OOP Spending Research Articles

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.

Measuring the Protective Effect of Health Insurance Coverage on Out-of-Pocket Expenditures During the COVID-19 Pandemic in the Peruvian Population.

Health insurance coverage is expected to protect individuals from out-of-pocket (OOP) expenditures, potentially preventing them from falling into poverty. However, to date, the effect of health insurance on OOP spending during the coronavirus disease 2019 (COVID-19) pandemic has not been fully explored. This study aimed to estimate differences in the proportion and the amount of OOP expenditures among Peruvians during the pre- and post-mandatory lockdown response to COVID-19 in 2020 according to the health insurance coverage status. This study utilized repeated cross-sectional data from the National Household Survey on Living and Poverty Conditions (ENAHO) from the first quarter of 2017 until the fourth quarter of 2020. The outcomes were (i) the proportion of individuals who incurred OOP expenditures and (ii) the monetary value of OOP expenditures. An interrupted time series analysis (ITS) and a quasi-experimental difference-in-difference (DID) analysis were performed to examine the outcomes among the control (individuals without health insurance) and treatment groups (individuals with health insurance) after the COVID-19 pandemic. ITS analysis showed that the proportion of individuals reporting OOP expenditures after implementation of mandatory lockdown due to COVID-19 in Peru decreased in both groups, but no difference in the slope trend was found (P=.916). The average quarterly amount of OOP spending increased in both groups, but no difference in the slope trend was found (P=.073). Lastly, the DID analysis showed that the mandatory lockdown was associated with a higher amount of OOP, but there was no evidence to indicate that the higher amount was different between the control and treatment groups. The mandatory lockdown in response to the COVID-19 was associated with a higher amount of OOP expenditures and a lower likelihood of incurring OOP expenditures. However, our findings suggest that health insurance coverage does not lower OOP expenditures or reduce the likelihood of incurring OOP expenditures.

Out-of-Pocket Health Expenditures and Health Care Services Use Among Older Americans With Cognitive Impairment: Results From the 2008-2016 Health and Retirement Study.

The evidence base on health services use and cost burdens associated with transition to severe cognitive impairment (SCI) and dementia is underdeveloped. We examine how the change in cognitive impairment status influences nursing home use, hospitalizations, and out-of-pocket (OOP) expenditures. We use prospective data from the Health and Retirement Study (2007/2008-2015/2016) on adults 70 years and older meeting research criteria for cognitive impairment not dementia (CIND) at baseline (unweighted n = 1,692) to fit 2-part models testing how reversion to normal cognition, stability (CIND maintenance), and transition into SCI/dementia influence change in yearly nursing home use, hospitalizations, and OOP expenditures. Over 8 years, 5.9% reverted, 15.9% remained CIND, 14.9% transitioned to SCI/dementia, and 63.3% died. We observed substantial increases in the propensity of any nursing home use which were particularly pronounced among those who transitioned or died during follow-up and similar but less pronounced differences in patterns of inpatient hospitalizations. Average baseline OOP spending was similar among reverters ($1156 [95% confidence interval = 832-1,479]), maintainers ($1,145 [993-1,296]), and transitioners ($1,385 [1,041-1,730]). Individuals who died during follow-up spent $2,529 (2,101-2,957). By the eighth year of follow-up, spending among reverters increased to $1,402 (869-1,934) and $2,188 (1,402-2,974) and $8,988 (5,820-12,157) for maintainers and transitioners, respectively. Average spending at the wave preceding death was $7,719 (4,345-11,094). Estimates were only partly attenuated through adjustment to covariables. A better understanding of variations in health services use and cost burdens among individuals with mild cognitive impairment can help guide targeted care and financial planning.

Health-related out-of-pocket expenses for children living with rare diseases - tuberous sclerosis and mitochondrial disorders: A prospective pilot study in Australian families.

