending was $10 118.79 (IQR = $6365.95-$10 600.37) for an incident 28-day TCD supply. Total spending increased $1083.56 for each 10-point increase in NHB score (95% confidence interval = $1050.27 to $1116.84, P < .01 for null hypothesis H0 = $0). Low-NHB TCDs were prescribed less frequently than medium- and high-NHB TCDs. Total spending on oral TCDs was high and positively associated with NHB. Commercially insured patients were largely shielded from high OOP spending on oral TCDs.

Patient Out-of-Pocket Costs for Biologic Drugs After Biosimilar Competition

Biologic drugs account for a growing share of US pharmaceutical spending. Competition from follow-on biosimilar products (subsequent versions that have no clinically meaningful differences from the original biologic) has led to modest reductions in US health care spending, but these savings may not translate to lower out-of-pocket (OOP) costs for patients. To investigate whether biosimilar competition is associated with lower OOP spending for patients using biologics. This cohort study used a national commercial claims database (Optum Clinformatics Data Mart) to identify outpatient claims for 1 of 7 clinician-administered biologics (filgrastim, infliximab, pegfilgrastim, epoetin alfa, bevacizumab, rituximab, and trastuzumab) from January 2009 through March 2022. Claims by commercially insured patients younger than 65 years were included. Year relative to first biosimilar availability and use of original or biosimilar version. Patients' annual OOP spending on biologics for each calendar year was determined, and OOP spending per claim between reference biologic and biosimilar versions was compared. Two-part regression models assessed for differences in OOP spending, adjusting for patient and clinical characteristics (age, sex, US Census region, health plan type, diagnosis, and place of service) and year relative to initial biosimilar entry. Over 1.7 million claims from 190 364 individuals (median [IQR] age, 53 [42-59] years; 58.3% females) who used at least 1 of the 7 biologics between 2009 and 2022 were included in the analysis. Over 251 566 patient-years of observation, annual OOP costs increased before and after biosimilar availability. Two years after the start of biosimilar competition, the adjusted odds ratio of nonzero annual OOP spending was 1.08 (95% CI, 1.04-1.12; P < .001) and average nonzero annual spending was 12% higher (95% CI, 10%-14%; P < .001) compared with the year before biosimilar competition. After biosimilars became available, claims for biosimilars were more likely than reference biologics to have nonzero OOP costs (adjusted odds ratio, 1.13 [95% CI, 1.11-1.16]; P < .001) but had 8% lower mean nonzero OOP costs (adjusted mean ratio, 0.92 [95% CI, 0.90-0.93; P < .001). Findings varied by drug. Findings of this cohort study suggest that biosimilar competition was not consistently associated with lower OOP costs for commercially insured outpatients, highlighting the need for targeted policy interventions to ensure that the savings generated from biosimilar competition translate into increased affordability for patients who need biologics.

Changes in Healthcare Spending Attributable to High Deductible Health Plan Offer Among Enrollees with Comorbid Substance Use Disorder and Cardiovascular Disease.

The rise in prevalence of high deductible health plans (HDHPs) in the United States may raise concerns for high-need, high-utilization populations such as those with comorbid chronic conditions. In this study, we examine changes in total and out-of-pocket (OOP) spending attributable to HDHPs for enrollees with comorbid substance use disorder (SUD) and cardiovascular disease (CVD). We used de-identified administrative claims data from 2007 to 2017. SUD and CVD were defined using algorithms of ICD 9 and 10 codes and HEDIS guidelines. The main outcome measures of interest were spending measure for all non-SUD/CVD-related services, SUD-specific services, and CVD-specific services, for all services and medications specifically. We assessed both total and OOP spending. We used an intent-to-treat two-part model approach to model spending and computed the marginal effect of HDHP offer as both the dollar change and percent change in spending attributable to HDHP offer. Our sample included 33,684 enrollee-years and was predominantly white and male with a mean age of 53 years. The sample had high demonstrated substantial healthcare utilization with 94% using any non-SUD/CVD services, and 84% and 78% using SUD and CVD services, respectively. HDHP offer was associated with a 17.0% (95% CI = [0.07, 0.27] increase in OOP spending for all non-SUD/CVD services, a 21.1% (95% CI = [0.11, 0.31]) increase in OOP spending for all SUD-specific services, and a 13.1% (95% CI = [0.04, 0.23]) increase in OOP spending for all CVD-specific services. HDHP offer was also associated with a significant increase in OOP spending on non-SUD/CVD-specific medications and SUD-specific medications, but not CVD-specific medications. This study suggests that while HDHPs do not change overall levels of annual spending among enrollees with comorbid CVD and SUD, they may increase the financial burden of healthcare services by raising OOP costs, which could negatively impact this high-need and high-utilization population.

