Out Of Pocket Costs Research Articles

General practitioners' adherence to work-up and referral recommendations in fertility care.

What is the current guideline adherence by general practitioners (GPs) for work-up and subsequent referral from primary to secondary care for patients suffering from infertility? Guideline adherence by GPs concerning infertility was 9.2% in couples referred. Adherence to recommendations can decrease unnecessary referral, diagnostics and treatments, and consequently result in lower expenditures. Moreover, patients can be saved from unnecessary hospital visits, emotional burden and out of pocket costs. A retrospective cohort study among 306 patients referred for basic fertility work-up between January 2011 and June 2013 from primary care to a secondary care teaching hospital or a tertiary hospital with IVF facilities. Couples were eligible to participate when there was no previous referral for fertility problems and the duration of the child wish was <2 years. Data to assess guideline adherence were collected from the referral letter and the medical records. A patient questionnaire was used to determine patients' general and fertility-related characteristics. The GP performed a Chlamydia Antibody Titre (CAT) testing and semen analysis as recommended in 15.9% and 42.2% of the referred patients, respectively. According to the guideline, 39% of the couples were under referred (i.e. not immediately referred as recommended), 8.8% were unnecessarily referred and the CAT and semen analysis were unnecessarily repeated in secondary care in 80.0% and 57.1% of cases, respectively. We could not include non-referred patients with expectant management in primary care, an unknown number of whom became pregnant in this period. This may have resulted in an underestimation of primary care performance. Our findings show that guideline adherence concerning work-up and subsequent referral for fertility problems is low. The influence of patient demands for referral remains largely unknown. Barriers and facilitators for guideline adherence should be determined to develop interventions to improve guideline adherence in the areas of work-up and referral for fertility care and to diminish duplicate tests in secondary care. Funded by CZ, a Dutch healthcare insurer (grant number AFVV 11-232). CZ had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: None. Not applicable.

An exploration of the socio-economic profile of women and costs of receiving abortion services at public health facilities of Madhya Pradesh, India

BackgroundMaternal mortality, which primarily burdens developing countries, reflects the greatest health divide between rich and poor. This is especially pronounced for access to safe abortion services which alone avert 1 of every 10 maternal deaths in India. Primarily due to confidentiality concerns, poor women in India prefer private services which are often offered by untrained providers and may be expensive. In 2006 the state government of Madhya Pradesh (population 73 million) began a concerted effort to ensure access to safe abortion services at public health facilities to both rural and urban poor women. This study aims to understand the socio-economic profile of women seeking abortion services in public health facilities across this state and out of pocket cost accessing abortion services. In particular, we examine the level of access that poor women have to safe abortion services in Madhya Pradesh.MethodsThis study consisted of a cross-sectional client follow-up design. A total of 19 facilities were selected using two-stage random sampling and 1036 women presenting to chosen facilities with abortion and post-abortion complications were interviewed between May and December 2014. A structured data collection tool was developed. A composite wealth index computed using principal component analysis derived weights from consumer durables and asset holding and classified women into three categories, poor, moderate, and rich.ResultsFindings highlight that overall 57% of women who received abortion care at public health facilities were poor, followed by 21% moderate and 22% rich. More poor women sought care at primary level facilities (58%) than secondary level facilities and among women presenting for postabortion complications (67%) than induced abortion. Women reported spending no money to access abortion services as abortion services are free of cost at public facilities. However, poor women spend INR 64 (1 USD) while visiting primary level facilities and INR 256 (USD 4) while visiting urban hospitals, primarily for transportation and food.ConclusionsImproved availability of safe abortion services at the primary level in Madhya Pradesh has helped meeting the need of safe abortion services among poor, which eventually will help reducing the maternal mortality and morbidity due to unsafe abortion.

Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya

BackgroundMonitoring the incidence and intensity of catastrophic health expenditure, as well as the impoverishing effects of out of pocket costs to access healthcare, is a key part of benchmarking Kenya’s progress towards reducing the financial burden that households experience when accessing healthcare.MethodsThe study relies on data from the nationally-representative Kenya Household Expenditure and Utilization Survey conducted in 2013 (n =33,675). We undertook health equity analysis to estimate the incidence and intensity of catastrophic expenditure. Households were considered to have incurred catastrophic expenditures if their annual out of-pocket health expenditures exceeded 40% of their annual non-food expenditure. We assessed the impoverishing effects of out of pocket payments using the Kenya national poverty line. We distinguished between direct payments for healthcare such as payments for consultation, medicines, medical procedures, and total healthcare expenditure that includes direct healthcare payments and the cost of transportation to and from health facilities. We used logistic regression analysis to explore the factors associated with the incidence of catastrophic expenditures.ResultsWhen only direct payments to healthcare providers were considered, the incidence of catastrophic expenditures was 4.52%. When transport costs are included, the incidence of catastrophic expenditure increased to 6.58%. 453,470 Kenyans are pushed into poverty annually as a result of direct payments for healthcare. When the cost of transport is included, that number increases by more than one third to 619,541. Unemployment of the household head, presence of an elderly person, a person with a chronic ailment, a large household size, lower household social-economic status, and residence in marginalized regions of the country are significantly associated with increased odds of incurring catastrophic expenditures.ConclusionsKenyan policy makers should prioritize extending pre-payment mechanisms to more vulnerable groups, specifically the poor, the elderly, those suffering from chronic ailments and those living in marginalized regions of the country. The range of services covered under these mechanisms should also be extended such that the proportion of direct costs paid to access care is reduced. Policy makers should also prioritize reducing supply side bottlenecks such as availability of healthcare facilities in close proximity to the population, especially in rural and marginalized areas, and improvements in quality of care. For the poor and the vulnerable, initiatives to cover the cost of transport to and from a health facility, such as transport vouchers could also be explored.