We aimed to describe health-related out-of-pocket (OOP) expenses incurred by Australian families living with children with chronic and complex diseases. A prospective pilot study of OOP expenses in families with children with tuberous sclerosis (TS) or mitochondrial disorders (MD) in 2016-2017. An initial survey assessed the family's financial situation, child's health functioning and estimated previous 6 months' and lifetime OOP expenses. Thereafter, families completed a survey each month for 6 months, prospectively tracking OOP expenses. Initial surveys were completed by 13 families with 15 children; median age 7 years (range: 1-12); 5 with MD, 10 with TS. All families reported OOP expenses: 38% paid $2000 per annum, more than double the annual per-capita OOP costs reported for Australia by the Organisation for Economic Co-operation and Development. Eight families estimated $5000-$25 000 in OOP expenses over their child's lifetime and 62% of mothers reduced or stopped work due to caring responsibilities. Eleven families paid annual private health insurance premiums of $2000-$5122, but 72% said this was poor value-for-money. Prospective tracking by eight families (9 children) identified the median OOP expenditure was $863 (range $55-$1398) per family for 6months. OOP spending was associated with visits to allied health professionals, non-prescription medicines, special foods, supplements and disposable items. Eight families paid for 91 prescription medications over 6months. All families caring for children with TS or MD reported OOP expenses. A larger study is needed to explore the affordability of health care for children living with a broader range of chronic diseases.

Out-of-Pocket Spending for Asthma-Related Care Among Commercially Insured Patients, 2004-2016

Out-of-pocket (OOP) health care costs can cause financial burden and deferred care for many Americans. Little is known about OOP spending for asthma-related care among the commercially insured. To analyze OOP spending for asthma-related care overall, across types of care, and by income. Using enrollment, claims, and geocoded census tract data on income from a large US commercial health plan from 2004 to 2016, we measured inflation-adjusted OOP spending for individuals with asthma ages 4 to 64 years (n= 1,986,769). We estimated annual asthma-related OOP spending over time, and average total, asthma-related, asthma type of care, and asthma medication spending by income. We measured trends in median OOP cost per medication. Linear regression models were adjusted for patient covariates and deductible level. Asthma-related OOP spending decreased over time both for patients enrolled in high-deductible health plans and for those in traditional plans. High-deductible plan enrollment increased from 7% to 54%. Compared with patients living in high-income areas, patients in the lowest-income areas had similar annual total and asthma-related OOP spending, but spent 30% less on controller medications and a higher proportion of their asthma-related OOP spending on inpatient and emergency care (10% vs 3%; P < .001). Asthma-related OOP spending represented a higher proportion of household income for patients in lower-income areas. Patients with asthma living in the lowest-income areas have greater cost burden, lower spending on controller medications, and greater spending on high-acuity care than higher-income counterparts.

Trends in high deductible health plan enrolment and spending among commercially insured members with and without chronic conditions: a Natural Experiment for Translation in Diabetes (NEXT-D2) Study

ObjectivesTo examine trends in high deductible health plan (HDHP) enrolment among members with diabetes and cardiovascular disease (CVD) compared with healthy members and compare out-of-pocket (OOP) and total spending for...

National Trends in Out-of-Pocket Costs Among U.S. Adults With Diabetes Aged 18-64 Years: 2001-2017.

To assess national trends in out-of-pocket (OOP) costs among adults aged 18-64 years with diabetes in the U.S. Using data from the 2001-2017 Medical Expenditure Panel Survey, we estimated total per person annual OOP costs (insurance premiums, prescription drug costs, inpatient and outpatient deductibles, copays, and other payments not covered by insurance) and high OOP cost rate, defined as the percentage of people with OOP spending >10% of their family's pretax income. We examined trends overall, by subgroup (insurance type, income level, insulin use, size of patient's employer, and whether the patient was enrolled in a high deductible health plan), and by type of service. Changes in trends were identified using joinpoint analysis; costs were adjusted to 2017 U.S. dollars. From 2001 to 2017, OOP costs decreased 4.3%, from $4,328 to $4,139, and the high OOP cost rate fell 32%, from 28 to 19% (P < 0.001). Changes in the high OOP cost rate varied by subgroup, declining among those with public or no insurance and those with an income <200% of the federal poverty level (P < 0.001) but remaining stable among those with private insurance and higher income. Drug prescription OOP costs decreased among all subgroups (P < 0.001). Decreases in total (-$58 vs. -$37, P < 0.001) and prescription (-$79 vs. -$68, P < 0.001) OOP costs were higher among insulin users than noninsulin users. OOP costs among U.S. nonelderly adults with diabetes declined, especially among those least able to afford them. Future studies may explore factors contributing to the decline in OOP costs and the impact on the quality of diabetes care and complication rates.