Effects of national health benefits expansion policy on out-of-pocket payments and utilization of patients with four major catastrophic diseases

Background As South Korea achieved universal health care (UHC) in 1989, patients’ access to low-cost health services has highly increased. However, as liability for high-cost procedures is still high, patients’ accessibility to high-cost services is has been limited. For this reason, the Korean government has implemented an initiative of the “Mid-term Health Benefits Security Plan” to expand the health benefits coverage since 2005. Nevertheless, it has been criticized as the policy has yet to show any transparent evidence of reducing patients’ out-of-pocket costs since its implementation. This study aims to identify if the benefit expansion policy affected a reduction of patients’ health care spending and utilization after policy implementation. Methods We analyze data from the Korean Health Panel Survey for years 2009-2016, a nationally representative survey of non-institutionalized Korean citizens that provide the most comprehensive information on health care utilization and costs. We utilize two-part difference-in-differences (DID) models to estimate the patients' probability of accessing any care and the intensity of care, health care spending and utilization, conditional on the initiated care Results The total out-of-pocket(OOP) payments and inpatient spending decreased by USD 175.33 (p = 0.033) and USD 358.86 (p =0.018), respectively, which were statistically significant. Outpatient spending increased by USD 57.43 (p =0.607), but it was not statistically significantly associated with the policy implementation. In utilization, there were no significant changes in either the number of visits or hospital stays. Conclusions Even though we found that the policy led to a reduction in patients' OOP spending, the effects of the policy were largely limited to inpatient services and patients with high incomes. As the limited benefits of the policy to the particular services and patients might raise some equity issues, the government needs to extend the range of coverage more broadly so that a more comprehensive population can benefit from the policy.

Out-of-pocket costs associated with chronic respiratory diseases in Korean adults.

Chronic respiratory diseases (CRDs) are a burden on both individuals and society. While previous literature has highlighted the clinical burden and total costs of care, it has not addressed patients' direct payments. This study aimed to estimate the incremental healthcare costs associated with patients with CRDs, specifically out-of-pocket (OOP) costs. We used survey data from the 2019 Korea Health Panel Survey to estimate the total OOP costs of CRDs by comparing the annual hospitalizations, outpatient visits, emergency room visits, and medications of patients with and without CRDs. Generalized linear regression models controlled for differences in other characteristics between groups. We identified 222 patients with CRDs, of whom 166 were aged 65 years and older. Compared with the non-CRD group, CRD patients spent more on OOP costs (238.3 USD on average). Incremental costs were driven by outpatient visits and medications, which are subject to a coinsurance of 30% or more and may include items not covered by public insurance. Moreover, CRD patients aged 50-64years incurred the highest incremental costs. The financial burden associated with CRDs is significant, and outpatient visits and medications constitute the largest components of OOP spending. Policymakers should introduce appropriate strategies to reduce CRD-associated burdens.

Sociodemographic and spending characteristics of Medicare beneficiaries taking prescription drugs subject to price negotiations.