The determinants and costs of bypassing small hospitals in a ‘free’ health system: A cross sectional study in Sri Lanka

Background: Rising out-of-pocket health expenditure due to policy issues is a major factor contributing to deterioration of efficiency and equity of healthcare systems. Objective: The objective of this study was to estimate the determinants of bypassing divisional hospitals in Sri Lanka, and to estimate the effect of bypassing behaviour on the direct out of pocket costs of the patients. Methods: The study employed a hospital based cross sectional analytical design. Out patients department of District General Hospital – Gampaha was selected as the referral facility. Out patients departments of the two selected divisional hospitals were selected as the bypassed facilities. The patients who bypassed the two divisional hospitals and attended the out patients department of the general hospital were identified using a screening tool and a map. The reasons for bypassing were evaluated among those who bypassed. Out of pocket costs of the bypassed were assessed using an interviewer administered questionnaire and compared with the patients who did not bypass the divisional hospitals. Bivariate analysis of the out of pocket expenditure was performed using the Mann-Whitney test, placing the level of significance at 0.05. Results: Patients who bypassed the divisional hospitals were more likely to be married, permanently employed, and have monthly incomes above Rs. 20000. The mean out of pocket expenditure for travelling of bypassed patients and their family members was more than four folds higher than those who did not bypass. The out of pocket expenditure on meals and snacks was also higher among the bypassed. However, more patients among the bypassed group had to spend on outside purchase of medicine and investigations. The average out of pocket expenditure among the bypassed group was about 75% greater than (Rs 63/= more) their counterparts who did not bypass. Conclusions: Bypassing increases the out of pocket expenditure of patients. A primary care based model with designated draining areas and proper referral policies would help to address the issue.

568P_PR Changes in household income levels as a result of cancer diagnosis and treatment – A single centre study

Background Improvements in cancer diagnosis and treatment have resulted in substantial growth in the costs of cancer care. Changes in a patient’s household income as a result of a cancer diagnosis or its treatment, in combination with the out-of-pocket costs of care, can place a significant financial burden on patients and their families. Methods The study is a prospective observational pilot study among adults treated with anti-cancer therapy in both adjuvant and palliative settings, in an outpatient department of a tertiary cancer hospital in Sydney, Australia. We have prospectively collected data from 14 patients currently receiving treatment for their cancer in the outpatient setting at one cancer centre thus far. Participants completed a questionnaire comprising four sections relating to socio-demographic characteristics, employment/ income history, health insurance status and cancer-related treatment. The data presented here has been collected as part of a larger pilot study investigating the out-of pocket costs of cancer care for patients at three Australian cancer centres. Results Preliminary results for 14 participants, The median age in our cohort was 57 years (range: 37 – 77). The most common cancer type was breast (n=7), followed by prostate (n=2), lung (n=2), renal cell carcinoma (n=1) and gastroesophageal (n=1). 10 patients described a reduction in their household income after the diagnosis of cancer and 4 patients reported no change in their household income level. 12 patients were working part-time or full-time in paid work prior to the diagnosis of cancer, of which 10 described changes in their work conditions, most commonly decreased work hours (6), ceased working (3) and retired (1). Conclusions We aim to continue recruitment of participants at a further two sites, which will allow for a more heterogeneous population from different socioeconomic backgrounds. These preliminary findings are informative and may be indicative towards the changes in household income status as a result of a diagnosis of cancer and its treatment. Further results from the ongoing study will help to inform us regarding the magnitude and significance of these changes. Legal entity responsible for the study Sydney Local Health District Human Research Ethics Committee Funding Study conducted within cancer centre with no funding Disclosure All authors have declared no conflicts of interest.