Impact of High Deductible Health Plans on Continuous Buprenorphine Treatment for Opioid Use Disorder.

Long-term, continuous treatment with medication like buprenorphine is the gold standard for opioid use disorder (OUD). As high deductible health plans (HDHPs) become more prevalent in the commercial insurance market, they may pose financial barriers to people with OUD. To estimate the impact of HDHPs on continuity of buprenorphine treatment, concurrent visits for counseling/psychotherapy and OUD-related evaluation and management, and out-of-pocket spending. Difference-in-differences analysis comparing trends in outcomes among enrollees whose employers offer an HDHP (treatment group) to enrollees whose employers never offer an HDHP (comparison group). Enrollees with OUD from a national sample of commercial health insurance plans during 2007-2017 who initiate buprenorphine treatment. Number of days of continuous buprenorphine treatment; probabilities of continuous buprenorphine treatment ≥30, ≥90, ≥180, and ≥365 days; probability of concurrent (i.e., within the same month) behavioral therapy (i.e., counseling or psychotherapy); probability of concurrent OUD-related evaluation and management visits; proportions of buprenorphine treatment episodes with counseling/psychotherapy and evaluation and management visits; and out-of-pocket (OOP) spending on buprenorphine, behavioral therapy, and evaluation and management visits. HDHPs were associated with an average increase of $98 (95% CI: $48, $150) on OOP spending on buprenorphine per treatment episode but no change in the number of days of continuous buprenorphine treatment or concurrent use of related services. HDHPs do not reduce continuity of buprenorphine treatment among commercially insured enrollees with OUD but may increase financial burden for this population.

Out-of-Pocket Expenditures for Delivery for Maternity Waiting Home Users and Non-users in Rural Zambia.

Utilizing maternity waiting homes (MWHs) is a strategy to improve access to skilled obstetric care in rural Zambia. However, out-of-pocket (OOP) expenses remain a barrier for many women. We assessed delivery-related expenditure for women who used MWHs and those who did not who delivered at a rural health facility. During the endline of an impact evaluation for an MWH intervention, household surveys (n = 826) were conducted with women who delivered a baby in the previous 13 months at a rural health facility and lived >10 km from a health facility in seven districts of rural Zambia. We captured the amount women reported spending on delivery. We compared OOP spending between women who used MWHs and those who did not. Amounts were converted from Zambian kwacha (ZMW) to US dollar (USD). After controlling for confounders, there was no significant difference in delivery-related expenditure between women who used MWHs (US$40.01) and those who did not (US$36.66) (P=.06). Both groups reported baby clothes as the largest expenditure. MWH users reported spending slightly more on accommodation compared to those did not use MWHs, but this difference represents only a fraction of total costs associated with delivery. Findings suggest that for women coming from far away, utilizing MWHs while awaiting delivery is not costlier overall than for women who deliver at a health facility but do not utilize a MWH.

Importance of Evidence-Based Health Insurance Reimbursement and Health Technology Assessment for Achieving Universal Health Coverage and Improved Access to Health in India