The 2022 Inflation Reduction Act authorizes Medicare to negotiate the prices of 10 drugs in 2026 and additional drugs thereafter. Understanding the sociodemographic and spending characteristics of beneficiaries taking these specific drugs could be important describing the impact of the legislation. To describe sociodemographic and spending characteristics of Medicare beneficiaries who use the 10 prescription drugs ("negotiated drugs") that will face Medicare drug price negotiations in 2026. A 20% sample of Medicare Part D beneficiaries from 2020 (n = 10,224,642) was used. Sociodemographic and spending characteristics were descriptively reported for beneficiaries taking the negotiated drugs, including subgroups by low-income subsidy (LIS) status and by drug, and for Part D beneficiaries not taking negotiated drugs. Part D beneficiaries taking a negotiated drug compared with Part D beneficiaries not taking a negotiated drug overall had similar sociodemographic characteristics, more comorbidities (3.9 vs 2.2) and higher mean [median] Medicare ($33,882 [$18,251] vs $12,366 [$3,429]) and out-of-pocket (OOP) spending ($813 [$307] vs $441 [$160]). There was variation in characteristics by LIS status. The mean age was highest among non-LIS beneficiaries taking a negotiated drug compared with LIS beneficiaries taking a negotiated drug and beneficiaries not taking a negotiated drug (76.2 vs 69.9 vs 71.4). Among beneficiaries using negotiated drugs, a higher percentage of LIS beneficiaries compared with non-LIS was female (59.7% vs 48.0%), was Black (20.9% vs 6.6%), and resided in lower-income areas (39.1% vs 20.3%). Mean [median] annual Part D OOP spending for negotiated drugs was $115 [$59] for beneficiaries with LIS and $1,475 [$1,204] for beneficiaries without LIS. There were also differences depending on which negotiated drug was used. Drugs for cancer and blood clots had the highest proportions of White users, whereas type 2 diabetes and heart failure drugs had the highest proportions of Black users and beneficiaries residing in lower-income areas. Annual Part D OOP costs were lowest for sitagliptin (LIS: $104 [$60], non-LIS: $1,391 [$1,153]) and highest for ibrutinib (LIS: $649 [$649], non-LIS: $6,449 [$6,867]). Among non-LIS beneficiaries, 24% (22% to 76%) had more than $2,000 in OOP costs. Inflation Reduction Act OOP spending caps and LIS expansion will lower prescription drug costs for beneficiaries with OOP costs exceeding $2,000 who are mostly White and live in higher-income areas, insulin users who are disproportionately Black with multiple chronic conditions, and beneficiaries with low incomes. However, these provisions will not impact the 76% of non-LIS beneficiaries using negotiated drugs who have OOP costs that are still substantial but below $2,000. Negotiations could reduce OOP costs through reduced coinsurance payments for this group, which is older and has more chronic conditions compared with beneficiaries not taking negotiated drugs. Part D plan design, spending, and utilization changes should be monitored after negotiation to determine if further solutions are needed to lower OOP costs for this group.

Abstract 18944: Affordability of Insulin for Non-Elderly Adults in the United States Following $35 Monthly Out-of-Pocket Cap

Introduction: In March 2023, insulin manufacturers in the United States announced price reductions, with Eli Lilly adding a $35 OOP cap on their unbranded insulin products. Aims: To investigate estimated OOP savings of a $35 insulin cap for non-Medicare patients. Methods: We used the 2019 Medical Expenditure Panel Survey (MEPS). Non-Medicare adults aged 18-64 who filled at least one insulin prescription were included. We identified insulin prescriptions with OOP spending above $35 and estimated savings using a $35 OOP cap. For each respondent, we calculated annual insulin OOP spending, average OOP spending per prescription, and total estimated OOP savings with a $35 OOP cap. Analyses were done in SAS. Results: Over 4.1 million non-elderly civilians filled 32.7 million insulin prescriptions in 2019, totaling $1.7 billion in OOP costs, or $418 per person (Table 1). There were 1.6 million people (39.5%) eligible for reduced OOP spending under a $35 OOP cap. Those eligible were more often male and medium- or high-income. Only 16% of publicly insured patients were eligible for savings with a $35 OOP cap, compared to 53% among privately insured and 52% among uninsured groups. Of those eligible for savings, we estimated a $35 OOP cap would have reduced average annual OOP insulin spending from $984 to $231, saving an estimated $1.2 billion. Uninsured patients would see a 93% reduction in OOP spending. Hispanic patients would see an 87% reduction in OOP spending, compared to 73% among non-Hispanic patients. Near poor and low-income patients would see greater OOP reductions than patients in other income groups. Conclusions: Populations most likely to benefit under a $35 OOP insulin cap are those with the highest cost-sharing requirements, such as the uninsured and those just above the threshold for income-based social services. Future work should assess how insulin OOP caps affect patient adherence and outcomes.

Health insurance literacy among patients receiving outpatient cancer treatment.