Association Between Employee Earnings and Consumer-Directed Health Plan Choices

INTRODUCTIONThis study explores the relationship between employee earnings and choice of a consumer-directed health plan (CDI IP) verses a managed care plan in an employer-sponsored insurance (ESI) program. The increased variation in healthcare insurance plan designs over the past decade has led to a greater need to understand the impact of consumer choice with respect to health insurance plans. CDHPs are associated with plan designs that incorporate high deductibles and greater cost sharing. Researchers have consistently found that employee earnings are positively associated with CDHP enrollment (Barry, Cullen, Galusha, Slade, & Busch, 2008; Buntin et al., 2006; Cohen & Martinez, 2009; Dicken, 2006; lx) Sasso, Rice, Gabel, & Whitmore, 2004; Parente, Feldman, & Christianson, 2004a, 2004b, 2008; Tollen, Ross, & Poor, 2004). However, it is unclear if variations in CDHP choice are discernable at all levels of employee earnings.CDHPs emerged in the early 2000s as an alternative healthcare insurance plan design intended to slow the persistent cost increases of ESI, which have nearly doubled since the late 1990s (Claxton et al., 2014). From 2006 to 2014, CDHP enrollment for ESI plans has grown from 4% to 20%, with 27% of employers offering at least one CDHP plan (Kaiser Family Foundation, 2013). Through high deductibles and greater upfront cost sharing by enrollees, CDHPs encourage consumer engagement in healthcare decision making to presumably lower discretionary healthcare use and facilitate better healthcare choices, thus reducing ESI costs or slowing their rate of growth.Health Reimbursement Arrangements and Health Savings Account-Eligible PlansHealth reimbursement arrangements (I IRAs) and health savings account (1ISA)-eligible high-deductible plans have become the two primary CDHP models. From the perspective of enrollees, HRA designs are similar to HSAs relative to the financing arrangement or savings account, but unlike I IS As, I IRA funds are not owned by employees and do not require coupling with a highdeductible plan (Bloche, 2006).HRAs emerged in 2001 and were modeled on the 1996 medical savings account (MSA) pilot program that was part of the Health Insurance Portability and Accountability Act (Parente et al., 2008). Although I IRAs can be offered as a stand-alone, defined-contribution vehicle, they usually are coupled with a high-deductible plan. Employers finance the HRA to offset enrollee out-of-pocket costs; however, a gap or donut hole in coverage remains. The donut-hole phase-the employee's high-deductible period-takes place when I IRA funds are exhausted and before plan indemnity begins.HSAs were established as part of Medicare legislation passed in 2003 (Parente et al., 2008). HSAs introduced employee funding and ownership of the medical spending account, which is portable, may contain investment characteristics, and allows greater employee control over the level of funding to subsidize healthcare costs. The level of employee funding, and annual accrual of such funds, determines enrollees' exposure to out-ofpocket costs during the high-deductible period.Association Between CDHPs and Enrollee EarningsResearch findings show a positive association between CDHPs and enrollee earnings, which may suggest favorable selection (Barry et al., 2008; Buntin et al., 2006; Cohen & Martinez, 2009; Dicken, 2006; Id Sasso et al., 2004; Parente et al., 2004a, 2004b, 2008; Tollen et al., 2004). Individuals in higher socioeconomic groups are generally healthier and require fewer healthcare services than do those in lower socioeconomic groups (Bloche, 2007; Hughes-Cromwick, Root, & Reohrig, 2007; Marquis et al., 2006). Alternatively, households with higher earnings may have a higher risk tolerance or premium cost elasticity, meaning they are less willing to pay higher premiums for lower cost-sharing risk (Callan & Johnson, 2002; Parente et al. …

Effectiveness of a Patient Support Program in Supporting Access to Therapy for Solid Tumor Malignancies.

Background: Certain governmental agencies, patient advocacy organizations, and pharmaceutical manufacturers have implemented programs to assist patients in overcoming barriers to accessing healthcare. Recently, such programs have expanded their services, helping both uninsured and insured patients to navigate the complex healthcare system, and assisting with increasing out-of pocket costs and copays for the drugs. Objective: To better understand the effect of patient support programs on access to therapy for solid tumor malignancies, this study evaluated service use, case outcomes, and patient characteristics from a manufacturer-sponsored program in the United States. Methods: Sociodemographic characteristics, services use rates, and outcomes by case and insurance type were evaluated at the patient- and case-level in a random sample of patients prescribed nab-paclitaxel for solid tumor malignancies who enrolled in the Celgene Patient Support (CPS) program (April 2011-November 2013). Results: This analysis included 4566 patients (8134 cases); most patients were female (64.7%), aged <65 years (59.2%), in the South (53.9%), and treated in community settings (87.9%). Patients were primarily insured by Medicare (38.5%) or commercial plans (37.3%), or were uninsured (16.6%). Following benefits investigations for new patients entering the program (98.5%), CPS provided support to obtain free medicine (29.4%), appeal denial of coverage (15.0%), receive commercial co-payment assistance (8.1%), or obtain prior payer authorization (1.3%). Nab-paclitaxel was provided at no cost in 89.4% of cases where patients sought financial support; payer reimbursement was obtained in 63.2% of reimbursement appeals. Of commercially-insured patients who required assistance with co-payments and met financial criteria, 93.3% received a mean of $597 in co-payment support. Conclusion: The CPS program was successful in gaining access to therapy. Healthcare providers and both insured or uninsured patients accessed CPS for prior authorization/precertification, appeals support, and financial support through the Free Medication Program and the Commercial Co-Pay program.