ObjectiveTo review the importance of evidence-based methods in health insurance reimbursement for achieving universal health coverage in India. MethodsA narrative literature review was performed. ResultsThe out-of-pocket (OOP) healthcare expenditure in India is among the highest in the world. This situation is despite the implementation of numerous government health schemes and the availability of a large number of health insurance programs, both public and private. Compromised quality of care in many public healthcare facilities is a major factor driving the average Indian citizen to increasingly depend upon private healthcare facilities, further escalating OOP spending. The low awareness and poor uptake of insurance policies among Indians is one of the biggest challenges in the implementation of universal health coverage (UHC) in India. The catastrophic burden of high OOP expenses on individual households could be reduced by taking steps to enhance health insurance uptake, which can be in turn achieved by strengthening the healthcare reimbursement system in India. ConclusionsThe application of the principles of evidence-based healthcare for reimbursement requires the systematic assessment of all health technologies, which is already being done in developed countries. The enactment of health schemes such as Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana and setting up of Health Technology Assessment in India are steps toward reducing OOP expenditure and achieving UHC in India. We review the importance and challenges of evidence-based reimbursement and health technology assessment toward achieving UHC in India.

Out-of-pocket payments by end-stage kidney disease patients on regular hemodialysis: Cost of illness analysis, experience from Sudan.

In Sudan, the number of end-stage kidney disease (ESKD) patients receiving hemodialysis (HD) is growing. Patients and their families incur a high out-of-pocket expenditure (OOPE), given that HD treatment is expensive. There are limited data about OOP spending on HD in the country. This study aims to explore patients' OOP expense on direct medical and nonmedical goods and services and to which extent they can be predicted from sociodemographic characteristics, health insurance status, comorbidity, and accommodation change. This is descriptive a cross-sectional study conducted in Ibn Sina Hospital. One hundred and thirty patients undergo regular HD were randomly selected. Among the study participants (130), the median of the overall total OOP (direct medical and direct nonmedical) spending per patients per year was found to be US$ 3859.1 (interquartile range [IQR]: 2298.1-6261.1). As for the medians OOP expenditure on direct medical and nonmedical costs, they were found to be US$ 2327.6 (IQR: 1421.5-3804.8) and US$ 1096 (IQR: 715.2-2345.2), respectively. The direct medical expenditure (355,586 US$) accounted for 60% of the overall total expenses. Medications and investigations were the primary drivers of direct medical spending. Higher OOPE rates were found among those with one or more of these factors; uninsured patients, patient with comorbidity, female gender, and over 40 years aged. The multivariate analysis showed that the significant predictors of direct medical expenditure were health insurance and comorbid conditions, where as the predictors for direct nonmedical expenditure were accommodation change and gender. This study results in a better understanding of OOP spending on direct medical and nonmedical services and its associated predictors among HD patients within the context of Sudan. Further research is needed in this area.

Comparison of Safety and Insurance Payments for Minor Hand Procedures Across Operative Settings

Surgical procedures can be performed in different settings, but the association between the operative setting and patient safety and cost to the patient and payer is unknown. To examine differences in complications, total payments, and out-of-pocket (OOP) spending for minor hand surgical procedures performed in office, ambulatory surgery center (ASC), and hospital outpatient department (HOPD) operative settings. A retrospective, population-based cohort study was conducted using deidentified claims data from private employer-sponsored health insurance from January 1, 2009, to December 31, 2017. Patients aged 18 years or older undergoing carpal tunnel release, trigger finger release, excision of wrist ganglion, and excision of small hand masses (N = 468 365) were included. Operative setting, defined as procedures performed in the clinic setting, ASC, and HOPD. Complications during the 90-day postoperative period, total payments (total facility and payer reimbursement), and OOP spending. Of the 468 365 patients, 296 378 women (63.3%) and 171 987 men (36.7%) underwent minor hand surgical procedures from 2009 to 2017, with 284 889 procedures (60.8%) performed in HOPDs, 158 659 procedures (33.9%) performed in ASCs, and 24 817 procedures (5.3%) performed in the office setting. Ninety-day complications occurred in 3.4% of procedures performed in HOPDs, 3.3% in ASCs, and 2.9% in office settings (P < .001). After controlling for patient characteristics, procedures performed outside of the office had higher odds of complications (HOPDs: odds ratio [OR], 1.32; 95% CI, 1.22-1.43; ASCs: OR, 1.24; 95% CI, 1.14-1.34). Compared with the office setting, procedures performed in HOPDs incurred an extra $1216 in total payments (95% CI, $1184-$1248) and $115 in OOP expenses (95% CI, $109-$121). Procedures performed in ASCs cost an additional $709 (95% CI, $676-$741) and $140 in OOP expenses (95% CI, $134-$146). Transitioning ASC and HOPD procedures to the office setting could have saved an estimated $6 million annually in OOP expenses during the study period. The findings of this study suggest that minor hand surgery performed in the office setting is safe and less costly compared with ambulatory and hospital-based operations. Shifting minor surgical procedures to the office setting may lead to substantial cost savings for payers and patients without compromising care quality.