339 Background: Limited health insurance literacy (HIL) has been linked to problems paying medical bills or delaying care among patients with cancer. In this study, we describe the prevalence and correlates of HIL in a cohort of cancer patients measured using a ten-question HIL quiz developed by the Kaiser Family Foundation. Methods: We examined HIL in 393 adult patients (aged &gt;18 years) receiving cancer treatment in two ambulatory infusion centers, Mayo Clinic in Phoenix, Arizona (12/2019 to 2/2020 and 8/2020 to 10/2020) and University of Mississippi Medical Center in Jackson, Mississippi (9/2020 to 1/2021). HIL was categorized as low, moderate, or high based on the total number of correct answers: 0-4 (low), 5-6 (moderate), and 7-10 (high). Descriptive statistics characterized the sample and chi-square statistics compared HIL by sociodemographic factors. Results: Most patients understood basic insurance terms, such as premiums and deductibles (Table). However, fewer patients answered questions correctly about provider networks (46.1%), formularies (48.6%), and calculating out-of-pocket (OOP) spending (16.8%). 53 (13.5%), 69 (17.6%), and 271 (69.0%) patients had low, moderate, and high HIL scores, respectively. Lower HIL was more common among patients of younger age (&lt;65 years: 17.8%, 65+ years: 8.7%), lower educational attainment (less than college: 23.2%; college or higher: 4.4%), and lower household income (&lt;$4999: 21.1%, $5000+: 6.1%) (all p-values&lt;0.05). Conclusions: Although HIL in our cohort of cancer patients was relatively high - 69% answered at least 7 questions correctly - there were gaps in understanding of provider networks, formularies, and calculation of OOP spending. Efforts to improve HIL and help with navigation of health insurance plans may be required, especially for socioeconomically vulnerable patients.[Table: see text]

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.

Do discussions of financial burdens decrease long-term financial toxicity in adolescent and young adult cancer survivors?

This study aims to evaluate the associations between patient-provider cost discussions with patient-reported out-of-pocket (OOP) spending and long-term financial toxicity (FT) among adolescent and young adult (AYA; 15-39years old) cancer survivors. Using a cross-sectional survey, we assessed the themes and quality of patient discussions with providers about financial needs and general survivorship preparation, quantified patients' levels of FT, and evaluated patient-reported OOP spending. We determined the association between cancer treatment cost discussion and FT using multivariable analysis. In a subset of survivors (n = 18), we conducted qualitative interviews and used thematic analysis to characterize responses. Two hundred forty-seven AYA survivors completed the survey at a mean of 7years post treatment and with a median COST score of 13. 70% of AYA survivors did not recall having any cost discussion about their cancer treatment with a provider. Having any cost discussion with a provider was associated with decreased FT (β = 3.00; p = 0.02) but not associated with reduced OOP spending (χ2 = 3.77; p = 0.44). In a second adjusted model, with OOP spending included as a covariate, OOP spending was a significant predictor of FT (β = - 1.40; p = 0.002). Key qualitative themes included survivors' frustration about the lack of communication related to financial issues throughout treatment and in survivorship, feeling unprepared, and reluctance to seek help. AYA patients are not fully informed about the costs of cancer care and FT; the dearth of cost discussions between patients and providers may represent a missed opportunity to reduce costs.

Maxed out: Reaching the annual maximum out-of-pocket limit among insured patients diagnosed with cancer.