Extramammary findings in diagnostic breast magnetic resonance imaging among patients with known breast cancer: incidence and cost analysis

BackgroundExtramammary findings (EMFs) are common on breast magnetic resonance imaging (MRI). MethodsA retrospective review of breast MRIs in breast cancer patients between January 2009 and December 2014 was performed to identify EMF occurrences, resultant evaluation, and added cost. ResultsEMFs were noted in 185 (59%) of 316 MRIs. Overall, 201 new EMFs were identified with 178 (89%) benign and 23 (11%) malignant. New malignant findings included 19 metastatic nodes (18 axillary, 1 internal mammary) and 4 primary malignancies (2 thyroid, 2 lung). New malignant nonaxillary EMFs occurred at a rate of 1.6% (5/316). EMFs resulted in 65 patients undergoing 98 imaging studies, 37 procedures, and 10 consultations with a median (range) total charge of $3,491 ($222 to $29,076] and out of pocket cost of $2,206 ($44 to $12,780) per patient. ConclusionsEMFs occurred in more than half of our patients, were usually benign, and frequently led to additional testing and costs.

Costs associated with functional gastrointestinal disorders and related signs and symptoms in infants: a systematic review protocol

IntroductionFunctional gastrointestinal disorders (FGIDs) and FGID-related signs and symptoms have a fundamental impact on the psychosocial, physical and mental well-being of infants and their parents alike. Recent reviews and studies...

‘The bills that were coming in…’: out of pocket costs during relocation for specialist treatment for haematological malignancies

This paper responds to the call for more research to fully understand out of pocket (OOP) costs for cancer patients by providing a detailed discussion of such costs for adult haematology patients from Queensland, Australia. The descriptive qualitative research was based on in-depth interviews with 45 (n = 45) haematology patients from regional, rural and remote areas. The discussion itemises the OOP costs under four categories including the costs associated with travel and accommodation, the costs associated with family and friends during relocation, the costs associated with diagnosis and treatment, and the costs of parking. The paper provides evidence of the categories of financial burden experienced by haematology patients who have to relocate for specialist treatment by detailing the extensive range of OOP costs. The expectation is that the itemisation of OOP cost variables will contribute to future efforts of quantification.

The financial impact of head and neck cancer caregiving: a qualitative study.

There is a lack of research on the financial impacts that head and neck cancer has on caregivers. To explore the overall financial impact of head and neck cancer on caregivers; to describe the factors that mitigate this impact. Interviews with 31 caregivers (mean time caring: 5.7years). Head and neck cancer had a considerable financial impact on caregivers. It resulted in out of pocket costs and caregivers and/or their relative/friend with cancer often became under- or un-employed. Caregivers with large debts or ongoing expenses appeared to be particularly vulnerable to cancer-related financial pressures. Finance related psychological stress was prevalent, although some caregivers hid their psychological difficulties from other people. Factors which help caregivers to mitigate financial distress included having private health insurance and being able to access to medical and/or social welfare benefits. Head and neck cancer can cause caregivers substantial financial and psychological distress. Distress may be mitigated by providing caregivers and their households with access to welfare benefits. Health professionals should be aware that head and neck cancer can have short and long-term financial consequences for caregivers and their families. Health professionals should refer patients and their caregivers to medical social workers who can help them with their financial issues. Copyright © 2016 John Wiley & Sons, Ltd.

Multiple Myeloma Patient Experience with Financial Toxicity: Findings from the Cancer Experience Registry