Out-of-pocket spending among a cohort of Australians living with gout.

To measure the direct and indirect out-of-pocket (OOP) costs borne by Australians with gout. A cross-sectional, Australia-wide, web-based survey was conducted over 12months between May 2017 and April 2018. Participants were recruited via advertisements in doctors' clinics and healthcare organizations' websites, and social media platforms such as Facebook and Twitter. Survey questions collected information about participants' OOP spending on direct medical and non-medical gout-related healthcare costs. Participant demographics, gout status, healthcare sought, workdays lost to due gout and health-related quality of life were also collected. Seventy-nine patients with gout completed the survey; 70 (89%) were male, and on average were 56 (SD 16) years of age and had gout for 14 (SD 12) years. For this cohort, the median total OOP direct medical cost was AU$200 per year (interquartile range [IQR]: AU$60-AU$570). Sixty (76%) people with gout reported being affected by gout during work; however, only 0.25 (IQR: 0-3) days of work (approximately $60) were lost due to gout in a year. Nine percent (n=7) of participants experienced cost-related treatment attrition and 33% reported economic hardship (n=26). Participants who experienced economic hardship or cost-related treatment attrition had higher median total gout-related direct costs than those who did not. In Australia, gout has an OOP financial cost and reduces work productivity. The presence of cost-related treatment attrition among people with gout indicates that financial costs may be a significant barrier to seeking treatment for a subset of patients with gout.

Financial risk protection of individuals with private health insurance

Abstract Background Financial Protection is a key dimension of universal health coverage and health system performance assessment and is also monitored within the framework of the sustainable development goals. Analyses of financial hardship among people who have out-of-pocket (OOP) spending through the use of health services in Germany usually focus solely on households with statutory health insurance due to the peculiarities of private health insurance (PHI) data. This study aims to analyse financial protection among privately insured in Germany. Methods A cross-sectional survey was conducted in 2018 with 20,000 privately insured in Germany. The survey comprised questions on household net-income, OOP spending on health, unmet needs, perceived financial burden). Catastrophic expenditure was analysed and defined as share of households with OOP spending greater than 10% of household income. Further results on financial protection and access are based on descriptive analyses. Results A total of 3,601 participants (18.0%) completed the survey (58.6 years ± 14.6; 64.6% male). 82.2% of households reported OOP spending, mostly on OTC drugs, deductibles and medical aids. Median OOP spending was €300-499 per year. Average OOP spending as share of household income was 1.3% and 0.6% of households have catastrophic OOP spending. In total, 6.6% of respondents reported unmet needs due to financial barriers, of which 5.3% had no OOP spending. 11.2% of all respondents reported to feel strongly financially burdened by OOP spending with a gap between the lowest (26.2%) and highest income group (9.9%). Conclusions PHI insured have comparatively low OOP spending with less than 1% of households having catastrophic expenditures on health. However, 6.2% of respondents reported to forgo care due to financial reasons which supports the assumption that OOP payments can create a barrier to access. Unmet needs and financial burden are higher in lower income groups which raises concerns about equity. Key messages Financial protection is good among privately insured in Germany with only few households reporting catastrophic expenditures which indicates a broad and sufficient benefit coverage under PHI. Although out-of-pocket spending is low, privately insured perceive a strong financial burden (particularly in lower income groups) and face financial barriers to access care mirrored in forgone care.

Comparing patient OOP spending for specialty drugs in Medicare Part D and employer-sponsored insurance.