6646 Background: Patients with cancer face potentially high out-of-pocket costs associated with their medical care, which may lead to adverse medical and financial outcomes. Depending on their health insurance plan, patients may have to pay several thousands for medical care costs until they reach the annual maximum out-of-pocket [MOOP] spending limit; after which care costs are covered by insurance. The purpose of this study was to measure the proportion of adult patients who reach their health plan MOOP limit in the year of cancer diagnosis. Methods: Electronic health record data from 13,057 patients aged ≥18 years, diagnosed with cancer between Jan. 1, 2016–March 31, 2021 [index cancer], with ≥12 months of continuous health insurance coverage pre-cancer diagnosis were included. The primary outcome was defined as reaching the MOOP limit in the health plan benefit year of index cancer diagnosis (binary, yes/no). We additionally created a secondary outcome using 3 categories: (i) did not reach MOOP; (ii) reached MOOP prior to cancer diagnosis; (iii) reached MOOP after cancer diagnosis. Descriptive statistics were used to assess the distribution of outcomes across patient characteristics including health insurance type (e.g., commercial), high-deductible health plan (HDHP), cancer type, age at diagnosis, and Census-level household income was included. Multivariable logistic regression estimated the association between patient characteristics and the primary outcome. Complete case analyses were performed using Stata 16.1. Results: Patients’ mean age was 66 years (standard deviation [sd]: 13) and mean Census-level household income was $73,100 (sd: $24,000). Approximately 40% of patients had commercial health insurance and 62% had Medicare; 2% (n=283) had a HDHP. Breast (18%), lung (11%) and prostate (11%) cancers were most common. The mean annual MOOP limit was $3,040 for commercial plans and $2,688 for Medicare plans. Among patients with a commercial plan insurance, 46% reached their MOOP limit including 8% before and 37% after cancer diagnosis. For Medicare patients, 20% reached their MOOP limit, including 3% before and 17% after cancer diagnosis. Patients with a HDHP (adjusted Odds Ratio [aOR]: 2.61, 95% CI: 1.96-3.47), breast cancer (aOR: 2.29, 95% CI: 1.84-2.84), and lung cancer (aOR: 2.71, 95% CI: 2.04-3.61) had significantly greater odds of reaching the MOOP than those with a non-HDHP and other cancers. Household income was also significantly associated (aOR: 0.97, 95% CI:0.95-0.99) with reaching the MOOP. Conclusions: A substantial proportion of patients reach the annual MOOP limit during the year of cancer diagnosis, representing a population at high-risk for medical financial hardship. Future longitudinal studies are needed to assess the trajectory of OOP spending and implications on care utilization and health outcomes.

Health services for catastrophic patients through the national health insurance program: literature review

Introduction. Achieving universal health coverage, also known as UHC, has emerged as an essential global health policy, especially in addressing the burden of spending on major (catastrophic) diseases. However, catastrophic health expenditures are not always synonymous with high healthcare costs. However, a major disaster for low-income households is financing that is not entirely covered by insurance. Objective. This study aims to provide data on the effects of national health insurance on disaster victims in various nations. Materials and Methods. this research is a literature study; electronic searches were carried out in five databases, Pro-quest, Google Scholar, JACC, Science Direct, and Pubmed, for relevant research published between 1986 and 2022. Only 102 articles were relevant. After screening by reading abstracts and viewing all articles, concerning the impact of catastrophic disease health insurance, only 12 articles were declared eligible from 2017 to 22. Results. The review results show that most health insurance positively affects disasters, as seen from the decrease in the incidence of CHE and the risk of OOP spending in a country. Income is a CHE factor in LMICs notwithstanding unfortunate preventive ways of behaving. Conclusion. This study concludes that health insurance impacts those who need treatment, especially those who suffer from costly diseases or catastrophic diseases. Even though insurance is a poverty alleviation factor, without a good economic status, health services will still be an obstacle for a person to access health services. Furthermore, factors other than insurance cause poverty, namely small expenses such as accommodation and transportation that are not covered.

Impact of High Deductible Health Plans on U.S. Adults With Chronic Pain

Chronic pain affects an estimated 20% of U.S. adults. Because high-deductible health plans have captured a growing share of the commercial insurance market, it is unknown how high-deductible health plans impact care for chronic pain. Using 2007-2017 claims data from a large national commercial insurer, statistical analyses conducted in 2022-2023 estimated changes in enrollee outcomes before and after their firm began offering a high-deductible health plan compared with changes in outcomes in a comparison group of enrollees at firms never offering a high-deductible health plan. The sample included 757,530 commercially insured adults aged 18-64 years with headache, low back pain, arthritis, neuropathic pain, or fibromyalgia. Outcomes, measured at the enrollee year level, included the probability of receiving any chronic pain treatment, nonpharmacologic pain treatment, and opioid and nonopioid prescriptions; the number of nonpharmacologic pain treatment days; number and days' supply of opioid and nonopioid prescriptions; and total annual spending and out-of-pocket spending. High-deductible health plan offer was associated with a 1.2 percentage point reduction (95% CI= -1.8, -0.5) in the probability of any chronic pain treatment and an $11 increase (95% CI=$6, $15) in annual out-of-pocket spending on chronic pain treatments among those with any use, representing a 16% increase in average annual out-of-pocket spending over the pre-high deductible health plan offer annual average. Results were driven by changes in nonpharmacologic treatment use. By reducing the use of nonpharmacologic chronic pain treatments and marginally increasing out-of-pocket costs among those using these services, high-deductible health plans may discourage more holistic, integrated approaches to caring for patients with chronic pain conditions.