Background: The US prevalence of multiple myeloma (MM) is estimated at 83,118 as of January 1, 2011 (SEER, 2014), and about 24,050 new MM cases will be diagnosed in 2014 (ACS, 2014). With advances in treatment, MM patients are living longer and are confronted with increasingly complex therapeutic decisions. Many people living with MM may have to manage a significant financial burden related to care, including medication copays and coinsurance, and other out of pocket costs. Financial toxicity can reduce quality of life and impede delivery of quality care. With the movement towards value-based cancer care, oncologists are encouraged to discuss costs with patients when considering treatment choices. We aimed to describe financial distress among MM patients and patient-provider communication about cost.Methods: From July 2013-2014, the Cancer Support Community (CSC) registered 495 MM patients to the "Cancer Experience Registry: MM," an online initiative to study and raise awareness about MM's psychosocial impact. Registrants were recruited through an outreach program including the CSC and The Leukemia & Lymphoma Society networks of communities and resources. 266 US-based registrants completed surveys including questions about the financial cost of MM and cancer-related distress. Stress-related intrusive ideation about managing the financial impact of MM was measured using the validated 7-item Impact of Event Scale (IES); levels >13 were used to indicate clinically significant symptoms associated with anxiety. Twenty-seven items from a validated distress screener (α=0.94) (CancerSupportSource, Miller 2014) were summed to create a score for overall distress (mean=33, SD=21, range 0-103), and 4 items were summed for a depression score (α=0.83) with a binary variable created to indicate at risk for depression (score≥5).Results: The sample (n=266) was 52% female, 91% Caucasian, median age 64. Median time since MM diagnosis was 4.5 years. Total annual income: 35% <$40K; 35% $40-79K; 30% at least $80K. 73% reported spending at least $100/mo on all out of pocket costs related to MM; nearly half (48%) spent $250 or more; and 22% spent $500 or more. Because of the medical costs of MM, 32% reported depleting their savings; 22% borrowed against or used money from retirement; and 35% reported cutting their grocery expenses. About one-third used pharmaceutical assistance programs (35%). In order to reduce health care costs, only 5% reported skipping dosages of medicine at least sometimes, and 6% postponed filling prescriptions. Seventeen percent reported they postponed seeking psychological counseling or support. Just over half (56%) reported a member of their health care team talked to them about resources related to getting financial help or financial counseling, and only 28% reported their health care team ever discussed the impact of MM on personal finances. Yet, 82% reported financial counseling would be 'quite a bit' or 'very much' helpful to someone with MM. A large proportion of participants reported they would be 'quite a bit' or 'very much' willing to receive financial assistance for medications (81%) and cost of treatment (77%), and, to a lesser extent, for transportation costs (55%) and living expenses (46%). There was a significant linear increase in overall distress (p=0.009) and risk for depression (p=0.010) with greater monthly increment in out of pocket costs, adjusting for income, until monthly out of pocket costs exceeded $1000. Nearly one-third (32%) reported currently experiencing clinically high levels of intrusive ideation (IES>13) about the financial cost of care. Similarly, 33% reported they were often or always upset about money and the cost of care, and 47% were moderately, seriously or very seriously concerned about health insurance or money worries.Conclusion: MM places a financial burden on patients that can significantly impact quality of life and may negatively affect treatment outcomes. Implications for future research and practice include the development and evaluation of interventions to enhance doctor-patient communication and support (e.g., financial counseling and assistance) to help ensure that the financial burden of MM does not negatively impact the patient's quality of life, course of cancer care, and health outcomes. DisclosuresLeBlanc:Epi-Q: Consultancy; Helsinn Therapeutics: Honoraria, Research Funding; Boehringer Ingelheim: Membership on an entity's Board of Directors or advisory committees; Flatiron: Consultancy.

Healthcare access for cancer patients in the era of economic crisis. Results from the HOPE III study

Abstract Background: Despite the documentation of addressing healthcare disparities in detection and treatment of cancer and health outcomes for cancer patients, the inequalities persist. Cancer patients of several vulnerable groups suffer disproportionally the effect of economic crisis on health and healthcare. Patients &amp; Methods: A cross sectional survey was carried out between July and October 2014 in order to assess the cancer patients’ barriers to healthcare access. A total of 426 cancer patients, members of cancer patient organization participated in the study. Data were collected by using an online, self reported questionnaire evaluating three main areas: healthcare access (7 items), economic status and financial burden of the disease (17 items) and the alteration on several aspects related to the disease (8 items) from 2009 to 2014. Results: Approximately 31% of cancer patients reported that they faced barriers to healthcare access for cancer treatment during the last 12 months. The main barriers included long waiting time for a medical appointment (51%) and inability to visit a private physician due to the incapability to pay the out of pocket cost (44%). One in four patient encountered obstacles in medication access which resulted to treatment delay (46%), worsened health status (96%) and increased out of pocket costs (39%). Conclusions: Results suggest that there are vulnerable groups among cancer patients in Greece who suffer disproportionally more the impact of economic crisis on health and healthcare. Healthcare reforms and targeted interventions should be implemented in order to effectively address the inequities in access for cancer patients.

Cost of Illness (Out of Pocket Costs Paid By Patient) for T.B in Quetta City, Pakistan

The objective of study is to measure the cost of illness (out of pocket costs paid by patients) for T.B in Quetta city, Pakistan. Cross sectional study was performed on TB patient in Fatima Jinnah chest hospital Quetta. The TB patients who were registered in hospital were interviewed to determine the out of pocket cost paid by TB patients by using standardized data collection tool. The descriptive statistics was used to present the data. All analyses were performed using SPSS 20.0. The total of 70 TB patients were agree to participate in the study. Majority (62%, n=44) were females with rural residency 51.4%, n=36). Majority of patients had monthly income were 8000-15000. The total average out of pocket cost was Pk. Rs. 11,685 per month for an individual patient. In addition, it was calculated that a patient spend Pk. Rs. 292 for diagnostic tests including chest x-ray, additional medicine purchased were of Pk. Rs. 1465, travel cost were Pk. Rs. 3,485 , special food cost were Pk. Rs. 2,128 rupees accommodation cost were Pk. Rs. 3,825 rupees, & the other cost were Pk. Rs. 490. It is worth mentioning here that all the medication and other treatment cost is paid by the government. The study concluded that although government paid all the medication and other treatment cost for TB patients, yet patient had to bear a high amount of money from his pocket which put additional burden to the poor patient suffering with a disease like TB.