Per capita spending on specialty drugs increased 55% between 2014 and 2018. Individuals aged 55 to 75 years using specialty drugs make the transition from employer-sponsored insurance (ESI) to Medicare Part D coverage. We compared out-of-pocket (OOP) spending across ESI, Medicare fee-for-service (FFS), and Medicare Advantage (MA) prescription drug plans to examine the impact of benefit design on OOP spending. Analyses consisted of Truven MarketScan and Medicare Part D prescription drug claims from 2013 to 2017 for individuals enrolled in ESI, FFS, and MA drug plans taking at least 1 drug among the top 4 specialty drug classes: rheumatoid arthritis (RA), multiple sclerosis (MS), cancer, and hepatitis C. Multivariate regression analyses with fixed effects were used to assess whether there are differences in OOP spending by insurance type and the impact of benefit design differences. A secondary outcome was drug choice within a therapeutic class. There were small differences in drug choice between Medicare and ESI but significant differences in OOP spending. Monthly OOP spending for ESI relative to FFS was $108 less for RA drugs, $288 less for MS drugs, $504 less for cancer drugs, and $1437 less for hepatitis C drugs. Spending was slightly greater for beneficiaries in MA plans compared with FFS. Higher Medicare spending was driven by gaps in coverage in the Part D benefit phases because beneficiaries pay a percentage of list price. OOP spending was substantially higher for Medicare enrollees compared with ESI enrollees as a result of the Part D benefit structure.

An analysis of financial protection before and after the Iranian Health Transformation Plan.

Protecting people against the financial consequences of health-care payments is a key objective of health systems. We carried out a descriptive analysis of changes in health spending associated with the implementation of the latest health sector reform in the Islamic Republic of Iran, the Health Transformation Plan (HTP). The study relied on 2 rounds of data from the Household Expenditure and Income Survey (2014 and 2015). Key indicators of financial protection in health expenditure were estimated. The Kakwani index was used for out-of-pocket (OOP) health expenditure to measure the degree of progressivity in the distribution of such payments. Total OOP per capita health expenditure showed a 2.5% relative decrease in real terms in 2015 compared to 2014. Estimation of the Kakwani index suggested OOP spending became slightly more progressive over the time period of HTP reform. The share of the population facing catastrophic health expenditure also decreased significantly from 2.9% to 2.1% at the national level. However, the incidence of impoverishment due to OOP payments increased slightly between preand post-HTP, from 0.2% to 0.5%. Our findings suggest that the new policies have a positive association in improving financial protection against health costs among Iranians, albeit slightly less so for the poor. Future efforts to increase public spending for financial protection would be challenging and should rely on efficiency gains such as a move from fee-for-service to performance- based payment systems and more organized OOP collection mechanisms involving prepayment and risk pooling.

Evaluating patient preferences for thermal ablation versus nonthermal, nontumescent varicose vein treatments

ObjectiveTo measure patient preferences for attributes associated with thermal ablation and nonthermal, nontumescent varicose vein treatments. MethodsData were collected from an electronic patient preference survey taken by 70 adult participants (aged 20 years or older) at three Center for Vein Restoration clinics in New Jersey from July 19, 2019, through August 13, 2019. Survey participation was voluntary and anonymous (participation rate of 80.5% [70/87]). Patients were shown 10 consecutive screens that displayed three hypothetical treatment scenarios with different combinations of six attributes of interest and a none option. Choice-based conjoint analysis estimated the relative importance of different aspects of care, trade-offs between these aspects, and total satisfaction that respondents derived from different healthcare procedures. Market simulation analysis compared clusters of attributes mimicking thermal ablation and nonthermal, nontumescent treatments. ResultsOf the six attributes studied, out-of-pocket (OOP) expenditures were the most important to patients (37.2%), followed by postoperative discomfort (17.1%), risk of adverse events (16.3%), time to return to normal activity (11.0%), number of injections (10.0%), and number of visits (8.4%). Patients were willing to pay the most to avoid postoperative discomfort ($68.9) and risk of adverse events ($65.8). The market simulation analysis found that, regardless of the level of OOP spending, 60% to 80% of respondents favored attribute combinations corresponding with nonthermal, nontumescent procedures over thermal ablation, and that less than 1% of participants would forgo either treatment under no cost sharing. ConclusionsPatients are highly sensitive to OOP costs for minimally invasive varicose vein treatments. Market simulation analysis favored nonthermal, nontumescent procedures over thermal ablation.