Out-of-Pocket Spending and Work Loss after Common Surgical Procedures Among Working-Age Adults

INTRODUCTION: Half of surgical patients report financial toxicity, which results from direct out-of-pocket (OOP) cost and indirect loss of income. This study aimed to assess the economic impact of common surgical procedures on patient OOP spending and work loss among working-age adults. METHODS: We used the 2017 to 2019 MarketScan Database to identify adults ages 19 to 64 years who underwent 1 of 20 common surgical procedures. These data were linked to the Health Productivity and Management (HPM) Database, which reports work absence and disability for a subset of employers. Outcomes included spending after index operation, disability, and return to work. Multivariable regression models adjusted for patient demographics and clinical variables. To control for secular trends, we used 4:1 propensity score matching using patient and employment variables. RESULTS: We identified 135,480 patients and 541,920 matched controls. Among this cohort, 25% of patients had a nonelective presentation and 12% had an ICU admission. Spending, missed work, and disability for patients linked to the HPM database are shown in the Table. Nonelective presentation was associated with higher OOP spending and more short-term disability (p < 0.05). Patients requiring ICU stay had higher OOP spending and more missed days of work and disability (p < 0.05). Table. - Six Month Out-of-Pocket Spending and Missed Work after Common Surgical Procedures Variable Surgical patients Matched controls Difference p Value Mean OOP spending (median, IQR) $3,487 ($2,020, $749-3,597) $636 ($12, $0-422) $2,851 <0.001 Any missed work 62.1% 32.5% 29.6% <0.001 Mean total days missed (median, IQR) 23 (15,4-36) 3 (2, 0-4) 20 <0.001 Any short-term disability 36.2% 2.7% 33.5% <0.001 Mean total days of short-term disability (median, SD) 41 (32, 19-56) 35 (15, 0-54) 6 <0.001 Surgical cohorts include common cardiac, vascular, general, and orthopedic procedures. OOP spending represents coinsurance, copays, and deductibles per patient. Missed work and short-term disability outcomes are only for those linked to the HPM database and employed at time of index admission. CONCLUSION: Patients recovering from operation face high OOP payments, miss over a month of work on average, and one in three receive short-term disability benefits. These findings demonstrate the double burden of medical expense and productivity loss and can inform policies for improved financial risk protection after operation.

Out-of-pocket costs attributable to dementia: A longitudinal analysis.

Alzheimer's disease and related dementias (ADRD) affect 5.7 million Americans, and are expensive despite the lack of a cure or even treatments effective in managing the disease. The literature thus far has tended to focus on the costs to Medicare, even though one of the main characteristics of ADRD (the loss of independence and ability to care for oneself) incurs costs not covered by Medicare. In this paper, we use survey data for 2002-2016 from the Health and Retirement Study to estimate the out-of-pocket costs of ADRD for the patient and their family through the first 8 years after the onset of symptoms, as defined by a standardized 27-point scale of cognitive ability. A two-part model developed by Basu and Manning (2010) allows us to separate the costs attributable to ADRD into two components, one driven by differences in longevity and one driven by differences in utilization. We identified a cohort of 3619 incident dementia cases, 38.9% were male, and 66.9% were non-Hispanic White. Dementia onset was 77.7 years of age, on average. OOP costs attributable to dementia are $8751 over the first 8 years after the onset. These incremental costs are driven by nursing home expenditures, which are largely uninsured in the US. OOP spending is highest for whites and women. The financial burden of ADRD is significant, and largely attributable to the lack of wide-spread long-term care insurance.