PD52-09 OUT OF POCKET COSTS OF MALE INFERTILITY CARE AND ASSOCIATED FINANCIAL STRAIN

You have accessJournal of UrologyInfertility: Evaluation1 Apr 2015PD52-09 OUT OF POCKET COSTS OF MALE INFERTILITY CARE AND ASSOCIATED FINANCIAL STRAIN Peter Elliott, Matthew Abad-Santos, Patti Katz, and James Smith Peter ElliottPeter Elliott More articles by this author , Matthew Abad-SantosMatthew Abad-Santos More articles by this author , Patti KatzPatti Katz More articles by this author , and James SmithJames Smith More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1783AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Infertility affects approximately 15% of couples, with a male factor responsible in 20% and contributing in 30-40% of couples. Often with little insurance to mitigate costs, pursuing such care is known to be expensive, yet is currently uncharacterized in men. Our aim is to determine the out of pocket expenses, measures taken to finance these costs, and associated financial strain for men seeking fertility care. METHODS In this retrospective cohort, patients completed questionnaires recording the total amount of money spent on infertility care, and on what aspect of their care the money was spent. Participants also recorded measures taken to finance these costs, the amount of financial strain they experienced and how this strain impacted their decisions to seek and continue care. Multivariable logistic regression was performed to assess relationship between fertility characteristics, financial costs and financial strain. RESULTS 111 participants completed full surveys. Over the course of their care, 16% of patients spent over $50,000 dollars. 16% spent between $30,000 and $49,999. 32% spent between $15,000 and $29,999. 37% of subjects spent less than $15,000 dollars. Procedures comprised the largest component of costs. 47% of subjects reported financial strain. Patients with no infertility insurance coverage had significantly higher costs (p=0.03). IVF/ICSI was associated with the highest costs of any treatment modality (p<0.01). After multivariable analysis, patients who used savings and went into debt were significantly more likely to experience financial strain (p=0.03 and p<0.01, respectively). CONCLUSIONS Our study elucidates the previously uncharacterized economic hardships of male infertility care. Overall, 64% of men who pursued fertility treatment had out of pocket expenses exceeding $15,000 dollars. Nearly half reported financial strain and limitation of treatment options due to these expenses. This data gives men and their partners a realistic expectation of the cost of pursuing fertility treatment, the extreme measures many patients take to finance their care and the financial strain associated with such options. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1116 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Peter Elliott More articles by this author Matthew Abad-Santos More articles by this author Patti Katz More articles by this author James Smith More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A multilevel health promotion intervention in minority-owned workplaces.

Changing health behaviors and health-related environments is important in reducing chronic disease. Minority workplaces are potential venues to provide regular, effective health promotion opportunities to underserved individuals. The purpose of this study was to test the feasibility of changing workplace policy, programs, and practices in minority-owned workplaces. Four minority Native American-owned businesses were recruited to participate in this study. The intervention was a set of recommended standards and guidelines gleaned from the US Preventive Task Force and The Community Guide relevant to workplaces. Each workplace selected between 4 and 6 target areas to improve over the year-long intervention period. The evaluation tool was a semi-structured survey conducted at baseline and at one-year follow-up, with workplace staff responsible for benefits and services to employees. Feasibility was evaluated by assessing the likelihood that the workplaces implemented health promotion activities in the year-long intervention. Several practices and policies changed significantly during the intervention in the four workplaces, including coverage for nicotine replacement therapy (NRT), elimination of out of pocket costs for screening and tobacco cessation, accountability systems for providers, posted stair use, cessation line availability that included NRT, offering weight loss programs, offering physical activity programs, and conducting targeted communication programs about health promotion. Other practices and polices changed in the expected direction, but were not significant. Changing workplace programs, practices, and policies is feasible in minority workplaces, with support and tools provided by outside organizations. These findings could drive a full-scale test of the intervention in minority businesses in order to improve the health of disadvantaged workers.

Patient costs of breast cancer endocrine therapy agents under Medicare Part D vs with generic formulations.