Variation in out‐of‐Pocket Spending Among Low‐Income Versus High‐Income Commercially Insured Patients with Asthma

Research ObjectivePatient cost‐sharing has been increasing over the past two decades, in particular due to high‐deductible health plans (HDHP). Asthma is a very common, serious, chronic disease in the United States. We analyzed a large, national sample of asthma patients to provide new evidence on OOP spending overall, across types of asthma care, and variation by patient income.Study DesignWe used 11 years (2004‐2014) of enrollment, claims, and geocoded census tract data on income. Annual OOP costs were measured as the sum of actual patient‐paid deductible, coinsurance and copayments on all medical care; spending was adjusted to 2014 dollars using the Medical CPI. Annual asthma OOP spending included OOP payments for asthma services (ie, asthma medications, office and emergency department (ED) visits, and hospitalizations with ICD‐9 codes for asthma, spacers for inhalers, asthma nebulizers). Patient income was measured using the census tract income associated with the patient’s address, and then, patients were categorized into income quintiles based on the distribution of household income across the United States (eg, not within sample). We report the association of OOP spending with patient income based on linear regression models controlling for patient age, sex, state, morbidity and asthma severity (using the Johns Hopkins ACG system), and year; models were stratified by annual HDHP enrollment.Population StudiedAll patients ages 4‐64 years with asthma (defined as having an asthma ICD‐9 diagnosis code for an outpatient or ED visit or hospitalization) in a large, national Commercial and Medicare Advantage claims database (n = 2 018 178).Principal FindingsMore patients in the lowest‐income quintile had a HDHP. Within plan type, levels of spending associated with income quintiles were similar but represented a significantly larger proportion of income for the lowest‐income quintile (Table).ConclusionsBecause patients spent similar amounts of OOP for asthma care, the lowest‐income quintile patients experienced greater cost burden. The majority of OOP asthma spending was on asthma medications, but lowest‐income quintile patients had greater spending on high acuity care than those in higher income quintiles.Implications for Policy or PracticeEfforts should be made to understand whether these differences in cost burden are associated with cost‐related underuse of medications or other adverse outcomes to inform policy and insurance benefit design.Primary Funding SourcePatient‐Centered Outcomes Research Institute.

Asthma Care and Out‐of‐Pocket Costs for Families of Children with Asthma in High‐Deductible Health Plans

Asthma is the most common pediatric chronic condition, with substantial morbidity, health care utilization, and costs. Enrollment has increased in high‐deductible health plans (HDHPs) that require families to assume greater responsibility for out‐of‐pocket (OOP) costs for asthma and other family health care needs, creating potential barriers to use of recommended asthma controller medications. Data are limited on children in HDHPs. We sought to examine changes in asthma controller medication use, exacerbations, and OOP costs for children with asthma enrolling in HDHPs and whether this varies for children in families with multiple competing health care needs.We measured OOP costs for children’s asthma care and for care for all family members in the same insurance plan, and children’s rates of 30‐day fills for asthma controller medications and exacerbations (measured by oral steroid bursts). We controlled for the number of chronic conditions among all family members, defining high illness burden as presence of ≥ 4 chronic conditions. We used a difference‐in‐differences design with models controlling for individual and employer‐level characteristics, and tested for effect modification by family illness burden using a three‐way interaction.We identified children aged 4‐17 years with persistent asthma with employer coverage in a large commercial and Medicare Advantage claims database between 2002 and 2014. We selected children with 12 months of enrollment in a plan with low or no deductible (“traditional plan”) before either switching to a HDHP or staying in the traditional plan (controls) for another 12 months. The sample included only employers offering a single deductible level.The sample included 4708 children who switched to HDHPs and 47,414 who remained in traditional plans. Children switching to HDHPs had higher OOP costs for asthma care than controls (difference‐in‐differences (DiD) $21; 95% confidence interval (CI) $14‐$28), a relative increase of 21.5% (13.5%‐29.4%). Their families had greater OOP spending (DiD $605; 95% CI $505‐$704), a relative increase of 26.8% (21.8%‐31.8%). Children in HDHPs had a relative decrease in 30‐day controller medication fills (−7.4%, 95% CI −12.0% to −2.8%) but no relative difference in exacerbations (1.3%, 95% CI −10.5% to 13.2%). There was no evidence of effect modification by family illness burden.This study found increases in OOP asthma costs for children in HDHPs and lower rates of controller medication use, but no differences in asthma exacerbations. Families experienced an increase in total OOP costs in HDHPs, although this may have been offset by lower premiums. The lack of difference in the impact of HDHP enrollment on children’s controller use in families with high illness burden suggests these families are not trading off OOP spending on children’s asthma care for OOP spending on other care.Although families face increased OOP costs in HDHPs for children’s asthma and other health care, the impact on asthma medication use and exacerbations may be moderated by the fact that medications were subject to copayments rather than the deductible in most plans in our study. Value‐based insurance designs that exempt important pediatric health services from the deductible may help reduce adverse outcomes in HDHPs.Patient‐Centered Outcomes Research Institute.