Addressing child health inequity through case management of under-five malaria in Nigeria: an extended cost-effectiveness analysis

BackgroundUnder-five malaria in Nigeria is a leading cause of global child mortality, accounting for 95,000 annual child deaths. High out-of-pocket medical expenditure contributes to under-five malaria mortality by discouraging care-seeking and use of effective anti-malarials in the poorest households. The significant inequity in child health outcomes in Nigeria stresses the need to evaluate the outcomes of potential interventions across socioeconomic lines.MethodsUsing a decision tree model, an extended cost-effectiveness analysis was done to determine the effects of subsidies covering the direct and indirect costs of case management of under-five malaria in Nigeria. This analysis estimates the number of child deaths averted, out-of-pocket (OOP) expenditure averted, cases of catastrophic health expenditure (CHE) averted, and cost of implementation. An optimization analysis was also done to determine how to optimally allocate money across wealth groups using different combinations of interventions.ResultsFully subsidizing direct medical, non-medical, and indirect costs could annually avert over 19,000 under-five deaths, 8600 cases of CHE, and US$187 million in OOP spending. Per US$1 million invested, this corresponds to an annual reduction of 76 under-five deaths, 34 cases of CHE, and over US$730,000 in OOP expenditure. Due to low initial treatment coverage in poorer socioeconomic groups, health and financial-risk protection benefits would be pro-poor, with the poorest 40% of Nigerians accounting for 72% of all deaths averted, 55% of all OOP expenditure averted, and 74% of all cases of CHE averted. Subsidies targeted to the poor would see greater benefits per dollar spent than broad, non-targeted subsidies. In an optimization scenario, the strategy of fully subsidizing direct medical costs would be dominated by a partial subsidy of direct medical costs as well as a full subsidy of direct medical, nonmedical, and indirect costs.ConclusionSubsidizing case management of under-five malaria for the poorest and most vulnerable would reduce illness-related impoverishment and child mortality in Nigeria while preserving limited financial resources. This study is an example of how focusing a targeted policy-intervention on a single, high-burden disease can yield large health and financial-risk protection benefits in a low and middle-income country context and address equity consideration in evidence-informed policymaking.

Effects of an out-of-pocket maximum in Medicare Part D.

Three different out-of-pocket (OOP) maximums in Medicare Part D have been proposed: $2000 by the House of Representatives, $3100 by the Senate Finance Committee, and the beginning of catastrophic coverage by the Medicare Payment Advisory Commission. However, little is known about how beneficiaries would be affected. We estimated multivariate linear regression models to determine which beneficiary characteristics were associated with the greatest savings under each proposed OOP maximum and simulated a potential behavioral response by beneficiaries. Using Part D 2017 claims data for beneficiaries in stand-alone prescription drug plans (PDPs) and Medicare Advantage prescription drug (MA-PD) plans, we estimated the number of beneficiaries affected, their demographic characteristics, and their drug utilization patterns. We then simulated a potential behavioral response by beneficiaries. Under the $2000 OOP proposed threshold, only 7% of PDP and 4% of MA-PD plan beneficiaries would have spending high enough to reach the OOP maximum. Annual mean (SD) savings would be $1301 ($1849) for PDP beneficiaries and $1363 ($1888) for MA-PD plan beneficiaries, concentrated among beneficiaries taking specialty drugs. As the threshold increases, fewer beneficiaries would accrue savings, but savings would increase. For the highest proposed OOP maximum, mean (SD) savings would be $2720 ($3465) and $2473 ($2805) for PDP and MA-PD plan beneficiaries, respectively. In our simulations, we estimated that the number of beneficiaries affected by an OOP maximum could increase by 2% to 11%, depending on the magnitude of response, but changes in savings would be minimal. As currently drafted, proposed OOP maximums would reduce OOP spending for a small population of Part D beneficiaries, with savings concentrated among beneficiaries with the very highest costs who are taking specialty medications.

Effect of Out-of-Pocket Costs on Subsequent Mammography Screening.