PurposeThe high expense of newer, more effective adjuvant endocrine therapy agents (aromatase inhibitors [AIs]) for postmenopausal breast cancer contributes to socioeconomic disparities in breast cancer outcomes. This study compares endocrine therapy costs for breast cancer patients during the first five years of Medicare Part D implementation, and when generic alternatives became available.MethodsThe out of pocket patient costs for AIs and tamoxifen under Medicare Part D drug plans were determined for 2006–2011 from the CMS Website for the 50 US states and District of Columbia.ResultsBetween 2006 and 2010, the mean annual patient drug cost under Medicare Part D in the median state rose 19% for tamoxifen, 113% for anastrozole, 89% for exemestane, and 129% for letrozole, resulting in median annual out of pocket costs in 2010 of $701, $3050, $2804, and $3664 respectively. However, the 2011 availability of generic AI preparations led to median annual costs in 2011 of $804, $872, $1837, and $2217 respectively. Not included in the reported patient costs, the mean monthly drug premiums in the median state increased 58% in 2011 compared to 2007.ConclusionsThe more effective AI agents became considerably more expensive during the first several years of the Medicare Part D program. Cost decreased with the introduction of generic agents, an intervention that was independent of the Part D program. It is unlikely that the Part D program ameliorated existing socioeconomic disparities in survival among breast cancer patients, but the availability of generic agents may do so.

A Cost-Effectiveness Analysis Comparing Different Strategies to Implement Noninvasive Prenatal Testing Into a Down Syndrome Screening Program

Noninvasive prenatal testing (NIPT) can analyze cell-free DNA of placental origin in maternal serum for trisomy 21. The detection rate is 99.5%, and the false-positive rate (FPR) is 0.2%. Noninvasive prenatal testing is recommended only for highrisk women after conventional screening. Noninvasive prenatal testing is deemed a screening modality, and invasive diagnostic testing is required for confirmation following a “positive” result. The present study was performed to evaluate NIPT by comparing 4 strategies examining cost-effectiveness and budget impacts for health care systems and parturients. A decision-analytic model was created to compare screening-related costs and consequences of NIPT implementation. The first strategy involved current practices using combined first-trimester screening (CFTS) is offered to all women at 11 to 13 weeks’ gestation. Women at high risk for DS are offered invasive diagnostic testing, via amniocentesis with fluorescence in situ hybridization and karyotyping. For strategy 2, NIPT is a second investigation after high-risk CFTS stratification. It was assumed that only women with a positive NIPT undergo invasive diagnostic testing and further counseling. Strategies 3A and 3B categorize women as high or low risk. Women 35 years or older are considered high risk and are initially offered NIPT; all others are offered CFTS, and only those considered at high risk for DS undergo NIPT. All women who are NIPT positive are referred for invasive diagnostic testing. In strategy 4, universal NIPT replaces CFTS with NIPT as the primary screening modality. All women with a positive NIPT undergo invasive diagnostic testing and counseling. Estimated costs for each strategy were those directly related to screening and accruing to government agencies and out-of-pocket costs to the woman. Outcomes included the number of DS cases detected and the number of procedure-related losses (PRLs) avoided by not performing invasive diagnostic testing. Two cost estimates for each strategy were calculated. The low estimate included costs to the health system and patients based on the current Medicare Benefits Schedule cost and the lowest estimate of patient outof-pocket costs; the high estimate was based on both Medicare costs and the highest estimates of private health care prices. Universal NIPT was the most effective strategy and detected 657 DS cases, resulting in 11 PRLs. Strategies 3A and 3B (maternal ages >35 and >40 years, respectively) were more effective than current practices for detecting DS and avoiding PRLs. Strategy 2 was less effective for DS detection, but more effective in avoiding PRLs. Five to 11 PRLs occurred with the new strategies compared with 101 PRLs for the current practice. Strategy 2 was the least expensive option. Implementing universal NIPT would cost more than 4 times the current expenditures on DS screening. The higher cost estimates were double or triple those of the low cost, with higher out-of-pocket costs for patients. Based on DS detection, the most cost-effective new strategy was 3B. Strategies 3A and 4 offered less value for money compared with current practice. Although strategy 2 was less costly and less effective for DS detection, when based on avoiding PRLs, it was the most cost-effective. Strategy 4 had the highest incremental cost per PRL avoided. The benefits of NIPT are its ability to detect a high percentage of DS cases while decreasing the number of PRLs. These advantages generate higher costs to health systems and parturients. The substitution of NIPT for CFTS would be significantly more expensive. Benefits of replacing CFTS with NIPT include an 18% increase in DS cases detected and a decrease in the overall screening positive rate from 3.8% to less than 0.42%. Additional research is necessary to confirm these results.