The Global State of Health Care System

Globally, health care has recently known indisputable challenges. Even the strongest nations have seen their supposedly strong health systems crush down. No health organisation has been left un-disrupted with the coming of Covid-19. If even the mighty have fallen what becomes of the weak? African countries at independence were organized and financed by governments which provided facilities, personnel and other inputs. By the 1980s, however economic downturn and the embrace of international monetary fund loans with stringent conditionality meant that many governments had to cut public spending on infrastructure and services, including healthcare and education. Consequently, many African governments stopped subsidizing public services and began implementing various costs – recovery measures in public services. The cost recovery era witnessed the introduction of OOP (out-of-pocket) for healthcare services, public water supply and consumables in schools. Thus, since the 1980s and 1990s, OOP by individuals and households have accounted for a larger scale of healthcare expenditure in many African countries of sub-Saharan Africa (1). These payments popularly known as user-fees or the ‘cash and carry’ health system in Ghana are known for raising the cost of healthcare, thus making it un-affordable for a large number of the population. In many sub-Saharan countries, governments rank healthcare relatively low among development priorities (2). For this reason, insufficient resources are allocated to healthcare, including drugs; which is often financed OOP (3) Healthcare statistics in sub-Sahara Africa are generally poor. For example, although the region makes up only 11 per cent, of the world’s population; it accounts for e’ per cent of the global disease burden and commands less than 1 per cent of global expenditure (4). Although the WHP suggests thresholds of OOP for health as a guarantee of adequate financial protection is in the region of 15-20 per cent, residents of many African countries spend more (5). For example, OOP spending on health was between 27 – 37 per cent in Ghana in 2012 about 52 per cent in Kenya, 6405-70 per cent in Nigeria in the 1998 – 2008 period: while in South Africa, the government contributes about 42 per cent of all expenditures on health. The remaining 58 per cent is paid by private sources insurance premiums and OOP. The United Nations recommends minimum required budgetary allocation to health is 15 per cent, many African countries fall below this minimum in their budgetary allocations. In 2007 more than half of the 53 African countries spent less than $50 per person (as average) on health (6). Of the total expenditure, 30 per cent came from governments, 20 per cent from donors and 50 per cent from private sources of which 71 per cent was paid by patients themselves, the so-called out-of-pocket-payments. The dire picture of the healthcare system in the world and particularly in sub-Saharan Africa described above, coupled with Africa’s status as a ‘low-income’ region where poverty is a major barrier to accessing healthcare and underscores the need to rethink the health system. To talk of healthcare systems, we must first consider the elements that make up this system. If the target is having a better health system then the individual elements making up the system must be reviewed. Knowing what it is to be what is has been and what it could be, will be a good step forward.