Although the Affordable Care Act eliminated cost sharing for screening mammography, a concern is that grandfathered plans, diagnostic mammograms, and follow-up testing may still lead to out-of-pocket (OOP) spending. Our study examines how OOP spending among women at their baseline screening mammogram may impact the decision to receive subsequent screening. The study included commercially insured women aged 40 to 41 years with a screening mammogram between 2011 and 2014. We estimated multivariate linear probability models of the effect of OOP spending at the baseline mammogram on subsequent screening 12 to 36 months later. Having any OOP payments for the baseline screening mammogram significantly reduced the probability of screening in the subsequent 12 to 24 months by 3.0 percentage points (pp) (95% confidence interval [CI]: 1.1-4.8 pp decrease). For every $100 increase in the OOP expenses for the baseline mammogram, the likelihood of subsequent screening within 12 to 24 months decreased by 1.9 pp (95% CI: 0.8-3.1 pp decrease). Similarly, any OOP spending for follow-up tests resulting from the baseline screening led to a 2.7 pp lower probability of screening 12 to 24 months later (95% CI: 0.9-4.1 pp decrease). Higher OOP expenses were associated with significantly lower screening 24 to 36 months later (coefficient=-0.014, 95% CI:-0.025 to-0.003). Although cost sharing has been eliminated for screening mammograms, OOP costs may still arise, particularly for diagnostic and follow-up testing services, both of which may reduce rates of subsequent screening. For preventive services, reducing or eliminating cost sharing through policy and legislation may be important to ensuring continued adherence to screening guidelines.

Redistribution and the health financing transition.

Public financing is necessary for realizing universal health coverage (UHC), a policy commitment that emphasizes that everyone should have access to health services they need, of sufficient quality to be effective, and that the use of these services does not expose individuals to financial hardship. As countries undergo their health financing transitions, moving away from external and out-of-pocket (OOP) financing toward domestically-sourced public financing, finding ways to increase public financing in an efficient, equitable, and sustainable manner is front and center in the policy dialogue around UHC. This paper focuses on one aspect of the health financing transition that has generally received less attention: that UHC is also intrinsically about a policy direction that emphasizes at its core redistribution of resources from the well-off to the poor. Differences in the level and organization of public financing for health for a given level of national income also reflect differences in social and political preferences for redistribution and equity across countries. Hence, navigation of a country’s health financing transition in ways that accelerates progress towards UHC also implies that public resources are targeted and expended in ways to improve effective service coverage and reduce OOP spending specifically for the poor. To leverage a country’s health financing transition for UHC, mechanisms should be introduced for: (i) ensuring that benefit entitlements are explicit and intertemporally commensurate with levels of public financing; (ii) fragmentation in pooling mechanisms is reduced to facilitate cross-subsidization without jeopardizing equity; (iii) levels of OOP and complementary sources of financing are nudged towards the well-off until core levels of public financing are adequate to provide similar levels of coverage for all; and (v) that purchasing of services is done in ways that helps reduce geographic- and income-related inequities in access and supply of quality health services. This implies careful policy choices need to be made, ones that require looking beyond the simplistic dichotomy between OOP and public sources of financing for UHC at the aggregate level to more nuanced and disaggregated assessments of the organization, use, and net fiscal incidence of financing and expenditures.

Out-of-pocket payments for part d covered medications by medicare fee-for-service beneficiaries with heart failure with reduced ejection fraction

Out-of-pocket (OOP) drug costs for MedicareFee-for-Service (FFS) beneficiaries with heart failure withreduced ejection fraction (HFrEF) are not well characterized.This study evaluated Part D OOP spending by Medicare beneficiaries with chronic HFrEF, stratified by thosewithand withouta worsening HF event (WHFE). Medicare FFS 100% Part D claims were used to identify HFrEF patients with 12 months of continuous Part D enrollment in 2018. HFrEF was defined as 1 inpatient or 2 outpatient claims of systolic HF or 1 systolic HF plus 1 HF outpatient claim. WHFE was defined as having a HF hospitalization or intravenous diuretic use within 12 months of HFrEF index date. OOP costs by Medicare Part D coverage phase for all covered drugs were calculated for HFrEF patients, and those with and without WHFE. Of 305,373 Medicare patients with HFrEF, 26% had a WHFE. Total mean (SD) OOP drug costs among all HFrEF patients was $1,166 (1,205)/year. Patients with WHFE and patients without WHFE had respectively a mean (SD) annual OOP costs of $1,302 (1,273) and $1,117 (1,176). Over 39% of HFrEF patients entered the "donut hole" (44% and 37% of patients with WHFE and without WHFE, respectively), while 11% of HFrEF patients entered the catastrophic phase (13% and 10% of patients with and without WHFE, respectively). More than 1 in 10 patients with heart failure entered the catastrophic phase within Medicare-Fee-For-Service, whereas in 2018 only 10% of costs were attributable to heart failure medication and 90% to comorbidities.