Health Status, Medicare Part D Enrollment, and Prescription Drug Use Among Older Adults

To account for potential selection factors in the observed relationship between Medicare Part D coverage and prescription drug use, this study uses data from the 2010 and 2012 waves of the Health and Retirement Study (HRS) to first examine the determinants of Medicare Part D enrollment, paying particular attention to the role of functional health status on the enrollment decision. Next, the study assesses whether and to what extent Medicare Part D coverage moderates the effect of functional health status on prescription drug use and monthly out-of-pocket spending among older adults. As prior studies indicate, the findings reveal that individuals who take up Medicare Part D have poorer (functional) health relative to nonparticipants, and thus, exhibit greater demand for prescription drugs. Taking functional health status into account, Medicare Part D coverage is significantly associated with greater prescription drug use among those with few health limitations, and is also significantly associated with greater out-of-pocket spending among those with the most health limitations. Thus, while prior studies have compared Medicare eligible- to non-eligible individuals to find that Medicare Part D coverage significantly lowers out-ofpocket costs, and therefore, increases prescription drug use, this study compared Medicare Part D enrollees to eligible non-enrollees to generate findings that imply that the presumed effect of Medicare Part D coverage on prescription drug use may be spurious. In turn, advocacy efforts may be best directed at ensuring that the existing coverage gaps in Medicare Part D are continually addressed.

The Financial Costs of Chronic Myeloid Leukemia and Implications for Quality of Life and Adherence: Findings from the Cancer Experience Registry

Background: US prevalence of CML is estimated at 33,990 of January 1, 2011 (SEER, 2014). In 2014, about 5,980 new CML cases will be diagnosed (ACS, 2014). The era of tyrosine kinase inhibitors has transformed CML from an often fatal disease to one with an excellent prognosis, with ongoing treatment. Many people living with CML may have to manage a significant financial burden related to care, including medication copays and coinsurance, and other out of pocket costs. Several studies have reported that the financial burden of CML care is associated with decreased adherence (Dusetzina, 2014; Abraham, 2012; Noens, 2009). Poor adherence is associated with statistically significant decreases in 5-year event-free survival and may occur more frequently than either patients or physicians recognize (Oehler, 2013).Methods: From October 2013 to June 2014, the Cancer Support Community (CSC) and The Leukemia & Lymphoma Society (LLS) registered 484 people living with CML to the Cancer Experience Registry: CML, an online initiative designed to learn and raise awareness about the psychosocial impact of CML. Registrants were recruited through an outreach program that leveraged CSC’s and LLS’s networks of community-based affiliates and chapters, online communities, CSC’s helpline and LLS’s information resource center, other advocacy organizations, social and other media channels. 393 registrants (81%) responded to a survey, including questions about the financial cost of CML and cancer-related distress. Stress-related intrusive ideation about managing the financial impact of CML was measured using the Impact of Event Scale (IES, 7 items, Horowitz, 1979); levels >13 were used to indicate clinically significant symptoms associated with anxiety. Fifteen items from a validated distress screener (α=0.93) (CancerSupportSource, Miller 2014) were summed to create a score for overall distress (mean=23, SD=14, range 0-60), and 4 items were summed for a depression score (α=0.88) with a binary variable created to indicate at risk for depression (score≥5). For these analyses, we excluded survey participants living outside the US (n=54) and bone marrow transplant patients not taking oral CML medications (n=11). The sample (n=327) was 68% female, 98% Caucasian, median age 59. Median time since CML diagnosis was 4 years. Total annual income: 32% <$40K; 30% $40-79K; 37% at least $80K.Results: Nearly half (48%) reported spending at least $100 per month on all out of pocket costs related to CML; 27% spent $250 or more; 15% spent $500 or more; 5% spent $1,000 or more. Greater out of pocket costs were associated with higher overall distress (p<0.001) and increased risk of depression (p<0.001), adjusting for income. One-third (34%) reported that CML-related out of pocket costs affect their household “quite a bit” or “very much”; 21% responded “a little bit”; 27% responded “not at all.” More than one-third (37%) reported currently experiencing clinically high levels of intrusive ideation (IES>13) about the financial cost of care. Oral CML medicine was the greatest cost burden to participants. Because of the medical costs of CML, 33% reported depleting their savings; 20% borrowed against or used money from retirement; and 35% reported cutting their grocery expenses. Nine percent enrolled in a clinical trial that paid for most of their treatment expenses. About one-third used pharmaceutical assistance programs (30%) and co-pay assistance programs (38%). In order to reduce health care costs, 10% reported skipping dosages of medicine at least sometimes, and 14% postponed filling prescriptions. Twelve percent reported they postponed seeking psychological counseling or support. Half (51%) of participants did not know if they were eligible for Social Security Disability Insurance or Supplemental Security Income; 44% wished they had received more help with financial advice and assistance.Conclusion: CML places a financial burden on patients that is associated with patients taking measures that may significantly impact quality of life and may negatively affect treatment outcomes. Implications for future research and practice include the development and evaluation of interventions to enhance oncology team-patient communication and support (e.g., financial counseling and assistance) to help ensure that the financial burden of CML does not negatively impact the patient’s quality of life, course of cancer care, and health outcomes. DisclosuresNo relevant conflicts of interest to declare.